Post-test Research Articles

Accuracy of second and third molar maturity indices, Olze, Haavikko, and Demirjian methods for 14- and 16-year-old age thresholds assessment in Croatian children and adolescents.

This study explores the reliability of four established legal age threshold estimation approaches in a Croatian sample. We applied Haavikko stages, Demirjian stages, Olze's third molar eruption stages, and second and third molar maturity indices measurement in 593 orthopantomograms of Croatian children and adolescents aged 11.00-20.99years old. The left mandibular second and third molar were assessed. Logistic regression analysis was conducted to test the significance of predictive variables. Logistic Receiver operating characteristic (ROC) curves were performed to evaluate the classification ability of variables for estimating 14- and 16-year-old thresholds. The areas under the ROC curve (AUC), accuracy (Acc), sensitivity (Se), specificity (Sp), Positive Likelihood Ratio (LR +), Negative Likelihood Ratio (LR-), and Bayes post-test probability (Bayes PTP) were calculated to evaluate classification performance. Results suggest that the combination of I2M&I3M is the best classifier for the 14-year-old threshold (AUC = 0.879); for males alone, I2M is an even better classifier (AUC = 0.881). The highest Acc 80.1% (95%CI, 75.9%-83.9%), Bayes PTP 86.5% (95%CI, 82.8%-89.7%) and Sp 88.9% (95%CI, 83.0%-93.3%) were by I3M < 0.81 & I2M < 0.03 in total samples; the highest Acc 86.1% (80.6%- 90.6%), Bayes PTP 87.2% (95%CI, 81.7%- 91.4%) and Sp 87.8% (95%CI, 78.2%- 94.3%) were by I2M < 0.01 in males, Acc of Haavikko Ac and Demirjian H stage in second molar is very close with slightly lower Bayes PTP and Sp. I3M is a good classifier for 16-year-old threshold (AUC = 0.889). The cut-off value I3M < 0.34 can be used to classify the 16-year-old threshold with Acc of 80.6% (95%CI, 77.2%-83.7%), Sp of 83.4% (95%CI, 79.0%-87.3%), and 81.7% (95%CI, 78.4%-84.8%) Bayes PTP. In conclusion, to classify the 14-year-old threshold, a pair of cut-off values I3M < 0.81 & I2M < 0.03 can be used in Croatian females; I2M < 0.01, Demirjian H stage, Haavikko Ac stage in second molar, and the pair I3M < 0.81 & I2M < 0.03 can all be used in Croatian males. I3M < 0.34 can classify the 16-year-old threshold in Croatian populations.

Real world data after the implementation of coronary computed tomography angiography in Swedish primary care to rule out coronary artery disease, a cross-sectional study based on pre-test probability

Abstract Background In primary care, most patients with of non-acute chest pain will neither receive a heart related diagnosis nor be referred to a cardiologist. Studies indicate a better cardiovascular prognosis in chest pain patients referred to Coronary Computed Tomography Angiography (CCTA) as compared to risk stratification solely based on risk prediction instruments(1). CCTA is recommended since 2019 for low to intermediate cardiovascular (CV) risk patients(2). In the study setting, the primary care has implemented CCTA as first line test for patients with suspected obstructive coronary artery disease (CAD) and a Pre-Test Probability (PTP) of &amp;lt;15% and any CV risk factor, with PTP mandatorily entered in the referral letters. Purpose To study the outcome of CCTA based on referred PTP values categorised into &amp;lt;5%, 5-15% and &amp;gt;15%. We hypothesized that the presence of significant stenosis would be on par with the mean PTP. Methods In this cross-sectional retrospective cohort study, all consecutive clinical referrals for a CCTA from primary health care centres with a catchment area of ~470 000 inhabitants in the country of Sweden between 1 June 2021 and 7 Dec. 2022, with PTP estimates and completed CCTA were included. CCTA findings were stratified as normal, atheromatosis, or significant stenosis (≥50% coronary lumen obstruction). Patient baseline characteristics routinely registered on the day of CCTA was retrieved from a nationwide quality registry, SWEDEHEART(3). Pearsons’s Chi2 and one-way ANOVA was used to test differences in group distributions. Results During the study period, 381 patients with a PTP had obtained CCTA, of which 75% (n=286) had PTP &amp;lt;15%. The mean age was 60 years (standard deviation [SD] 11), 70% were female, 30% were prescribed lipid-lowering medication and 47% anti-hypertensives (Table 1). In total, the mean PTP was 12.4% (SD 8.7) and in 18% a suspected significant stenosis was identified. (Figure 1). Among patients referred with PTP 5-15%, the presence of suspected significant stenosis was 12% and cardiology consultation was less frequently described than for PTP &amp;lt;5 or ≥15% (14% vs 33% vs 44%, p &amp;lt; 0.001). Conclusions This study indicates that PTP is an efficient means to select patients for CCTA in primary care. In total, about 1/5 had a suspected significant stenosis, which often requires further investigations, and about 4/5 could be reassured that symptoms were not due to coronary artery disease. In 31% atheromatosis was identified, potentially facilitating counselling on CV prevention. We conclude that CCTA is a clinically effective option for primary care physicians to rule out CAD in patients with low PTP.Figure 1Table 1

