BrighT STAR was a diagnostic stewardship collaborative of 14 pediatric intensive care units (PICUs) across the United States designed to standardize and reduce unnecessary blood cultures and study the impact on patient outcomes and broad-spectrum antibiotic use. We now examine the implementation process in detail to understand how sites facilitated this diagnostic stewardship program in their PICUs.

A multi-center electronic survey of the 14 BrighT STAR sites, based on qualitative data about the implementation process collected during the primary phase of BrighT STAR.

14 PICUs enrolled in BrighT STAR.

Site leads at each enrolled site.

An electronic survey guided by implementation science literature and based on data collected during BrighT STAR was administered to all 14 sites after completion of the primary phase of the collaborative.

10 specific tasks appear critical to implementing blood culture diagnostic stewardship, with variability in site-level strategies employed to accomplish those tasks. Sites rated certain tasks and strategies as highly important. Strategies used in top-performing sites were distinct from those used in lower-performing sites. Certain strategies may link to drivers of culture overuse and represent key targets for changing clinician behavior.

BrighT STAR offers important insights into the tasks and strategies used to facilitate successful diagnostic stewardship in the PICU. More work is needed to compare specific strategies and optimize stewardship outcomes in this complex environment.

Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children (Bright STAR). NCT03441126. https://www.clinicaltrials.gov/study/NCT03441126?term=Bright%20STAR&aggFilters=status:com&checkSpell=false&rank=1

With the rise of online references, podcasts, webinars, self-test tools, and social media, it is worthwhile to understand whether textbooks continue to provide value in medical education, and to assess the capacity they serve during fellowship training.

A prospective mixed-methods study based on surveys that were disseminated to seven paediatric cardiology fellowship programmes around the world. Participants were asked to read an assigned chapter of Anderson’s Pediatric Cardiology 4th Edition textbook, followed by the completion of the survey. Open-ended questions included theming and grouping responses as appropriate.

The survey was completed by 36 participants. When asked about the content, organisation, and utility of the chapter, responses were generally positive, at greater than 89%. The chapters, overall, were rated relatively easy to read, scoring at 6.91, with standard deviations plus or minus 1.72, on a scale from 1 to 10, with higher values meaning better results. When asked to rank their preferences in where they obtain educational content, textbooks were ranked the second highest, with in-person teaching ranking first. Several themes were identified including the limitations of the use of textbook use, their value, and ways to enhance learning from their reading. There was also a near-unanimous desire for more time to self-learn and read during fellowship.

Textbooks are still highly valued by trainees. Many opportunities exist, nonetheless, to improve how they can be organised to deliver information optimally. Future efforts should look towards making them more accessible, and to include more resources for asynchronous learning.

Yoga has been demonstrated to have a range of beneficial effects on individuals with substance use disorders, including opioid use disorders. We initiated a randomized clinical trial to find out the efficacy of add-on yoga among patients with opioid dependence stabilized on treatment to find out whether it led to improvement in sleep and quality of life. However, the rate of enrolment into the study was quite low.

In this interim analysis, we present the preliminary data on the reasons for non-enrolment in the yoga trial.

The single-centre trial involved 1:1 randomization of patients with opioid dependence stabilized on medications (naltrexone or buprenorphine) for a period of at least 4 weeks into two groups (add-on yoga or wait-list control). The yoga included asanas and panchakosha meditation, taught for a period of 7 days and to be practiced by the participants for a period of 12 weeks. We recorded the reasons for non-participation among those who did not participate and asked them questions about their views on yoga.

Of the 310 patients recruited between August 2022 and July 2023 (99.7% male, mean age 34 years, 56.5% married), 255 (82.3%) could not be enrolled in the trial. The most common reasons for non-enrolment were not having time for training (n = 206, 80.8%), not having time for doing yoga (n = 180, 70.6%), not having a smartphone for continued training or contact (n = 31, 12.2%), distance from the center (n = 17, 5.5%) do not feel the need for yoga (n = 16, 5.2%), injury or disability (n = 9, 3.5%), old age or medical condition (n = 7, 2.7%), already doing gym exercises (n = 7, 2.7%), nature of job (n = 5, 2.0%), do not have knowledge of yoga (n = 5, 2.0%), and do not think yoga would be useful (n = 4, 1.6%). Among those who could not be enrolled, 35.1% reported doing yoga sometime in the past, and 21.6% reported that at least one of the family members did yoga. When asked whether they would be interested if yoga was available online, 16 (5.2%) responded ‘yes’ and 45 (14.5%) responded ‘maybe’.

Expressed time constraints may be an important factor deterring patients with opioid dependence from engaging in yoga as an add-on yoga. There are other reasons as well that may deter patients from such an intervention. The findings should be seen in the light of the limitation of a single medically oriented center, and patients already stabilized on treatment.

