In part one of this editorial covering fifty observations about the history and evolution of the health promotion discipline I shared twenty five observations relating to societal trends, definitional nuances and seminal studies and resources that have contributed to the trajectory of the field. In this, part two of the editorial, I list an additional twenty five observations focused on polemics and controversies and on the importance of effective teaching, research and writing. I reflect on the different approaches used by public sector and private sector health promotion experts respectively. I also share inspirational quotes that I consider closely aligned with the vision and mission of our profession.

Background This study investigated the anticoagulant properties of sulfated chitosan derived from the internal bone of the spineless cuttlefish Sepiella inermis. Chitosan, a biopolymer, is used in various biomedical applications including anticoagulation. Sulfation of chitosan enhances its biological activity, making it a potential therapeutic agent. This study explored the efficacy of sulfated chitosan in preventing blood clot formation to provide a novel anticoagulant alternative. Objectives This study aimed to synthesize and characterize the anticoagulant properties of sulfated chitosan extracted from the internal bone of the spineless cuttlefish S. inermis using Fourier Transform Infrared Spectroscopy (FTIR), Field Emission Scanning Electron Microscopy (FESEM), and X-Ray Diffraction (XRD) and evaluate the anticoagulant properties of sulfated chitosan extracted from the internal bone of spineless cuttlefish S. inermis. Materials and methods Chitin and chitosan were extracted from the cuttlebone of a specimen of S. inermis, and sulfated chitosan was synthesized by sulfation of chitosan. Sulfated chitosan was subsequently used to evaluate its anticoagulant properties using tests such as activated partial thromboplastin time (APTT) and prothrombin time (PT). Characteristic investigations were conducted, including FTIR, FESEM, and XRD analyses. Results The results of this study suggested the possibility of using S. inermis internal bone as an unconventional source of natural anticoagulant that can be combined with biomedical applications. Anticoagulant activity measured using APTT and PT showed that sulfated chitosan was a strong anticoagulant. Conclusion We examined the anticoagulant activity of S. inermis extract using thrombin and activated partial thromboplastin times. Our results demonstrated the heparin-like anticoagulant action of the extracted sulfated chitosan, suggesting that it may be a great alternative anticoagulant treatment.

Gamification is emerging as an active learning innovation in medical education to enhance student engagement and promote life-long learning in a unique and collaborative environment. Clinical enzymology in biochemistry is one of the core topics in the medical curriculum. However, students face challenges in comprehension and retention of information. Hence, CARd & Board GAmes in Medical Education (CARBGAME) was introduced and evaluated for its effectiveness in enhancing learning, application, and retention of knowledge in clinical enzymology via gamification context. This mixed-method study involved 150 first-year undergraduate medical students. Before the game, students completed a pre-test in clinical enzymology. Later they were divided into 25 small groups to compete in the board game designed for enzymology in biochemistry. The students took turns throwing the dice and answering the questions on the game board to continue moving forward. The first team to reach 100 and solve the case-based question was deemed the winner. Following the board game, the students took up the post-test to compare the educational impact of the innovation. Also, the subsequent internal assessment scores were compared with previous batch who were not implemented with this intervention. Then students evaluated the effectiveness of CARBGAME-Clinical Enzymology using a 32-item questionnaire on 5-point Likert scale. The feedback obtained on a 10-point rating scale and for qualitative analysis, students\' and faculty perceptions were recorded in small groups. CARBGAME received overwhelmingly positive feedback from both students and faculty. It was perceived well by students for being fun, relevant, consistent, motivating, collaborative, and promoting experiential learning. The game\'s low-stakes approach, effective feedback, and sense of accomplishment were highly appreciated, making it a valuable tool for education. A significant improvement in knowledge was recorded, from a mean score of 8.37 ± 1.126 on a 20-point scoring scale before the game to 16.53 ± 1.219 after with a p-value of 0.0001. The comparison of the internal assessment scores between the intervention and non-intervention group of students also showed a significant improvement among those implemented with CARBGAME (p < 0.0001). The CARBGAME innovation has achieved the intended outcome of promoting active learning and enhanced performance in clinical enzymology. Highly positive responses from faculty and students also indicate the exigent need to introduce innovative components like games into curricula to achieve student engagement and promote a meaningful learning experience.

