Research Network Research Articles

Cardiovascular mortality with oral potassium-binders in patients with CKD and heart failure

Abstract Introduction Hyperkalemia is an inherent consequence of advancing chronic kidney disease (CKD) as a result of the kidney’s decreased ability to excrete potassium. Heart failure patients with concomitant CKD may not tolerate maximum doses of guideline-directed medical therapies (GDMT) like ACE inhibitors (ACEi), angiotensin receptor blockers (ARB), angiotensin receptor/neprilysin inhibitors (ARNI) and mineralocorticoid receptor antagonists (MRA) due to dose-limiting hyperkalemia. Many randomized controlled trials in heart failure exclude patients with advanced CKD. Two oral therapies exist to manage hyperkalemia - patiromer sorbitex calcium and sodium zirconium cyclosilicate. This study aims to identify the potassium-binder with better outcomes as defined by less readmissions, hyperkalemia episodes, and death. Purpose This project was undertaken to better understand the impact of using potassium-binders in CKD patients with heart failure. Improved management of hyperkalemia will be an avenue for optimization of GDMT in this population. Methods and materials The TriNetX research network was used for this study. Two cohorts of patients were created by using International Classification of Disease 10 (ICD-10) codes and CPT codes. Both cohorts consisted of patients with no prior history of hyperkalemia within 30 days of hospital discharge at which time one cohort was prescribed patiromer and the other received sodium zirconium cyclosilicate. Each cohort was prohibited from exposure to the other medication. The cohorts were balanced by propensity score matching and the greedy nearest neighbor algorithm for age, race, gender, ethnicity. They were also balanced for systolic and diastolic heart failure diagnoses, and for each individual stage of CKD (1 through 5 and end stage). They were also balanced for use of ACEi, ARBs, and MRAs. This resulted in 8,921 patients in each arm. They were then evaluated for the outcomes of hospital readmission, hyperkalemia episodes (>6.1 mmol/L), and death within 12 months. Results Patients treated with patiromer were more likely to be hospitalized over the following twelve months (44% vs 40%, RR 1.11, 95% CI (1.07,1.15), p value <0.0001). They were also more likely to experience hyperkalemia (11.7% vs 9.2%, RR 1.27, 95% CI (1.16,1.38), p value <0.0001). Patiromer was also associated with slightly greater all cause mortality (27% vs 25%, RR 1.08, 95% CI (1.03,1.13), p value 0.0021). Discussion This study demonstrates patiromer has more readmissions and hyperkalemia episodes along with greater mortality. In conclusion, sodium zirconium cyclosilicate was found to have better outcomes compared to that of patiromer. Further studies are necessary to better understand the utility of using sodium zirconium cyclosilicate as maintenance therapy for hyperkalemia in order to maximize GDMT in CKD patients with heart failure.

Comparison of cardiovascular outcomes in patients with diabetes treated with tirzepatide versus semaglutide: a multi-institutional analysis

Abstract Introduction Glucagon-like-peptide-1 (GLP-1) receptor agonists have been demonstrated to have cardiovascular benefits in patients with diabetes. Two of the most prescribed medications in this class are tirzepatide and semaglutide. Tirzepatide is a dual glucose-dependent insulinotropic polypeptide and GLP-1 receptor agonist, while semaglutide is a selective GLP-1 receptor agonist. Tirzepatide and semaglutide have previously been directly compared to assess efficacy in glycemic control as the primary endpoint. However, there is limited data directly comparing cardiovascular outcomes between the two medications in patients with diabetes. This retrospective cohort study compares the incidence of major adverse cardiovascular events (MACE) in patients with diabetes treated with tirzepatide or semaglutide. Purpose The purpose of this study is to identify differences in cardiovascular outcomes between patients with diabetes treated with tirzepatide as compared to semaglutide. Materials and Methods The TriNetX research network was used for this study. Two patient cohorts were generated using International Classification of Disease 10 (ICD-10) codes and medication codes in the TriNetX system. Both cohorts of patients had a history of diabetes (E08-E13) and no prior history of cerebral vascular accident (I63) or myocardial infarction (I21). One cohort received semaglutide and the other tirzepatide. Each cohort was prohibited from receiving the other agent. The cohorts were balanced for age, race, gender, and ethnicity by propensity score matching and the greedy nearest neighbor algorithm resulting in 36,212 patients in each arm. They were then evaluated for the 3-year outcomes of major adverse cardiovascular events (myocardial infarction, cerebral vascular accident, and death). Results Tirzepatide was associated with statistically significantly fewer MACE outcomes compared to semaglutide for each of the individual endpoints as well as the overall composite endpoint over the 3 year follow up period. Table 1. MACE events for semaglutide and tirzepatide. Table 2. Relative risks for semaglutide MACE endpoints compared to tirzepatide. Conclusions In this retrospective cohort study, tirzepatide was associated with a lower incidence of major adverse cardiovascular events compared to semaglutide in patients with diabetes. These findings suggest that tirzepatide offers superior cardiovascular protection for primary prevention compared to semaglutide and warrant further investigation in future studies and clinical trials.Table 1Table 2