None Declared

Depression is a widespread problem that affects individuals of all ages. This study looks at the use of omega-3 polyunsaturated fatty acids (PUFAs) as an additional therapy for depression in people of different ages. Depression has an impact on everyone, from youth to the elderly, causing therapeutic concerns such as treatment resistance and recurrence. Omega-3 PUFAs, which may be found in fish and flaxseed, are important because of their impact on neurochemistry, inflammation, and neuroprotection. While pharmacotherapy, including antidepressants, has proven beneficial for many, the likelihood of remission and recurrence remains substantial. In recent years, there has been a growing interest in the potential role of omega-3 polyunsaturated fatty acids (n-3 PUFAs) in mitigating depressive symptoms. The primary constituents of n-3 PUFAs are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Understanding the potential of omega-3 PUFAs across the lifespan can help address the multifaceted challenges posed by depression and improve mental health outcomes for diverse age groups.

This review aims to assess the role of omega-3 fatty acids in depression treatment across different age groups: children and adolescents, adults (18–60), and the elderly (60+). It investigates the effectiveness and potential differences in omega-3 supplementation among these age cohorts.

A comprehensive literature search was conducted from 2003 to 2023 using PubMed, Google Scholar, and EMBASE, using specific keywords. Studies with inadequate age group information or Omega-3 intervention were excluded.

In children and adolescents, several studies indicate a positive association between omega-3 supplementation and improved depressive symptoms. In adults, results are mixed, with some studies showing benefits while others do not. In the elderly, omega-3 PUFAs appear to have a more consistent positive effect on depression. In contrast, a consistent positive association was observed in the geriatric population, suggesting that Omega-3 PUFAs may hold particular promise in the treatment of depression among older adults. However, variations in methodology, dosage, and study populations contribute to these mixed findings.

Omega-3 PUFAs show promise as an adjunct therapy for depression across different age groups. Further research with standardized methodologies and larger sample sizes is needed to clarify their role and establish optimal dosage guidelines. Omega-3 PUFAs should be considered as a potential complement to conventional depression treatments, emphasizing the need for personalized approaches in depression management.

None Declared

Synthetic drugs pose one of the most significant drug problems worldwide. In this category, W18 emerges as a potent drug of abuse chemically related to fentanyl. W18 has an analgesic potency 10,000 times greater than morphine. Recent in-vitro studies reported no activity of W18 towards opioid receptors. However, its presence in seized drug samples indicates its use as a precursor in fentanyl synthesis. This emphasizes the need to develop methods for its detection in developing countries dealing with emerging new drugs.

To develop an analytical method for the determination of W18 in urine samples.

Standards with W18 concentrations ranging from 5-500 ng/ml were prepared in negative urine along with deuterated internal standard. The samples were diluted with methanol, centrifuged and the supernatant was subjected to Liquid chromatography-tandem mass spectrometry (LC-MS-MS) with time of flight (QTOF) analysis. For chromatographic separation, a C18 column with 50 degrees oven temperature was used. The mobile phase consists of formic acid, water, and acetonitrile. The TOF MS was operated in positive ion mode and multiple reaction monitoring was used for quantification.

The retention time of W18 was obtained at 9.57 minutes. The parent ion with molecular weight 422.1 along with precursor ions Q1-273, Q2-111.0, Q3-150.0 g/mol were measured. The area of the standards ranges from 1 to 9.0 log 5 with R square of 0.99. The limit of detection (LOD) and quantitation were 5 and 20 ng/ml respectively. The recovery of W18 was estimated to be 96% from the from spiked urine standards.

The developed method is able to detect W18 presence in urine samples. This method has the potential to be used in clinical and research studies.

None Declared

We aim to analyze the efficacy and safety of TMS on cognition in mild cognitive impairment (MCI), Alzheimer’s disease (AD), AD-related dementias, and nondementia conditions with comorbid cognitive impairment.

Systematic review, Meta-Analysis

We searched MEDLINE, Embase, Cochrane database, APA PsycINFO, Web of Science, and Scopus from January 1, 2000, to February 9, 2023.

RCTs, open-label, and case series studies reporting cognitive outcomes following TMS intervention were included.

Cognitive and safety outcomes were measured. Cochrane Risk of Bias for RCTs and MINORS (Methodological Index for Non-Randomized Studies) criteria were used to evaluate study quality. This study was registered with PROSPERO (CRD42022326423).