Heart failure (HF) continues to impact the population globally with increasing prevalence. While the pathophysiology of HF is quite complex, the dysregulation of the autonomic nervous system, as evident in heightened sympathetic activity, serves as an attractive pathophysiological target for newer therapies and HF. The degree of neurohormonal activation has been found to correlate to the severity of symptoms, decline in functional capacity, and mortality. Neuromodulation of the autonomic nervous system aims to restore the balance between sympathetic nervous system and the parasympathetic nervous system. Given that autonomic dysregulation plays a major role in the development and progression of HF, restoring this balance may potentially have an impact on the core pathophysiological mechanisms and various HF syndromes. Autonomic modulation has been proposed as a potential therapeutic strategy aimed at reduction of systemic inflammation. Such therapies, complementary to drug and device-based therapies may lead to improved patient outcomes and reduce disease burden. Most professional societies currently do not provide a clear recommendation on the use of neuromodulation techniques in HF. These include direct and indirect vagal nerve stimulation, spinal cord stimulation, baroreflex activation therapy, carotid sinus stimulation, aortic arch stimulation, splanchnic nerve modulation, cardiopulmonary nerve stimulation, and renal sympathetic nerve denervation. In this review, we provide a comprehensive overview of neuromodulation in HF.

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BACKGROUND: Medical device expenditures have increased in the 21st century, with cardiac devices comprising an outsized portion of the market. Meanwhile, the disproportionate share of FDA recalls of cardiac devices is often overshadowed. Using the FDA 510(k) premarket notification pathway and FDA recalls issued from 2000-2020, this project seeks to engage our understanding of innovation and recalls in the cardiac device space.
METHODS: 510(k) premarket notification submission dates, outcomes, and recalls from 1/1/2000 to 12/31/2019 were obtained from publicly available FDA data as a function of cardiac device innovation. We compared the annual number of 510(k) premarket clearances and FDA recalls from 1/1/2000 to 12/31/2009 to 1/1/2010 to 12/31/2019.
RESULTS: We found 343 moderate risk cardiac medical devices cleared for sale between the years 2000 and 2020. Comparing the last 10 years of the study period to the first, the yearly number of cleared devices decreased 39.7%, from 21.4 to just 12.9 (p=0.0019), defying positive trends in U.S. GDP and healthcare expenditures. Meanwhile, the number of FDA recalls issued for these devices increased 94.5% from 7.3 to 14.2 recalls per year (p=0.031). 215 device recalls were issued; 78% Class II and 16% Class I which constitute serious, potentially fatal recalls.
CONCLUSIONS: While United States healthcare spending continue to trend upward, there was a distinct decrease in the number of new and updated cardiac devices entering the market between 2000 and 2020. Meanwhile, recalls of these devices have uncomfortably increased. Together, these trends suggest cardiac device innovation has become risk averse.

