To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Introduction: Intravenous insertion (IVI) is identified by children as extremely painful and the resultant distress can have lasting negative consequences. There is an urgent need to effectively manage such procedures. Our primary objective was to compare the pain and distress of IVI with the addition of humanoid robot-based distraction to standard care, versus standard care alone. Methods: This two-armed randomized controlled trial (RCT) was conducted from April 2017 to May 2018 at the Stollery Children's Hospital emergency department (ED). Children aged 6 to 11 years who required IVI were included. Exclusion criteria included hearing or visual impairments, neurocognitive delays, sensory impairment to pain, previous enrolment, and discretion of the ED clinical staff. Primary outcomes were measured using the Observational Scale of Behavioural Distress-Revised (OSBD-R) (distress) and the Faces Pain Scale-Revised (FPS-R) (pain). A total of 426 pediatric patients were screened and 340 were excluded. Results: We recruited 86 children, of which 55% (47/86) were male; 9% (7/82) were premature at birth; 82% (67/82) had a previous ED visit; 30% (25/82) required previous hospitalization; 78% (64/82) had previous IV placement and 96% (78/81) received topical anesthesia. The mean total OSBD-R score was 1.49 ± 2.36 (standard care) compared to 0.78 ± 1.32 (robot group) (p = 0.047). The median FPS-R during the IV procedure was 4 (IQR 2,6) in the standard care group alone, compared to 2 (IQR 0,4) with the addition of humanoid robot-based distraction (p = 0.10). Change in parental state anxiety pre-procedure versus post-procedure was not significantly different between groups (p = 0.49). Parental satisfaction with the IV start was 93% (39/42) in the robot arm compared to 74% (29/39) in the standard care arm (p = 0.03). Parents were also more satisfied with management of their child's pain in the robot group (95% very satisfied) compared with standard care (72% very satisfied) (p = 0.002). Conclusion: A statistically significant reduction in distress was observed with the addition of robot-based distraction to standard care. Humanoid robot-based distraction therapy reduces distress and to a lesser extent, pain, in children undergoing IVI in the ED. Further trials are required to confirm utility in other age groups and settings.
Introduction: Although acute gastroenteritis is an extremely common childhood illness, there is a paucity of literature characterizing the associated pain and its management. Our primary objective was to quantify the pain experienced by children with acute gastroenteritis in the 24-hours prior to emergency department (ED) presentation. Secondary objectives included describing maximum pain, analgesic use, discharge recommendations, and factors that influenced analgesic use in the ED. Methods: Study participants were recruited into this prospective cohort study by the Alberta Provincial Pediatric EnTeric Infection TEam between January 2014 and September 2017. This study was conducted at two Canadian pediatric EDs; the Alberta Children's Hospital (Calgary) and the Stollery Children's Hospital (Edmonton). Eligibility criteria included < 18 years of age, acute gastroenteritis (□ 3 episodes of diarrhea or vomiting in the previous 24 hours), and symptom duration □ 7 days. The primary study outcome, caregiver-reported maximum pain in the 24-hours prior to presentation, was assessed using the 11-point Verbal Numerical Rating Scale. Results: We recruited 2136 patients, median age 20.8 months (IQR 10.4, 47.4); 45.8% (979/2136) female. In the 24-hours prior to enrolment, 28.6% (610/2136) of caregivers reported that their child experienced moderate (4-6) and 46.2% (986/2136) severe (7-10) pain in the preceding 24-hours. During the emergency visit, 31.1% (664/2136) described pain as moderate and 26.7% (571/2136) as severe. In the ED, analgesia was provided to 21.2% (452/2131) of children. The most commonly administered analgesics in the ED were ibuprofen (68.1%, 308/452) and acetaminophen (43.4%, 196/452); at home, acetaminophen was most commonly administered (77.7%, 700/901), followed by ibuprofen (37.5%, 338/901). Factors associated with analgesia use in the ED were greater pain scores during the visit, having a primary-care physician, shorter illness duration, fewer diarrheal episodes, presence of fever and hospitalization. Conclusion: Although children presenting to the ED with acute gastroenteritis experience moderate to severe pain, both prior to and during their emergency visit, analgesic use is limited. Future research should focus on appropriate pain management through the development of effective and safe pain treatment plans.
