Single Course Research Articles

Association between antenatal corticosteroid treatment and severe adverse events in pregnant women

BackgroundAntenatal corticosteroids are considered the standard of care for pregnant women at risk for preterm birth, but studies examining their potential risks are scarce. We aimed to estimate the associations of antenatal corticosteroids with three severe adverse events: sepsis, heart failure, and gastrointestinal bleeding, in pregnant women.MethodsOf 2,157,321 pregnant women, 52,119 at 24 weeks 0/7 days to 36 weeks 6/7 days of gestation were included in this self-controlled case series study during the study period of 2009–2018. We estimated incidence rates of three severe adverse events: sepsis, heart failure, and gastrointestinal bleeding. Conditional Poisson regression was used to calculate incidence rate ratios (IRRs) for comparing incidence rates of the adverse events in each post-treatment period compared to those during the baseline period among pregnant women exposed to a single course of antenatal corticosteroid treatment.ResultsAmong 52,119 eligible participants who received antenatal corticosteroid treatment, the estimated incidence rates per 1000 person-years were 0.76 (95% confidence interval (CI): 0.69–0.83) for sepsis, 0.31 (95% CI: 0.27–0.36) for heart failure, and 11.57 (95% CI: 11.27–11.87) for gastrointestinal bleeding. The IRRs at 5 ~ 60 days after administration of antenatal corticosteroids were 5.91 (95% CI: 3.10–11.30) for sepsis and 4.45 (95% CI: 2.63–7.55) for heart failure, and 1.26 (95% CI: 1.02–1.55) for gastrointestinal bleeding; and the IRRs for days 61 ~ 180 were 2.00 (95% CI: 1.01–3.96) for sepsis, 3.65 (95% CI: 2.14–6.22) for heart failure, and 1.81 (95% CI: 1.56–2.10) for gastrointestinal bleeding.ConclusionsThis nationwide population-based study suggests that a single course of antenatal corticosteroids is significantly associated with a 1.3- to 5.9-fold increased risk of sepsis, heart failure, and gastrointestinal bleeding in pregnant women. Maternal health considerations, including recommendations for adverse event monitoring, should be included in future guidelines for antenatal corticosteroid treatment.

Is Intradiscal Ozone Injection Effective in Ameliorating Symptoms of Lumbosacral Discopathy?

Background: Oxygen-ozone (O2-O3) gas mixture as a newly prescribed substance became popular among clinicians to relieve low back pain (LBP) in discogenic patients as an alternative method rather than surgery. We developed this study to uncover whether this combination could be helpful in the Middle Eastern population or not.
 Methods: In the present randomized clinical trial, we included 40 patients with L1 to S1 disc herniation assigned to schedule for intervention [a single course of ozone (O3) therapy without corticosteroids] or to consider as the control (physiotherapy including exercises based on extension). All patients were followed with a mean time of 12 weeks after injection, and pain severity and level of quality of life (QOL) were assessed. The severity of disc herniations was evaluated by a spine surgeon within the Michigan State University (MSU) classification frame.
 Results: The current study represented two identical groups regarding lumbosacral segment involvement during 12 weeks of our survey (P > 0.05). The QOL level was equivalent in two groups. The mean pain score was decreased in the intervention group against the control group after two weeks, but it failed to thrive in the further weeks and was raised afterward. On the other hand, the mean pain score for the control group [6.1; 95% confidence interval (CI): 5.4-6.8] proceeded with a steady slope notably lower than the intervention group (7.5; 95% CI: 6.9-8.2) (P < 0.001).
 Conclusion: Patients with LBP do not get more benefit from O2-O3 mixture injection.