Baseline characteristics and outcomes of patients admitted to intensive cardiovascular care unit

Abstract Background Intensive Cardiovascular Care Unit (ICCU) is a crucial element of care for critically ill patients suffering from cardiovascular disease. Therefore, we aimed to provide data on the characteristics and outcomes of patients admitted to ICCU. Methods Data was obtained from One Intensive Cardiovascular Care Unit (One ICCU) Registry, a collaborative multicentre research network of ICCU. A total of 10 centres participated in this registry, eight centres were ICCU level III and the remaining were ICCU level II. Each participating centre collected data of patients admitted to ICCU from August 2021 until August 2023. Data recorded were demographics, past medical history, diagnosis, treatment, complications, outcome, and 30-day follow up. Only first ICCU admission data from each patient was analysed to prevent outcome-related bias from readmission data. Results 12,950 patients were included in the analysis of which 9308 (71.9%) were male and the median age was 59 (51-66) years. Most common diagnosis on admission was acute coronary syndromes (69.8%) followed by acute heart failure (34.6%) and arrhythmias (25.8%). Cardiovascular complication most frequently during ICCU stay was cardiogenic shock (18.9%) while for non-cardiovascular complication was acute kidney injury (17.4%). Cardiac arrest (61.2%), respiratory failure (43%), and sepsis (38%) were among the highest case fatality rates for ICCU complications. Overall mortality was found to be approximately 11.4%, 14.3%, and 15.2% for intra ICCU, in-hospital and 30-day mortality, respectively. Non-cardiovascular variables which were independently associated with 30-day mortality were pre-existing asthma (OR 2.12, CI 1.315 – 3.411, p=0.002) and chronic kidney disease (OR 1.67, CI 1.308 – 2.139, p<0.001), initial diagnosis of respiratory failure (OR 4.01, CI 3.373 – 4.773, p<0.001), haemorrhagic stroke(OR 3.46, CI 1.396 – 8.574, p=0.007), ischaemic stroke (OR 3.12, CI 2.248 – 4.345, p<0.001), sepsis (OR 2.00, CI 1.715 – 2.334, p<0.001), urinary tract infection (OR 1.60, CI 1.228 – 2.226, p=0.001) and pneumonia (OR 1.29, CI 1.120 – 1.482, p<0.001), as well as complications during ICCU stay which consisted of haemorrhagic stroke (OR 3.91, CI 1.062 – 14.414, p=0.040), respiratory failure (OR 2.91, CI 2.081 – 4.070, p<0.001), sepsis (OR 2.17, CI 1.686 – 2.790, p<0.001), ischaemic stroke (OR 1.84, CI 1.074 – 3.139, p=0.026), and urinary tract infection (OR 1.39, CI 1.039 – 1.851, p=0.026). Conclusion Patients admitted to our ICCU were relatively younger and the cause for ICCU admission was still predominated by acute coronary syndrome. Despite that, non-cardiovascular condition also warrants clinicians attention due to its significant role as predictors of mortality. Non-cardiac complications that arise during ICCU care also emphasize the importance of collaboration with specialists in other disciplines to improve patient’s outcomes.Diagnosis (A) and Case Fatality (B)Mortality Predictors at 30 days

Association between hidradenitis suppurativa and gout: a propensity-score-matched cohort study.

