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BackgroundPostoperative respiratory failure (PRF) is associated with increased hospital charges and worse patient outcomes. Reliable prediction models can help to guide postoperative planning to optimize care, to guide resource allocation, and to foster shared decision-making with patients.Research questionCan a predictive model be developed to accurately identify patients at high risk of PRF?Study design and methodsIn this single-site proof-of-concept study, we used structured query language to extract, transform, and load electronic health record data from 23,999 consecutive adult patients admitted for elective surgery (2014-2021). Our primary outcome was PRF, defined as mechanical ventilation after surgery of > 48 h. Predictors of interest included demographics, comorbidities, and intraoperative factors. We used logistic regression to build a predictive model and the least absolute shrinkage and selection operator procedure to select variables and to estimate model coefficients. We evaluated model performance using optimism-corrected area under the receiver operating curve and area under the precision-recall curve and calculated sensitivity, specificity, positive and negative predictive values, and Brier scores.ResultsTwo hundred twenty-five patients (0.94%) demonstrated PRF. The 18-variable predictive model included: operations on the cardiovascular, nervous, digestive, urinary, or musculoskeletal system; surgical specialty orthopedic (nonspine); Medicare or Medicaid (as the primary payer); race unknown; American Society of Anesthesiologists class ≥ III; BMI of 30 to 34.9 kg/m2; anesthesia duration (per hour); net fluid at end of the operation (per liter); median intraoperative FIO2, end title CO2, heart rate, and tidal volume; and intraoperative vasopressor medications. The optimism-corrected area under the receiver operating curve was 0.835 (95% CI,0.808-0.862) and the area under the precision-recall curve was 0.156 (95% CI, 0.105-0.203).InterpretationThis single-center proof-of-concept study demonstrated that a structured query language extract, transform, and load process, based on readily available patient and intraoperative variables, can be used to develop a prediction model for PRF. This PRF prediction model is scalable for multicenter research. Clinical applications include decision support to guide postoperative level of care admission and treatment decisions.

Abstract Background Platelets play a key role in the natural history of aortic stenosis (AS) and after transcatheter aortic valve implantation (TAVI). An echo-based staging system stratifies patients with severe AS into 5 groups according to the associated cardiac damage phenotype. We aimed to correlate these AS stages with platelet indices in post-TAVI patients. Methods Patients with severe AS who underwent TAVI and were admitted to intensive cardiac care unit (ICCU) were prospectively identified and divided into 5 groups according to extra-valvular cardiac damage [no extravalvular cardiac damage (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or right ventricular damage (Stage 4)]. Baseline characteristics and complete blood count including mean platelet volume (MPV) and immature platelet fraction (IPF) were collected within 2 h after the procedure and analyzed in relation to aortic stenosis staging. Results A total of 220 patients were included. The mean age was 81 years old and 112 (50.9%) were female. Two (1%) patients were classified in stage 0; 34 (15%) in stage 1; 48 (22%) in stage 2; 49 (22%) in stage 3 and 87 (40%) in stage 4. Higher mean MPV values were correlated with higher AS staging (10.8 fL, 11 fL, 11.3 fL and 10.8 fL in stages 1, 2, 3 and 4, respectively, P = 0.02) as well as lower hemoglobin values (12 mg/dl, 11.6 mg/dl, 11 mg/dl and 11.3 mg/dl in stages 1, 2, 3 and 4, respectively P = 0.04). Mean IPF values were 5.3%, 5.58%, 5.57% and 4.83% in stage 1, 2, 3 and 4, respectively (P = 0.4). In a multivariate logistic regression model only MPV (OR = 2.6, P = 0.03) and body mass index (BMI) (OR = 1.17, P = 0.004) were correlated with higher staging (0–3) of AS. Conclusions Although IPF and MPV levels increased in stages 0–3, there was a decrease in indices in stage 4, (probably due to bone marrow dysfunction) in this end-stage population. Higher levels of MPV and lower levels of hemoglobin were independently correlated with higher stages (0–3) of AS.