Academic satisfaction among university students during the COVID-19 pandemic: the influence of individual, social, and organizational variables

IntroductionAcademic satisfaction (AS) is considered by researchers and educators as a key variable to explain both academic success and the main problems of university students. AS is a complex construct affected by a range of factors, both internal and external to the individual. The aim of this study was to analyze the influence of certain individual (motivation and self-regulated learning), social (relationships with other students and with the instructor) and organizational (course organization and class attendance mode) variables on AS during the Covid-19 emergency, when face-to-face learning was replaced with online learning environments.MethodsWe hypothesized a model in which AS would be directly influenced by the social and organizational variables, and indirectly influenced by the social, organizational, and individual variables via the mediation of perceived learning. The study sample comprised 104 students (83.7% female) with a mean age of 26.6 years (SD = 9.8), enrolled on bachelor’s or master’s degree at a Northern Italian University. Participants filled out an online questionnaire, which they were instructed to complete with reference to a single course that they had taken during the second semester of the 2020–21 academic year.ResultsThe hypothesized model, tested using a structural equation modelling technique for observed variables, offered an acceptable fit for the data [χ2(3) = 7.569, p = 0.0558; RMSEA = 0.121; CFI = 0.974; SRMR = 0.012]. Perceived learning (R2 = 0.454), was influenced by self-regulated learning (β = 0.243, p < 0.01) and course organization (β = 0.453, p < 0.001); AS (R2 = 0.857) was influenced by relationship with the instructor (β = 0.613, p < 0.001) and course organization (β = 0.221, p < 0.001), as well as by the mediating variable, perceived learning (β = 0.227, p < 0.001). The indirect effects of self-regulated learning and course organization on AS were statistically significant but of low magnitude.ConclusionThese outcomes point up the active role of students in terms of self-regulated learning and perceived learning and the key role of course organization and the student-instructor relationship in promoting students’ AS during the Covid-19 pandemic, when the learning environment changed abruptly. These findings can usefully inform the work of instructors and instructional designers, including in non-emergency contexts.

Accessibility crisis of essential medicines at Sudanese primary healthcare facilities: a cross-sectional drugs’ dispensaries assessment and patients’ perspectives

BackgroundAccess to essential medicines is a critical component of universal health coverage. However, the availability of essential medicines in Sudan isn’t well studied. As well, most Sudanese people lack health insurance, making out-of-pocket spending the primary source of drug financing. Therefore, the affordability of medicines in Sudan is questionable, with only 30% of the total population being covered by a public health service or public health insurance. We undertook this study to assess the availability and prices of essential medicines in public-sector health facilities in Khartoum state. Moreover, this study aims at assessing patients’ perceived affordability of essential medicines, and accommodation and acceptability of the public facility.MethodsA cross-sectional study was carried out at 30 primary healthcare facilities’ drug dispensaries across three districts in Khartoum state. Within each Centre’s dispensary unit, a standardized checklist evaluated the availability and affordability of 21 essential medicines selected from Sudan’s national essential medicines list and assessed their storage conditions. Furthermore, 630 patients were selected from all dispensary units for an exit interview that assessed their perceived accessibility, acceptability, accommodation, and affordability of essential medicines. Data were collected through the Kobo toolbox and analyzed using SPSS version 26.ResultsParticipants’ ratings of accessibility, affordability, accommodation, and acceptability were 3.7/5, 1.5/4, 5/6, and 5.4/6, respectively, with a 26.7% full access and weak correlation between some of the indices. The overall availability of adults and pediatric medicines was 36.8% 6.7%, respectively. Cost of a single course of treatment for 10 and 16 drugs out of the 19 drugs consumed exceeds the daily wage of insured and uninsured patients, with a median price ratio of 16.4 and 62.8, respectively. Moreover, the dispensary area conditions were found to be of good quality, yet the storerooms were not functioning in 40% of the outlets.ConclusionPatients had limited access to their needed drugs due to high prices and physical unavailability, and primary healthcare capacities are not meeting the demands of citizens. The outcomes for the patients’ access variables (accessibility, accommodation, acceptance, and affordability) are comparable to those in countries with low incomes. Ensuring access to free medicines is likely to improve patients’ satisfaction with healthcare services and reduce private expenditure on medicines, which is a long-term, sustainable way towards universal health coverage in Sudan.

Effects of Single-Course Betamethasone on the Outcomes of Late Preterm Neonates.