Introduction While an association between hidradenitis suppurativa (HS) and inflammatory arthritis has been reported in clinical studies, the potential link between HS and gout remains uncertain. As HS and gout share common immunological pathways, we conducted a retrospective cohort study to determine whether HS patients are at an increased risk of developing gout in the future. Methods This retrospective multicenter cohort study obtained information through the US collaborative network, a subset of the TriNetX research network. Patients diagnosed with HS between January 01, 2005, and December 31, 2017, were recruited, and a 1:1 propensity score matching was conducted to identify appropriate controls. The hazard ratio for the new-onset of gout in HS patients was subsequently calculated. Results Compared to individuals without HS, those with HS were associated with a 1.39-fold higher risk (95% CI, 1.20, 1.62) of developing new-onset gout within five years after the index date. This association remained significant in shorter follow-up times and sensitivity analyses utilizing different matching models. For both male and female HS patients, the risk of developing new-onset gout within 5 years after the index date was statistically significant, with respective hazard ratios of 1.61 (95% CI, 1.28,2.02) for males and 1.41 (95% CI, 1.11,1.78) for females. Conclusion HS patients are at a high risk of developing gout within five years after an HS diagnosis while comparing with non-HS controls.

Epidemiology of cardiogenic shock using the Shock Academic Research Consortium (SHARC) consensus definitions.

The Shock Academic Research Consortium (SHARC) recently proposed pragmatic consensus definitions to standardize classification of cardiogenic shock (CS) in registries and clinical trials. We aimed to describe contemporary CS epidemiology using the SHARC definitions in a cardiac intensive care unit (CICU) population. The Critical Care Cardiology Trials Network (CCCTN) is a multinational research network of advanced CICUs coordinated by the TIMI Study Group (Boston, MA). Cardiogenic shock was defined as a cardiac disorder resulting in SBP < 90 mmHg for ≥30 min [or the need for vasopressors, inotropes, or mechanical circulatory support (MCS) to maintain SBP ≥ 90 mmHg] with evidence of hypoperfusion. Primary aetiologic categories included acute myocardial infarction-related CS (AMI-CS), heart failure-related CS (HF-CS), and non-myocardial (secondary) CS. Post-cardiotomy CS was not included. Heart failure-related CS was further subcategorized as de novo vs. acute-on-chronic HF-CS. Patients with both cardiogenic and non-cardiogenic components of shock were classified separately as mixed CS. Of 8974 patients meeting shock criteria (2017-23), 65% had isolated CS and 17% had mixed shock. Among patients with CS (n = 5869), 27% had AMI-CS (65% STEMI), 59% HF-CS (72% acute-on-chronic, 28% de novo), and 14% secondary CS. Patients with AMI-CS and de novo HF-CS were most likely to have had concomitant cardiac arrest (P < 0.001). Patients with AMI-CS and mixed CS were most likely to present in more severe shock stages (SCAI D or E; P < 0.001). Temporary MCS use was highest in AMI-CS (59%). In-hospital mortality was highest in mixed CS (48%), followed by AMI-CS (41%), similar in de novo HF-CS (31%) and secondary CS (31%), and lowest in acute-on-chronic HF-CS (25%; P < 0.001). SHARC consensus definitions for CS classification can be pragmatically applied in contemporary registries and reveal discrete subpopulations of CS with distinct phenotypes and outcomes that may be relevant to clinical practice and future research.

7.K. Round table: Approaching new public health frontiers: health literacy on a global level