Variability of pre-test probability for obstructive coronary artery disease between referring primary care physicians and estimations from the referral letters

Abstract Background Estimation of Pre-Test Probability (PTP) for obstructive Coronary Artery Disease (CAD), derived from sex, age and characterization of chest pain or dyspnea, is recommended by European guidelines to guide further investigation. When Coronary Computed Tomography Angiography (CCTA) was introduced as first line investigation in patients with PTP &amp;lt;15%, in the primary care of a catchment area of ~470 000 inhabitants in Sweden, attachment of PTP was made compulsory to the referral. The interrater variability, or consistency of agreement, of PTP estimation is not known. The validity of PTP to guide healthcare decisions depends to some extent on the reliability of estimations. Appropriate prioritization of invesigations is reliant on the information included in referral letters. Purpose The purpose was to study the interrater variability of estimations of PTP. We hypothesized: 1) the interrater variability of PTP estimations to be less than excellent (ICC &amp;lt; 0.9), and 2) not statistically different among PTP classes; 3) a significant difference between clinical estimations and estimations made from the referral letters. Methods We studied the 545 patients referred for CCTA from primary care, 1st of June 2021 to 7th of Dec. 2022, with available PTP estimations. The interrater variability, expressed as Intraclass Correlation Coefficients (ICC), was determined for estimations of PTP by the referring physicians (RP) and three external raters (ER). The latter were physicians practising in primary care who rated PTP based on the referral letters to CCTA, independently and blinded. Each rater assessed multiple patients and each patient was assessed by all raters. ICC with a two-way random consistency model for single raters was calculated and evaluated according to a proposed standard(1). Results The ICC for PTP estimations between the RP and the median of three ER was 0.75 (CI 95 % 0.71-0.83, p&amp;lt;0.001). ICC was higher for PTP class &amp;gt; 15% compared to the lower classes: &amp;lt;5% (n = 65, ICC ≈ 0); 5-15% (n = 343, ICC 0.48, CI 95 % [0.39-0.56]); &amp;gt;15% (n = 137, ICC 0.71, CI 95 % [0.62-0.78]) (Figure 1). The ICC for PTP estimations was significantly higher between the three ER (0.88, SE 0.009, CI 95% [0.86-0.89]) than when the RP was added as a rater (ICC 0.80, SE 0.012, CI 95 % [0.77-0.82]). Adding a fixed effect of the difference in ratings between RP and ERs to the ICC model did not change model output (R = 0.80 (SE 0.012, CI 95 % [0.77-0.82]). Conclusions There is a good repeatability, in estimation of PTP based on medical history as described in referral letters, between blinded independent reviewers of CCTA referrals. The repeatability between the external raters and the referring physicians’ compulsory entered PTPs is lower, yet good. The variability of PTP estimations, speculatively from disagreement on main symptom and inconsistency in characterization of chest pain, may impact patient selection and outcomes and is understudied.

ClinicAl verSus algorIthmic predictioN of Obstructive Coronary Artery Disease - the CASINO study

Abstract Background The estimation of pretest probability (PTP) is a key step when evaluating patients with suspected coronary artery disease (CAD). Current European guidelines recommend using an algorithm based on age, sex, and symptom typicality. However, many cardiologists do not regularly use this method, relying instead on overall clinical impression. The aim of this study was to compare clinical and algorithmic prediction of obstructive CAD in a set of symptomatic patients with suspected chronic coronary syndrome (CCS). Methods In this survey study, 10 cardiologists from were asked to estimate the probability of obstructive CAD (on a scale of 1-99% and without the aid of any score or algorithm) for 120 anonymized clinical vignettes of outpatients who underwent diagnostic workup for suspected CCS. The provided information included age, sex, symptom description, cardiovascular risk factors, and know comorbidities. Whenever non-invasive tests had been performed, physicians were also asked to estimate the probability of obstructive CAD after knowing that results. Obstructive CAD was defined as diameter stenosis ≥50% confirmed by invasive coronary angiography. Results Among the 120 included patients (62 women, mean age 61±10 years), symptoms consisted of chest pain in 104 and dyspnea in the remainder. The median PTP of obstructive CAD was 15% (IQR 10-25%) according to the ESC algorithm, and 30% (IQR 15-50%) according to cardiologists’ estimates (p&amp;lt;0.001). The observed prevalence of obstructive CAD was 20% (n=24), yielding suitable calibration for the ESC model (predicted vs. observed p=0.631), and significant overestimation for clinicians’ assessments (predicted vs. observed p=0.014) – Figure 1A. Despite using the same data, cardiologists’ PTP estimates varied widely within the same patients (mean inter-observer coefficient of variation 56%±22%). In a subset of 29 patients whose PTP was appraised twice by the same physicians, the mean absolute difference between assessments (intra-observer variability) was 22%±8%. The ESC algorithm showed fair discriminative power to identify patients with obstructive CAD (C-statistic 0.68, 95% CI 0.58-0.79, p=0.005), whereas the C-statistic for clinicians ranged from 0.53 to 0.72 (average 0.62±0.05, p values for comparisons 0.001-0.677) – Fig 1B. In the subset of 70 patients with prior non-invasive tests, clinicians significantly changed their predictions after knowing test results (mean absolute difference 22%±12%, p&amp;lt;0.001), improving their discriminative power significantly (mean change in C-statistic of 0.08±0.09, p=0.020). Conclusion Clinicians’ assessments of PTP in symptomatic patients display high inter- and intra-observer variability, and tend to overestimate the likelihood of obstructive CAD. Despite using more clinical data, cardiologists fail to outperform the ESC algorithm. The systematic use of this tool should be promoted in order to improve disease prediction and guide non-invasive testing.

