Due to the rigor and pace of undergraduate medical anatomy courses, it is not uncommon for students to struggle and fail initially. However, repetition of coursework places an additional burden on the student, instructor, and institution. The purpose of this study was to compare the exam preparation strategies of repeating and non‐repeating students to identify areas where struggling students can be supported prior to course failure. As part of their integrated anatomy course, first‐year medical students at Indiana University completed a metacognitive Practice‐Based Learning and Improvement (PBLI) assignment prior to and after their first exam. In the PBLIs, students were asked to reflect on their exam preparation strategies, confidence, and satisfaction, as well as their predicted and actual exam performance. PBLI responses from non‐repeating and repeating students were then analyzed quantitatively and qualitatively. A total of 1802 medical students were included in this study, including 1751 non‐repeating and 51 repeating students. Based on their PBLI responses, non‐repeating students were appropriately confident, somewhat satisfied, and more accurate when predicting their exam performance. Repeating students were overconfident, dissatisfied, and inaccurate when predicting their first exam performance on their initial, unsuccessful attempt but were more successful on their second, repeat attempt. Qualitative analysis revealed that repeating students aimed to improve their studying by modifying their existing study strategies and managing their time more effectively. In conjunction with other known risk factors, these insights into repeater and non‐repeater exam preparation practices can help anatomy educators better identify and support potential struggling students.
Given a bounded planar domain with boundary, , and a weight , we show that the corresponding truncated Beurling operator is a bounded operator sending into itself. Weighted Sobolev estimates for other Cauchy‐type integrals are also obtained.
Purpose There are limited data examining the impact of both donor and recipient race on outcomes following orthotopic heart transplant (OHT). The purpose of this study was to evaluate the relationship between donor and recipient race and OHT outcomes. Methods The United Network for Organ Sharing (UNOS) database was retrospectively reviewed from January 2000 to March 2018 for donor hearts. A comparison was conducted based on donor and recipient race (White, Black, Hispanic, Other/Unknown). Races for which there were limited numbers were excluded from the analysis (Asian, n = 1292; American Indian, n = 132; Pacific Islander, n = 132, Multiple ethnicities, n = 225). The primary endpoint was survival at 30 days, 1 year survival, and post‐transplant rejection. Logistic and Cox models were used to quantify survival endpoints. Results A total of 41 841 OHT were included. Of the recipients, 29 894 (71%) were White, 8475 (20%) were Black, and 3472 (8%) were Hispanic. Of the donors 27 783 (66%) were White, 6277 (15%) were Black, 6576 (16%) were Hispanic, and 1205 (3%) were Unknown/Other race. In a comparison of recipient demographics, White recipients were older (54.09 ± 12.21 years) compared to Black (49.44 ± 12.83 years) and Hispanic (49.97 ± 13.27 years) recipients. All other differences between groups were not clinically significant. Black recipients were more likely to receive a heart with an “urgent” status (probability .80) compared to White (.73) and Hispanic (.75) recipients ( p < .001). Hispanic recipients were more likely to receive a transplant when listed as “non‐urgent” (Probability .47) compared to White (.37) and Black (.30) recipients ( p < .001). In terms of outcomes, compared to White recipients, Hispanic patients experienced a decreased 30‐day survival (OR 1.27; p = .011) and 1‐year survival (OR 1.17; p = .016). In comparing Donor/Recipient combinations compared to a White Donor/White Recipient combination, overall survival was decreased in White donor/African American recipient (HR 1.36; p < .001), African American donor/African American recipient (HR 1.41; p < .001) and Hispanic donor/African American recipient (HR 1.30; p < .001) combinations (Table 1). Conclusions African American and Hispanic recipients have decreased survival compared to White recipients after heart transplant. The African American donor does not decrease survival. Racial differences still exist in donor and recipient characteristics and recipient outcomes after OHT. Increasing the donor pool for all races and ethnicities would potentially benefit all recipients. Continued study is warranted in order to minimize these differences among recipients and identify factors that could be contributing to decreased survival, in order to optimize outcomes for African American and Hispanic recipients post‐transplant and eliminate disparities.
