Routine Implementation Research Articles

Computational Stabilization of a Non‐Heme Iron Enzyme Enables Efficient Evolution of New Function

AbstractDeep learning tools for enzyme design are rapidly emerging, and there is a critical need to evaluate their effectiveness in engineering workflows. Here we show that the deep learning‐based tool ProteinMPNN can be used to redesign Fe(II)/αKG superfamily enzymes for greater stability, solubility, and expression while retaining both native activity and industrially relevant non‐native functions. This superfamily has diverse catalytic functions and could provide a rich new source of biocatalysts for synthesis and industrial processes. Through systematic comparisons of directed evolution trajectories for a non‐native, remote C(sp3)−H hydroxylation reaction, we demonstrate that the stabilized redesign can be evolved more efficiently than the wild‐type enzyme. After three rounds of directed evolution, we obtained a 6‐fold activity increase from the wild‐type parent and an 80‐fold increase from the stabilized variant. To generate the initial stabilized variant, we identified multiple structural and sequence constraints to preserve catalytic function. We applied these criteria to produce stabilized, catalytically active variants of a second Fe(II)/αKG enzyme, suggesting that the approach is generalizable to additional members of the Fe(II)/αKG superfamily. ProteinMPNN is user‐friendly and widely accessible, and our results provide a framework for the routine implementation of deep learning‐based protein stabilization tools in directed evolution workflows for novel biocatalysts.

Results of a survey of anesthesiologists and resuscitation specialists: possible prediction and diagnosis of cardiac complications after non-cardiac surgery

Relevance. A critical task of modern anesthesiology and resuscitation is the prediction and diagnosis of cardiac complications after non-cardiac surgeries. There are clinical guidelines for reducing the incidence of such complications; however, in practice, routine implementation of the full-risk stratification algorithm is not always performed. Objective. To assess the possibility of predicting and diagnosing cardiac complications after non-cardiac surgeries in medical organizations of constituent entities of the Russian Federation with a population of less than 1 million people. Materials and methods. An anonymous online survey of anesthesiologists and resuscitators of one of the constituent entities of the Russian Federation was developed using Yandex Forms.Results. We processed 62 completed questionnaires. Cardiac complications during the postoperative period are registered by 33 (53.2 %) respondents. Cardiac risk indices were used by 10 (16.1 %) physicians and load tests (treadmill, bicycle ergometry) by 9 (14.5 %). Routine ECG monitoring after surgery was performed by 27 (43.5 %) respondents. Cardiac-specific troponin determination is available to 60 (96.8 %) physicians; however, only 6 (9.7 %) respondents measured it routinely before surgery and 4 (6.5 %) respondents measured it after surgery. Natriuretic peptide or its prohormone determination is available to 19 (30.6 %) physicians; however, only 3 (4.8 %) prescribe it before surgery and 0 after surgery. The possibility of performing echocardiography before and after surgery was noted by 54 (87.1 %) respondents. Only 9 (14.5 %) respondents reported that their hospital could perform coronary angiography.Conclusions. The results of this survey revealed that many cardiac complications could have been missed because of insufficient preoperative prognosis and postoperative diagnostic data.

Fastidious adherence to 0/1-hour high-sensitivity troponin T testing reduces emergency department length of stay in patients presenting with suspected acute coronary syndromes