Improved quantification of coronary stenosis in patients with high calcium scores using spectral reconstructions in coronary CT angiography

Abstract Background Coronary CT angiography has demonstrated reduced accuracy in patients with high calcium scores due to blooming artifacts, often resulting in overestimated stenosis. Purpose This study aimed to assess the impact of spectral reconstructions on coronary stenosis quantification in patients with high calcium scores (&amp;gt;500), utilizing invasive coronary angiography as the gold standard. Methods Twenty consecutive patients referred for coronary artery disease assessment underwent both coronary CT angiography and invasivecoronary angiography. Conventional 120 kV images, 100 keV virtual monoenergetic images, and iodine-no-water images were reconstructed. Two blinded operators independently reviewed the images. Lesions were qualitatively classified in both CCTA and invasive angiography as stenosis of 1-24%, 25-49%, 50-70%, and &amp;gt;70%. Results A total of 87 plaques were evaluated. Mean age was 72 years (SD=7.7) and 79% were male. Pre-test probability were low, medium and high in 15.8, 26.3% and 57.9% of patients respectively. Mean calcium score was 1662, with an average dose of 7.5 mSv (67.9% retrospective studies). Nitrates were administered in 89.5% of patients, and 47.4% received intravenous beta-blockers. Sensitivity, specificity, positive predictive value, and negative predictive value to detect lesions &amp;gt; 50% improved from 94%, 57%, 38%, 97% with conventional images to 94%, 82%, 59%, 98% with 100 keV virtual monoenergetic images. Conclusion Spectral reconstructions significantly enhance diagnostic accuracy in coronary CT angiography of severely calcified coronary arteries.

Endomyocardial biopsy in the diagnosis of cardiac sarcoidosis

Abstract Background Definite diagnosis of cardiac sarcoidosis (CS) requires proof of sarcoid granulomas in the heart. Endomyocardial biopsy (EMB) is considered a risky procedure with poor sensitivity (&amp;lt;25%) in CS (1), although comprehensive studies on its diagnostic performance are not available. Purpose We investigated the sensitivity, complications, and prognostic significance of EMB in a large cohort of patients with CS to help to choose diagnostic strategy when the disease is suspected. Methods We analysed the data of 260 consecutive patients diagnosed with CS in 1988-2022 at our institution. All met the diagnostic criteria of the Heart Rhythm Society (1). The use, findings, and complications of EMB were retrospectively noted in addition to patients’ demographics, presenting phenotype, diagnostic examinations, and future serious cardiac events. The data were retrieved from hospital records and an ongoing CS registry (2). Advanced imaging studies (cardiac magnetic resonance, positron emission tomography) were re-analysed and the follow-up information was updated until June 2023. EMB’s performance was assessed also in 30 cardiac transplant recipients having CS at the histopathologic study of the explanted heart. Results Of the 260 patients (mean age 49, 60% females), 216 (83%) underwent diagnostic EMB, 48 with repeat procedures. The sensitivity of EMB was 38%, rising to 49% after repeats. The predictors of positive EMB (Table 1) included the presenting phenotype and characteristics of the activity, extent, and location of myocardial involvement. Presentation with ventricular tachyarrhythmia, left ventricular (LV) ejection fraction ≤45%, elevation of cardiac troponins, and presence of middle or apical LV septal late gadolinium enhancement on magnetic resonance imaging were independent predictors (p&amp;lt;0.05) of positive biopsy. The sensitivity of EMB was directly related to the count of the predictors present (Figure 1). The rate of procedural complications was 9.7% overall and 0.7% for major events. One pericardial effusion needed drainage, but no deaths or long-term sequels followed the biopsies. Minor complications included 10 paroxysms of ventricular tachycardia and 6 small pericardial effusions. The 10-year rate (95% CI) of the composite of cardiac death, end-stage heart failure, or ventricular tachyarrhythmia was 55% (44-67%) with positive EMB vs 29% (17-44%) with negative EMB (p&amp;lt;0.001). When adjusted for the presenting phenotype and LV ejection fraction, EMB did not predict outcome events. In the 30 patients with CS in explanted hearts, the sensitivity of EMB, including the repeats, was 60%. Conclusion The sensitivity of EMB is better than usually presented in CS and the higher the more extensive myocardial involvement is. Risk of serious complications is &amp;lt;1%. In patients with suspect CS, the pre-test likelihood and value of positive EMB should be weighed against the procedural risks in shared decision-making when choosing the diagnostic pathway.

