VA Healthcare System Serving Ohio, Indiana and Michigan

Importance: Selecting effective antidepressants for the treatment of major depressive disorder (MDD) is an imprecise practice, with remission rates of about 30% at the initial treatment. Objective: To determine whether pharmacogenomic testing affects antidepressant medication selection and whether such testing leads to better clinical outcomes. Design, Setting, and Participants: A pragmatic, randomized clinical trial that compared treatment guided by pharmacogenomic testing vs usual care. Participants included 676 clinicians and 1944 patients. Participants were enrolled from 22 Department of Veterans Affairs medical centers from July 2017 through February 2021, with follow-up ending November 2021. Eligible patients were those with MDD who were initiating or switching treatment with a single antidepressant. Exclusion criteria included an active substance use disorder, mania, psychosis, or concurrent treatment with a specified list of medications. Interventions: Results from a commercial pharmacogenomic test were given to clinicians in the pharmacogenomic-guided group (n = 966). The comparison group received usual care and access to pharmacogenomic results after 24 weeks (n = 978). Main Outcomes and Measures: The co-primary outcomes were the proportion of prescriptions with a predicted drug-gene interaction written in the 30 days after randomization and remission of depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9) (remission was defined as PHQ-9 ≤ 5). Remission was analyzed as a repeated measure across 24 weeks by blinded raters. Results: Among 1944 patients who were randomized (mean age, 48 years; 491 women [25%]), 1541 (79%) completed the 24-week assessment. The estimated risks for receiving an antidepressant with none, moderate, and substantial drug-gene interactions for the pharmacogenomic-guided group were 59.3%, 30.0%, and 10.7% compared with 25.7%, 54.6%, and 19.7% in the usual care group. The pharmacogenomic-guided group was more likely to receive a medication with a lower potential drug-gene interaction for no drug-gene vs moderate/substantial interaction (odds ratio [OR], 4.32 [95% CI, 3.47 to 5.39]; P < .001) and no/moderate vs substantial interaction (OR, 2.08 [95% CI, 1.52 to 2.84]; P = .005) (P < .001 for overall comparison). Remission rates over 24 weeks were higher among patients whose care was guided by pharmacogenomic testing than those in usual care (OR, 1.28 [95% CI, 1.05 to 1.57]; P = .02; risk difference, 2.8% [95% CI, 0.6% to 5.1%]) but were not significantly higher at week 24 when 130 patients in the pharmacogenomic-guided group and 126 patients in the usual care group were in remission (estimated risk difference, 1.5% [95% CI, -2.4% to 5.3%]; P = .45). Conclusions and Relevance: Among patients with MDD, provision of pharmacogenomic testing for drug-gene interactions reduced prescription of medications with predicted drug-gene interactions compared with usual care. Provision of test results had small nonpersistent effects on symptom remission. Trial Registration: ClinicalTrials.gov Identifier: NCT03170362.

An understanding of the impact of antibiotics on the intestinal reservoir of KPC carbapenemase-producing Klebsiella pneumoniae (KPC-Kp) is important to prevent its emergence. We used a mouse model to examine the effect of antibiotic treatment on the establishment and elimination of intestinal colonization with KPC-Kp. Mice (10 per group) received subcutaneous antibiotics daily for 8 days. On day 3 of treatment, 10(3) CFU of KPC-Kp was given orogastrically, and concentrations of KPC-Kp in stool were monitored. Additional experiments assessed the effects of antibiotic treatment on concentrations of total anaerobes and Bacteroides spp. in stool and the efficacy of orogastric gentamicin and polymyxin E in suppressing KPC-Kp colonization. Of four antibiotics with minimal activity against the KPC-Kp test strain (MIC ≥ 16 μg/ml), those that suppressed total anaerobes and bacteroides (i.e., clindamycin and piperacillin-tazobactam) promoted colonization by KPC-Kp (P < 0.001), whereas agents that did not suppress total anaerobes or bacteroides (i.e., ciprofloxacin and cefepime) did not (P = 0.35). Of two agents with moderate activity against the KPC-Kp test strain, ertapenem (MIC, 4 μg/ml) did not promote colonization by KPC-Kp, whereas tigecycline (MIC, 3 μg/ml) did (P < 0.001), despite not reducing levels of total anaerobes or bacteroides. Orogastric treatment with gentamicin and polymyxin E suppressed KPC-Kp to undetectable levels in the majority of mice. These data suggest that antibiotics that disturb the intestinal anaerobic microflora and lack significant activity against KPC-Kp promote colonization by this organism. The administration of nonabsorbed oral antibiotics may be an effective strategy to suppress colonization with KPC-Kp.