Abstract Background High-sensitivity cardiac troponins (hs-cTn) are key clinical biomarkers in patients presenting with suspected acute coronary syndromes (ACS) to Emergency Departments (EDs). They have facilitated rapid 0h/1h troponin testing protocols, leading to safe, effective, and efficient triage of patients. However, early distinction of myocardial infarction (MI), which has a reported frequency of less than 10% in most cohorts, from the apparently stable hs-cTn elevations of chronic myocardial injury (CMI) remains a challenge. Often CMI patients require confirmation by further testing and observation, prolonging patient length of stay. Further, reliably obtaining serial hs-cTn samples at 60-minutes in a busy ED setting may be difficult. A potential explanation for only 5-6% of Australian sites adopting 0h/1h hs-cTn testing. Methods and Results We undertook a case-control study between March and August 2023 among patients with suspected ACS presenting to Liverpool Hospital ED (Sydney, Australia). 185 patients (cases) underwent hs-cTnT sampling at 30- and 60-minutes (± 5 minutes) after baseline. Diagnosis of MI was made in 8.6%, 35.7% were placed into a further observation group and MI ruled-out in 55.7%. The latter two groups were matched to 169 patients (controls) who received ‘usual’ care, which was a 0h/1h hs-cTnT testing protocol. The case and control arms were matched by age, gender, time from symptom onset and main presenting symptom. Control patients had a median sampling interval of 118 [85 to 174] minutes, rather 60 minutes as the protocol directs. When comparing the paired differences between the case and control arms, there was a mean reduction in length of stay of 104 (95% CI: 41 to 186, P = 0.01) and 47 (95% CI: 11 to 84, P = 0.01) minutes, for the observation and rule-out MI groups respectively. The figure shows the distribution of lengths of stay by group. Among the rule-out group, Wilcoxon signed rank test indicated the control arm had a longer median length of stay of 6.3 [5.1 to 8.4] hours, compared to 5.0 [4.5 to 7.1] hours in the case arm (P=0.005). Similarly, in the further observation group, control patients also had a longer median length of stay of 9.2 [6.9 to 10.4] hours compared to case patients of 8.1 [5.1 to 10.3] hours (P = 0.009). At 30-days, ED representation rates were 10.7% in controls and 8.3% in cases, rehospitalisation 3.6% in controls and 5.3% in cases, cardiac death 0% in both arms and non-cardiac death 1% in both arms. There were no differences in event rates between each arm (P > 0.05). Conclusion Accurate 0h/1h hs-cTnT testing reduces patient length of stay in ED and offers more personalised prediction of MI risk. The importance of adherence to protocol-directed sampling times is clear, where further studies are required regarding routine implementation in a busy ED setting.Exact 60 min TnT and LOSOutcomes at 30 days

Digital health in the EP lab: routine implementation of remote access and technical support for complex ablation procedures

Abstract Background Complex electrophysiological procedures are performed using three-dimensional (3D) electroanatomical mapping (EAM) systems, which are usually operated on site, by field technical engineers (FTE). Due to a lack of skilled personnel, the engineers usually must travel between different hospitals and the procedures have to be planed in advance. Remote access (RA) technologies were recently implemented in clinical practice, aiming to increase the flexibility in the EP lab and maximise healthcare resources use. Methods Electroanatomical mapping was performed remotely by means of an integrated audio-visual solution for RA. The operator and the FTE communicated exclusively using the RA system, while the latter worked only in home office. Consecutive procedures were prospectively enrolled and analysed in terms of indication, procedural characteristics, feasibility and saved travelled time by the FTA. Results Between September 2022 and July 2023, a total of 133 EP procedures were performed in a high volume, tertiary electrophysiological centre in Germany. The mean age was 67 (57.5, 75.5) years. Women represented 39.8% of the population. The median BMI was 26.2 (23.1, 30.3) Kg/m2. A total of 56 (42.1%) patients underwent an atrial fibrillation ablation procedure (37.5% paroxysmal), 22 (16.5%) an atrial tachycardia ablation, 13 (9.8%) cavotricuspid isthmus ablation, 15 (11.3%) supraventricular tachycardia ablation, 14 (10.5%) a premature ventricular contraction ablation, 12 (9%) ventricular tachycardia ablations and 1 patient an electrophysiological diagnostic study. The median time length of procedure was 130 (96.5, 168) minutes. The median number of radiofrequency applications was 63.5 (22.3, 109.5), while the median RF time was 14.2 (6.9, 25.1) minutes. The fluoroscopy time was 9.2 (6.5, 12.6) minutes, with a median radiation dose of 408.5 (233.0, 631.8) cGy x cm2. The median amount of contrast media was 40 (8.75, 50.0) ml and the median amount of heparin administered was 12000 (8000, 16000) UI. Protamine was used in 9 cases, with a median of 7000 (5000, 7000) UI. Except for one supraventricular procedure, where no arrhythmia induction was possible, all procedures were successful. One major complication was observed. In one case, the internet-based headphone connection was not stable. Therefore, the communication was established via a conventional smartphone. No change to on-site support was needed. The travel time reduction was available in 130 cases. In total, 290 travel hours could be saved. Conclusion The routine implementation of RA for complex EP procedures proved to be safe and efficient. This approach has the potential to increase the feasibility in case of emergency procedures, reduce travel times for FTE and streamline healthcare resources allocation.