Purpose of review Heart transplant is the gold standard treatment for patients with end-stage heart failure, improving both quality of life and survival. Despite advances in donor and recipient management, primary graft dysfunction (PGD) remains the most common cause of morbidity and mortality in the early posttransplant period. This review summarizes recent discoveries in the underlying pathophysiology, risk prediction and management of PGD. Recent findings The incidence of PGD appears to be rising and it is not clear whether this is due to better recognition or secular changes in transplant practice. The utilization of donation after circulatory death organs for transplant is a further consideration for the development of PGD. Organ transport systems and preservation techniques may help to prevent PGD. As some of the risk factors for developing PGD remain modifiable, we summarize the current evidence for prevention and management of PGD. Summary A better understanding will allow us to appropriately manage donors and recipients to reduce the complex interactions that lead to PGD. The development of an international consortium provides the opportunity for deep phenotyping and development of contemporary risk prediction models for PGD, which may reduce the incidence and consequent early mortality associated with heart transplantation.
The new AACN Essentials: Core Competencies for Professional Nursing Education create an opportunity to nursing education to transform the educational preparation of our workforce with new standards for all member schools to implement into their academic programs as we prepare the future nursing workforce. With the advent of these updated academic standards, many nursing schools across the nation are reviewing program outcomes and transitioning from concepts to competencies. The purpose of the article is to describe the early phases of a quality improvement initiative to implement the new AACN Essentials within the undergraduate curriculum of a large school of nursing spanning multiple campuses. The article conveys lessons learned to help support and guide other schools of nursing.
Background: Recent evidence has demonstrated that transplantation of hearts with blood culture positive donors (BCPDs) to pediatric recipients is safe and effective. Few studies have analyzed the effect of BCPD on adult heart transplant recipients. Methods: The United Network for Organ Sharing (UNOS) database was retrospectively reviewed from September, 1987 to March, 2021. Exclusion criteria included pediatric donors/recipients, donor ejection fraction <10% or >85%, inactive listed recipients, donors missing blood cultures, and recipients missing follow-up time. Outcomes were compared with fully adjusted logistic models. To account for discrepancies in BCPD and non-BCPD covariates, an inverse proportionally weighted model with regression adjustment (IPWRA) was used. Results: A total of 60 592 donors were non-BCPD, while 4009 were BCPD. 7% of hearts not transplanted were BCPD, while 6% of hearts transplanted were BCPD (p = .001). These rates have been nearly constant since 2005. There were no differences in short term survival between the two groups in the adjusted or IPWRA models (p = .103 and .277, respectively). Additionally, the BCPD group had longer ischemic time (3.24 vs. 3.06 h, p < .001), older donor age (32.73 vs. 31.65 years, p < .001), and older recipient age (52.76 vs. 52.09 years, p = .001). The IPWRA revealed an average additional 3.4 years of overall survival and 2.25 years of graft function for BCPD versus non-BCPD recipients, although these results failed to reach statistical significance (p = .387 and .527, respectively). Conclusions: Given the need for more donor hearts, donors with positive blood cultures should be considered. Great care in evaluating such patients is advised to eliminate donors with untreated infections, while carefully selected donors can be considered and used.
The COVID-19 pandemic transformed many aspects of health and daily life. A subset of people who were infected with the virus have ongoing chronic health issues that range in type of symptom and severity. In this study, we conducted a qualitative assessment of self-reported post-COVID symptoms from patients' electronic health records (EHR, n=564) and a randomized collection of Reddit and Twitter posts (n=500 for each). We show the inconsistencies in what types of symptoms are shared between platforms in addition to assessing the severity of the symptoms and how social media characterizations of post-COVID do not tell a complete story of this phenomenon. This research contributes to CSCW health literature by connecting digital traces of post-COVID with EHR data, critiquing the use of social media as a health proxy and points to its potential to add context to the analysis of traditional health data extracted from the EHR.
The freedom‐from oppression model is an integrative conceptual and practical framework for addressing the deleterious impact of oppression on clients. Applying multiculturally grounded counseling strategies as well as various techniques across three existential‐humanistic stages and 12 cognitive intervention steps, the proposed model supports counselor and client discovery of psychological freedom‐from oppression.