ABSTRACT A thick sedimentary cover over the midwestern United States has restricted geologic investigation of the basement complex in the past to a slow and fragmentary study based on a few deep wells. Recent basement studies have been stimulated by State-wide geophysical surveys now available for regional interpretation. Modern investigations have included mapping of basement configuration, lithology, orogenic trends, and geochronology. A map showing basement configuration reflects the basin and arch provinces recognized in the Paleozoic rocks of the Midwest, and thus supports the usual premise that the basement forms a regional structural framework for the overlying sedimentary strata. Cross sections based upon seismic surveys and extrapolations from deep well data show that Paleozoic structures, such as the La Salle anticline and the Rough Creek and Kentucky fault systems, are underlain by basement ridges and scarps. Thickening and thinning of Lower Ordovician and Cambrian strata over basement scarps and ridges demonstrate basement influence on early Paleozoic sedimentation. The relation of basement relief to oil accumulation is a possibility that has not yet been demonstrated fully. Lithologic studies of well samples reveal that the basement in the Midwest is predominantly granitic. Linear gravity and magnetic anomalies in Michigan, Indiana, Ohio, and Kentucky may be caused by Keweenawan-type basalts superposed on the granite. A study of basement lithologies and isotopic age determinations helps in the recognition of extensions of structural provinces of the Canadian shield into this region. A geochronological map based on sparse age data shows, for example, a southwestern extension of the Grenville front through Michigan and Indiana.

BACKGROUND: Pain is challenging after recovery from total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures, and patients often receive prescription opioids. However, opioid consumption by patients remains unclear, and unused opioids may lead to risks including misuse and diversion. The objective of this systematic review and meta-analysis was to compare prescription size versus patient-reported consumption of opioids after discharge following TKA and THA. METHODS: PubMed and Embase were systematically searched for publications published between 2015 and 2022 on patient-reported consumption of opioids after TKA and THA. The primary outcome was opioid use in oxycodone 5-mg equivalents. Team members independently reviewed studies for screening, inclusion, data extraction, and risk of bias. RESULTS: Among the 17 included studies (15 TKA and 11 THA), discharge opioid prescribing exceeded consumption for both TKA (88.4 versus 65.0 pills at 6 weeks) and THA (64.0 versus 29.8 pills at 12 weeks). For both TKA and THA, the range of opioids prescribed varied significantly, by 1.6-fold for TKA and 2.8-fold for THA. Most studies reported pain outcomes (89%) and the use of nonopioid medications (72%). Of the 4 studies offering prescribing recommendations, the amounts ranged from 50 to 104 pills for TKA and 30 to 45 pills for THA. CONCLUSIONS: Opioid prescribing exceeds the amount consumed following TKA and THA. These findings serve as a call to action to tailor prescribing guidelines to how much patients actually consume while emphasizing the use of nonopioid medications to better optimize recovery from surgery.