Adherence to the ABC pathway improves prognosis in patients with AF: preliminary findings from an updated meta-analysis of 360,000 patients

Abstract Background With the increasing complexity of patients with Atrial Fibrillation (AF), the ‘Atrial Fibrillation Better Care’ (ABC) pathway was proposed to streamline a holistic approach for the comprehensive management of patients with AF. The ABC pathway is based on three main pillars: ‘A’ Avoid stroke (through optimal anticoagulant use); ‘B’ Better symptom control; and ‘C’ Cardiovascular and Comorbidity management optimization. Such a holistic and integrated approach is currently recommended by international guidelines, including the ones from the European Society of Cardiology (ESC); a previous meta-analysis showed sub-optimal adherence to such approach in real-world cohorts, with an overall reduction in the risk of major outcomes in patients treated according to the ABC pathway. We hereby performed an updated systematic review and meta-analysis of the current evidence on the implementation of the ABC pathway in patients with AF. Methods We performed a systematic review and meta-analysis according to PRISMA Guidelines. MEDLINE and EMBASE were searched for all studies reporting data on the prevalence of ABC pathway adherent management in patients with AF, and/or the association between ABC pathway management and the incidence of major outcomes, including all-cause death, cardiovascular death, thromboembolism, and major bleeding. Data on the prevalence of ABC pathway management were pooled using a generalized linear mixed model; number of events and total number of patients were pooled using a random-effect model. Pooled estimates were reported as odds ratios (OR) and 95% Confidence Intervals (95%CI); heterogeneity was estimated using the restricted maximum-likelihood estimator, and the Inconsistency index (I2) was also reported. Results 4,059 articles were retrieved from the literature search; after duplicates removal, title and abstract screening and full-text evaluation, 16 studies were included, for a total of more than 360,000 patients. Pooled prevalence of adherence to the ABC pathway was 28.5% (95%CI: 21.1-37.3%, I2=100%; Figure 1). Adherence to the ABC pathway was associated with a significant lower risk of all-cause death (pooled OR: 0.47, 95%CI: 0.40-0.56, I2=97%), cardiovascular death (pooled OR: 0.43, 95%CI: 0.33-0.56, I2=95%) and stroke (pooled OR: 0.61, 95%CI: 0.47-0.79, I2=91%; Figure 1). Patients treated adherent to the ABC pathway also showed a lower risk of major bleeding (pooled OR: 0.77, 95%CI: 0.66-0.90, I2=85%). Conclusions In this updated systematic review and meta-analysis, adherence to the ABC pathway was found in less than one-third of patients with AF. Implementation of the ABC pathway was associated with lower risk of all major adverse events in patients with AF, including all-cause death, and thromboembolic and bleeding events. These data further reinforce the need for routine implementation of the ABC pathway for the management of AF in clinical practice.Figure 1

The potential promise and pitfalls of point-of-care viral load monitoring to expedite HIV treatment decision-making in rural Uganda: a qualitative study

BackgroundHIV treatment programs in Africa have implemented centralized testing for routine viral load monitoring (VLM), which may result in specimen processing delays inhibiting timely return of viral load results. Decentralized, point-of-care (PoC) VLM is a promising tool for expediting HIV clinical decision-making but remains unavailable in most African settings. We qualitatively explored the perceived feasibility and appropriateness of PoC VLM to address gaps along the viral load monitoring continuum in rural Uganda.MethodsBetween May and September 2022, we conducted 15 in-depth interviews with HIV clinicians (facility in-charges, clinical officers, nurses, counselors) and six focus group discussions with 47 peer health workers from three south-central Ugandan districts. Topics explored centralized VLM implementation and opportunities/challenges to optimizing routine VLM implementation with PoC testing platforms. We explored perspectives on PoC VLM suitability and feasibility using iterative thematic analysis. Applying the Framework Method, we then mapped salient constraints and enablers of PoC VLM to constructs from the Consolidated Framework for Implementation Research.ResultsClinicians and peers alike emphasized centralized viral load monitoring’s resource-intensiveness and susceptibility to procedural/infrastructural bottlenecks (e.g., supply stockouts, testing backlogs, community tracing of clients with delayed VLM results), inhibiting timely clinical decision-making. Participants reacted enthusiastically to the prospect of PoC VLM, anticipating accelerated turnarounds in specimen processing, shorter and/or fewer client encounters with treatment services, and streamlined efficiencies in HIV care provision (including expedited VLM-driven clinical decision-making). Anticipated constraints to PoC VLM implementation included human resource requirements for processing large quantities of specimens (especially when machinery require repair), procurement and maintenance costs, training needs in the existing health workforce for operating point-of-care technology, and insufficient space in lower-tier health facilities to accommodate installation of new laboratory equipment.ConclusionsAnticipated implementation challenges, primarily clustering around resource requirements, did not diminish enthusiasm for PoC VLM monitoring among rural Ugandan clinicians and peer health workers, who perceived PoC platforms as potential solutions to existing inefficiencies within the centralized VLM ecosystem. Prioritizing PoC VLM rollout in facilities with available resources for optimal implementation (e.g., adequate physical and fiscal infrastructure, capacity to manage high specimen volumes) could help overcome anticipated barriers to decentralizing viral load monitoring.