The ageing global population puts heavy pressure on healthcare systems everywhere. Addressing ageing-related chronic conditions requires employment of novel innovative solutions. Telehealth technologies, including telepresence robots (TPRs), are being rapidly developed to provide healthcare services efficiently wherever needed. This article explores the role of TPRs in addressing the challenges of providing healthcare to an ageing population, emphasizing their potential advantages and drawbacks. Employing an exploratory research approach with qualitative data collection techniques, we tested three TPR usage scenarios in simulated healthcare settings: anamnesis, measurements, and falls and frailty. The study employed a non-random purposive sample comprising 25 participants, and was conducted at a medical facility in June 2023. The findings suggest that TPRs offer promising solutions for healthcare professionals and patients, especially in scenarios when physical presence is impossible or physical isolation is required to prevent contagion. However, the technology is not yet ready to substitute fully human medical workers, potentially causing patient reluctance and emphasizing the need for patient-centered approaches to technology adoption. In addition, more studies are needed to address ethical, privacy, and scalability concerns.

Abstract Introduction Out of hospital cardiac arrest (OHCA) is a major public health problem with substantial mortality rates worldwide. Genetic diseases and primary electrical disorders are the most common etiologies at younger ages, while ischemic heart disease and cardiomyopathies are common causes at older ages. Despite improvement in prevention and treatment in recent years, OHCA is still a major cause of cardiovascular death. Method We report prospective data regarding etiology, characteristics, clinical course, and outcomes of patients with OHCA who were admitted to a tertiary care center intensive cardiac care unit (ICCU) between 2020–2023. Results A total of 92 patients admitted after OHCA were included in the cohort. Mean age was 63.8 ± 13.8 years and 75 (82%) were males. The most common etiology of OHCA was acute coronary syndrome (ACS) in 54 (59%) patients, of whom 46 (85%) patients had ST elevation myocardial infarction and 8 (15%) had non-ST elevation myocardial infarction. During hospitalization, 42 (46%) patients underwent targeted temperature management and 13 (14%) received mechanical circulatory support. Interestingly, 77 (84%) patients underwent coronary angiography, while only 51 (55%) received percutaneous coronary intervention (PCI). Neurologic status was favorable in 49 (53%) patients with Cerebral Performance Category score of 1–2. Overall, mortality rates were relatively low, with 15 (16%) in-hospital deaths and 24 (26%) deaths at 30-day follow-up. Conclusion Although ACS was the most common etiology for OHCA, only 55% of patients underwent PCI. Most OHCA patients admitted to the ICCU survived hospitalization and were discharged. Increased awareness, public education, worldwide registries, and specific evidence-based guidelines for the treatment of OHCA patients may lead to improved outcomes for these patients who often carry poor prognoses.

The paper presents a study of library and information science students’ perceptions and experiences related to the use of telepresence robots (TPRs) in libraries, with a specific focus on students assuming the role of library consultants. The study explores the innovative application of TPRs, such as Double, Ohmni and Temi, within library settings. The findings of the research reveal a positive perception of TPRs, emphasising their potential for fostering innovation, increasing engagement, providing flexibility and overcoming geographical constraints. The study also identifies distinct advantages of TPRs, including remote accessibility, enhanced communication, flexibility, a personalised user experience and cost savings. However, concurrent challenges, such as limitations in nonverbal communication, pointing accuracy, connectivity issues, space requirements, costs, safety, security concerns and varying levels of user acceptance emerge as crucial areas for refinement. While the results may not be generalisable due to the limited sample size, the study underscores the transformative potential of TPRs in libraries and the necessity of addressing these challenges to optimise their application. Further research, technological advancements and user feedback can help refine and optimise the use of TPRs in libraries to provide innovative and accessible assistance.