OBJECTIVE: To investigate the phenotypic and functional characteristics of peripheral and tissue-infiltrating stem cells called fibrocytes in patients with idiopathic orbital inflammation (IOI). METHODS: Seven patients with IOI were studied. In the 3 patients requiring orbital biopsy, fibrocytes were identified in orbital tissue from patients with IOI compared with healthy controls using immunohistochemistry. Fibrocytes from the peripheral blood of all 7 patients and controls were quantified and phenotyped by flow cytometry and immunofluorescence for expression of CD34, alpha smooth muscle actin, CD40, and collagen 1. Quantitation of CD40-mediated interleukin-6 (IL-6) production was measured using enzyme-linked immunosorbent assay. RESULTS: Orbital biopsy specimens from patients with IOI demonstrate tissue infiltration by fibrocytes (n = 3). Fibrocytes are present in the peripheral blood of IOI patients (n = 7) but are scarce in healthy donors (n = 19). Fibrocytes from IOI patients express substantial levels of CD40, and ligation of CD40 increases IL-6 expression. CONCLUSIONS: Fibrocytes are present in the peripheral blood and orbital tissues of patients with IOI and constitutively express CD40 and express IL-6 in response to ligation. This site-specific predilection of CD34(+) fibrocytes to sites of orbital inflammation and fibrosis may suggest a role in IOI. Moreover, CD40-mediated activation cytokine production may contribute to the proinflammatory and profibrotic features of IOI and may provide a mechanism for future targeted therapy.

PURPOSE: The purpose of this quality improvement project was to identify stage 1 pressure injuries (PIs) in patients with darker skin tones using an enhanced skin assessment (Skin Assessment for Dark Skin, SADS) and halogen lighting. PARTICIPANTS AND SETTING: This quality improvement project was conducted on 3 units at a large university teaching hospital in Southeast Michigan. The project was originally designed so that participating patients were identified by bedside nurses as having sufficient melanin to obscure blanching on the hand/forearm using regular lighting, but this goal was not met. Data analysis is based on patients who self-identified as African American or Black, Native Hawaiian or Pacific Islander, Asian, American Indian, and Native Alaskan. Bedside nurses participating in this project were also asked to complete a questionnaire describing their knowledge and experiences with this project and assessment of early-stage PI in patients with darker skin tones. APPROACH: The Iowa Model of Evidence-Based Practice was used to guide this quality improvement initiative. Following a trigger event, we reviewed pertinent literature and developed an enhanced technique for assessing patients with darker skin tones that involved use of halogen lighting (SADS) and documentation of findings. We selected units from our facility and taught nurses to apply the SADS approach. Data from the electronic medical record and a survey of participating nurses were used to compare findings before and after project implementation. Comparisons were based on descriptive data analysis. OUTCOMES: Following implementation of the enhanced physical assessment, the participating units experienced a 6% decrease in the total number of facility-acquired PIs during the implementation period. IMPLICATIONS FOR PRACTICE: The enhanced physical assessment, when paired with halogen lighting, enhanced identification of stage 1 PI in persons with dark skin. The assessment method was easy to teach, learn, and can be performed at the bedside as part of a shift assessment which routinely includes inspection of skin.

Approximately 1 in 10 patients undergoing surgery is considered at high risk for poor pain and opioid-related outcomes due to chronic pain or persistent opioid use prior to surgery, leading to increased hospital lengths of stay, emergency department visits, hospital readmissions, and worse long-term outcomes. Multidisciplinary transitional pain services (TPSs) have been shown to effectively identify and optimize high-risk patients before surgery, leading to a reduction in healthcare utilization. We conducted a series of semistructured interviews, a literature search, and a financial analysis to develop a reproducible business case for establishing a TPS. These interviews involved discussions with clinicians and administrators at Michigan Medicine, as well as leaders of TPS initiatives at peer institutions across the USA and Canada. The aim was to understand possible operational structures and potential sources of revenue and cost savings that needed inclusion in our model. Subsequently, the authors developed a modifiable financial modeling tool, which is freely available for download and adaptable to any healthcare institution. The model suggests that the primary source of cost savings can be attributed to a reduction in length of stay. Furthermore, several operational options exist for incorporating a TPS that performs at breakeven or positive net profit. This tool and these findings are important for informing health systems of operational and financial considerations when implementing a TPS program. Future research should evaluate this financial tool's reproducibility in community health system contexts.