Abstract This workshop will introduce the newly established WHO Collaborating Centre for Health Literacy (WHO CC HL) at TU Munich (TUM) in Germany and reflect on its goals and discuss the potential impact on European public health research, policy, and practice. With the launch of the WHO CC HL, TUM, WHO, and their collaborators, among which are the EUPHA Health Literacy Section, the International Health Literacy Association, and the Global Health Literacy Research Network, jointly aim at systematically developing health literacy as part of the WHO Sustainable Development and Well-being agenda. Health literacy represents the skills and attitudes to find, understand, appraise, and apply health information and services. Low health literacy is prevalent among all population and age groups and it is linked to worse health outcomes and health inequalities. Across the social gradient, people from low socioeconomic backgrounds are more likely to have low health literacy, which is why the European Commission and WHO both highlighted the need to invest in health literacy and, in particular, in school health literacy. Two emerging fields of study include data generation and interventions. Both of which are highly critical to monitoring change and providing evidence-based data on population and system-level health literacy within and between countries. However, there are no health literacy monitoring systems in place on a global scale nor is there robust evaluation data on school-based interventions. These shortcomings will be addressed through the WHO CC HL at TUM. In this round table workshop with five key health literacy and public health experts, the main goal is to present the WHO CC HL and its roadmap for the next four years and critically discuss how the work can influence European and Global public health: Dr. Faten Ben Abdelaziz, WHO; Anastasia Kyoylu, WHO/Europe; Dr Kristine Sorensen, Global Health Literacy Academy; Dr. Charlotte Marchandise, EUPHA; Prof. Dr. Orkan Okan, WHO Collaborating Centre for Health Literacy at Technical University of Munich. First, the chair will provide a short introduction to the WHO CC HL and will, together with the co-chair, facilitate the following panel discussion. The panel members will share a short 2-to-3-minute statement from their point of view in relation to planned activities of the WHO CC HL and highlight synergies to public health and health literacy development. Following the short statement, the chairs will prepare individual questions for each panellist and engage them in a discussion, which shortly after will open towards the audience for them to participate actively with the panellists in a 30-minutes discussion. Key messages • The round table workshop will introduce the newly established WHO CC HL, highlight its goals and impact on public health, and highlight collaboration opportunities. • The key experts will reflect about the WHO CC HL from their unique standpoints and reveal new perspectives on the way forward and how the work can benefit from ongoing public health initiatives. Speakers/Panelists Faten Ben Abdelaziz WHO, Geneva, Switzerland Anastasia Koylyu WHO, Copenhagen, Denmark Kristine Sørensen Global Health Literacy Academy, Risskov, Denmark Charlotte Marchandise EUPHA Orkan Okan Technical University of Munich, Munich, Germany

Core set of indicators to evaluate healthcare workers support programmes: a consensus-based approach

Abstract Objectives Considering the widespread implementation of support programmes for healthcare workers (HCWs), there is an urgent need to establish a standardised set of indicators for their ongoing assessment. This study seeks to develop a consensus framework for evaluating interventions aimed at supporting HCWs affected by patient safety incidents (PSIs) or other distressing situations, commonly referred to as second victims (SVs). Having a core set of indicators it is crucial for facilitating comparative analyses across different organisations and time periods. Methods A qualitative study was conducted from June 2023 to March 2024. The study involved a multidisciplinary group of members part of the European Researchers Network Working on Second Victims. The consensus-building process utilised insights from a scoping review (phase 0) and a nominal group technique (phase 1) to develop a questionnaire for Delphi Rounds (phase 2). Indicators were rated on a scale of 1-5, with consensus reached if over 70% of participants rated an indicator as both feasible and sensitive scoring above 4. A consensus conference was subsequently organised. Results From an initial pool of 91 indicators, 55 were rated online, with 35 progressing to the Delphi rounds. A total of two Delphi rounds were performed and achieved response rates exceeding 60% and 80% respectively, resulting in consensus on 11 indicators for evaluating SV’ support programmes. These indicators encompass various aspects such as awareness and activation of the programmes, organisational processes and structures, institutional training provisions and assessment of the impact of the programme in the SVs. Conclusions This study endeavors to provide guidance for future SVs’ programs namely in the critical areas of programme’s awareness and activation, structural and process enhancements, and programme’s impact on SVs. Moreover, these indicators are suitable for multiple healthcare contexts and levels of implementation. Key messages • The priorities for evaluation of second victim programmes’ include their impact on healthcare workers, awareness and activation, organisational processes and structures and institutional training. • Utilizing a multidisciplinary consensus approach, we defined a set of indicators that are adaptable to diverse contexts that provide care and varying levels of second victim support implementation.

System infection prevention in hospital networks in the United States-an SHEA research network inquiry into operational characteristics and current challenges.

A 54-question survey about System Healthcare Infection Prevention Programs (SHIPPs) was sent out to SHEA Research Network participants in August 2023. Thirty-eight United States-based institutions responded (38/93, 41%), of which 23 have SHIPPs. We found heterogeneity in the structure, staffing, and resources for system infection prevention (IP) programs.

Prediction of incident major adverse cardiac events in patients starting haemodialysis for end stage kidney disease, using clinical laboratory cardiac biomarkers - a real world analysis.

