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Clinicians have a sincere desire to ensure that the decision-making processes of seriously ill patients are well informed throughout illness trajectories. A quagmire of variable terminology (e.g., advance care planning, serious illness conversations, goals-of-care discussions, etc.), however, currently predominates the field of serious illness communication. This creates uncertainty among clinicians as to the overall purpose, tasks, and specific outcomes of conversations that address serious illness. The Preparing or Deciding model is a unifying framework that provides conceptual clarity by helping clinicians understand their role in leading these important conversations. The Preparing or Deciding model simply posits that conversations with seriously ill patients are about either preparing or deciding. It considers these tasks to be mutually exclusive, which can help bypass many of the barriers to having these conversations. The Preparing or Deciding model compliments all existing resources and frameworks and is applicable to all healthcare practitioners in every care setting. To help move forward serious illness communication education and research, as well as process improvement efforts more effectively, here, we describe the Preparing or Deciding model.

Abstract Background Understanding the characteristics of pulmonary resistance and elastance in relation to the location of airway narrowing, e.g., tracheal stenosis vs. intrapulmonary airway obstruction, will help us understand lung function characteristics and mechanisms related to different airway diseases. Methods In this study, we used ex vivo sheep lungs as a model to measure lung resistance and elastance across a range of transpulmonary pressures (5–30 cmH2O) and ventilation frequencies (0.125–2 Hz). We established two tracheal stenosis models by inserting plastic tubes into the tracheas, representing mild (71.8% lumen area reduction) and severe (92.1%) obstructions. For intrapulmonary airway obstruction, we induced airway narrowing by challenging the lung with acetylcholine (ACh). Results We found a pattern change in the lung resistance and apparent lung elastance as functions of ventilation frequency that depended on the transpulmonary pressure (or lung volume). At a transpulmonary pressure of 10 cmH2O, lung resistance increased with ventilation frequency in severe tracheal stenosis, whereas in ACh-induced airway narrowing the opposite occurred. Furthermore, apparent lung elastance at 10 cmH2O decreased with increasing ventilation frequency in severe tracheal stenosis whereas in ACh-induced airway narrowing the opposite occurred. Flow-volume analysis revealed that the flow amplitude was much sensitive to ventilation frequency in tracheal stenosis than it was in ACh induced airway constriction. Conclusions Results from this study suggest that lung resistance and apparent elastance measured at 10 cmH2O over the frequency range of 0.125-2 Hz can differentiate tracheal stenosis vs. intrapulmonary airway narrowing in ex vivo sheep lungs.

Background/Objective: Non–islet cell tumor hypoglycemia (NICTH) is an uncommon condition, of which only a few cases caused by malignant phyllodes tumor of the breast have been reported. We describe a case of NICTH secondary to malignant phyllodes tumor with good response to glucocorticoid therapy. Case Report: A 62-year-old woman with a rapidly enlarging left breast mass presented with drowsiness and a capillary blood glucose level of 32.4 mg/dL. Her plasma glucose and insulin levels were 36.0 mg/dL (reference range, 72-144 mg/dL) and 0.6 mIU/L (reference range, 0.0-25.0 mIU/L), respectively. Her beta-hydroxybutyrate and c-peptide levels were undetectable. The insulin-like growth factor (IGF)-I and IGF-II levels were 37 μg/L (reference range, 43-220 μg/L) and 1062 ng/mL (reference range, 333-967 ng/mL), respectively, with an IGF-II:IGF-I molar ratio of 29.4. Prednisolone 30 mg per day was initiated with improvement in hypoglycemia. Outpatient flash glucose monitoring profile was stable with mild hypoglycemia (glucose level, 54-68.5 mg/dL) detected 5% of the time. The patient underwent left mastectomy with axillary clearance 4 weeks later. Histology was reported as malignant phyllodes tumor with extensive ductal carcinoma in situ. Prednisolone was stopped after surgery. The patient was treated with letrozole and adjuvant radiotherapy. There was no recurrence of hypoglycemia during the subsequent 24-month follow-up. Discussion: The mainstay of treatment for NICTH is surgical resection of the culprit tumor. Although glucocorticoid treatment has also been widely used for NICTH, few reports have demonstrated efficacy for NICTH secondary to phyllodes tumor. Conclusion: We report a rare case of malignant phyllodes tumor of the breast resulting in NICTH and demonstrated good response to glucocorticoids as a bridge to definitive surgery.

Abstract Natural products encompass a diverse range of compounds with high impact applications in consumer care, agriculture and most notably, therapeutics. However, despite the expansive chemical repertoire indicated in genomic information of microbes, only a small subset can be obtained under laboratory conditions. To increase accessible chemical space and realize Nature’s full chemical potential, a multi-pronged genetic- and cultivation-based strategy has been employed to activate and upregulate natural product biosyntheses in native and heterologous strains. This data descriptor documents a characterized collection of 2,138 liquid chromatography-tandem mass spectrometry (LC/MS-MS) spectra of fermentation extracts from 54 native actinobacterial strains collected from soil and marine environments in Singapore, and their 459 activated mutants in 3 to 5 media. A total of 743 unique metabolites have been identified, with the activated mutants demonstrating an approximately 2-fold expansion in accessible chemical space over wild type strains. Interrogating this expanded chemical diversity with cheminformatic tools can provide direction for the discovery of novel natural products with desirable functional activity.