SIGNIFICANCE: The Fitting of Orthokeratology in the United States (FOKUS) survey provides information about the US orthokeratology market. This independent survey is the first to attain detailed assessment of the orthokeratology market. PURPOSE: This study aimed to develop and administer a survey to eye care providers in the United States who are managing orthokeratology patients and those who are not, to determine a profile of prescribers, patients, and overall market. METHODS: The FOKUS survey was administered and distributed online. Outcome measures of the FOKUS survey involved general categories of (1) practice and practitioner profiles, (2) clinical prescribing patterns, (3) patient profile, (4) products and marketing, (5) fees, and (6) market size and growth. RESULTS: The number of eye care providers who are actively fitting and managing orthokeratology patients in the United States is approximately 3000. A total of 545 responded to the survey; 283 reported that they were actively fitting orthokeratology. Furthermore, 68% of respondents prescribed orthokeratology with the intent of managing myopia, 53% monitor axial length, and 61% start orthokeratology patients at 13 years or younger. The mean number of years a patient wears orthokeratology is 7.8 years. A commonly reported complication with orthokeratology is corneal staining. Microbial keratitis is rarely or never seen by 86% of respondents. Of those currently fitting, 56% anticipate growth of orthokeratology fitting over the next 12 months. Of those not currently fitting orthokeratology, 46% plan to start within 2 years. CONCLUSIONS: Orthokeratology represents a small but growing segment of the US contact lens market. The number of practitioners actively prescribing and fitting orthokeratology in the United States is approximately 3000 with high potential for growth within the next 2 years. Results of the FOKUS survey are relevant to practitioners currently fitting or considering orthokeratology, manufacturers, educators, and researchers as baseline for future orthokeratology market assessment.

INTRODUCTION: Most Americans live in a state that has legalized cannabis as a medical treatment for pain, but it is unclear how chronic pain intensity relates to cannabis use. Our objective was to examine the association between patient-reported pain measures and cannabis among adults with chronic pain. METHODS: This cross-sectional study of a representative sample of adults reporting chronic non-cancer pain in 36 states and DC with active medical cannabis programs from March to April 2022 assessed cannabis use for chronic pain, categorized as active (within 30 days), past (>31 days), or never use (referent). Measures were pain intensity (primary) and interference, Widespread Pain Index, and number of chronic pain diagnoses. RESULTS: Among 1628 participants (57% female, 69% white), 352 (22%) actively used cannabis to treat chronic pain, 137 (8%) reported past cannabis use, and 1139 (70%) never used cannabis. In adjusted models, active cannabis use was associated with higher scores for pain intensity (score difference 1.03, 95% CI 0.05 to 2.02) and pain interference (score difference 1.82, 95% CI 0.99 to 2.65) compared with never use. Persons who actively used cannabis had higher Widespread Pain Index scores (score difference 0.56, 95% CI 0.26 to 0.86) and more chronic pain diagnoses (difference 0.45, 95% CI 0.06 to 0.83). CONCLUSION: People with chronic non-cancer pain who used cannabis for pain reported non-clinically meaningful worse pain measures and greater burden of chronic pain conditions than their counterparts who never used cannabis. Alternatively, those with worse pain and greater burden of pain appear more likely to use cannabis.

Visual information can have different meanings across species, and the same visual stimulus can drive appetitive or aversive behavior. The superior colliculus (SC), a visual center located in the midbrain has been involved in driving such behaviors. Within this structure, the wide-field vertical cells (WFV) are a conserved morphological cell type that is present in species ranging from reptiles to cats (Basso et al., 2021). Here, we report our investigation of the connectivity of the WFV, their visual responses, and how these responses are modulated by locomotion in male and female laboratory mice. We also address the molecular definition of these cells and attempt to reconcile recent findings acquired by RNA sequencing of single cells in the SC with the Ntsr1-Cre GN209 transgenic mouse line which was previously used to investigate WFV. We use viral strategies to reveal WFV inputs and outputs and confirm their unique response properties using in vivo two-photon imaging. Among the stimuli tested, WFV prefer looming stimuli, a small moving spot, and upward-moving visual stimuli. We find that only visual responses driven by a looming stimulus show a significant modulation by locomotion. We identify several inputs to the WFV as potential candidates for this modulation. These results suggest that WFV integrate information across multiple brain regions and are subject to behavioral modulation. Taken together, our results pave the way to elucidate the role of these neurons in visual behavior and allow us to interrogate the definition of cell types in the light of new molecular definitions.