An iron catalyst supported on the modified Tamazert kaolin has been prepared and tested in catalytic wet peroxide oxidation using phenol and 4-chlorophenol (4-CP) as target compounds (100 mg/L initial concentration). Kaolin is not usually employed as a catalytic support due to its low developed porous structure, but its textural properties may be improved upon calcination and acid and basic treatment. The catalyst was characterized by N2 adsorption–desorption and chemical analysis by total-reflection X-ray fluorescence spectroscopy. The catalytic tests were carried out in a batch reactor with a stoichiometric amount of H2O2. The catalytic efficiency was studied within the temperature range of 25–55°C at an initial pH of 3.3 and 1 g/L catalyst. Complete phenol and 4-CP removal was achieved with no significant differences in phenol and 4-CP conversions within the temperature range tested. Meanwhile, total organic carbon (TOC) reduction was greatly favoured by increasing the temperature, which may be partially attributed to a probable contribution of a homogeneous reaction associated with iron leaching. However, this effect might be of limited significance because the highest concentrations of iron in the liquid phase were below 4.5 and 8.5 mg/L in the experiments with phenol and 4-CP, respectively. At 55°C, TOC was reduced by ~70% after 4 h reaction time, with the remaining by-products corresponding almost completely to low-molecular-weight carboxylic acids of very low ecotoxicity.
We examine disturbances leading to optimal energy growth in a spatially developing, zero-pressure-gradient turbulent boundary layer. The slow development of the turbulent mean flow in the streamwise direction is modelled through a parabolized formulation to enable a spatial marching procedure. In the present framework, conventional spatial optimal disturbances arise naturally as the homogeneous solution to the linearized equations subject to a turbulent forcing at particular wavenumber combinations. A wave-like decomposition for the disturbance is considered to incorporate both conventional stationary modes as well as propagating modes formed by non-zero frequency/streamwise wavenumber and representative of convective structures naturally observed in wall turbulence. The optimal streamwise wavenumber, which varies with the spatial development of the turbulent mean flow, is computed locally via an auxiliary optimization constraint. The present approach can then be considered, in part, as an extension of the resolvent-based analyses for slowly developing flows. Optimization results reveal highly amplified disturbances for both stationary and propagating modes. Stationary modes identify peak amplification of structures residing near the centre of the logarithmic layer of the turbulent mean flow. Inner-scaled disturbances reminiscent of near wall streaks, and amplified over short streamwise distances, are identified in the computed streamwise energy spectra. In all cases, however, propagating modes surpass their stationary counterpart in both energy amplification and relative contribution to total fluctuation energy. We identify two classes of large-scale energetic modes associated with the logarithmic and wake layers of the turbulent mean flow. The outer-scaled wake modes agree well with the large-scale motions that populate the wake layer. For high Reynolds numbers, the log modes increasingly dominate the energy spectra with the predicted streamwise and wall-normal scales in agreement with superstructures observed in turbulent boundary layers.
United Arab Emirates is an important range country for the ‘Vulnerable’ Socotra Cormorant Phalacrocorax nigrogularis and Abu Dhabi Emirate holds most of the remaining breeding colonies. Emirate-wide monitoring of all breeding colonies was undertaken annually for 11 breeding seasons from 2006–2007 to 2016–2017 to monitor the status of breeding colonies and estimate the nesting population. Breeding was recorded in 10 colonies that were used intermittently with an average of four (± 1.3 SD) colonies active each year. The highest number of eight active colonies was recorded in 2016–2017. Establishment of two new breeding colonies on Butinah and Digala in 2016–2017 and recolonisation of three previously inactive colonies during the monitoring period emphasised the ability of the species to relocate and colonise suitable sites. Continued threats at some breeding colonies caused abandonment and subsequent relocation, resulting in a gradual shift of breeding colonies to safer areas. Presently, most of the breeding sites (62%) with an increased number of breeding birds are found in colonies with restricted access. The Emirate-wide nesting population witnessed a 10-fold increase in the last decade; after an initial decline in 2006–2007 it increased from about 5,000 pairs in 2007–2008 to nearly 52,000 nesting pairs in 2016–2017. Combined with the nesting population from the Siniya colony, the overall UAE nesting population is estimated at 60,000 to 70,000 pairs, nearly half of the global breeding population. Further augmentation of the current breeding numbers is possible if breeding colonies remain safe from human disturbance and invasive predators. For long-term conservation of Socotra Cormorant, protection of all remaining colony sites, including inactive ones, is important in addition to minimising disturbance along with widespread public awareness to change the people’s perception of the species as a competitor to commercial fisheries.