UPDATE KNOWLEDGE: PERAN GENDER DAN MASA KERJA TERHADAP MOTIVASI KERJA PERAWAT DI RAWAT INAP RUMAH SAKIT

&lt;p&gt;&lt;em&gt;Quantitative workload can be expressed as the amount of work required to fulfil a patient's medical needs. High-quality workload represents a high level of responsibility in patient care. Nurses' workload is the most important predictor of mental health, stress, job dissatisfaction, fatigue, and the presence of burnout. This service activity aims to provide and increase student knowledge about the Effect of Gender and Years of Service on Work Motivation of Nurses in Hospital Inpatients to Students of the Hospital Administration Study Program, Undergraduate Program, Faculty of Health Sciences, Kusuma Husada University, Surakarta by using a pre-experiment design with a research design of one group pretest and post-test design with a total of 35 students and the activity time in May 2024. This service uses quantitative research with multiple linear regression. There is an increase in the knowledge of participants before and after the provision of material marked by the pre-test and post test which shows that the level of knowledge before being given the material is 69% but after being given the material has increased to 89%. There is a significant difference between students' knowledge about gender roles and tenure on nurses' work motivation in hospital inpatient care.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Keywords: Workload, Gender, Work motivation, Nurses, Hospitalisation&lt;/em&gt;&lt;/strong&gt;&lt;em&gt;&lt;/em&gt;&lt;/p&gt;

Enhancement of the Mayo Clinic Genotype Predictor Score using Cardiac MRI

Abstract Introduction Hypertrophic cardiomyopathy (HCM) is the most prevalent heritable cardiomyopathy typically transmitted in an autosomal dominant fashion. There is growing importance in identifying genetic test positive patients given its prognostic value. The Mayo HCM Genotype Predictor Score has been extensively validated for assessment of patient’s pre-test probability for genotype positive HCM and helps guide clinical decision-making based on clinical and echocardiographic variables. Herein, we evaluated the role of cardiac magnetic resonance (CMR) to enhance the genotype predictor score. Purpose Evaluate performance of the Mayo Clinic HCM Genotype Predictor Score using CMR variables, and develop an updated, CMR incorporated score. Methods Retrospective analysis was conducted on 175 unrelated HCM patients with at least 1 MRI and a HCM genetic testing seen at the Mayo Clinic between April 2004 and April 2018. Phenotyping information was obtained through review of electronic medical records. The original Mayo HCM Genotype Predictor Score was calculated using both echocardiography and clinical variables. An updated score was created incorporating CMR-specific variables. Diagnostic accuracy of the models was assessed thought Receiver Operating Characteristic (ROC) curves. Results Overall, 108 (62%) were males with a mean age at CMR of 51 ± 18 years. The yield of positive genetic test for the echocardiogram-derived Mayo HCM Genotype Predictor Score ranged from 38% for patients with -1 point to 100% for patients with 4 or 5 points. There was a significant incremental increase in diagnostic yield between score subgroups (p &amp;lt; 0.01) with an AUC of 0.659 (Figure 1A). Similar findings were observed using CMR variables (AUC of 0.697; Figure 1B). Univariate and multivariate analysis identified late gadolinium enhancement (LGE) as a strong predictor of a positive genetic test (OR 3.72; p=0.002), and it was added to the original score to create a new version. The Updated Mayo HCM Genotype Predictor Score predicted a positive genetic test ranging from 25% for patients with -1 point to 100% for patients with 5 or 6 points (p &amp;lt; 0.01). There was a significant increase in diagnostic accuracy when compared to the original score (AUC 0.724 vs 0.679; p=0.03; Figure 1C). Conclusion Using LGE, the updated CMR-based Mayo HCM Genotype Predictor score provides a simple and improved tool to aid in genetic counseling for HCM patients.

The added value of cardiopulmonary exercise testing in the diagnosis of heart failure with preserved ejection fraction

Abstract Background Diagnosing heart failure with preserved ejection fraction (HFpEF) is challenging. Two validated algorithms, the HFA-PEFF and H2FPEF scores, have been proposed to guide our clinical practice. Many patients are categorized into an intermediate probability for HFpEF, representing a diagnostic "gray zone." This necessitates further evaluation, including right heart catheterization (RHC) at rest and possibly during exercise, to confirm or exclude the diagnosis. RHC, while informative, is resource-consuming and requires execution in specialized centers. Cardiopulmonary exercise testing (CPET) may offer a non-invasive and cost-effective alternative for differential dyspnea diagnosis. Purpose To evaluate the role of CPET in the diagnostic algorithm of unexplained dyspnea/suspected HFpEF. Methods This single-center retrospective study analyzed patients with a left ventricular ejection fraction (LVEF) ≥ 50% who underwent CPET for unexplained dyspnea from 2016 to 2020. We assessed HFpEF probability using the H2FPEF score and the HFA-PEFF algorithm. We hypothesized that specific CPET parameters (VO2 peak&amp;lt; 80% of predicted and/or VE/VCO2 slope &amp;gt; 35) might provide complementary information to the HFpEF probability scores. Additionally, we hypothesized that CPET could help identifying HFpEF in patients with intermediate probability in a subcohort of patients who underwent exercise RHC. Results Out of 103 patients, 61 (59%) were categorized as intermediate probability of HFpEF according to the HFA-PEFF score, and 59 (57%) according to the H2FPEF score. CPET results (VO2 peak and VE/VCO2 slope) were not associated with the pre-test probability of HFpEF as defined by either of the two scores. Exercise RHC was performed in 26 (43%) and in 27 (46%) patients with intermediate HFA-PEFF score and intermediate H2FPEF score, respectively. Among these patients with intermediate HFpEF probability, VO2 peak &amp;lt; 80% and/or VE/VCO2 slope &amp;gt; 35 had a good specificity and positive predictive value for HFpEF, as compared with exercise RHC (Table). Conclusions CPET provides complementary information to HFA-PEFF and H2FPEF scores. In particular, our results suggest that CPET may reclassify as HFpEF over 25% of patients with an intermediate HFpEF probability according to either the HFA-PEFF score or the H2FPEF score, potentially obviating the need for RHC. Thus, CPET might be incorporated into the HFpEF diagnostic algorithms.Table