Background Prenatal glucocorticoids are commonly used in pregnancies before 34 weeks of gestation in women at risk of preterm delivery; however, the effects of these drugs on late preterm infants (those born after the 34th week of pregnancy) are controversial. As a result, we aimed to investigate the effect of a single course of betamethasone (two doses of betamethasone every 24 hours) on the neonatal outcome of late preterm births. Methods We retrospectively assessed all spontaneous late preterm births (34-36+6 weeks of gestation) at a tertiary hospital in Iran over a period of two and a half years. Exclusion criteria included multiple pregnancies, induced labor, and fetal malformations identified in sonograms. Neonatal outcome measures encompassed first and five-minute Apgar scores, respiratory distress syndrome, neonatal death, birth asphyxia, and the need for positive pressure ventilation, continuous positive airway pressure, tracheal intubation, and surfactant. Baseline characteristics, such as maternal age, parity, fetal gender, and high-risk pregnancy, were considered confounding variables. High-risk pregnancies were defined as any cases involving prolonged rupture of membranes or maternal comorbidities such as severe anemia, preeclampsia, diabetes, or COVID-19. Results During the study period, there were 830 spontaneous preterm births at our center. Of these, only 195 (23.5%) received complete doses of betamethasone. Low birth weight was more common in mothers who did not receive betamethasone compared to those who did (63.6% vs. 41.2%). The mean gestational age was lower in mothers who received betamethasone than in those who did not. Respiratory distress syndrome was more common in mothers who received betamethasone (P<0.001, RR 2.11, 95% CI (0.98-4.18)). However, after adjusting for confounding factors, such as gestational age and birth weight, betamethasone did not increase the risk of respiratory distress syndrome. Other adverse neonatal outcomes did not differ significantly. Conclusions There were no differences in neonatal outcomes between those who received betamethasone and those who did not.

Teaching About Nonprofits in American Legal Education

This article discusses the various ways in which nonprofits are taught in American legal education, indicating the focus on nonprofit law and management as well as on experiential education and focus on tax issues. It also discusses teaching materials used and the possibilities for going beyond the single course model in teaching nonprofit in American legal education.

Hyperfractionated Reirradiation for Locally Recurrent Thoracic Tumors

For patients with locally recurrent thoracic tumors or second primaries within previously irradiated volumes, hyperfractionated reirradiation (re-RT) may mitigate late toxicity compared to conventional fractionation, but clinical outcomes have not been extensively studied. We herein report our institutional experience with thoracic hyperfractionated reirradiation. We identified 26 cases among 23 patients treated with re-RT to either primary or metastatic thoracic tumors, 60 Gy in 50 fractions, twice daily over 5 weeks using highly conformal image guided RT with motion management. Nineteen patients had dosimetry data available. The primary outcome was Grade (G2) or higher toxicity rates per CTCAEv5.0. Secondary endpoints were 12-month local control (LC), progression free survival (PFS)-determined by treating physician and/or multidisciplinary tumor board-and overall survival (OS). Median follow-up was 13 months. Half had non-small cell lung cancer, 95.8% had ultracentral tumors, 57.7% had single prior thoracic RT course; 38.5%, 11.5% and 11.5% received concurrent chemotherapy, immunotherapy, and targeted agents, respectively. Minimum and median intervals between RT courses were 10 and 39.5 months, respectively; 94.7% of re-irradiation plans had overlapping 80% isodose volumes. Median OS and PFS were 13 and 10 months, respectively. Crude 12-month LC was 73.1%. Of those with a recurrence, the first recurrence occurred locally in 6 (54.6%), regionally in 3 (27.3%), and distantly in 8 (72.7%) patients. ≥G2 and ≥G3 toxicity rates were 30.8% and 7.69%, respectively (one G3 atrial fibrillation; one G5 pneumonitis). Using the American Radium Society guidelines for thoracic reirradiation, only 10.5% met all dose volume constraint recommendations. Definitive hyperfractionated thoracic re-RT was well tolerated with promising local control. ≥G3 toxicities were rare. Patients should be counseled on the low but potential risk of life-threatening toxicity. Consensus guidelines for dose constraints may be difficult to meet in reirradiation setting; in this cohort, rates of severe toxicity were low despite exceeding putative constraints in most patients.

