Implementing Goals-of-Care Conversations: Lessons From High- and Low-Performing Sites From a VA National Initiative

ContextThe Veterans Health Administration (VA) National Center for Ethics in Healthcare implemented the Life-Sustaining Treatment Decisions Initiative, including policy and practice standards, clinician communication training, a documentation template, and central implementation support to foster advance care planning via goals-of-care conversations for seriously ill veterans in 2014, spreading nationally to other Veterans Health Affairs (VA) sites in 2017.ObjectivesOur goal was to describe the range of early implementation experiences among the pilot sites, and compare them with spread sites that implemented LSTDI about two years later, identifying cross-site best practices and pitfalls.MethodsWe conducted semistructured interviews with 32 key stakeholders from 12 sites to identify cross-site best practices and pitfalls related to implementation.ResultsThree primary implementation themes emerged: organizational readiness for transformation, importance of champions, and time and resources needed to achieve implementation. Each theme's barriers and facilitators highlighted variability in success based on complexity in terms of vertical hierarchy and horizontal cross-role/cross-clinic relationships.ConclusionLearning health care systems need multilevel interdisciplinary implementation approaches to support communication about serious illness, from broad-based system-level training and education to build communication skills, to focusing on characteristics of successful individual champions who listen to critics and are tenacious in addressing concerns.     

The Effect of Polymerization Method in Stereo-active Block Copolymers on the Stability of Polymeric Micelles and their Drug Release Profile

Purpose

To investigate the effect of polymerization method on the stability and drug release properties of polymeric micelles formed using stereo-active block copolymers.

Methods

Diblock copolymers consisting of methoxy poly ethylene oxide (MePEO) and poly(lactide)s (PLA)s of different stereochemistry were synthesized by bulk or solution polymerization. Polymers and micelles were characterized for their chemical structure by ¹H NMR, optical rotation by polarimetry, critical micellar concentration by fluorescence spectroscopy, thermal properties by differential scanning calorimetry, morphology by transmission electron microscopy and size as well as kinetic stability by dynamic light scattering. Release of encapsulated nimodipine from polymeric micelles at different levels of loading was also investigated.

Results

Solution polymerization yielded a higher degree of crystallinity for stereo-regular PLA blocks. Consequently, the related polymeric micelles were kinetically more stable than those prepared by bulk polymerization. At high drug loading levels, the release of nimodipine was more rapid from polymeric micelles with crystalline cores. At lower levels of drug loading, drug release was slower and independent of the stereochemistry of the core.

Conclusions

The results underline the effect of polymerization method in defining core crystallinity in stereoregular block copolymer micelles. It also shows the impact of core crystallinity on enhancing micellar stability and drug release.     

Multivesicular hepatic human hydatid cyst from Iran: First genotyping‐based confirmation

Cystic echinococcosis is one of the most important zoonotic parasitic diseases caused by the tapeworm Echinococcus granulosus. To date, the genotype of multivesicular CE has not been identified. In this regard, the genotyping of multivesicular types of CE could help clinicians understand and manage the disease effectively.     

Fatal outcome following multiple bee stings: A rare case

Anaphylactic shock is an unexpected, life‐threatening, and sometimes fatal occurrence that affects patients in 75% of instances without a prior history of allergies. The severity of the reaction can vary among individuals. We report a case who died suddenly after being stung by bees in various parts of his body.     

Occurrence of acute cholinergic syndrome in an infant due to donepezil ingestion

Donepezil and acetyl cholinesterase inhibitors are the most commonly prescribed medications for the treatment of Alzheimer''s disease. We describe a 2‐year‐old infant who was referred to the emergency department after developing cholinergic syndrome 6 hours after ingesting 10 mg of his grandmother''s donepezil tablets and was finally discharged in stable condition.     

Worldwide prevalence of microbial agents’ coinfection among COVID‐19 patients: A comprehensive updated systematic review and meta‐analysis