Multi-modality deep learning model for prediction of chronic obstructive coronary artery disease

Abstract Background/Introduction The incidence of coronary artery disease (CAD) is on the rise with an increasing burden of stable ischemic heart disease (SIHD) and high prevalence of obesity, diabetes, hyperlipidemia, and other cardiovascular risk factors. Pre-test probability estimation for CAD based on demographic features and characterization of chest pain is insufficient to accurately assess whether further evaluation for CAD is warranted. Purpose To develop and validate a deep learning (DL) algorithm utilizing electrocardiogram (ECG) waveforms and clinical features to predict obstructive CAD. Methods Clinical data from subjects undergoing invasive angiography over a 4-year period at a quaternary care center exclusive of subjects who had concern for acute coronary syndromes were used for model training. ECGs obtained up to 5 years prior to angiography were included; ECGs were partitioned 8:1:1 for training, validation, and test datasets. Obstructive CAD was defined as receiving percutaneous coronary intervention during elective angiography. Convolutional neural network models were developed for ECG waveforms alone (DL-ECG), clinical features from standard risk scores (DL-Clinical), and the combination of ECG waveforms and clinical features (DL-ECG+Clinical); a commonly used pre-test probability estimation tool derived from the CAD Consortium study was used as a comparison (PTP). The models were evaluated based on area under the curve receiver operating characteristics (AUC). Shapley additive explanations (SHAP) analysis was performed to understand feature importance in the DL models. Results A total of 40,602 ECGs and 8,361 coronary angiograms from 7,201 patients were included in the analysis. The median age was 66 (IQR 56-75), 71.9% were men, 34.9% had hypertension, 30.6% had diabetes mellitus, and 39.0% had dyslipidemia. The PTP model (AUC 0.733 [0.717-0.750]) had similar performance as the DL-Clinical model (AUC 0.762 [0.746-0.778]). The DL-ECG model (AUC 0.741 [0.726-0.758]) had similar performance as both the clinical feature models. The DL-ECG+Clinical model (AUC 0.807 [0.793-0.822]) trained on ECG waveforms and clinical features had a superior performance (Figure 1). SHAP analysis for the DL-ECG+Clinical model revealed that ECG waveforms had the largest influence on the model’s output followed by age and chest pain type (Figure 2). Conclusions Multi-modality DL model utilizing ECG and commonly used features can improve prediction of obstructive CAD in SIHD compared to traditional pre-test probability estimates. Prospective research is warranted to determine whether incorporation of DL methods to ECG analysis effectively improves diagnosis and outcomes in obstructive CAD.Figure 1.Figure 2.

Effects of an online program about intimate and romantic relationships for people with mental disorders (AIRIKI): a study protocol for a randomized controlled trial

BackgroundThe concept of recovery has become internationally widespread. To promote personal recovery of individuals with mental disorders, it is important that they live life on their own terms. Many people with mental disorders wish to build intimate relationships and marry. However, people with mental disorders face obstacles in building such relationships and communicating with their partners. The program AIRIKI, which means “power to love,” was developed to help people with mental disorders gain confidence in building intimate relationships. The AIRIKI pilot study with one-group pre post test showed positive effects on self-esteem, hope, and communication. Therefore, the purpose of the proposed randomized controlled trial (RCT) is to determine the effects of the videoconferencing program on self-esteem, hope, and self-confidence in communication among un-married people with mental disorders.MethodsThe proposed randomized controlled trial has two arms (intervention group and control group). After baseline questionnaire assessment, participants will be allocated randomly. Within two months of allocation, the intervention group will participate in videoconferences about intimate relationships and marriage with 2–5 participants and 3 facilitators, which will last 3 h, for two days. Three facilitators will support participants in each session. The intervention group will complete a questionnaire for outcome assessment at termination and one month after the program. The control group will complete the outcome questionnaire at one month after baseline and two months after baseline. The questionnaire will include the Rosenberg Self-Esteem Scale (RSES), Herth Hope Index (HHI), and Self-confidence in Communication Scale (SCS). Control group members can participate in a videoconference program, which will be held separately from the intervention group, after completing their outcome assessments.DiscussionThis trial is the first randomized controlled trial of which we are aware to test the effects of an online program for un-married people with mental disorders to consider and discuss their romantic relationship and marriage. The results will provide information on the effectiveness of an online program for people with mental disorders to imagine their romantic relationships and marriages.Trial registrationThis trial has been registered with the UNIN Clinical Trials Registry (UMIN000052027; 2023/08/28).