New frontiers in the teaching of the agricultural enterprise: elements for a debate

The ecological transition assigns a strategic role to farms in achieving the sustainable transformation of agricultural systems. Therefore, teaching of agricultural economics must make these demands of civil society its own and rethink topics, decision-making tools, and teaching methods fostering the transition to sustainable agriculture. The main aim of this article is discussing the relevant teaching topics and the useful decision support tools useful for concrete progress in agricultural economics in the cycles of university studies. Five topics are recognized as priorities for the rethinking of courses on agricultural economics: agricultural systems, equitable distribution of value, quality and value of agri-food products, territorial regeneration, protection and regeneration of natural resources. The paper focuses also on the nature and role of decision support tools in university teaching. Finally, some considerations are extended to the opportunities offered by formal teaching in the context of informal training such as university-enterprise cooperation and in the context of the internationalization of degree courses supported by the Erasmus+ program. Further analysis is needed to evaluate how to rethink both single training courses, and global study programs in agricultural economics.

Overcoming oral communication apprehension: A call for a renewed focus on confidence building in business education

This study explored communication apprehension at the beginning and end of a business communication course. Nearly 200 students completed pre-class and post-class assessments of their communication apprehension in speech situations, class discussions, and group discussions. This study showed that a single business communication course significantly reduces oral communication apprehension. Yet, many students still hold communication apprehension at the end of the class. Thus, an approach that is strategic and program long could better address communication apprehension. The confidence gap between women and men is the most striking aspect of this study, with women possessing much more communication apprehension. Business educators should consider interventions to reduce or eliminate this gap.

Sequential or Combination Treatments as Rescue Therapies in Immunocompromised Patients with Persistent SARS-CoV-2 Infection in the Omicron Era: A Case Series.

Prolonged SARS-CoV-2 infections are widely described in immunosuppressed patients, but safe and effective treatment strategies are lacking. We aimed to outline our approach to treating persistent COVID-19 in patients with immunosuppression from different causes. In this case series, we retrospectively enrolled all immunosuppressed patients with persistent SARS-CoV-2 infections treated at our centers between March 2022 and February 2023. Patients received different sequential or combination regimens, including antivirals (remdesivir, nirmatrelvir/ritonavir, or molnupiravir) and/or monoclonal antibodies (mAbs) (tixagevimab/cilgavimab or sotrovimab). The main outcome was a complete virological response (negative SARS-CoV-2 RT-PCR on nasopharyngeal swabs) at the end of treatment. Fifteen patients were included as follows: eleven (11/15; 73%) with hematological disease and four (4/15; 27%) with recently diagnosed HIV/AIDS infection. Six patients (6/15; 40%) received a single antiviral course, four patients (4/15; 27%) received an antiviral and mAbs sequentially, and two patients (13%) received three lines of treatment (a sequence of three antivirals or two antivirals and mAbs). A combination of two antivirals or one antiviral plus mAbs was administered in three cases (3/15, 20%). One patient died while still positive for SARS-CoV-2, while fourteen (14/15; 93%) tested negative within 16 days after the end of treatment. The median time to negativization since the last treatment was 2.5 days. Both sequential and combination regimens used in this study demonstrated high efficacy and safety in the high-risk group of immunosuppressed patients.

P04.05.B ADJUVANT DOXORUBICIN AS ADD-ON THERAPY IN PEDIATRIC MALIGNANT GLIOMAS: A SINGLE-ARM OPEN-LABEL PHASE 2 INTERVENTIONAL STUDY