Mapping the distribution of tuberculosis cases and associated factors identified through routine program implementation and community-based active screening in Central Ethiopia.

Smear-positive TB patients greatly contribute to community-level transmission of this disease. Locating hotspots would make it easier to prioritize and target control interventions. This study aimed to assess the spatial distribution of smear-positive index TB cases and their secondary cases and the predictors of clustering of smear-positive TB cases. This study was conducted in the Silti Zone of Central Ethiopia from 2020 to 2022. The data of smear-positive index TB patients were collected from the unit TB registries of healthcare facilities. Contacts of all index TB patients were screened in the community and tested to identify secondary TB patients. We performed spatial analysis, including Moran's I statistic, the Getis-Ord Gi* statistic and geographically weighted regression (GWR), to assess the global distribution, local clustering and predictors of clustering of smear-positive TB patients, respectively. Additionally, we used inverse distance weighting (IDW) interpolation to predict the distribution of smear-positive TB cases and develop a continuous raster map for places with no data. Spatial autocorrelation analysis revealed that the distribution of smear-positive TB patients exhibited significant clustering (Moran's I = 0.70029; p value < 0.000). The Getis-Ord Gi* output indicated the presence of statistically significant hotspots as well as cold spots in the study area. Significant hotspots were found in 11 Kebeles of the Silti, Dalocha and Misrak Silti districts. Significant coldspots were also found in five kebeles of the Silti and Misrak districts. GWR analysis revealed that no education, primary education, family size and thatched roof houses were significant predictors of the spatial clustering of smear-positive TB cases. We also found that the majority of the secondary TB cases were found in hotspots identified through spatial analysis. The study revealed a heterogenous distribution of smear positive TB in the study area and it could act as a model that can be replicated in other regions. The identified hotspots of TB could be targeted through location-based interventions such as systematic active screening in the form of outreach programs to improve the performance of TB prevention and control, including reducing the transmission of TB. Educational status, family size and housing type were some of the factors that significantly influenced the spatial distribution of smear-positive TB in the study area. The distribution of secondary TB cases found through household contact screening coincided with the identified hotspots, indicating greater transmission of the disease in these places.

Computational Stabilization of a Non-Heme Iron Enzyme Enables Efficient Evolution of New Function.

Deep learning tools for enzyme design are rapidly emerging, and there is a critical need to evaluate their effectiveness in engineering workflows. Here we show that the deep learning-based tool ProteinMPNN can be used to redesign Fe(II)/αKG superfamily enzymes for greater stability, solubility, and expression while retaining both native activity and industrially relevant non-native functions. This superfamily has diverse catalytic functions and could provide a rich new source of biocatalysts for synthesis and industrial processes. Through systematic comparisons of directed evolution trajectories for a non-native, remote C(sp3)-H hydroxylation reaction, we demonstrate that the stabilized redesign can be evolved more efficiently than the wild-type enzyme. After three rounds of directed evolution, we obtained a 6-fold activity increase from the wild-type parent and an 80-fold increase from the stabilized variant. To generate the initial stabilized variant, we identified multiple structural and sequence constraints to preserve catalytic function. We applied these criteria to produce stabilized, catalytically active variants of a second Fe(II)/αKG enzyme, suggesting that the approach is generalizable to additional members of the Fe(II)/αKG superfamily. ProteinMPNN is user-friendly and widely accessible, and our results provide a framework for the routine implementation of deep learning-based protein stabilization tools in directed evolution workflows for novel biocatalysts.