Efrat Neter,1 Efrat Esterkin-Hubner,2 Lea Glass-Marmor,2 Anat Wolkowitz,2 Idit Lavi3 ,† Ariel Miller2,4 1Ruppin Academic Center, Emeq Hefer, Israel; 2Multiple Sclerosis Center & Department of Neurology,Carmel Medical Center, Haifa, Israel; 3Department of Community Medicine & Epidemiology, Carmel Medical Center, Haifa, Israel; 4Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel†Idit Lavi passed away on 31.7.2022Correspondence: Efrat Neter, Ruppin Academic Center, 3 Bait, Emeq Hefer, 4025000, Israel, Tel +972-54-6462677, Fax +972-9-8983043, Email neter@ruppin.ac.il; neter@ruppin.ac.ilPurpose: To evaluate the acceptability, retention, and efficacy of face-to-face intervention, incorporating education and Motivational Interviewing (MI) to support persons with relapsing-remitting multiple sclerosis (PwRRMS) and increase self-reported medication adherence.Patients and Methods: PwRRMS (N = 60) prescribed Disease Modifying Treatment (DMT), who were identified as non-adherent and consented to participate in an intervention, received verbal education and counseling from their treating physician, a tailored MI counseling and a booster session via telephone with a health psychologist, and a concluding MI counseling six months later. Each PwRRMS filled a battery of patient-reported outcomes (PROs) at baseline, six and 12 months later. The design was a quasi-experimental pre-test post-test across a year.Results: Of the sixty identified persons who consented to enroll, 52 completed the intervention and 46 completed the follow-up. At six months following the baseline, adherence scores increased (median = 12.0) and were significantly different than at baseline (median=10.0, p = 0.030). Still, at 12 months follow-up there was no significant difference from baseline in reported adherence (median = 11.0, p = 0.106).Conclusion: This study demonstrated reasonable retention and initial efficacy of a combined psycho-education and MI protocol for PwRRMS to enhance medication adherence to DMT. To maintain the change, a more sustained intervention is required.Plain Language Summary: The study focused on persons with relapsing-remitting multiple sclerosis (PwRRMS) who do not adhere to their prescribed medication.Following the identification of non-adherent persons, PwRRMS were offered an intervention to increase their adherence. The study examined how many of those identified consented to enroll in the intervention, how many remained in the intervention, and whether the intervention was efficacious in terms of self-reported adherence.The intervention included verbal education and counseling from the treating physician, immediately followed by tailored counseling by a psychologist. There was a booster session via telephone with the psychologist, and a concluding counseling meeting six months later. Participants were followed for a year after the initial counseling.Two-thirds of PWMS identified as non-adherent consented to enroll (n = 60), 52 completed the intervention and 46 completed the follow-up. At six months following counseling, self-reported adherence scores significantly increased, but at 12 months follow-up there was no significant difference from baseline in reported adherence. To maintain the change, a more sustained intervention is required.Keywords: disease modifying therapy, medication adherence, medication beliefs, motivational interviewing, multiple sclerosis, participatory medicine, patient reported outcomes

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Abstract Background Treatment of Mycobacterium avium complex pulmonary disease (MAC-PD) involves prolonged courses of multiple antibiotics that are variably tolerated and commonly cause adverse drug reactions (ADR). The purpose of this retrospective, single-center study was to identify demographic and disease-related variables associated with significant ADRs among patients treated with antibiotics against MAC-PD. Methods We reviewed all patients treated with antibiotic therapy for MAC-PD at a single center from 2000 to 2021. Patients were included if they met diagnostic criteria for MAC-PD, were prescribed targeted antibiotic therapy for any length of time and had their treatment course documented in their health record. We compared patients who completed antibiotics as originally prescribed (tolerant) with those whose antibiotic treatment course was modified or terminated secondary to an ADR (intolerant). Results Over the study period, 235 patients were prescribed antibiotic treatment with their clinical course documented in our center’s electronic health record, and 246 treatment courses were analyzed. One hundred forty-three (57%) tolerated therapy versus 108 (43%) experienced ADRs. Among the 108 intolerant courses, 67 (63%) required treatment modification and 49 (46%) required premature treatment termination. Treatment intolerance was associated more frequently with smear positive sputum cultures (34% vs. 20%, p = 0.009), a higher Charlson Comorbidity Index (CCI) (4 vs. 6, p = 0.007), and existing liver disease (7% vs. 1%, p = 0.03). There was no between-group difference in BMI (21 vs. 22), fibrocavitary disease (24 vs. 19%), or macrolide sensitivity (94 vs. 80%). The use of daily therapy was not associated with intolerance (77 vs. 79%). Intolerant patients were more likely to be culture positive after 6 months of treatment (44 vs. 25%). Conclusions Patients prescribed antibiotic therapy for MAC-PD are more likely to experience ADRs if they have smear positive sputum cultures at diagnosis, a higher CCI, or existing liver disease. Our study’s rate of early treatment cessation due to ADR’s was similar to that of other studies (20%) but is the first of its kind to evaluate patient and disease factors associated with ADR’s. A systematic approach to classifying and addressing ADRs for patients undergoing treatment for MAC-PD is an area for further investigation.