Abstract BACKGROUND Pediatric high grade gliomas (pHGGs) are leading causes of tumor related death in pediatric age. Beyond surgical and radiotherapy backbone treatment, chemotherapy regimen is a fundamental part of the therapeutic strategy, but its standardization and benefits are still disputed. Recent advances in molecular understanding are promising, nevertheless prognosis remains dismal. After proof-of-concept in vitro and in vivo assays to explore HGG cell lines sensibility to anthracyclines, we aim to introduce doxorubicin (DOX) as add-on therapy to the standard of care. MATERIAL AND METHODS Pediatric patients with newly diagnosed, histologically confirmed HGG were randomly assigned to receive radiotherapy plus concomitant and adjuvant temozolomide and valproic acid (as Weller-Stupp 2011 treatment) with or without doxorubicin (DOX) in a monocentric single-arm open-label phase II interventional study. We opted for a 96-hours continuous infusion DOX schedule (25 mg per square meter of body-surface area per day). We initially administered 3 DOX courses during standard radio-chemiotherapy regimen, then reduced to 1 course after 8 weeks from the end of radiotherapy due to an increasing heamatologic toxicities after the third course. The primary end point was safety and tolerability of experimental treatment, the secondary end point was clinical outcome. RESULTS From February 2016 to January 2020, 21 patients underwent randomization. 7 (33.3%) patients were affected by glioblastoma, 10 (47,6%) by diffuse intrinsic pontine glioma, 4 (19%) by anaplastic astrocytoma. All patients were Caucasian, 42.9% were females and the mean age was 10 years. 12 patients were treated with doxorubicin (DOX group), whom 2 patients received three doxorubicin (DOX) courses and 10 a single DOX course. 19 of 21 (90.5%) presented at least one serious adverse event (SAEs). 6 of 12 (50%) patients exposed to DOX group had clinically relevant toxic effects related to DOX, mainly as cytopenias, mucositis and febrile neutropenia. After the switch to a 1 DOX course outline the treatment showed a more tolerable toxicity profile. No patients had suspected unexpected serious adverse reactions (SUSAR), early DOX-treatment interruption or death related to DOX. All study withdrawals were related to disease progression and not to investigational drug side effects. 18/21 (85.7%) patients showed disease progression. Among DOX-group, 1 patient show complete remission and 2 showed stable disease. DOX-group show a longer progression free survival (EFS) compared to control group, although this trend was not statistically significative. CONCLUSION Adjuvant doxorubicin as add-on therapy to the standard of care treatment of pHGGs is a safe and tolerable option. We need further investigations to optimize the timing and dosing of doxorubicin and to verify the effects on clinical outcome. SAEs must be carefully evaluated.

Sustained post-rituximab B-cell depletion is common in ANCA-associated vasculitis and is affected by sex and renal function.

Despite the increasing use of rituximab in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), it remains unclear what the optimal dosing is, especially for maintenance of remission. A deeper understanding of post-rituximab B-cell repopulation patterns may aid better-tailored treatment. This is a monocentric, retrospective study including ANCA-positive AAV patients receiving a single course of rituximab induction. CD19+ B cells were longitudinally monitored with flow cytometry. B-cell repopulation was defined as CD19+ >10 cells/μL. Seventy-one patients were included, the majority with microscopic polyangiitis (75%), myeloperoxidase-ANCA positivity (75%) and with renal involvement (79%). During a median follow-up of 54months since the first rituximab infusion, 44 patients (62%) repopulated B cells, with a median time to repopulation of 39months (range 7-102). Patients experiencing B-cell depletion lasting longer than the overall median time to repopulation (39months) exhibited a lower risk of flare and higher risk of serious infection. In multivariate Cox regression, higher estimated glomerular filtration rate (eGFR) [hazard ratio (HR) 1.84, 95% confidence interval (CI) 1.13-2.98 per 30mL/min/1.73 m2 eGFR] and female sex (HR 2.70, 95% CI 1.37-5.31) were independent predictors of increased rate of B-cell repopulation. A subset of AAV patients develop sustained post-rituximab B-cell depletion, which associates with reduced risk of flare and increased risk of serious infection in the long term. Preserved renal function and female sex are associated with faster B-cell repopulation. These observations further highlight the need to personalize immunosuppression to improve clinical outcomes.

Risk Factors and Characteristics of Recalcitrant Osteomyelitis Following Initial Surgical and Antibiotic Treatment.