Purpose: The purpose of this study is to investigate students' attitudes, self-efficacy and emotional behaviour associated with online learning and the effectiveness of online learning. Design/methodology/approach: A research model was formulated and analysed with the structural equation modelling technique. The respondents consist of 843 students pursuing their studies at a private university's foundation, undergraduate and postgraduate levels. A two-step systematic approach was used using the SmartPLS version 3 software to conduct statistical analysis and draw meaningful insights. Findings: The study's findings have demonstrated that students' attitudes and self-efficacy exhibit a positive relationship with online learning behaviour (OLB). It is observed that the students' emotions are related to online learning effectiveness (OLE) and mediate the relationship between OLB and OLE. Furthermore, OLB partially mediates the relationship between attitude and OLE and between self-efficacy and OLE. Research limitations/implications: The operational instructions and digital resources have proven to be highly effective in providing valuable learning experiences to the students. As a result, the students are now expanding and applying their new encounters to a broader range of learning opportunities. This study has provided valuable insights for stakeholders, including scholars, higher education institutions and the Ministry of Higher Education, in providing the ideas of online learning or Web-based education. Originality/value: The originality of this study sheds light on the role of OLB as a mediator. It was underlined that emotion is critical in improving students' OLE. Thus, students' attitudes and self-efficacy have been essential in reassuring OLB and enhancing OLE.

Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.

The optimal management of chronic kidney disease (CKD) requires lifestyle changes and adherence to long-term medications. Knowledge is a component of health literacy and is needed for self-management. Limited health literacy can lead to negative outcomes, such as adverse clinical events and mortality.1

Abstract Counterstereotypes challenge the deleterious effects that gender-typed beliefs exert on people’s occupational aspirations and lifestyle choices. Surprisingly, however, the critical issue of how readily unexpected person-related knowledge can be acquired remains poorly understood. Accordingly, in two experiments in which the facial appearance of targets was varied to manipulate goodness-of-stereotype-fit (i.e., high vs. low femininity/masculinity), here we used a probabilistic selection task to probe the rate at which counter-stereotypic and stereotypic individuals can be learned. Whether occupational (Expt. 1) or trait-related (Expt. 2) gender stereotypes were explored, a computational analysis yielded consistent results. Underscoring the potency of surprising information (i.e., facial misfits), knowledge acquisition was accelerated for unexpected compared to expected persons, both in counter-stereotypic and stereotypic learning contexts. These findings affirm predictive accounts of social perception and speak to the optimal characteristics of interventions designed to reduce stereotyping outside the laboratory.

Abstract The impact of age (≥ 85 vs 1 V) and persistence of His-Purkinje capture on follow-up. Among 984 patients (age 74.1 ± 11.2 years, 41% CSP, 16% ≥ 85 years), CSP was independently associated with reduced hazard of the primary endpoint compared to RVP, regardless of age-group ( 0.05). CSP improves clinical outcomes in all age-groups, without compromising procedural safety or pacemaker performance in the very elderly.

Abstract Background Klebsiella pneumoniae invasive syndrome (KPIS) is characterized by primary pyogenic liver abscess associated with metastatic infections. Although rare, Klebsiella endocarditis carries a high mortality risk. Case presentation A 60-year-old lady with type II diabetes mellitus presented with fever, malaise, right hypochondriac pain and vomiting for two weeks. Ultrasound abdomen revealed a collection within liver, and distended gallbladder with echogenic debris within. 3 days after ultrasound guided pigtail drainage of gallbladder empyema, newly presence murmur detected. Pus, urine, and blood cultures obtained were positive for Klebsiella pneumonia. Echocardiogram exhibited oscillating mass attached to anterior mitral valve leaflet. After 6 weeks of intravenous ceftriaxone, follow-up echocardiogram and ultrasound showed complete resolution of mitral valve vegetation, hepatic and gallbladder collection. Conclusion Concomitant extrahepatic infective endocarditis (IE) should raise concerns in daily practice for patients with Klebsiella pneumoniae liver abscesses, despite the rarity of Klebsiella endocarditis. In the absence of diagnostic suspicion, antibiotic treatment regimens may be shortened, and adverse effects from IE infection may ensue.