Desenvolvimento de plug-in BIM para verificação de conformidade de Projetos Arquitetônicos segundo as Leis Municipais – O Caso de Passo Fundo/RS

The construction industry plays a significant role in job creation and the socioeconomic development of cities. However, architects and urban planners face challenges due to the delay in the approval of architectural projects by municipal governments, attributed to the non-compliance of projects with local laws. In this context, this study proposes the use of programming in BIM (Building Information Modeling) software, with the aim of developing a plug-in to assist in the process of approving architectural projects in compliance with the municipal laws and regulations of Passo Fundo-RS. The methodology adopted was based on a thorough literature review, document analysis, and the development of a plug-in prototype for Revit, developed in Dynamo using the Python language. The proposed prototype involves the integration of urban data into Revit to automate the collection of information such as building dimensions, lot areas, setbacks, and other metrics. The results revealed that the implementation of programming routines in BIM, especially for Revit, has the potential to significantly reduce the waiting times for project approvals by the municipal government, improve their compliance with local regulations, and minimize pending issues and rework.

Class V Students' Environmental Concern Attitude Through Clean and Healthy Friday Activities

This research is motivated by the many cases of environmental pollution and careless waste disposal which can trigger environmental damage. Even though the function of the environment is very important in supporting human life. So, a caring attitude towards the environment must be implemented from an early age. This research aims to describe the environmental care attitudes of students at SD Negeri 1 Bantrung through clean and healthy Friday activities. This type of research uses qualitative research with a case study approach. The case study approach aims to comprehensively reveal the values​​of caring character in clean and healthy Friday activities. Data collection techniques use observation, interviews and documentation obtained by researchers during research implementation. This research was carried out at SD Negeri 1 Bantrung. Based on the results of research, students' environmental care attitudes towards the environment are quite good, students can love the surrounding environment with 5 indicators of environmental care attitudes, 4 of which are appropriate, namely saving electricity and water by using enough, the availability of rubbish bins and hand washing facilities available in the area. . in each class, maintain the cleanliness of the school environment by participating in maintaining the cleanliness of the environment, providing bathrooms and sufficient clean water for all school residents. A caring attitude towards the environment is instilled at the educational level through the routine implementation of clean and healthy Friday activities. Clean and healthy Friday activities have a positive impact on caring attitudes towards the environment.

Remote coaching for supporting the implementation of treatment for depression in primary care in Madhya Pradesh, India: protocol for a cluster randomized controlled trial.

Upwards of ninety percent of individuals living with depression in India do not have access to evidence-based treatments, especially in rural areas. Integrating these treatments into primary care is essential for bridging this care gap. This trial aims to evaluate whether a remote coaching implementation support strategy, referred to as Enhanced Implementation Support, is superior to routine support, referred to as Routine Implementation Support, in supporting the delivery of collaborative depression care in rural primary care centers. Employing a cluster-randomized hybrid type-III implementation trial design, 14 primary care facilities in Sehore district, Madhya Pradesh, will implement a collaborative depression care package based on the WHO's mhGAP program. Facilities will be randomized to either Enhanced Implementation Support or the Routine Implementation Support control condition. Enhanced Implementation Support consists of remote coaching and technical assistance, supplemented with in-person visits, and guided by the Plan-Do-Study-Act implementation cycles. The primary implementation outcome is the proportion of outpatients screened for depression by facility staff, with secondary outcomes including the proportions of outpatients who screen positive for depression, are referred to the medical officer, and initiate treatment. Secondary patient outcomes include proportion of patients who achieve reduction in depression symptom severity at 3-month follow up. Acceptability, feasibility, and fidelity of the depression care package will be assessed through routine observations collected during field visits, facility audits, and qualitative exit interviews with facility staff. Costs of delivering the Enhanced Implementation Support strategy will also be estimated. This trial can inform efforts to integrate depression care in rural primary care facilities in a low-resource setting, and illuminate whether external coaching support is superior relative to existing implementation support for achieving these goals. NCT05264792.

Blurring the Boundaries of Governance: China’s Work Teams in Comparative Perspective

A notable feature of Chinese Communist rule, from revolutionary days on, has been the blurred boundaries of its governance mechanisms. The lines separating formal from informal, legal from illegal, and state from societal have – at least until quite recently – proven exceptionally permeable. This paper focuses on an especially fluid and flexible means of Chinese Communist governance: the deployment of mobile task forces, or “work teams,” for both routine and crisis policy implementation. Directed by higher-levels of the party-state to advance a specific mission at the grassroots, work teams mobilize society in a manner that reflects the continuing influence of China’s revolutionary experience. The paper assesses the contributions and costs of this “campaign-style” of governance in comparison to the practices of other Communist and non-Communist systems, past and present.