To evaluate the injury, patient, and microbiological characteristics that place patients at risk for recalcitrant fracture related infection and osteomyelitis despite appropriate initial treatment. Retrospective Chart Review. Three level I trauma centers. Two hundred and fifty-seven patients undergoing surgical debridement and antibiotic therapy for osteomyelitis from 2003 to 2019. Patients were categorized as having undergone serial bone debridement if they had two separate procedures a minimum of six weeks apart with a full course of appropriate antibiotics in between. Patient records were reviewed for age, injury location, body mass index (BMI), smoking status, comorbidities, and culture results including the presence of multidrug resistant organisms (MDRO) and culture-negative osteomyelitis. A total of 257 patients were identified; 49% (n=125) had a successful single course of treatment, and 51% (n=132) required repeat debridement for recalcitrant osteomyelitis. At the index treatment for osteomyelitis, the most common organisms in both groups were Methicillin-resistant (MRSA) and Methicillin-sensitive Staphylococcus aureus (MSSA). There was no significant difference in incidence of polymicrobial infection between the two groups (25% vs 20%, p=0.49). The most common organisms cultured at the time of repeat saucerization remained MRSA and MSSA, however, the same organism was cultured from both the index and repeat procedure in only 28% (n=37) of cases. Diabetic patients, IVDU, delay to diagnosis, and open fractures of the lower leg are independent risk factors for failure of initial treatment of post-traumatic osteomyelitis. Successful eradication of fracture related infection and post-traumatic osteomyelitis is difficult and fails 51% of the time despite standard surgical and antimicrobial therapy. While MRSA and MSSA remain the most common organisms cultured, patients who fail initial treatment for osteomyelitis often do not culture the same organisms as those obtained at the index procedure.

Clinical standards for the diagnosis and management of asthma in low- and middle-income countries.

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

NeoTalk: Communication Skills Training for Neonatal Clinicians.

Despite proven benefit, pediatric subspecialists often have not been offered formal serious illness communication skills training. We sought to: 1) develop and evaluate the impact of a communication skills course, based on the VitalTalk framework, on Neonatal Intensive Care Unit (NICU) clinicians; 2) evaluate provider comfort with key serious illness communication skills and frequency of use of those skills, before and after "NeoTalk" and; 3) explore differences and similarities between adult and pediatric serious illness communication skills courses. We developed a NICU specific communication skills course and surveyed course participants to evaluate comfort with key communication skills before and after course participation, and frequency of use of key skills before and 2 months after our course. Wilcoxon signed rank tests and Kruskal-Wallis tests were performed to compare participant responses across time points. 34 providers completed NeoTalk training. Complete pre- and post-course data was available for 29 participants. Participants reported increased comfort with skills including 'sharing difficult news' (P = .018), and 'responding to emotion' (P = .002). Participants did not report increased frequency in using target skills 2 months after training. A multi-disciplinary cohort of NICU providers endorsed increased confidence in key communication skills but not increased skill application 2-months post-course completion. While a single course can successfully teach skills, additional exposure may be necessary to build new communication habits. Our experience developing NeoTalk helped elucidate some of the ways in which conversations about seriously ill infants may be different from conversations about seriously ill adults.

Experience with agomelatine therapy for non-psychotic depression with a single and recurrent course