Abstract Background and Aims Despite its many advantages, haemodialysis (HD) is associated with increased cardiovascular mortality and morbidity, with some studies reporting 48% higher mortality within 2 years of starting HD. Cardiac biomarkers provide insight into cardiac structure and function, including myocyte stress, inflammation and fibrosis. We aimed to investigate the prognostic significance of routine cardiac biomarkers (troponin and natriuretic peptides) in the prediction of incident major adverse cardiac events (MACE) within 5 years if commencing HD. Methods A retrospective cohort study was performed using electronic medical records from a global federated research network from the US. The network was searched on 26th February 2023. The cohorts commenced HD post-diagnosis of end-stage kidney disease. Data censoring for MACE was invoked prior to the index event of HD. Cardiac biomarkers were the first reported result within 3 months of starting HD. Cohorts were grouped according to biomarker-specific thresholds and 1:1 propensity-score matched for age, gender and co-morbidities (hypertension, diabetes mellitus and smoking status). Logistical regression produced odds ratios with 95%CI for 5-year incident MACE. MACE was defined, a priori, as a composite of ischaemic heart disease, angina pectoris, acute myocardial infarction, heart failure, AF, stroke and all-cause mortality. All statistical analysis was performed on the online platform. Results The results are shown Tables 1(Troponin I and BNP alone) and 2 (Combined Troponin I and BNP). Results that reached statistical significance (p&amp;lt;0.05) are shown. Conclusion Routinely available cardiac biomarkers can predict MACE and cardiac outcomes in incident HD, although results differ between markers of myocyte injury (troponin) and stress (BNP). A combined approach may prove most beneficial. The results suggest the clinical need for CV mortality and morbidity risk profiling in incident dialysis using a combination of clinical and laboratory variables and the need for prospective validation.Table 1Table 2

PCSK9 inhibitors in HIV patients with dyslipidemia

Abstract Introduction Cardiovascular disease has become increasingly prevalent in the HIV (human immunodeficiency virus) population. Antiretroviral therapy and HIV itself independently increase the risk of dyslipidemia. While statins are currently the predominant therapy to treat dyslipidemia in HIV patients, drug-drug interactions and adverse drug events can limit their use. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a naturally occurring inhibitor of the LDL-receptor pathway. PCSK9 inhibitors offer an alternative in patients who cannot tolerate or need additional therapy in addition to statin for optimal dyslipidemia management. Purpose The purpose of this study is to compare major adverse cardiovascular events in HIV patients on a PCSK9 inhibitor (evolucumab, alirocumab, inclisiran) vs patients not on a PCSK9 inhibitor. Methods A retrospective cohort study was conducted using electronic medical records from a global federated health research network. The TriNetX network was searched on February 10, 2024, including records from 2020 to 2024. Patients were included based on a diagnosis of HIV status and concomitant dyslipidemia. Patients with HIV and dyslipidemia on a PCSK9 inhibitor were propensity-score matched for age, sex, race, and comorbidities with patients who were not on a PCSK9 inhibitor. The outcomes were mortality, myocardial infarction, heart failure and stroke. Results A total of 485 patients were included in the study. PCSK9 inhibitor use associated with 9% lower odds of all-cause mortality (odds radio, .29; 95% CI, 0.18-0.48; p&amp;lt;.0001). PCSK9 inhibitor use was also associated with 8% lower odds of heart failure (odds radio, .63; 95% CI, 0.47-0.85; p&amp;lt;.0023). No significant associations were noted for myocardial infarction (odds radio, .87; 95% CI, 0.63-1.21; p=0.406) or stroke (odds radio, .67; 95% CI, 0.45-1.01; p=0.052). Conclusion The role of dyslipidemia in HIV is challenging due the complex pathophysiology of HIV. There is an apparent increased risk of cardiovascular disease from the infection itself as well current antiretroviral therapies. While current guidelines recommend the use of statins as first line therapy for dyslipidemia in this population, the drug-drug interaction of statins with ARTs, as well as their side effects, limit their use at times. PCSK9 inhibitors are associated with lower odds of all-cause mortality and heart failure. No significant association was seen for myocardial infarction or stroke. They should be considered as an early intervention alongside statins in HIV patients with dyslipidemia. Further research should be done for the long term safety and tolerance of this therapy as well as cost-effectiveness and access to PCSK9 inhibitors in this population.

Lyme disease in UK primary care: a knowledge, attitude and practice survey.