BACKGROUND: Launched in 2018 for revision total ankle arthroplasty (rTAA), the INVISION talar component addresses subsidence when poor talar bone stock is present. Due to the recency of the market-availability of the INVISION, studies evaluating its efficacy are lacking. This study presents the first analysis of early-term outcomes of patients undergoing rTAA with the INVISION talar component.
METHODS: This was a single-center, retrospective review of 28 patients undergoing rTAA with the INVISION talar component and INBONE II tibial component performed between 2018 and 2022. Data on preoperative characteristics, postoperative complications, secondary procedures, and survivorship were collected. The primary outcome measures were rates of major complications, re-operation, and implant failure. Secondary outcomes included post-operative changes in varus and valgus alignment of the tibia and talus.
RESULTS: The most common secondary procedures performed with rTAA were medial malleolus fixation (n = 22, 78.6%) and gastrocnemius recession (n = 14, 50%). Overall, 10.7% (n = 3) of patients underwent reoperation and 14.3% (n = 4) suffered major complications. Incidence of implant failure was 10.7% (n = 3). All reoperations were caused by infection. Mean varus alignment of the tibia and talus improved from 4.07 degrees and 4.83 degrees to 1.67 degrees and 1.23 degrees, respectively. Mean valgus alignment of the tibia and talus improved from 3.67 degrees and 4.22 degrees to 2.00 degrees and 2.32 degrees, respectively.
CONCLUSIONS: In a series of 28 patients undergoing rTAA with the INVISION talar component, we discovered comparatively low rates of reoperation, major complication, and implant failure (10.7%, 14.3%, and 10.7%). The INVISION system appears to have a reasonable safety profile, but further studies evaluating long-term outcomes are required to assess the efficacy of the INVISION system.

Gender differences exist in mental and physical health in schizophrenia, and healthcare education is part of the associated clinical approach. The main goal of the present paper is to describe a women\'s clinic for schizophrenia and carry out a narrative review about innovative healthcare and learning strategies in the context of women who suffer from schizophrenia, and to discuss innovative strategies for both healthcare and learning projects to be applied in this context. Observing the development of our unit, four clear innovation phases can be distinguished: the generation of new ideas (clinical and social needs), strategic planning (five observatories), the execution of these strategies (observatories/teams/interventions) and feedback, iteration and scaling. We found that the observatory for morbi-mortality adopted a retroactive proactive approach, and the observatory for hyperprolactinemia was proactive and deliberate. We describe the innovation aspects, both clinical and educational, as incremental. There was one exception, the introduction of a social exclusion and discrimination observatory, that from our perspective, was not gradual, but transformative. Future learning projects should include the role of social sciences and humanities and new technologies. Our pilot project gave us the opportunity to apply new learning methods to a relatively neglected field of care.

The treatment of pain remains a critical, unmet public health challenge. According to the CDC, in 2021, an estimated 20.9% of US adults (51.6 million people) endured chronic pain, and 6.9% (17.1 million people) endured high-impact chronic pain. Additionally, the impact of the social determinants of health on pain treatment are beginning to emerge. Treating pain addresses its control and relief, enhancing patient outcomes and quality of life. However, current treatment options have limitations, creating a significant need for innovative solutions. This raises the role of innovation in identifying new pain medicines. Thus, the clinical development of novel pain medicines is an unmet need to address public health worldwide.
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In 2009, Massachusetts General Hospital and the Red Sox Foundation launched Home Base, a nonprofit dedicated to providing care to veterans, service members, and their loved ones who struggle with the invisible wounds of war free of charge. Significant needs exist for mental health services in each of these populations, and a need for innovative approaches to address shortcomings in existing treatment models. Three inventive components of our programming are highlighted herein: a Veteran Outreach Team, which helps to engage patients in care, programming, and services specifically for family members, and an intensive outpatient substance use treatment program. More than 4,000 patients, 3,031 veterans and service members, and 1,025 family members have engaged in treatment at Home Base. Patients were asked to complete post-treatment self-measures, including a satisfaction questionnaire via an electronic data collection system. The vast majority of individuals who engaged in our treatment model were satisfied with the care they received (>92%) and would refer their peers to the Home Base program (>75%). Data from 78 individuals who completed the dual diagnosis services demonstrated large effect sizes in reductions in alcohol use and comorbid mental health symptoms. These data suggest that novel components to the standard outpatient mental health model might provide substantive benefits for the patients served. While internal data is prone to a lack of generalizability, these additional offerings help ameliorate patients\' expressed shortcomings with existing models; present literature that describes the benefits that these additions provide is also reviewed. The lessons learned and limitations are discussed.