Castration-resistant prostate cancer monitoring by cell-free circulating biomarkers.

Prostate cancer is the second leading cause of male cancer-related deaths in Western countries, which is predominantly attributed to the metastatic castration-resistant stage of the disease (CRPC). There is an urgent need for better prognostic and predictive biomarkers, particularly for androgen receptor targeted agents and taxanes. We have searched the PubMed database for original articles and meta-analyses providing information on blood-based markers for castration-resistant prostate cancer monitoring, risk group stratification and prediction of therapy response. The molecular markers are discussed along with the standard clinical parameters, such as prostate specific antigen, lactate dehydrogenase or C-reactive protein. Androgen receptor (AR) alterations are commonly associated with progression to CRPC. These include amplification of AR and its enhancer, point mutations and splice variants. Among DNA methylations, a novel 5-hydroxymethylcytosine activation marker of TOP2A and EZH2 has been identified for the aggressive disease. miR-375 is currently the most promising candidate among non-coding RNAs and sphingolipid analysis has recently emerged as a novel approach. The promising biomarkers have the potential to improve the care of metastatic prostate cancer patients, however, they need further validation for routine implementation.

A Prevention Protocol Reduces Spinal Cord Ischemia in Patients Undergoing Branched/Fenestrated Endovascular Aortic Repair

ObjectivesSpinal cord ischemia (SCI) is a devastating complication that is associated with thoracoabdominal aortic repair, with higher risk associated with increased aortic coverage length, making patients undergoing branched/fenestrated endovascular repair(B/FEVAR) particularly vulnerable. A bundled SCI prevention protocol was previously reported to reduce SCI rates when compared to a historic cohort in a single-center study. Therefore, this analysis aims to further validate and update outcomes associated with the protocol given the routine implementation of this strategy at two institutions (University of Florida [UF] and the University of Alabama at Birmingham [UAB]) since inception. MethodsComponents of the SCI prevention protocol include selective cerebrospinal fluid (CSF) drainage, specified blood pressure parameters, transfusion goals, and selective pharmacologic adjuncts (naloxone, steroids). This protocol was routinely implemented in May 2015. Patients undergoing B/FEVAR from May 2015-December 2022 constituted the post-protocol cohort(n=402) and were compared to the pre-protocol cohort (n=160, January 2010-April 2015). The primary outcome was SCI incidence and subgroup analysis was conducted among patients deemed to be high-risk (Crawford extent I- III thoracoabdominal aneurysms (TAAA) dissection-related disease, prior aortic repair, coverage proximal to zone 5). Survival analysis was performed using Kaplan-Meier methodology. ResultsThe pre- and post-protocol cohorts were demographically similar, though more post-protocol patients were American Society of Anesthesiology(ASA) class IV (86.1% vs. 55.0%; p<0.001). TAAA was the most common indication in both groups. CSF drain placement was more common in the post-protocol group, particularly among high-risk patients. SCI occurred in 15.9% of pre-protocol patients versus 3.0% of post-protocol patients(p<0.001). In high-risk patients, the pre- and post-protocol cohort SCI incidence was 23.2% vs. 5.0%, respectively (p<0.001). 30-day mortality was decreased in the post-protocol cohort (6.3% vs. 2.2%, p=0.02). Although the post-protocol group had a trend toward improved 1-year survival, this was not statistically significant (84.4% vs. 88.3%, log-rank p=0.35). Among SCI patients, one-year mortality was 28% and 33.3% in the pre- and post-protocol groups, respectively(p=0.46). ConclusionImplementation of a bundled SCI prevention protocol significantly reduces SCI rates in B/FEVAR patients, which has now been validated at two institutions, with the most significant reductions occurring among high-risk patients. Although the overall one-year mortality difference was not significantly different between the cohorts, the high mortality rates among SCI patients highlights the importance of preventative measures.