The systematic review included 143 studies (n = 5,800 participants) worldwide, encompassing 94 RCTs, 43 open-label prospective, 3 open-label retrospective, and 3 case series. The meta-analysis included 25 RCTs in MCI and AD. Collectively, these studies provide evidence of improved global and specific cognitive measures with TMS across diagnostic groups. Only 2 studies (among 143) reported 4 adverse events of seizures: 3 were deemed TMS unrelated and another resolved with coil repositioning. Meta-analysis showed large effect sizes on global cognition (Mini-Mental State Examination (SMD = 0.80 [0.26, 1.33], p = 0.003), Montreal Cognitive Assessment (SMD = 0.85 [0.26, 1.44], p = 0.005), Alzheimer’s Disease Assessment Scale–Cognitive Subscale (SMD = −0.96 [−1.32, −0.60], p < 0.001)) in MCI and AD, although with significant heterogeneity.

The reviewed studies provide favorable evidence of improved cognition with TMS across all groups with cognitive impairment. TMS was safe and well tolerated with infrequent serious adverse events.

There is no cure for dementia due to non-Alzheimer’s disease (non-AD), and current treatments are symptomatic. Noninvasive brain stimulation therapies such as transcranial magnetic stimulation (TMS) are increasingly being investigated to improve cognitive function in dementia. We conducted a systematic review to investigate the effectiveness of TMS on cognition in non-AD dementia.

Comprehensive search of databases (Medline, Embase, Cochrane, APA PsycINFO, Web of Science, and Scopus) from 2000 to February 2023 using keywords related to TMS and dementia (PROSPERO, CRD42022326423). Here we report outcomes from randomized controlled trials (RCTs) of TMS on non-AD dementia populations.

In total, 20 RCTs comprised of 660 patients, mean age 62 years (range 46-71). Diagnostic groups include stroke (n=8), Parkinson’s disease (n=6), Frontotemporal dementia (n=3), Huntington’s disease (n=2) and Progressive non-fluent aphasia (n=1). The most common site of stimulation was left (L) dorsolateral prefrontal cortex (DLPFC, n=13); other sites were primary motor cortex (n=2); Right (R) Broca's area, Brodmann area, Contralesional pars triangularis, R Inferior Frontal Gyrus (IFG) (all n=1); and multiple sites in 1 RCT (L and R IFG, L superior frontal gyrus, L DLPFC, L and R right anterior temporal lobe, supplementary motor area, anterior cingulate, and vertex). Studies used both low (1Hz, n=5) and high (50Hz, n=5) frequencies, or other high (5Hz, 10Hz, 20Hz) or combination low/high frequencies. Frequent duration of treatment was 10 days (n=7), range 1-40. Of 20 studies, 19 (95%) demonstrated improvement of global cognition (on MoCA, MMSE) and specific cognitive domains (learning and memory, language, executive function, problem-solving, attention, reaction time). The only RCT with no effect utilized a single session intermittent theta burst stimulation on the LDLPFC on PD patients. Adverse events in 7 studies included headaches (most common), dull skull pain, dizziness, insomnia, fatigue, anxiety, temporary decrease in hearing, and temporary decreased mental clarity.

There is favorable evidence that rTMS improves global and specific cognitive domains in non-AD dementia. Left DLPFC is the most common stimulation site, both low- and high-frequency are utilized, and 10 sessions is frequently used. Further studies are needed to determine optimal TMS treatments in cognitively impaired populations

Patients with diabetes have a higher risk of developing chronic kidney disease (CKD). Early detection of CKD through microalbuminuria screening, followed by treatment, delays the progression of CKD. We evaluated the cost-effectiveness of population-based screening of microalbuminuria among normotensive type 2 diabetes mellitus patients aged >40 years compared with no screening scenario using a decision tree combined with the Markov model.

We considered two scenarios: Scenario I – dipstick microalbuminuria followed by spot-urine albumin–creatinine ratio (ACR) and serum creatinine in sequence; Scenario II – spot urine ACR plus serum creatinine. A mathematical cohort of the target population was simulated over a lifetime horizon with an annual cycle. Data for the model were obtained from secondary resources. The incremental cost-effectiveness ratios (ICERs) were estimated for screening scenarios compared to nonscreening scenario, along with sensitivity analyses.

The discounted ICER per quality-adjusted life years gained for annual microalbuminuria screening in the normotensive diabetic population in India were ₹ 24,114 (US$ 308) and ₹ 13,790 (US$ 176) for scenarios I and II, respectively. Annual screening by scenarios I and II resulted in a reduction of 180 and 193 end-stage renal disease (ESRD) cases per 100,000 population, respectively, resulting in a cost saving of ₹ 12.3 and 13.3 Crore spent on ESRD management over 10 years. Both scenarios were also cost-effective even at the screening frequencies of 5 and 10 yearly.

Microalbuminuria screening was cost-effective at the threshold of one-time GDP per capita in India.