BACKGROUND: The optimal management of perioperative pain in patients using medications for opioid use disorder (MOUD) is unclear. To motivate and inform efforts to develop evidence-based guidelines for perioperative pain management in these patients, it is important to evaluate whether the prevalence of MOUD use in surgical patients is increasing and to identify which procedures have the highest rate of MOUD use. METHODS: This cohort study analyzed adults 18 to 64 yr undergoing 1 of 1,083 major surgical procedures from 2016 to 2022 from the Merative MarketScan Commercial Database, which includes commercial claims from 22 to 28 million privately insured patients annually. Annual changes in MOUD use from 1 to 180 days before surgery were evaluated using logistic regression models adjusting for patient demographics and comorbidities. For each procedure category, the prevalence of MOUD use among all instances of the procedure during 2016 to 2022 was calculated. RESULTS: Analyses included 8,137,973 surgical admissions for 5,013,213 adults (59.9% female). The adjusted prevalence of MOUD use increased from 55.2 per 100,000 in 2016 to 99.8 per 100,000 in 2022 (adjusted annual change, 16.9 per 100,000 procedures; 95% CI, 14.0 to 19.8). Among 15,701 surgical admissions for patients using MOUD during 2016 to 2022, the most common type of MOUD was buprenorphine (13,193; 84.0%). Procedures with the highest rate of MOUD use were debridement (719.0 per 100,000 procedures), shoulder arthroplasty (579.4 per 100,000 procedures), lower extremity amputation (529.6 per 100,000 procedures), and hip or pelvis open fracture repair (497.6 per 100,000 procedures). CONCLUSIONS: In this cohort study of surgical procedures among privately insured U.S. adults, the prevalence of MOUD use increased between 2016 and 2022, highlighting the importance of developing evidence-based guidelines for perioperative management of these patients. The high rates of MOUD use in common orthopedic procedures suggest that these guidelines may be particularly relevant to the practice of orthopedic surgeons.

Cystic fibrosis is a life-threatening genetic disease that causes persistent lung infections and progressively limits the ability to breathe. The median predicted survival age of the patient with cystic fibrosis is 40 years. In the terminal care of the patient with cystic fibrosis, the role of the bedside nurse is critical in providing seamless, interdisciplinary care in order to promote a “good death” and ensure that the patient’s and family’s wishes are respected at the end of life (EOL). Key components of the bedside nurse’s role in EOL care for the cystic fibrosis patient include the facilitation of interdisciplinary patient/family–centered communication, the provision of comfort to ease suffering from breathlessness and pain, and the promotion of patient and family closure within the family and among caregivers. This case study depicts the critical role of the bedside nurse in a young female patient with cystic fibrosis at the EOL to honor patient and family wishes and promote a peaceful, dignified death.

Recent research has established that the superior colliculus (SC) plays a key role in visual motion processing and visually guided behaviors. However, differences across species have made it difficult to integrate findings from various animal models to form a general understanding of the SC. Here we use the tree shrew-a species evolutionarily intermediate between rodents and primates-to help bridge our understanding of this ancient brain structure. We recorded visual responses from the tree shrew (of either sex) SC neurons in vivo using a battery of motion stimuli, including drifting gratings, random dot kinematograms, and plaid patterns of superimposed gratings. Tree shrew SC neurons overall preferred low spatial and high temporal frequencies, as well as high speed of motion. They showed a mixed selectivity for motion components and integrated pattern, with integration consistent with a vector sum rule. Compared to mice, tree shrew SC showed similar tuning properties to basic visual features but exhibited a lower degree of motion integration reminiscent of visual cortices in other species. Finally, tree shrews displayed optokinetic eye movements, a visual-motion-induced reflexive behavior, and the response induced by plaids largely followed the vector sum rule. Together, our study provides fundamental insights into visual motion representation in the tree shrew SC and establishes a foundation for future comparative studies on visual processing in the SC.