Objectives: There is limited data examining donor vasopressor and/or inotrope medications (vasoactives) on pediatric orthotopic heart transplant (OHT) outcomes. We aim to evaluate the effects of vasoactives on pediatric OHT outcomes. Methods: The United Network for Organ Sharing database was retrospectively reviewed from January 2000 to March 2018 for donor hearts. Exclusion criteria included multiorgan transplants and recipient age >18. Donors receiving vasoactives at the time of procurement were compared to donors not on vasoactives, including the number of vasoactives and the type. End-points of interest were survival at 30 days and 1 year as well as post-transplant rejection at 1 year. Logistic and Cox models were used to quantify survival end-points. Results: Of 6462 donors, 3187 (49.3%) were receiving at least one vasoactive. Comparing any vasoactive medication versus none, there was no difference in 30-day survival (p = .27), 1 year survival (p = .89), overall survival (p = .68), or post-transplant rejection (p = .98). There was no difference in 30-day survival for donors receiving 2 or more vasoactive infusions (p = .89), 1 year survival (p = .53), overall survival (p = .75), or post-transplant rejection at 1 year (p = .87). Vasopressin was associated with decreased 30-day mortality (OR = 0.22; p = .028), dobutamine with decreased 1-year mortality (OR = 0.37; p = .036), overall survival (HR = 0.51; p = .003), and decreased post-transplant rejection (HR = 0.63; p = .012). Conclusions: There is no difference in pediatric OHT outcomes when the cardiac donor is treated with vasoactive infusions at procurement. Vasopressin and dobutamine were associated with improved outcomes. This information can be used to guide medical management and donor selection.
Objectives: Due to an increasing incidence of new cancer diagnoses in the United States and longer survivorship, a growing number of patients with cancer receive care in emergency departments (EDs). This trend places an increasing burden on already crowded EDs, and experts are concerned these patients do not receive optimal care. The purpose of this study is to describe the experiences of ED physicians and nurses who care for patients with cancer. This information can inform strategies to improve oncology care for patients in ED settings. Methods: We used a qualitative descriptive design to summarize to the experiences of ED physicians and nurses (n=23) caring for patients with cancer. We conducted individual, semi-structured interviews to query participants about their perspectives on care for oncology patients in the ED. Results: Physician and nurse participants identified 11 challenges and suggested 3 potential strategies to improve care. The challenges included the following: risk of infection, poor communication between ED staff and other providers, poor communication between oncology or primary care providers and patients, poor communication between ED providers and patients, difficult disposition decisions, new cancer diagnoses, complex pain management, allocation of limited resources, lack of cancer-specific skills among providers, poor care coordination, and evolving end-of-life decisions. The solutions included the following: patient education, education for ED providers, and improved care coordination. Conclusions: Physicians and nurses experience challenges stemming from three overarching types of factors: illness factors, communication factors, and system-level factors. Solutions for the challenges of providing oncology care in the ED call for new strategies at the levels of the patient, provider, institution, and healthcare system.
EXECUTIVE SUMMARY. The work of the 2021-2022 AACP Research and Graduate Affairs Committee (RGAC) focused on barriers to graduate education and research-related careers in pharmacy education. AACP President Stuart Haines charged the RGAC with identifying the critical barriers that hinder current PharmD students/recent graduates as well as under-represented groups (e.g., Black and Latino) from pursuing advanced degrees and research-related career paths in the pharmaceutical, social & behavioral, and clinical sciences and recommending changes that might address these barriers - this may include recommendations to change the fundamental structure of graduate education.The committee began its work with a literature review to survey current perspectives on these barriers and assess the supporting evidence for effective solutions and programs, including their relevance to pharmacy education. Based on the review, the committee was able to identify numerous obstacles to entry into and progression through research training, for both underrepresented learners and student pharmacists. Obstacles are individual, e.g., lack of exposure to and self-efficacy in research, financial constraints, structural, e.g., lengthy training time, programmatic rigidity, and institutional, e.g., implicit and explicit bias. The committee found evidence of effective approaches and programs to address these barriers that could be applied in pharmacy schools. These approaches include improvements to existing practices in recruitment, admissions and hiring practices as well as creation of new programs and structural changes to existing programs to increase accessibility to learners. The committee also recognized a need for more research and development of additional approaches to address these barriers.The committee makes a series of recommendations that AACP develop resource guides and programs to address key issues in the recruitment and retention of underrepresented students and student pharmacists into graduate education and research careers, including as faculty. The committee also proposes new AACP policies to support innovative graduate programs and early, longitudinal engagement of learners from elementary school onward to increase access to graduate education and to support environments and cultures of commitment to accessibility, diversity, equity, inclusiveness, antiracism in pharmacy education.