Financial threat refers to fear, unease, and uncertainty regarding an individual’s present or forthcoming financial state. Despite consistent findings indicating that financial threats are harmful to individuals’ behaviors and mental health, their impacts remain largely unexplored in the context of organizational behaviors. This study examined whether and how financial threats are detrimental to various aspects of employees’ performance, including task, contextual, and counterproductive performance. A sample of 165 working adults in Malaysia responded to an online survey consisting of the Financial Threat Scale, Perceived Stress Scale, and Individual Work Performance Questionnaire. Confirmatory factor analysis supported the structure of the measurements, although some items were eliminated. Pearson correlation analysis showed that financial threats had a positive relationship with perceived stress and counterproductive performance. Meanwhile, perceived stress was negatively related to task performance and positively associated with counterproductive performance. Finally, structural equation modeling revealed that perceived stress mediates the relationship between financial threats and counterproductive performance. These findings illuminate the underlying mechanisms by which financial threats impact employees’ job performance. They also highlight the importance of addressing resource depletion’s effects on the mental health of working adults. The implications of these findings for organizational management and employee well-being are discussed.

Purpose We compared the incidence of venous thromboembolism (VTE) among Asian populations with localized colorectal cancer undergoing curative resection with and without the use of pharmacological thromboprophylaxis (PTP). Methods A comprehensive literature search was undertaken to identify relevant studies published from January 1, 1980 to February 28, 2022. The inclusion criteria were patients who underwent primary tumor resection for localized nonmetastatic colorectal cancer; an Asian population or studies conducted in an Asian country; randomized controlled trials, case-control studies, or cohort studies; and the incidence of symptomatic VTE, deep vein thrombosis, and/or pulmonary embolism as the primary study outcomes. Data were pooled using a random-effects model. This study was registered in PROSPERO on October 11, 2020 (No. CRD42020206793). Results Seven studies (2 randomized controlled trials and 5 observational cohort studies) were included, encompassing 5,302 patients. The overall incidence of VTE was 1.4%. The use of PTP did not significantly reduce overall VTE incidence: 1.1% (95% confidence interval [CI], 0%–3.1%) versus 1.9% (95% CI, 0.3%–4.4%; P=0.55). Similarly, PTP was not associated with significantly lower rates of symptomatic VTE, proximal deep vein thrombosis, or pulmonary embolism. Conclusion The benefit of PTP in reducing VTE incidence among Asian patients undergoing curative resection for localized colorectal cancer has not been clearly established. The decision to administer PTP should be evaluated on a case-by-case basis and with consideration of associated bleeding risks.

Purpose Prehabilitation (PH) is purported to improve patients’ preoperative functional status. This systematic review and meta-analysis sought to compare short-term postoperative outcomes between patients who underwent a protocolized PH program and the existing standard of care among colorectal cancer patients awaiting surgery. Methods A search in MEDLINE/PubMed, the Cochrane Library, Embase, Scopus, and CINAHL was conducted to identify relevant articles. Repetitive and exhaustive combinations of MeSH search terms (“prehabilitation,” “colorectal cancer,” “colon cancer,” and “rectal cancer”) were used to identify randomized and nonrandomized studies comparing PH versus standard of care for colorectal cancer patients awaiting surgery. The primary outcomes included postoperative morbidity, length of hospital stay, and readmission rates. Results Seven studies including 1,042 colorectal cancer patients (PH, 382) were included. No significant differences were found in intraoperative outcomes. The postoperative complication rates were comparable between groups (Clavien-Dindo grades I and II: risk ratio, 0.82; 95% confidence interval, 0.62–1.07; P=0.15; Clavien-Dindo grades ≥III: risk ratio, 1.02; 95% confidence interval, 0.72–1.44; P=0.92). There were also no significant differences in length of hospital stay (P=0.21) or the risk of 30-day readmission (P=0.68). Conclusion Although PH does not appear to improve short-term postoperative outcomes following colorectal cancer surgery, the quality of evidence is impaired by the limited trials and heterogeneity. Thus, further large-scale trials are warranted to draw definitive conclusions and establish the long-term effects of PH.

(1) Background: Pediatric intracranial aneurysms (PIA) are rare and clinicopathologically distinct neurovascular entities. The aims of this study are to evaluate our institution’s experience and corroborate our results with updated literature. (2) Methods: This is a single-institution, retrospective study. Patients with a confirmed diagnosis of PIA are included. Variables of interest include patient demographics, clinical presentation, treatment outcomes and features specific to each patient’s PIA. A literature review on PIA-centric clinical studies was conducted. (3) Results: A total of 14 PIAs in 11 patients were treated from 2000 to 2022. The mean age was 5.8 years old, and most were males (90.1%). Anterior circulation PIAs constituted 78.6% of the cohort. Half of the PIAs were of the dissecting type, and 14.3% were giant aneurysms. Of interest, 14.3% of patients had subsequent de novo aneurysms after treatment of their index aneurysm. For treatment, 57.1% underwent surgery, 35.7% had endovascular intervention and the remaining 7.1% were managed conservatively. Based on the literature review, this study had congruent findings to other existing publications. (4) Conclusions: PIAs are unique neurovascular lesions that have good outcomes if managed in a timely fashion by an experienced multidisciplinary team. We recommend longer surveillance periods due to the risk of developing de novo aneurysms.