The constantly increasing army of gardeners, with everything to learn, brings the problem of advising in a manner simple and yet complete, so that the initial efforts may be crowned with success.It is for such that we have designated IN BOLD FACE CAPITALS the varieties that we sell in the largest quantities, thereby assuming that these, on the average at least, are best suited to this locality.This does not mean, however, that the other varieties are not good; special conditions of soil and variations in taste should govern the choice of varieties and we therefore carry a goodly list, to suit all.For the benefit of our new customers we wish to state that we have made complete germination tests of every lot of vegetable seeds we offer, in testing chambers of our own construction, at consid- erable expense in time and labor, just so the chances of a crop failure are reduced to a minimum.The results are open to your inspection.Our Flower Seeds are always strictly new crop and thus of the highest vitality possible.Bear in mind that the best seeds are the more likely to make a good garden, no matter how much labor and expense you put into it and it is decidedly poor judgment to court failure right from the start by trying to save what at most can amount to but a small sum, by buying cheap seeds.The seed bill is the least part of the expense, anyway, and pedigree vegetables are not produced from mongrel seeds.This is especially true in this year of practically a famine in many lines of seeds.We believe it is policy to increase the price rather than reduce the quality and we wish to assure our customers that we are maintaining the same high standards in our stock, in this year of dearth, that we have in the past years of plenty.OUR TERMS ARE NET GASH OUR PRICES.-Weshall adhere as closely as possible to the prices quoted in this Catalogue, but the market value of some seeds is variable.This is most noticeable in grass, clover and field seeds, onion setts and seed potatoes.Quotations for such articles will be furnished on application.ORDERS, to secure prompt attention, should be accompanied with remittance, or satisfactory references.REMITTANCES may be made at our risk by draft, money order, cash by express, express money order, or in registered letter, or, in sums of two dollars or less, by ordinary mail.Postage stamps may be sent for amounts less than one dollar.SEEDS BY MAIL.-In justice to the vast majority of our customers who live in this immediate neighborhood and are not obliged to consider postage and express charges, we do not include such charges in the prices quoted in our catalogue; the prices given are for the goods here in our store.We will continue, however, to mail free all SEEDS in packets and ounces to any amount, anywhere in the United States, at catalogue prices.In larger pack ages, we will mail free in the FIRST, SECOND and THIRD ZONES, all VEGETABLE and FLOWER SEEDS, ROOTS and BULBS to the amount of ONE DOLLAR or more.On lesser amounts, add 10% to cover postage or at least 5c for the first pound, which is the minimum charge.Outside the THIRD ZONE add Postage according to the dis- tance.PARTICULAR ATTENTION is invited to this, for when omitted, the cost of postage will have to be deducted.On account of their perishable nature, PLANTS should be sent by Express.

This mixed methods study examined medical and social issues of older adults newly discharged from the hospital. Previous studies have focused primarily on medical conditions that lead to early readmission; clinicians, however, maintain that medical conditions are not the only cause of readmissions. Using the Healthy People 2020 framework of Social Determinants of Health (SDOH) we conducted a retrospective mixed methods study of 106 veterans admitted to a Home Based Primary Care Program (HBPC) after discharge from the hospital; all were diagnosed with CHF and/or COPD. Quantitative data abstracted from charts included socio-demographics, illness and utilization. Patient notes from HBPC staff were used for a qualitative analysis of SDOH, defined as social, physical, and functional factors that affect a person’s health. The mean age of the mostly male sample was 78 years (range=64–94). Mean Charlson score was 6.02; 28(21.4%) were readmitted within 30 days, 65(61.3%) were readmitted in 6 months. Content analysis indicated that 39 veterans (36.7%) had SDOH noted in their progress notes. The most commonly noted issue was caregiver problems/stress in 20(18.9%), followed by environmental issues in 14(13.2%). 8(7.5%) had falls, and 2(1.9%) had active substance abuse. 42(39.6%) were mismanaging prescribed medications. Network analysis will be used to evaluate associations between the identified factors and hospital readmissions. This small study provides preliminary evidence that social factors should be considered in future models that attempt to predict early readmission in patients with COPD and/or CHF.