Efficiency of a technology-assisted nutritional screening system: A retrospective analysis of 11,722 admissions in a tertiary hospital

Background and AimNutritional screening is essential for addressing malnutrition and its consequences. However, routine implementation in large hospitals faces several challenges. To overcome these obstacles, the Clinical Nutrition Service of a tertiary hospital developed a technology-assisted nutritional screening system. This study evaluates the system's efficiency in detecting and assessing patients at nutritional risk upon hospital admission. It also examines the association between nutritional risk, clinical outcomes, and sociodemographic characteristics. MethodsThis retrospective, analytical, observational study examined 11,722 hospital admissions of adult patients in 2019, each with a minimum hospital stay of 48 hours in a tertiary hospital. Rates and timing for the detection, referral, and assessment of patients at nutritional risk were calculated. Participants were divided into low (Malnutrition Screening Tool [MST] < 2 points) and moderate/high (MST ≥ 2) nutritional risk groups to evaluate the relationship between nutritional risk and clinical and demographic variables. ResultsWe found that 91% of patients underwent nutritional screening within the first hours of admission, with a median time of 9 hours from admission to screening (interquartile range [IQR] 3-19). The prevalence of nutritional risk (MST ≥ 2) was 21%. All patients identified as being at nutritional risk were immediately referred for a nutritional assessment once identified, with a median referral time of 0 hours (IQR 0-0). This assessment was carried out by a nutritionist for 98% of these patients, with a median time of 19 hours from referral to assessment (IQR 6-24). Compared to the low-risk group, patients with nutritional risk were older, had higher rates of mortality and admission to the intensive care unit (ICU), longer hospital stays, and a higher proportion of men and cancer diagnoses (p=0.00 for all comparisons). After adjusting for age and sex, nutritional risk was significantly associated with a higher probability of ICU admission (Odds Ratio [OR] 1.13; 95% CI 1.02-1.24) and in-hospital mortality (OR 2.32; 95% CI 1.97-2.73). ConclusionThe integration of technology into nutritional screening was highly efficient for early detection and assessment of at-risk patients upon hospital admission. Features of this system could guide other hospitals. The association found between nutritional risk and clinical outcomes emphasizes the importance of prompt and appropriate nutritional interventions.

EDNAqua-Plan—Standardisation Overview for eDNA Sequencing of Aquatic Organisms and the Downstream Data Ecosystem

The eDNAqua-Plan project stands as a beacon of innovation in the biomonitoring of marine and freshwater ecosystems, propelled by the urgent need to integrate DNA-based approaches in aquatic bioassessment and monitoring frameworks. The broad utilisation of cutting-edge environmental DNA (eDNA) and DNA barcoding methodologies is dependent on complete, reliable, and accessible reference DNA sequence data (Rimet et al. 2021). Complete and interoperable metadata is crucial to allow a broad reuse of (e)DNA data and analysis outputs, and for a broader uptake of results by end users. The eDNAqua-Plan project aims to address key limitations to the routine implementation of eDNA-based monitoring methods in Europe by developing plans for federated DNA barcode reference libraries and eDNA data repositories to support DNA-based environmental monitoring. This will ensure a sustainable and reliable infrastructure to underpin its broad use, thereby paving the way for more effective conservation and management strategies. The project is working towards creating a comprehensive overview of standardisation efforts and data workflows, through collaborations with other projects, initiatives and infrastructures for aquatic monitoring across the European Union (EU) and associated countries. We are analysing existing archives (e.g., International Nucleotide Sequence Database Collaboration (INSDC), Barcode of Life Data System (BOLD), Global Biodiversity Information Facility (GBIF), Ocean Biodiversity Information System (OBIS)), portals, and papers to determine current and best practices through the use of questionnaires, manual evaluation of repositories, and machine learning methods (LLMs). This includes an overview of the usage of existing metadata and data standards (e.g., Minimum Information about any (X) Sequence Specifications from the Genomics Standards Consortium (GSC), Darwin Core standard). The results are being integrated by a team of experts in marine and freshwater biomonitoring. With a diverse consortium comprising 18 partner institutions from 11 countries and one international institute, eDNAqua-Plan brings together experts in marine and freshwater monitoring, eDNA analysis, and data science. The collective effort by this consortium will lay the groundwork for the creation of a digital ecosystem of eDNA repositories and an integrated reference library of marine and freshwater species, adhering to FAIR (Findable, Accessible, Interoperable, and Reusable) principles.

Same-day discharge coronary interventions: How to succeed?