Lyme disease (LD) cases in the UK most commonly present within the primary care setting. Despite an upward trend of incidence, little is known regarding general practitioner (GP) experience with diagnosis and treatment. This study aims to describe baseline primary care clinician Knowledge, Attitude and Practice (KAP) in Scotland and England. Online KAP survey on Lyme disease for UK based practising GPs. An online KAP questionnaire was developed for use in UK primary care. The survey was distributed through UK based research networks, professional societies and via social media. 191 complete responses were analysed (England n=130, Scotland n=61). The Scotland-based respondent group had more relevant consultations in the previous 3 years. Respondents from Scotland demonstrated a greater awareness that erythema migrans (EM) is pathognomonic for Lyme disease and that serological testing of this patient group is not indicated. Less common cardiac and neurological symptoms were not as well associated with Lyme disease by both respondent groups for the former and England-based respondents for the latter. Prescribing according to the National institute for Health and Care Excellence (NICE) guidance was identified in 70% of Scotland and 42% of England-based GP responses. Targeted resources may improve clinician confidence on exposure risk, symptom recognition, testing limitations and treatment dose and duration. Scotland-based respondents' better survey performance potentially reflects greater clinical exposure and public awareness of the disease, due to high endemicity within the nation.

Double standards in status ascriptions? The role of gender, behaviors, and social networks in status orders among adolescents

Abstract We examine the gendered distribution of peer-ascribed status in schools. Using network data from more than 14,000 students in 676 classrooms, we explore gender differences in the ascription of status and the types of behavior rewarded with status. On average, girls receive slightly fewer status ascriptions than boys, and students tend to grant status more frequently within the same gender. Contextual analyses show that classroom demographics can moderate some of these patterns. We also uncover gender-specific differences and similarities in status-related behaviors. Notably, girls engaging in substance use are awarded with slightly more status ascriptions than boys. However, network models reveal that most behaviors affect peer status similarly for both genders, suggesting that previous findings of gender-behavioral differences based on regression analysis may be conflated with network processes. Our study updates long-held notions regarding gendered status orders in schools and highlights the value of a multidimensional approach to status processes. We discuss implications for future social network research on status ascriptions and other relational cognitions and consider how school-based interventions might benefit from our findings.

The LTAR Croplands Common Experiment at the Gulf Atlantic Coastal Plain.

The Gulf Atlantic Coastal Plain (GACP) Long-Term Agroecosystem Research (LTAR) Network site is characterized by hot and humid summers with low gradient stream channels surrounded by wetland forests and croplands. Beneath its sandy soils, a confining layer stifles recharge to the deeper aquifer system, so a substantial proportion of streamflow is driven by shallow subsurface baseflow. Agricultural practices in the area consist of forage and livestock production, forestry, and rotational cropping systems dominated by cotton (Gossypium hirsutum) and peanut (Arachis hypogaea). Certain factors impose challenges to the viability of GACP agricultural systems, like changing economics and demographics, as well as pest and disease pressures. The GACP communicates with stakeholders from various backgrounds, who provide their perspectives as agricultural research service scientists execute their research plans. The GACP LTAR common experiment (CE) is carried out via plot- and field-scale studies. The plot-scale CE compares prevailing practices, determined from regional data, with an alternative treatment including winter covers, such as the biofuel feedstock carinata (Brassica carinata, A. Braun), to provide both economic and environmental benefits. The field-scale CE is observational; key variables are monitored for two farms where management practices largely emulate the prevailing treatment. Data collection efforts quantify vegetation, hydrology, soils, and climate data to produce datasets for modeling and statistical analysis. Research teams quantify relationships between land management, environment, and socioeconomic benefits. Ultimately, the GACP LTAR site works to facilitate agricultural system health and wellbeing at local, regional, and national scales by providing long-term science-based solutions.

The LTAR Croplands Common Experiment at Upper Mississippi River Basin-Ames.

Agricultural systems evolve from the interactions of climate, crops, soils, management practices (e.g., tillage, cover crops, nutrient management), and economic risks and rewards. Alternatives to the corn (Zea mays L.)-soybean [Glycine max (L.) Merr.] (C-S) cropping systems that dominate in the US Midwest may provide more sustainable use of resources, reduce the documented environmental impacts of current C-S systems, and improve production efficiency and ecosystem services. Innovative management practices are needed to offer producers options to increase farm resilience to variable weather conditions and offset negative environmental impacts. In response to this need, the Upper Mississippi River Basin Long-Term Agroecosystem Research network site at Ames, IA, established a cropland experiment in 2016 to investigate an alternative crop management system that includes reduced tillage, cover crops, and right source, right rate, right time, and right place (4R) nitrogen (N) management. The experimental site is located on the Iowa State University Kelley Research Farm in Boone County, IA. Crop, soil, air, and tile drainage water measurements are made throughout the year using published methods for each agronomic and environmental metric. Our goal is to provide quantitative information to farmers, consultants, agribusiness partners, and state and federal agencies to help guide decisions on the effective use of alternative management practices. Future changes in experimental treatments will adopt a knowledge co-production approach whereby researchers and stakeholders will work collaboratively to identify problems, implement research protocols, and interpret results.