Two-Step Screening for Depression and Anxiety in Patients with Cancer: A Retrospective Validation Study Using Real-World Data

Background: Although screening for distress is recommended by many cancer care guidelines, the uptake of such screening in cancer centers remains limited. Improving the acceptability of screening programs in cancer centers requires a reduction in clinical burden and an improved detection of distress. The purpose of this study was to validate the performance of the two-step screening algorithm used in the Distress Assessment and Response Tool (DART) for identifying cases of anxiety and depression. Methods: This retrospective validation study consisted of patients at the Princess Margaret Cancer Centre (PM) who completed the DART, which includes the Edmonton Symptom Assessment System depression (ESAS-D) and anxiety (ESAS-A) items, the Patient Health Questionnaire (PHQ-9), and the Generalized Anxiety Disorder (GAD-7). We evaluated the performance of a two-step screening approach, which modeled the ESAS-D, followed by the PHQ-9 and ESAS-A, then the GAD-7 for predicting a diagnosis of depression and anxiety disorders, respectively. A clinical psychiatric assessment was used as the gold standard reference. Results: A total of 172 patients with cancer were included in this study. A total of 59/172 (34%) and 39/172 (23%) were diagnosed with a depression or anxiety disorder, respectively. The sequential administration of the PHQ-9 ≥15 following the ESAS-D (&gt;2) significantly increased the post-test probability of depression from 37% to 60% and improved the performance of predicting depression compared to both the ESAS-D or the PHQ-9 as standalone tests. The sequential administration of the GAD-7 after the ESAS-A did not improve the predictability of an anxiety diagnosis beyond the performance of the ESAS-A or the GAD-7 as standalone tests. Conclusions: The present study is among the first to demonstrate that a two-step screening algorithm for depression may improve depression screening in cancer using real-world data. Further research on optimal screening approaches for anxiety in cancer is warranted.

Relationship Between White Blood Cell Count and Bacteremia Using Interval Likelihood Ratios in Hospitalized Patients.

Patients with bacteremia often have elevated white blood cell (WBC) and neutrophil counts, yet these alone are poor predictors of bacteremia. Data on the continuous relationship between WBC response and bacteremia are lacking. This study aims to characterize the relationship of WBC count, neutrophil percentage, and absolute neutrophil count (ANC) to bacteremia using interval likelihood ratios (ILRs) derived from a large sample of hospitalized patients. Retrospective cohort study in a large healthcare system from 2017 to 2018. This study included non-surgical inpatients who had at least one complete blood count (CBC) with differential up to 24hours after admission and a blood culture. Patients with immunosuppression and malignancy or who received antibiotics before negative blood cultures were excluded. Predictors were WBC count, ANC, and neutrophil percentage. The outcome was bacteremia. We compared test discrimination using the area under the receiver operating characteristics curve (AUROC). We calculated ILRs for bacteremia across test value intervals. As a practical example, we assumed a 5% pre-test probability of bacteremia and calculated the post-test probability for each interval. We compared this approach to a threshold approach using a threshold of 70% neutrophils. Of 25,776 patients with a CBC with differential and blood culture, 1160 had bacteremia. AUROC was highest for neutrophil percentage (0.74), followed by ANC (0.63) and WBC count (0.58). Probability of bacteremia increased exponentially from neutrophil percentage 80 to 100%. Odds of bacteremia varied 35-fold based on neutrophil percentage. A threshold approach with a cut-off of 70% significantly underestimated bacteremia risk at higher levels. ILRs offered a more discriminating approach to estimating the probability of bacteremia than a single threshold. Physicians assessing risk of bacteremia should pay attention to the magnitude of abnormality because very high and very low values have much stronger predictive power than dichotomized results.

Edukasi Penerapan Prinsip Akuntansi Lingkungan Melalui Efisiensi Energi dan Pengelolaan Limbah Pada UMKM Tambakrejo Semarang

Management understanding and knowledge of environmental accounting, especially related to waste management and energy efficiency, is very important to achieve business sustainability, including for Micro, Small, and Medium Enterprises (MSMEs). The Tambakrejo MSME group often lacks understanding of milkfish waste management and faces increasing energy operational costs, especially for refrigerators. Lack of environmental awareness causes milkfish waste to pollute the environment and hinder water drains. Environmental accounting integrates environmental aspects in accounting practices to measure, report, and manage environmental impacts. This Community Service educates about waste management strategies and energy efficiency based on environmental accounting principles. The results of Community Service have a positive impact, the enthusiasm of MSME actors is very high, this is evidenced through pre and post testing measuring tools for MSMEs with the results of the increasing level of public understanding of environmental awareness and energy saving in MSMEs, as well as teaching environmental cost management methods through identification, recognition, measurement, reporting, and integration of environmental aspects in the accounting system.