Percutaneous coronary interventions(PCI) are the cornerstone of treatment in patients with coronary artery disease, generating substantial costs for the healthcare system. Considerable improvement in PCI technique, stent technology and antiplatelet therapy led to a complication rate of <5%, a success rate of >95% and lack of routine cardiothoracic surgical support. Thereby, the concept of same-day discharge following PCI has been proposed due to comparable efficacy, safety, and socioeconomic benefits to inpatient PCI. Although single-vessel disease was the primary indication for outpatient (OP) PCI, more complex scenarios such as multivessel disease, left main disease and chronic total occlusions were shown to be feasible and safe in OP setting as well. Currently available data shows that OP PCI leads to cost optimization, increased PCI center capacity, decrease in nosocomial infections rate and increased patient satisfaction, along with good clinical outcomes. Although OP PCI seems promising in a subset of well-prepared and compliant patients without severe comorbidities, there are some challenges to overcome before its routine implementation. To prevent unnecessary hospitalizations and unsafe same-day discharges, interventional cardiology teams should be trained to perform reliable risk-benefit assessments. Standardized forms should be created to obtain informed consent and instruct OP PCI patients and their relatives about postprocedural management. Here, we summarize the available data on OP and inpatient PCI outcomes, discuss the opportunities and challenges of OP PCI and propose a periprocedural patient management checklist, with the goal of facilitating OP PCI implementation in interventional cardiology centers.

How do organizations refine their post‐merger integration routines over consecutive acquisitions?

AbstractThe post‐merger integration (PMI) phase of mergers and acquisitions (M&amp;A) can determine M&amp;A success. Little is known about how organizations refine their PMI routines with accumulated M&amp;A experience. This study proposes a process model of PMI‐routine development, where the outcomes of routines enacted in earlier acquisitions shape routines in subsequent acquisitions. We test the model using 312 instances of routine implementation, across five consecutive acquisitions by the same acquiring company, and make two key scholarly contributions. First, we advance prior research by identifying how a routine's level of complexity moderates the association between routine adherence and routine outcomes. Second, we elucidate the effect of learning from failure—uncovering a learning process with performance feedback as input. Specifically, negative routine outcomes at the focal acquisition strengthened the positive effect of the improvisation (low adherence) enacted in the focal acquisition on the subsequent modifications to the codified routine, which are likely to improve its performance in future acquisitions.

Multiplex real-time PCR in non-invasive respiratory samples to reduce antibiotic use in community-acquired pneumonia: a randomised trial

We assessed whether multiplex real-time PCR plus conventional microbiological testing is safe and more effective than conventional microbiological testing alone for reducing antibiotic use in community-acquired pneumonia (CAP). In this randomised trial, we recruited adults hospitalised with CAP at four Spanish hospitals. Patients were randomly assigned (1:1) to undergo either multiplex real-time PCR in non-invasive respiratory samples plus conventional microbiological testing or conventional microbiological testing alone. The primary endpoint was antibiotic use measured by days of antibiotic therapy (DOT). Between February 20, 2020, and April 24, 2023, 242 patients were enrolled; 119 were randomly assigned to multiplex real-time PCR plus conventional microbiological testing and 123 to conventional microbiological testing alone. All but one of the patients allocated to multiplex real-time PCR plus conventional microbiological testing underwent PCR, which was performed in sputum samples in 77 patients (65.2%) and in nasopharyngeal swabs in 41 (34.7%). The median DOT was 10.04 (IQR 7.98, 12.94) in the multiplex PCR plus conventional microbiological testing group and 11.33 (IQR 8.15, 16.16) in the conventional microbiological testing alone group (difference −1.04; 95% CI, −2.42 to 0.17; p = 0.093). No differences were observed in adverse events and 30-day mortality. Our findings do not support the routine implementation of multiplex real-time PCR in the initial microbiological testing in hospitalised patients with CAP. Clinicaltrials.gov registration: NCT04158492.

ESR Essentials: basic physics of MR safety-practice recommendations by the European Society for Magnetic Resonance in Medicine and Biology.

The use of magnetic resonance imaging (MRI) is safe from a long-term perspective since there are no known cumulative risks for patients or personnel. However, the technique comes with several acute risks associated with the powerful electromagnetic fields that are necessary to produce medical images. These risks include, among other things, a projectile hazard, loud noise, and the risk of heating. Safe use of MRI requires knowledge about the different hazards related to MRI and organizational structured work including the implementation of routines describing a safe workflow from the referral of a patient to the signed report. In this article, the risks associated with MRI are described along with suggestions for how each risk can be minimized or eliminated. The aim of this article is to provide support for the development of, and compliance with, MRI safety routines, and to work with the technique in a safe way. The scope of this treatise does not cover specific details of implant safety, however, the physical principles described can be applied to the risk assessment of implants. Establish whether any MR contraindications apply to the patient. Evaluate means to deal with identified risks for both patients and personnel. It is imperative to always perform and document a risk-benefit assessment.