Traxoprodil is a selective N-methyl-d-aspartate receptor subunit 2B (NR2B) receptor inhibitor with rapid and long-lasting antidepressant effects. However, the appropriate dosage, duration of administration, and underlying mechanism of traxoprodil’s antidepressant effects remain unclear. The purpose of this study is to compare the antidepressant effects of traxoprodil in different doses and different durations of administration and to explore whether traxoprodil exerts antidepressant effects via the brain-derived neurotrophic factor/extracellular signal-regulated kinase/cAMP-response element binding protein (BDNF/ERK/CREB) and protein kinase B/Forkhead box O/building information modelling (AKT/FOXO/Bim) signaling pathway. Mice were randomly divided into control group, chronic unpredictable mild stress (CUMS) + vehicle group, CUMS + traxoprodil (10 mg/kg, 20 mg/kg, and 40 mg/kg) groups, and CUMS + fluoxetine (5 mg/kg) group, followed by a forced swimming test, tail suspension test, and sucrose preference test. Western blotting and immunohistochemistry were used to measure the protein expression of BDNF, p-ERK1/2, p-CREB, NR2B, AKT, FOXO1, FOXO3a, and Bim. Compared with the control group, CUMS treatment increased immobility time; decreased sucrose preference; reduced expression of BDNF, p-ERK1/2, and p-CREB; and increased expression of AKT, FOXO, and Bim in the hippocampus. These alterations were ameliorated by administration of 20 mg/kg or 40 mg/kg of traxoprodil after 7 or 14 days of administration and with 10 mg/kg of traxoprodil or 5 mg/kg of fluoxetine after 21 days of administration. At the 7-day and 14-day timepoints, traxoprodil displayed dose-dependent antidepressant effects, with 20 and 40 mg/kg doses of traxoprodil producing rapid and strong antidepressant effects. However, at 21 days of administration, 10 and 20 mg/kg doses of traxoprodil exerted more pronounced antidepressant effects. The mechanism of traxoprodil’s antidepressant effects may be closely related to the BDNF/ERK/CREB and AKT/FOXO/Bim signaling pathway.
Background: Cancer is the leading cause of death for Hispanics in the USA. Screening and prevention reduce cancer morbidity and mortality. Methods: This study administered a cross-sectional web-based survey to self-identified Hispanic residents in the state of Indiana to assess their cancer-related knowledge, beliefs, and behaviors, as well as to identify what factors might be associated with cancer screening and prevention. Chi-square and Fisher's exact test were used to compare associations and logistic regression used to develop both univariate and multivariate regression models. Results: A total of 1520 surveys were completed, median age of respondents was 53, 52% identified as men, 50.9% completed the survey in Spanish, and 60.4% identified the USA as their country of birth. Most were not able to accurately identify ages to begin screening for breast, colorectal, or lung cancer, and there were significant differences in cancer knowledge by education level. US-born individuals with higher income and education more often believed they were likely to develop cancer and worry about getting cancer. Sixty eight percent of respondents were up-to-date with colorectal, 44% with breast, and 61% with cervical cancer screening. Multivariate models showed that higher education, lack of fatalism, older age, lower household income, and unmarried status were associated with cervical cancer screening adherence. Conclusions: Among a Hispanic population in the state of Indiana, factors associated with cervical cancer screening adherence were similar to the general population, with the exceptions of income and marital status. Younger Hispanic individuals were more likely to be adherent with breast and colorectal cancer screening, and given the higher incidence of cancer among older individuals, these results should guide future research and targeted outreach.