Explainable Optimisation through Online and Offline Hyper-heuristics

Abstract - Research in the explainability of optimisation techniques has largely focused on metaheuristics and their movement of solutions around the search landscape. Hyper-heuristics create a different challenge for explainability as they make use of many more operators, or low-level heuristics and learning algorithms which modify their probability of selection online. This paper describes a set of methods for explaining hyper-heuristics decisions in both online and offline scenarios using selection hyper-heuristics as an example. These methods help to explain various aspects of the function of hyper-heuristics both at a particular juncture in the optimisation process and through time. Visualisations of each method acting on sequences provide an understanding of which operators are being utilised and when, and in which combinations to produce a greater understanding of the algorithm-problem nexus in hyper-heuristic search. These methods are demonstrated on a range of problems including those in operational research and water distribution network optimisation. They demonstrate the insight that can be generated from optimisation using selection hyper-heuristics, including building an understanding of heuristic usage, useful combinations of heuristics and heuristic parameterisations. Furthermore the dynamics of heuristic utility are explored throughout an optimisation run and we show that it is possible to cluster problem instances according to heuristic selection alone, providing insight into the perception of problems from a hyper-heuristic perspective.

Atmospheric Neutron Single Event Effects Research of Multiple Convolutional Neural Networks based on 28 nm and 16 nm SoC

Abstract The single event effects (SEEs) evaluations caused by atmospheric neutrons were conducted on three different convolutional neural network (CNN) models (Yolov3, MNIST, and ResNet50) in the atmospheric neutron irradiation spectrometer (ANIS) at the China Spallation Neutron Source (CSNS). The Yolov3 and MNIST models were implemented on the XILINX 28 nm system-on-chip (SoC). Meanwhile, the Yolov3 and ResNet50 models were deployed on the XILINX 16 nm FinFET UltraScale+ MPSoC. The atmospheric neutron SEEs on the tested CNN systems were comprehensively evaluated from six aspects, including chip type, network architecture, deployment methods, inference time, datasets, and the position of the anchor boxes. The various types of SEE soft errors, SEE cross-sections, and their distribution were analyzed to explore the radiation sensitivities and rules of 28 nm and 16 nm SoC. The current research can provide the technology support of radiation-resistant design of CNN system for developing and applying high-reliability, long-lifespan domestic artificial intelligence chips.

Biomarkers of microbial translocation and generalized inflammation are associated with frailty among people with HIV.

Frailty occurs at higher rates and younger ages among people with HIV (PWH) compared to the general population and is often attributed to chronic inflammation and subsequent immune exhaustion. We assessed how inflammatory biomarkers are associated with frailty among PWH. The Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort is comprised of adult PWH in care at 10 sites, and harmonizes demographic, clinical, and patient-reported outcomes (PRO) data. A panel of 13 inflammatory biomarkers was collected from a subset of virally suppressed PWH once per person between 2010-2018. Frailty was measured with a validated PRO phenotype, scored 0-4, from biomarker collection date through July 2022. With adjusted linear mixed models, we estimated longitudinal associations between standard deviation-scaled log2-transformed biomarkers and frailty score. Among 273 PWH, most were male (91%), average age at baseline was 45, 42% were non-Hispanic White while 35% were non-Hispanic Black, and average follow-up time was 5.5 years. Several biomarkers were associated with higher frailty, including those linked to microbial translocation (sCD14, LBP, KT ratio) and systemic inflammation (CRP, IL-6, suPAR, sTNFR1, sTNFR2). Higher IL-6 was associated with a 0.25-point higher frailty score (95%CI:0.12-0.39). Higher sTNFR1 (0.35 [0.13-0.56]), sCD14 (0.21 [0.11-0.31]), and suPAR (0.24 [0.11-0.36]) levels were also associated with higher frailty scores over follow-up. Higher levels of biomarkers linked to microbial translocation and systemic inflammation are associated with higher average frailty scores over time in a cohort of virally suppressed PWH, highlighting these pathways as potential interventional targets for mitigating frailty in PWH.