Effectiveness of Butterfly Pea ( Clitoria Ternatea ) Extract Against Streptococcus Mutans Bacterial Growth In Vitro

Dental caries is still a major problem in dentistry and is the most common infectious disease in children. Caries is a microbiological infectious disease that can damage the hard tissue of the teeth. This study aims to determine the effectiveness of butterfly pea flower extract ( Clitoria ternatea ) on the growth of Streptococcus mutans in vitro. This type of research is laboratory experimental research using a post test only control group design approach The samples used were butterfly pea flower extract ( Clitoria ternatea ) diluted with DMSO to a concentration of 100%, 50%, 25%, 12.5%, 3.125%, 6.125% and Streptococcus mutans ATCC 25175. This research was conducted using the MIC test dilution method and KBM to see the effectiveness of the antibacterial extract against the test bacteria. Analysis of research data using the one way ANOVA test (p &lt;0.05) to see significant differences between study groups with the number of test bacteria, followed by a double comparison test with the Post Hoc Least Significance Different (LSD) method to determine the average difference between treatment groups. Antibacterial effectiveness test results showed that butterfly pea flower extract ( Clitoria ternatea ) was effective in inhibiting Streptococcus mutans bacteria (p&lt;0.05), at a concentration of 25% was the minimum inhibitory level (MIC) and 50% concentration was the minimum killing rate (MBC). ). The conclusion of this study is that the extract of butterfly pea flower ( Clitoria ternatea ) is effective in inhibiting and killing Streptococcus mutans bacteria.

Update Motility Disorders: Gastro-Oesophageal Reflux Disease – Diagnostic and Conservative Approach

Background: Gastro-oesophageal reflux disease (GORD) is extremely common, with at least 1 in 10 people in the general population reporting heartburn and acid regurgitation on a weekly basis. GORD can also be associated with a variety of atypical symptoms, including chest pain, chronic cough, and laryngopharyngeal symptoms. The causes of GORD are multifactorial, and the severity of symptoms is influenced by peripheral and central factors, including psychosocial stress and anxiety. Therefore, for a variety of reasons, no single investigation provides a definitive diagnosis, and standard treatment with acid suppressants is not always effective. Summary: This review introduces the Lyon Consensus, now in its second iteration, a classification system that provides a “conclusive” positive or negative diagnosis of GORD by integrating the results of endoscopy, ambulatory reflux monitoring, and high-resolution manometry. Different algorithms are applied to patients with high and low pre-test probability of a causal relationship between reflux episodes and patient symptoms. The results of these studies identify patients with “actionable” results that require escalation, revision, or discontinuation of GORD treatment. Guidance is provided on the range of conservative treatments available for GORD, including dietary and lifestyle advice, antacids and alginates, and drugs that suppress acid secretion. Key Messages: GORD is a common disorder; however, the causes of reflux and symptoms can be complex. As a result, the diagnosis can be missed, and management is sometimes challenging, especially for patients with atypical symptoms. The Lyon classification establishes a conclusive diagnosis of GORD, based on results of endoscopic and physiological investigation. Typical symptoms usually respond to empiric use of alginate-antacid preparations and acid suppression; however, the management of treatment refractory symptoms is tailored to the individual.

GAME BOARD TO IMPROVE CHILDREN'S DENTAL AND ORAL HEALTH KNOWLEDGE

Background: The five-year period in the stage of child development is the golden age, which is a golden period in the period of growth and development of children. During this period, everything that is poured out and absorbed in the child will become the basis and sharp memory in the child, including the maintenance of dental health. The growth of 3 to 5-year-olds has some skills such as color naming. Children do tend to prefer to play. Children's activities while playing while learning can support growth and development and absorb learning optimally. Games that can be played while learning are putting together simple puzzles, drawing and coloring, composing and stacking block games, playing sand, clay or toy candles, singing, role-playing, playing music and board games. Objectives: To develop dental and oral health game boards for kindergarten children aged 3-5 years in kindergartens in the Kersamenak sub-district, Kawalu Tasikamalaya District. Methods: The research method is carried out by research and development (R&amp;D) methods and Quasi experiments with non-equivalent pre and post test designs. The research was conducted by conducting FGD with kindergarten teachers in the Kersamenak sub-district area, Kawalu District, Tasikmalaya City using a total sampling technique of 30 teachers. Results: The description of the conclusion to the respondents' answers is the development of dental and oral health game boards for kindergarten children aged 3-5 years in kindergartens in the Kersamenak sub-district, Kawalu Tasikamalaya District. Conclusion: Production of dental and oral health game boards and game board manuals.

Removal of Isolated Cannabis Use as an Order Indication for Urine Drug Screening (UDS) Eliminates Racial Inequity in Maternal UDS Testing and Reporting to Child Protective Services