Purpose: The purpose was to evaluate the effects of the most commonly used cardiac donor inotropes/vasopressors on subsequent post-heart transplant survival. Methods: Adult heart transplant recipients from January 2000-June 2022 were identified in the United Network for Organ Sharing (UNOS) database. Exclusion criteria included: multiorgan transplants, donor age < 15, and recipient age < 18. Donors receiving vasoactive medications at the time of procurement were compared to donors not receiving these medications. Those on vasoactive medications were stratified by medication: phenylephrine, dopamine, dobutamine, norepinephrine and epinephrine, the combination of these agents, and the concomitant administration of vasopressin with any single agent alone or in combination. The primary area of interest was short and long term survival. Survival at 30 days, 1 year, and long-term (Median = 13.6 yrs) was compared using logistic and Cox models to quantify survival endpoints. Results: A total of 45,198 donors met inclusion criteria and had data on the use of vasoactive agents available. Mean donor age was 32.3 years with 71% male. Vasoactive medications and potential combinations included phenylephrine in 8,156 donors (18.0%), dopamine in 9,550 (21.1%), dobutamine in 718 (1.6%), epinephrine in 332 (0.73%), and norepinephrine in 4,854 (10.7%). A total of 25,856 donors (57.2%) were receiving vasopressin at the time of procurement. There was no impact of donor inotropes on 30 day survival. Donors receiving 1 inotrope and no vasopressin were associated with increased 1 year mortality (OR 1.14; p = 0.021), as were donors recieving 2+ inotropes and no vasopressin (OR 1.26; p = 0.006). For individual agents, 1 year mortality was increased for dopamine (OR 1.11; p = 0.042) and epinephrine (OR 1.59; p = 0.004). Conclusions: There is no difference in heart transplant recipient survival at 30 days when the donor is receiving inotropes without vasopressin at the time of procurement. Inotropic support without vasopressin is associated with greater 1 year mortality. The impact of donor inotropic support on long term heart transplant survival, and the interaction with vasopressin warrants further study. This article is protected by copyright. All rights reserved.
Background Synchronized diaphragmatic stimulation (SDS) produces localized contractions of the diaphragm gated to the cardiac cycle to transiently modulate intrathoracic pressures, thereby impacting cardiac function for heart failure patients with reduced ejection fraction (HFrEF). This study prospectively evaluated the safety and 1-year effectiveness of SDS in an expanded first-in-patient cohort using multiple implant methods. Methods Symptomatic patients with HFrEF despite guideline-directed therapy were enrolled. Patients were evaluated at 3, 6 and 12 months for adverse events, quality of life (SF-36 QOL), echocardiography and 6-minute hall walk distance. The SDS system consists of 2 bipolar, active-fixation leads, and an implantable pulse generator. Results Nineteen men were enrolled (age 63 [57, 67] years, New York Heart Association class II [53%]/III [47%], N-terminal pro B-type natriuretic peptide 1779 [886, 2309] pg/mL, left ventricular ejection fraction 27 [23, 33] %). Three implant techniques (abdominal laparoscopy: sensing and stimulating leads on the inferior diaphragm (n = 15); subxiphoid access for an epicardial sensing lead and abdominal laparoscopy for stimulation on the inferior diaphragm (n = 2); thoracoscopy to place an epicardial sensing lead and a stimulating lead on the superior diaphragm (n = 2)) were employed with 100% success. Patients were unaware of diaphragmatic stimulation. From discharge to 12 months, 6-minute hall walk distance increased (315 [296, 332]m to 340 [319, 384]m; p = 0.002), left ventricular end-systolic volume decreased (135 [114, 140]mL to 99 [90, 105]mL; p = 0.04), and SF-36 QOL improved (physical scale 0 [0, 0] to 25 [0, 50], p = 0.004; emotional scale 0 [0, 33] to 67 [33, 67], p = 0.001). N-terminal pro B-type natriuretic peptide was lower (1784 [944, 2659]pg/mL vs. 962 [671, 1960]pg/mL; p = ns) and left ventricular ejection fraction increased (28 [23, 38]% vs. 35 [31, 40]%; p = ns) although neither reached statistical significance. There were no procedure- or SDS-related adverse events. Conclusions These data demonstrate that SDS can be delivered using alternative implantation methods without raising safety concerns and suggest improved outcomes over 1 year of follow-up. Adequately powered randomized trials are now needed to confirm these findings.
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