Re-Designing Secure Children’s Homes Through a Child-First Lens

This article explores existing learning gaps concerning optimal ways to support children within and beyond secure care in England and Wales, with a specific focus on Secure Children’s Homes (SCHs). Insights from key stakeholders working in SCHs are often omitted from research despite being fundamental to understanding both challenges and best-practice initiatives. The Children’s Residential Care Research Network, which is a collaboration between the authors, aims to develop novel research with stakeholders working across the secure children’s estate and expand the extant literature to inform the design and build of future Secure Children’s Homes (SCH) through a Child-First lens. The research presented here involves a mixed-methods approach gathering rich qualitative data from participants across the sector. Fifty-three participants engaged in participatory methodologies, focus groups, and interviews, which led to a large data set. Thematic analysis identified three key themes to inform the design and build of new SCHs. SCHs should (i) be close to home to enable family involvement and continuity of care, (ii) feel like a home, and (iii) be flexible and adaptive to changing needs. These findings are feeding into the design of two new homes in England as well as the refurbishment of existing provision and can also influence future expansion of the secure estate. The research also contributes to knowledge about how the Child-First tenets can be engaged to improve outcomes for children deprived of their liberty, both in and outside the youth justice system.

Adherence to Pediatric Screening.

Preventive screenings in children encourage maintenance of optimal cardiovascular health, but gaps may exist between recommendations and clinical practice. We evaluated adherence to pediatric guidelines for universal age-based and risk-based screening for body mass index, blood pressure, lipids, and blood glucose. We used 2010 to 2018 ambulatory visit data from children aged 2 to 12 years within CAPRICORN (Chicago Area Patient-Centered Outcomes Research Network), an electronic health record network in Chicago. This study included 87 549 children who attended 197 559 well-child encounters. Across all encounters, children were 51.5% male and mean (SD) age 6.4 (3.3) years. For each child who attended a well-child visit and met age and/or risk-based criteria, receipt of body mass index, blood pressure, lipids, and/or hemoglobin A1c or fasting blood glucose measurements were assessed. We used generalized estimating equations to calculate proportion adherence for each metric overall and stratified by age, sex, race and ethnicity, and insurance status. Universal age-based screening prevalence (95% CI) per 100 eligible visits was 77.1 (76.8-77.3) for body mass index, 33.4 (33.1-33.7) for blood pressure, and 9.6 (9.3-9.9) for lipids. Risk-based screening prevalence (95% CI) per 100 eligible visits was 13.9 (12.2-15.9) for blood pressure, 6.9 (6.4-7.5) for lipids, and 13.3 (12.6-14.1) for blood glucose. Early screening of cardiovascular health risk factors could lead to earlier interventions, which could alter cardiovascular health trajectories across the lifetime. Low-to-moderate levels of adherence to universal age-based and risk-based cardiovascular health screening highlight the gap between recommendations and clinical practice, emphasizing the need to understand and address barriers to screening in pediatric populations.

Family caregivers’ administration of medications at the end-of-life in China: a qualitative study

BackgroundEffective medication management is crucial for ensuring timely pain and symptom control at the end of life. Dying in pain is a major concern for patients, yet some find less effective pain control at home. Family caregivers (FCGs) play a vital role in managing pain and symptom control for dying patients. However, the experience of administering medications at home for terminal-stage patients has not been widely recognized or understood. Our study aimed to explore the experiences of FCGs in administering medications to adult dying patients.MethodsWe conducted a directed content analysis of data from 73 semi-structured interviews with FCGs across 19 Chinese provinces from 2021 to 2023. FCGs were recruited through the Voluntary Cooperative Network Research. We asked, “Could you recall the end-of-life care process for the patients?” We aligned the themes with the five issues identified by Wilson et al. (2018): administration, organizational skills, empowerment, relationships, and support.ResultsFCGs in China exhibit concerns about over-engagement and empowerment in medication administration, concealing medication information from the patient, and medication accessibility. FCGs faced significant challenges in accurately identifying and addressing pain and symptoms, determining appropriate dosages, accessing effective medications, and managing the emotional stress associated with potential medication errors. Financial burden, medication regulatory restrictions, geographical inequality, and travel restrictions during COVID impeded patients and FCGs from accessing medication. A culturally specific finding is the use of alternative medicine at the end of life.ConclusionOur findings build upon Wilson et al.‘s framework and extend their insights on empowerment, highlighting the need for policies to support home-based palliative care professionals in training FCGs for effective medication administration.