This study aims to determine whether financial performance is persistent in serial entrepreneurship and, if so, whether good performance is more persistent than bad. It is novel as studies focusing on financial performance in successive firms ran by serial entrepreneurs are scarce. The paper creates a multi-theoretical framework from which four hypotheses are drawn. These focus on the persistence of firm size, export intensity, financial risk level, and payment defaults in serial entrepreneurship, all of which have been rarely utilized in such research. The validation of hypotheses is conducted by using ordinary least squares regression with a sample of 1599 Estonian serial entrepreneurs, being further divided into those with earlier good or bad performance. The dependent and independent variables, supplemented by various controls, portray the four performance measures in serial entrepreneurs' new and old firms. The regression analyses show that financial performance persists in serial entrepreneurship in general. Good performance is more persistent than bad, indicating inter-firm transfer of financial success. In most cases, bad performance is not persistent at all, indicating that some serial entrepreneurs repeat their earlier poor results, while others improve their future performance.

Abstract. Objectives:. Determine the relevance of the most frequently used patient-reported outcome measures (PROMs) for monitoring patient recovery after ankle fracture, from the clinical perspective of orthopaedic trauma surgeons, given lack of validated PROMs. Design:. Prospective cohort. Setting:. Orthopaedic Trauma Association committee meetings, electronic correspondence. Patients/Participants:. Orthopaedic trauma surgeons. Intervention:. Delphi method for consensus activities. Level of Evidence:. IV. Main Outcome Measurements:. Most clinically relevant PROMs for ankle fracture recovery. Results:. Several English-language PROMs were identified based on use in literature and relevance to ankle fractures. 7 were selected by expert consensus. These are the Ankle Fracture Outcome of Rehabilitation Measure (A-FORM), Foot and Ankle Ability Measure (FAAM), American Academy of Orthopaedic Surgeons (AAOS), Foot and Ankle Disability Index (FADI) Score, Lower Extremity Functional Scale (LEFS), Olerud–Molander Ankle Score (OMAS), and Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF). The most clinically relevant PROM is the A-FORM, followed by the AAOS, LEFS, PROMIS PF, FADI, and OMAS, and the least clinically relevant overall, the FAAM. Conclusions:. Understanding which PROM best matches physician expectations for tracking recovery is an important step toward a robust, evidence-based approach to patient care. The A-FORM was identified as the most clinically relevant among the most used PROMs. These results will aid surgeons, clinicians, and scientists to identify a uniformly, clinically relevant PROM for the treatment and study of outcomes and recovery after isolated ankle fracture.

ABSTRACTThis article provides structure to developing, implementing, and evaluating a successful coaching program that effectively meets the needs of learners. We highlight the benefits of coaching in medical education and recognize that many educators desiring to build coaching programs seek resources to guide this process. We align 12 tips with Kern’s Six Steps for Curriculum Development and integrate theoretical frameworks from the literature to inform the process. Our tips include defining the reasons a coaching program is needed, learning from existing programs and prior literature, conducting a needs assessment of key stakeholders, identifying and obtaining resources, developing program goals, objectives, and approach, identifying coaching tools, recruiting and training coaches, orienting learners, and evaluating program outcomes for continuous program improvement. These tips can serve as a framework for initial program development as well as iterative program improvement.