Summary METTL3 is a key regulator of RNA metabolism, yet its genomic and epitranscriptomic roles in tissue development are largely unexplored. Using embryonic stem cell-derived 3D retinal organoids to model retinal progenitor cell (RPC) differentiation, we integrated transcriptome-wide m6A profiling (GLORI), protein-DNA (ChIP-seq and CUT&amp;RUN) and chromatin accessibility (ATAC-seq) mapping, and targeted m6A engineering (dCas13b-FTO) to dissect METTL3 function. Loss of METTL3 nuclear m6A activity disrupted Rx + retinal anlage formation in vitro , with dCas13b-FTO epitranscriptome engineering revealing that m6A at the Six3 3’UTR governs its stability. Surprisingly, while METTL3 loss altered histone modifications and chromatin accessibility, its direct chromatin targets showed little transcriptional correlation. A degron-based METTL3 degradation strategy, paired with protein-RNA interaction profiling, exposed rapid regulatory shifts in RPCs, revealing a METTL3- Ythdf1 protein-RNA axis. Our multi-omics approach establishes METTL3-dependent m6A as a critical epitranscriptomic layer in retinal development, unveiling a genomic paradigm in which chromatin accessibility diverges from transcriptional output.

Arabic is the sixth most spoken language in the U.S., with over 1.4 million speakers nationwide. Despite the significant population, Arabic-specific linguistic training for healthcare providers is limited. A novel Medical Arabic course was instituted to equip healthcare professionals with fundamental Arabic language skills to improve provider-patient relationships. A synchronized online course was delivered via Zoom over two semesters for three consecutive years. The course combines instructor-led lectures, interactive breakout-rooms, and role-play exercises. A post-course survey was conducted to evaluate the program's effectiveness in improving participants' Arabic language skills and confidence in engaging with Arabic-speaking patients. 117 participants completed Medical Arabic workshop I (MA-I) over the course of three semesters and 47 participants completed MA-II over the course of two semesters. Among 32 survey participants, 28% (n = 9) were graduate students in healthcare fields-including 19% (n = 6) medical students. 59% (n = 19) of respondents reported interacting with Arabic-speaking patients at least a few times a month. After completing the course, most participants felt "extremely or somewhat comfortable" using Arabic in medical context, including asking about medical history (81%, n = 26), communicating in a medical setting (78%, n = 25), recognizing medical Arabic terms (81%, n = 26), explaining basic diagnoses in Arabic (66%, n = 21), and giving physical exam instructions (56%, n = 18). Medical Arabic enhances healthcare providers' comfort and confidence in using Arabic with patients, contributing to stronger communication and improved care for Arabic-speaking patients. By building language proficiency, this course helps address critical gaps in provider preparedness, ultimately promoting more equitable, patient-centered care.

Overuse and misuse of antibiotics is an urgent health care problem and one of the key factors in antibiotic resistance. Validated clinical prediction rules have shown effectiveness in guiding providers to an appropriate diagnosis and identifying when antibiotics are the recommended choice for treatment.We aimed to study the relative ability of registered nurses using clinical prediction rules to guide the management of acute respiratory infections in a simulated environment compared with practicing primary care physicians.We evaluated a case-based simulation of the diagnosis and treatment for acute respiratory infections using clinical prediction rules. As a secondary outcome, we examined nursing self-efficacy by administering a survey before and after case evaluations. Participants included 40 registered nurses from three academic medical centers and five primary care physicians as comparators. Participants evaluated six simulated case studies, three for patients presenting with cough symptoms, and three for sore throat.Compared with physicians, nurses determined risk and treatment for simulated sore throat cases using clinical prediction rules with 100% accuracy in low-risk sore throat cases versus 80% for physicians. We found great variability in the accuracy of the risk level and appropriate treatment for cough cases. Nurses reported slight increases in self-efficacy from baseline to postcase evaluation suggesting further information is needed to understand correlation.Clinical prediction rules used by nurses in sore throat management workflows can guide accurate diagnosis and treatment in simulated cases, while cough management requires further exploration. Our results support the future implementation of automated prediction rules in a clinical decision support tool and a thorough examination of their effect on clinical practice and patient outcomes.