Therapy of depression is a current problem in psychiatry. Agomelatine is not inferior to other modern drugs in terms of antidepressant efficacy (response and remission rates) and is characterized by the best tolerability.Objective: to evaluate the efficacy and safety of agomelatine in the treatment of nonpsychotic depression with a single and recurrent course.Material and methods. Patients (n=37) with a current depressive episode (DE; F32 according to ICD-10), mean age 41.2±2.07 years, were studied. Clinical psychopathological and psychometric methods were used in the study (Hamilton Hospital Depression Scale – HAMD-17; Spielberger–Khanin Anxiety Self-Assessment Scale, Sheehan Anxiety Scale, Clinical Global Impression Scale – CGI-I). A single DE was diagnosed in 62.2% of patients, and recurrent depressive disorder in 37.8%. Stress-related onset of current DE was found in 56.8% of cases, autochthonous in 43.2%.Results. 94.6% of patients were responders, including 68.6% who went into remission. A statistically significant decrease in scores on the HAMD-17 scale was noted in the remission group from the 7th day of agomelatine therapy (p&lt;0.05), in the responder group – from the 14th day of therapy (p&lt;0.05). According to the Sheehan scale, a statistically significant decrease in scores was noted at the end of the first week of therapy (p&lt;0.05), according to the Spielberger–Khanin scale – in the second week (p&lt;0.05) in all patients. According to the CGI-I scale, the condition at the end of therapy improved in 57.1% of patients, significantly in 42.9%. Clinical predictors of therapeutic response in patients with remission included significantly higher frequency of a single DE (p&lt;0.02), moderate severity of current depression (p&lt;0.02), dizziness among autonomic disorders (p&lt;0.01), a significantly lower representation of the melancholic type of depression (p&lt;0.05), a symptom of a gloomy and pessimistic vision of the future (p&lt;0.05), sleep disturbances (p&lt;0.04), a factor of personal significance in the form of a threat in patients with stress-provoked onset of the current DE (p&lt;0.05).Adverse events occurred in the first week of treatment with agomelatine in 14.3% of cases (nausea – 8.6%, headache and dizziness – 2.9% each), they were mild and did not require discontinuation of the drug. Two patients taking agomelatine at a dose of 50 mg discontinued the study: in one case persisted social phobia, increased fatigue, motor retardation, and persistent modern insomnia; in the other case – a pronounced senestoalgic syndrome with cerebral localization.Conclusion. Agomelatine therapy has been shown to be highly effective and well tolerated in nonpsychotic depression.

Efficacy of scalp-sparing volumetric-modulated arc therapy approach in reducing scalp radiation dose for patients with glioblastoma: a cross-sectional study.

Radiation is integral to the treatment of glioblastoma (GBM). However, radiation-induced scalp toxicity can negatively impact patients' quality of life. Volumetric modulated arc therapy (VMAT) optimizes the dose to organs at risk (OARs). We hypothesize that a scalp-sparing VMAT (SSV) approach can significantly reduce undesirable doses to the scalp without compromising the target dose. This is a retrospective cross-sectional study of GBM patients who originally received radiation with non-SSV. We contoured the scalp as a 5 mm rind-like structure beneath the skin above the level of the foramen magnum. We replanned our patients using SSV techniques. We compared dosimetric data for the scalp, planning target volume (PTV), and select critical normal structures between non-SSV and SSV plans. Nineteen patients with newly diagnosed GBMs were included in our study. All patients received 60 Gy in 30 fractions. 9 patients received it in a single course. The rest received 46 Gy in 23 fractions to an initial volume followed by 14 Gy in 7 fractions to a cone-down volume (split course). New VMAT plans were generated after adding the scalp as an OAR. The median scalp volume was 416 cm3 (363-468 cm3). The median reductions in scalp Dmin, Dmax, and Dmean were 43.5% (-100% to 0%), 2.8% (+13.4% to -24.9%), and 15.7% (+2.1% to -39.9%) respectively. Median reductions in scalp D20cc and D30 cc were 19.5% (-2.7% to -54.5%), and 19.0% (-5.3% to -39.5%) respectively. The median volumes of the scalp receiving 30 Gy, 40 Gy, and 50 Gy were reduced by 42.3% (-70.6% to -12.5%), 72% (-100% to -2.3%), and 92.4% (-100% to +5.4%) respectively. There were no significant differences in the doses delivered to the PTV, brainstem, optic nerves, and optic chiasm between SSV and non-SSV plans. SSV can significantly reduce scalp radiation dose without compromising target coverage or critical normal structure doses. This may translate into reduced acute and late radiation toxicity to the scalp. A prospective trial evaluating the clinical benefits of SSV is ongoing (NCT03251027).