BackgroundTo provide information about pathogens’ coinfection prevalence with SARS‐CoV‐2 could be a real help to save patients’ lives. This study aims to evaluate the pathogens’ coinfection prevalence among COVID‐19 patients.MethodIn order to find all of the relevant articles, we used systematic search approach. Research‐based databases including PubMed, Web of Science, Embase, and Scopus, without language restrictions, were searched to identify the relevant bacterial, fungal, and viral coinfections among COVID‐19 cases from December 1, 2019, to August 23, 2021. In order to dig deeper, other scientific repositories such as Medrxiv were probed.ResultsA total of 13,023 studies were found through systematic search. After thorough analysis, only 64 studies with 61,547 patients were included in the study. The most common causative agents of coinfection among COVID‐19 patients were bacteria (pooled prevalence: 20.97%; 95% CI: 15.95–26.46; I ²: 99.9%) and less frequent were virus coinfections (pooled prevalence: 12.58%; 95% CI: 7.31–18.96; I ²: 98.7%). The pooled prevalence of fungal coinfections was also 12.60% (95% CI: 7.84–17.36; I ²: 98.3%). Meta‐regression analysis showed that the age sample size and WHO geographic region did not influenced heterogeneity.ConclusionWe identified a high prevalence of pathogenic microorganism coinfection among COVID‐19 patients. Because of this rate of coinfection empirical use of antibacterial, antifungal, and antiviral treatment are advisable specifically at the early stage of COVID‐19 infection. We also suggest running simultaneously diagnostic tests to identify other microbiological agents’ coinfection with SARS‐CoV‐2.     

Concanavalin A-conjugated gold nanoparticle/silica quantum dot (AuNPs/SiQDs-Con A)-based platform as a fluorescent nanoprobe for the bioimaging of glycan-positive cancer cells

The glycan receptor is a glycosylphosphatidylinositol glycoprotein that is overexpressed on the surface of various cancer cells and has been utilized for wide applications. In the present work, the surface of citrate-capped gold nanoparticles (cit-AuNPs) was modified with mercaptopropionic acid (MPA) molecules to provide carboxylic groups for secondary functionalization with amine anchored-silica quantum dots (Si-NH₂ QDs) to produce cit-AuNPs-MPA/Si-NH₂ QDs fluorescent nanoparticles. Concanavalin A (Con A) molecules were attached through thiol–AuNP bonds to produce the final cit-AuNPs/MPA/Si-NH₂ QDs/Con A smart nanoparticles. The synthesized novel cit-AuNPs/MPA/Si-NH₂ QDs/Con A nanoparticles were utilized for the bioimaging of glycan-overexpressed breast cancer cells. Fluorescence microscopy and flow cytometry results revealed that the cit-AuNPs/MPA/Si-NH₂ QDs/Con A NPs can be efficiently taken up by cancer cells, with differentiating ability between overexpressed cancer cells and low-expressed normal cells. The cellular viability of the cit-AuNPs/MPA/Si-NH₂ QDs/Con A NPs was tested by the MTT test, proving their biocompatible nature at the 200 μg mL⁻¹ level. In conclusion, the fabricated cit-AuNPs/MPA/Si-NH₂ QDs/Con A NPs could be utilized for the bioimaging of MCF-7 cancer cells even in the clinical setting after proper in vivo validation.

The glycan receptor is a glycosylphosphatidylinositol glycoprotein that is overexpressed on the surface of various cancer cells and has been utilized for wide applications.     

Post‐COVID‐19 maxillary osteonecrosis and floating maxillary teeth due to mucormycosis in two uncontrolled diabetic patients

Mucormycosis is a rare, invasive, quickly progressing fungal infection that generally affects patients who are immunocompromised. If left untreated, the disease is characterized by progressive necrosis and is often fatal. We present two cases of post‐COVID‐19 mucormycosis with a history of several years of uncontrolled diabetic mellitus.     

Seasonal variation in mood in African American college students in the Washington, D.C., metropolitan area

OBJECTIVE: The authors attempted to estimate the occurrence, frequency, and pattern (winter versus summer) of seasonal affective disorder in African American college students. They hypothesized that winter seasonal affective disorder would be more prevalent than summer seasonal affective disorder. METHOD: Undergraduate and graduate college students who identified themselves as African Americans living in the Washington, D.C., metropolitan area were invited to participate in the study. The Seasonal Pattern Assessment Questionnaire was used to calculate a global seasonality score and to estimate the frequency of seasonal affective disorder and subsyndromal seasonal affective disorder. The frequency of the summer versus winter pattern of seasonality of seasonal affective disorder was compared by using multinomial probability distribution tests. The effects of gender and the awareness of seasonal affective disorder were evaluated with a two-way analysis of variance. RESULTS: Of 646 students who were invited to participate, 597 returned the questionnaires, and 537 (83.1%) fully completed them. Winter seasonal affective disorder was significantly more prevalent than summer seasonal affective disorder. The mean global seasonality score was 8.3 (SD=5.3). The majority of the subjects (80%) were not aware of the existence of seasonal affective disorder. CONCLUSIONS: The authors found that the frequency, magnitude, and pattern of seasonality of mood in African American students were similar to those previously reported in the general population at similar latitude, but that awareness of the existence of seasonal affective disorder, a condition with safe and effective treatment options, was lower.