BACKGROUND: Despite many patients undergoing carotid endarterectomy (CEA) being on dual antiplatelet therapy (DAPT) for cardiac or neurologic indications, the impact of such therapy on perioperative outcomes remains unclear. We aim to compare rates of postoperative bleeding, stroke and major adverse events (stroke, death or MI) among patients on Aspirin alone (ASAA) versus DAPT (Clopidogrel and Aspirin). METHODS: Patients undergoing CEA for carotid artery stenosis between 2010 and 2021 in the Vascular Quality Initiative (VQI) were included. We excluded patients undergoing concomitant or re-do operations or patients with missing antiplatelet information. Propensity score matching was performed between the 2 groups ASAA and DAPT based on age, sex, race, presenting symptoms, major comorbidities [hypertension, diabetes and coronary artery disease (CAD)], degree of ipsilateral stenosis, presence of contralateral occlusion, as well as preoperative medications. Intergroup differences between the treatment groups and differences in perioperative outcomes were tested with the McNemars test for categorical variables and paired t-test or Wilcoxon matched-pairs signed-rank test for continuous variables where appropriate. Relative risks with 95% confidence intervals were estimated as the ratio of the probability of the outcome event in the patients treated within each treatment group. RESULTS: A total of 125,469 patients were included [ASAA n = 82,920 (66%) and DAPT n = 42,549 (34%)]. Patients on DAPT were more likely to be symptomatic, had higher rates of CAD, prior percutaneous coronary intervention or coronary artery bypass grafting, and higher rates of diabetes. After propensity score matching, the DAPT group had an increased rate of bleeding complications (RR: 1.6: 1.4-1.8, P

IntroductionAn increasing number of fellowship-trained orthopaedic trauma surgeons are working in non-Level I centers. This study aimed to examine trends of management of complex orthopaedic trauma in Level I centers versus non-Level I centers and its potential effect on patient outcomes.MethodsData from the National Trauma Data Bank from 2008 to 2017 were analyzed. Non-Level I to Level I center ratios for complex fractures and complication rates, median hours to procedure for time-sensitive fractures, and uninsured/underinsured rates of Level I and non-Level I centers were recorded.ResultsThree hundred one thousand patients were included. A statistically significant downward trend was identified in the percent of all complex orthopaedic trauma at Level I centers and per-hospital likelihood of seeing a complex orthopaedic fracture in a Level I versus non-Level I hospital. Per-hospital complication rates were consistently lower in non-Level I hospitals after controlling for injury severity and payer mix. Time-sensitive fractures were treated earlier in non-Level I centers.DiscussionThis study demonstrates a reduction of complex trauma treatment in Level I centers that did not translate to adverse effects on patient outcomes. Policymakers should notice this trend to ensure the continued quality of orthopaedic trauma training and maintenance of expertise in complex fracture management.

BACKGROUND: The classification of fractures is necessary to ensure a reliable means of communication for clinical interaction, education and research. The Neer classification is the most commonly used classification for proximal humerus fractures. In 2018 the Orthopedic Trauma Association (OTA) and the AO Foundation provided an update to the OTA/AO Fracture Classification Scheme addressing many of the concerns about the previous versions of the classification. The objective of the present study was to evaluate the rater reliability of the 2 classifications and if the classifications subjectively better characterized the fracture patterns. METHODS: X-rays and CT scans of 24 proximal humerus fractures were given to 7 independent raters for classification according to the Neer and 2018 OTA/AO classification. Both full-forms and short-forms of the classifications were tested. The Fleiss Kappa statistic was used to assess inter-rater agreement and intra-rater consistency for the 2 classifications. For each case the raters subjectively commented on how well each classification was able to characterize the fracture pattern. RESULTS: All raters graded the 2018 OTA/AO classification as good as or better than the Neer classification for an adequate description of the fracture patterns. The short-form 2018 OTA/AO classification had the most 4 rater and 5 rater agreement cases and the second most 6 rater agreement cases. The short-form Neer classification had the second most 4 rater and 5 rater agreement cases and the most 6 rater agreement cases. The full 2018 OTA/AO had the least 4, 5, or 6 rater agreement cases of all the classification systems. Inter-rater agreement was fair for the full and short form of both the Neer and 2018 OTA/AO classification. The full and short Neer classifications together with the short 2018 OTA/AO classification had moderate intra-rater consistency, while the full 2018 OTA/AO classification only had slight intra-rater consistency. CONCLUSIONS: The 2018 OTA/AO classification is equivalent in its short-form to the Neer classification in inter-rater reliability and intra-rater consistency; and is superior in its full form for characterizing specific fracture types. The low inter-rater reliability of the full 2018 OTA/AO classification is a concern that may need to be addressed in the future.