Abstract Black patients on labor and delivery (L&amp;D) units are more likely to undergo urine drug screening (UDS) and subsequent mandated reporting to child protective services (CPS), which can result in increased separation of the parent and infant, contributes to systemic inequities, and erodes the patient/provider relationship. These disparities are driven by a testing indication of isolated cannabis use (ICU), which based on previous data from our institution, disproportionately selects Black patients for testing. In October 2022, the Barnes-Jewish Hospital (St. Louis, MO) L&amp;D unit removed ICU as a UDS indication; concurrently, we implemented an electronic health record (EHR)-based order question requiring providers to select an indication for testing. The objective of this study was to analyze the impact of this intervention on racial equity in UDS testing and CPS reporting. Data on deliveries, UDS testing, and CPS reports were obtained from the EHR, and data for deliveries occurring during the pre- (1/1/2020-9/30/2022; 33 months) vs. post-implementation (10/1/2022-2/1/2024; 16 months) periods was compared. There were a total of 9,187 and 4,757 deliveries during the pre- and post-implementation periods, respectively. At baseline, there were more deliveries by Black patients in the pre-implementation (47.8%) vs. post-implementation (44.0%) period (p&amp;lt;0.001); there was no difference in age, multiparity, or neonatal outcomes between the two periods. In the pre-intervention period, 29.2% of Black and 13.8% of White patients had UDS testing (p&amp;lt;0.001), and 7.6% of Black and 4.1% of White patients underwent reporting to CPS (p&amp;lt;0.001); in the post-intervention period, 4.5% of Black and 3.6% of White patients had UDS testing (p=0.52), and 4.2% of Black and 3.5% of White patients underwent reporting to CPS (p=0.52). 34.6% vs. 67.8% of UDSs in the pre- and post-implementation were positive for any non-cannabis compound, respectively (p&amp;lt;0.001). In conclusion, removing ICU as an order indication dramatically improves racial equity in UDS testing and CPS reporting on a L&amp;D floor, and improves the pre-test probability of UDS testing for non-cannabis compounds.

Clinical Test Comparison for Improved Diagnosis of Mucormycosis

Abstract Mucormycosis is a rapidly progressive and invasive fungal infection caused by members of the order Mucorales. Proper treatment relies on a timely diagnosis. However, traditional fungal culture takes several days to weeks and has low sensitivity for recovering Mucorales, as these organisms are sensitive to specimen preparation, including tissue homogenization, and low storage temperatures. More rapid and sensitive diagnostic methods are needed to promptly detect infection. Our laboratory previously developed a real-time PCR assay that detects the most common genera associated with mucormycosis to help improve diagnosis. The assay was analytically validated for a variety of specimen types including serum, tissue (both fresh and FFPE), respiratory secretions and body fluids. Little is known about the agreement between our laboratory developed PCR and other detection methods such as culture or sequencing. We reviewed 6 years of laboratory data to assess overall PCR positivity rate, positivity rate across sample types, and agreement with culture and/or pan-fungal sequencing. We also calculated turnaround time to results to gauge the diagnostic value of Mucorales PCR. Test comparisons with fungal culture and/or pan-fungal sequencing were performed if testing was ordered within 30 days of each other. In our study, we reviewed 3,804 total PCR orders for 2,195 patients. The overall positivity rate of Mucorales PCR orders was 3.81% and varied among different sample types, with fresh tissue and body fluid having the highest positivity rates (18.11% total tissue (33.3% lung tissue) and 10.94% all body fluid (12.5% pleural fluid)) and sputum and CSF having the lowest positivity rates (&amp;lt;1% positivity for both). In a cohort of 428 patients with fungal culture and/or sequencing also performed, 29 patients tested positive for Mucorales by at least one method. PCR detected Mucorales on average 7.83 days sooner than fungal culture (average time to positive result: 3.65 vs. 11.47 days). In patients with culture- or sequencing-confirmed Mucorales infection, PCR had a 100% agreement when comparing shared samples from the same source and collection time. Mucorales PCR was also able to detect infection in 10 (34.5%) other patients who were culture-negative for Mucorales. Our findings suggest that PCR could be a valuable diagnostic tool for suspected mucormycosis, especially tissue invasive disease. PCR increased case detection by 34.5% with a faster turnaround time than culture with lesser cost than sequencing. The main limitation of our study was lack of access to patient information to assess pretest probability of Mucormycosis.

전공 연계 ‘기후⋅생태계 챌린지’ 교외 교육활동의 효과성 연구: 예비유아교사의 환경관심도 및 기후환경 위험인식과 공동체 의식, 협력적 자기효능감을 중심으로

Objectives The purpose of this study is to investigate the effectiveness of the major-integrated extracurricular program of ‘Climate Ecosystem Challenge’ on pre-service early childhood teachers, focusing on environmental concern, climate environmental risk perception, sense of community, and collaborative self-efficacy. Methods The research subjects consist of 9 students attending Nano-LAB Meta at A University in the Chungcheong region. The trends(mean, standard deviation) and normality(Kolmogorov-Smirnov test, Shapiro-Wilk test) of the study variables, along with the reliability assessment using Cronbach's α, were examined in SPSS 23.0. The effectiveness of major-integrated extracurricular program was tested using the non-parametric statistic of the Wilcoxon test, which is suitable for testing differences in paired samples. Results The main results are as follows: First, the difference (b-a) between the pre- and post-mean scores (a) and the post-mean score (b) indicated a minimum increaseof 0.55 points and a maximum improvement of 1.04 points in the post-mean score compared to the pre-mean score across all study variables. Second, despite the normality test not demonstrating statistical significance for some study variables, there is an intention to conduct nonparametric statistical analysis, which is justified by the central limit theorem. Third, the post test scores were higher than the pretest scores of the study variables, and the difference was statistically significant. Conclusions The research findings reaffirm the significance of extracurricular education integrated with the major. In this regard, we aim to promote mutual development between the university and the local community by proposing measures for major-integrated extracurricular education with consideration for community service contributions.