POSSIBILITY OF IMPROVING THE TRAINING COURSE'SCONTENTBASEDONSTATISTICALCOURSE'S CONTENT BASED ON STATISTICAL ANALYSISOFTHECOLLECTEDPOINTS

The research looks into the methods of visual representaƟ on of points accumulated by students in a single study course that are employed in modern data science. StaƟ sƟ cal indicators and prospects for improving the subject based on them are discussed: which parts of the subject should be adjusted to increase the training course's quality. Data processing and display methods that the course instructor can employ eff ecƟ vely in the pro-cess of observing conƟ nuous visualisaƟ on of scores are discussed.The arƟ cle introduces a novel approach for enhancing the content of a training course through staƟ sƟ cal anal-ysis and visual representaƟ on of student scores, uƟ lising React.js technology. The proposed plaƞ orm empowers course instructors to incorporate various assessment methods such as quizzes, presentaƟ ons, mid-term exams, and fi nal exams and subsequently display students' grades based on each assessment method. The plaƞ orm em-ploys advanced staƟ sƟ cal indicators and robust visual presentaƟ on capabiliƟ es to calculate and illustrate the points achieved. This enables instructors to easily idenƟ fy desired evaluaƟ on methods, observe the distribuƟ on of points, and simultaneously track mulƟ ple evaluaƟ on methods to monitor the dynamic progression of the training course. Consequently, this holisƟ c approach enables instructors to idenƟ fy and address problemaƟ c secƟ ons within the course content, leading to meaningful improvements.

Alterations of materno-placento-fetal glucose homeostasis after a single course of antenatal betamethasone

IntroductionIntrauterine growth impairment is associated with long-term metabolic changes (perinatal programming). We recently demonstrated that antenatal betamethasone (BET) decreased head circumference in term born females. Since glucose is the main energy source for fetal growth, BET-induced changes in maternal glucose homeostasis, a reduced transplacental glucose transfer or an altered fetal glucose utilization may be linked with the observed growth impairment. Methods86 pregnant women exposed to BET (single course, <34 + 0 weeks of gestation (wks)) were compared to 92 gestational-age/sex-matched controls. Glucose, insulin, leptin, insulin-like growth factors (IGF-1, IGF-2) and their binding proteins (IGFBP-1, IGFBP-3) were measured in maternal and umbilical cord blood samples. Homeostasis Model Assessment (HOMA-IR) was calculated. Placental glucose transporter 1 and 3 (GLUT1, GLUT3) protein levels were determined. Statistics were performed for overall and subgroup analysis (gestational age, sex). ResultsAfter BET maternal HOMA-IR was elevated, IGFBP-1 reduced. In female pregnancies, glucose levels ≥37 + 0 wks and IGF-1 levels <37 + 0 wks were tendentially increased. Placental GLUT1 and GLUT3 protein levels were not significantly altered. Fetal umbilical venous glucose levels ≥37 + 0 wks were increased. HOMA-IR tended to be elevated in females. DiscussionGrowth impairment after BET appears neither caused by maternal nor fetal hypoglycemia nor changes of GLUT1 and GLUT3 total protein levels. Nonetheless, glucose homeostasis of mothers and daughters was altered even beyond the BET time frame (hyperglycemia, enhanced insulin resistance). Despite glucose supply was sufficient, an anabolic effect was apparently absent. Overall, our results highlight the relevance of adequate glucose management after BET and peripartum.

Team-Teaching as a Promising Pathway toward Interdisciplinary Sustainability Competency Development

Through a qualitative, interview-based inquiry on students’ learning in a single team-taught course focused on energy resources and policy implications, our team explored how team-taught interdisciplinary courses facilitate students’ development as leaders in energy resource sustainability. We conducted pre- and post-course interviews of nine undergraduate student participants and the two co-instructors for the course. The students self-identified as seven women and two men, ranging in age from 18 to 21 years. Six students were White, two were Asian/Asian American, and one was Black; the co-instructors were White men. To develop our findings, all interviews were subjected to a process of qualitative coding to derive themes, which we present with rich data from participants’ verbatim quotes. Findings revealed that constructivist-informed interdisciplinary instruction by the teaching team deepened students’ understandings of the importance of the knowledge of both energy science and policy, helping them to become holistically informed on critical issues in energy resource sustainability. Further, students recognized that an integrated understanding of these bodies of knowledge was critical to writing energy resource policy memos that constituted the central learning/assessment activity of the course. The kind of literacy afforded to the students through the team-teaching endeavor is foundational to students’ development as climate leaders. We suggest that this mode of teaching may represent an effective teaching enhancement for preparing energy sustainability and climate change leaders at the University of Michigan, other US institutions and internationally.