Introduction: Intravenous (IV) cannulation is commonly performed in emergency departments (ED), often causing substantial pain and distress. Distraction has been shown to reduce child-reported pain, but there is currently little published about the effects of using iPad technology as a distraction tool. Our primary objective was to compare the reduction of pain and distress using iPad distraction (games, movies, books of the child’s choice) in addition to standard care, versus standard care alone. Methods: This randomized clinical trial, conducted at the Stollery Childrens Hospital ED, recruited children between ages 6 to 11 years requiring IV cannulation. Study arm assignment was performed using REDCaps randomization feature. Due to the nature of the intervention, blinding was not possible for the children, parents or research and ED staff, but the data analyst was blinded to intervention assignment until completion of analysis. Pain, distress, and parental anxiety were measured using the Faces Pain Scale-Revised, the Observed Scale of Behavioural Distress-Revised, and the State Trait Anxiety Inventory, respectively. The pain scores and observed behavioural distress scores were compared using the Mann-Whitney U test. Other co-variates were analyzed using a linear regression analysis. Results: A total of 85 children were enrolled, with 42 receiving iPad distraction and 43 standard care, of which 40 (95%) and 35 (81%) children received topical anesthesia, respectively (p=0.09). There were 40 girls (47.1%) with a mean age of 8.32 +/− 1.61 years. The pain scores during IV cannulation (p=0.35) and the change in pain score during the procedure compared to baseline (p=0.79) were not significantly different between the groups, nor were the observed distress scores during IV cannulation (p=0.09), or the change in observed distress during the procedure compared to baseline (p=0.44). A regression analysis showed children in both groups had greater total behavioural stress if it was their first ED visit (p=0.01), had prior hospitalization experience (p=0.04) or were admitted to hospital during this visit (p=0.007). A previous ED visit, however, was predictive of a greater increase in parental anxiety from baseline (p=0.02). When parents were asked whether they would use the same methods to manage pain for their child, parents of the iPad group were more likely to say yes than were parents of the standard care group (p=0.03). Conclusion: iPad distraction during IV cannulation in school-aged children was not found to decrease pain or distress more than standard care alone, but parents preferred its use. The effects of iPad distraction may have been over-shadowed by potent topical anesthetic effect. Future directions include exploring iPad distraction for other age groups, and studying novel technology such as virtual reality and interactive humanoid robots.
Geophysical flows occur over a large range of scales, with Reynolds numbers and Richardson numbers varying over several orders of magnitude. For this study, jets of different densities were ejected vertically into a large ambient region, considering conditions relevant to some geophysical phenomena. Using particle image velocimetry, the velocity fields were measured for three different gases exhausting into air – specifically helium, air and argon. Measurements focused on both the jet core and the entrained ambient. Experiments considered relatively low Reynolds numbers from approximately 1500 to 10 000 with Richardson numbers near 0.001 in magnitude. These included a variety of flow responses, notably a nearly laminar jet, turbulent jets and a transitioning jet in between. Several features were studied, including the jet development, the local entrainment ratio, the turbulent Reynolds stresses and the eddy strength. Compared to a fully turbulent jet, the transitioning jet showed up to 50 % higher local entrainment and more significant turbulent fluctuations. For this condition, the eddies were non-axisymmetric and larger than the exit radius. For turbulent jets, the eddies were initially smaller and axisymmetric while growing with the shear layer. At lower turbulent Reynolds number, the turbulent stresses were more than 50 % higher than at higher turbulent Reynolds number. In either case, the low-density jet developed faster than a comparable non-buoyant jet. Quadrant analysis and proper orthogonal decomposition were also utilized for insight into the entrainment of the jet, as well as to assess the energy distribution with respect to the number of eigenmodes. Reynolds shear stresses were dominant in Q1 and Q3 and exhibited negligible contributions from the remaining two quadrants. Both analysis techniques showed that the development of stresses downstream was dependent on the Reynolds number while the spanwise location of the stresses depended on the Richardson number.
Few methods exist for quantitatively estimating the diet composition of free-ranging herbivores. Because their patterns differ between species, plant n-alkanes have been successfully used as faecal markers to estimate the botanical composition of simple diets, however, the reliability of this methods may decline as the number of dietary plant species increases (Dove and Mayes, 1996). The objective of this study was to examine whether additional plant-wax compounds, such as long-chain fatty alcohols (Alc) or long–chain fatty acids (Ac) could be used along with n-alkanes (Alk) to allow reliable diet composition estimates to be made in herbivores consuming complex diets.
Four early-generation backcross populations (BC1F2) derived from one common recipient parental background, Weed Tolerant Rice 1 (‘WTR1’), and four different donor parents (‘Y134’, ‘Zhong 143’, ‘Khazar’, and ‘Cheng Hui-448’) were tested to identify suitable donor and recipient parents for weed competitiveness and to standardize evaluation of the weed-competitive ability in rice. ‘GSR IR2-6’ (G-6) derived from a backcross of WTR1/Y134//WTR1 was selected as the best population and was advanced for phenotypic experiments in the 2014 dry season. The introgression lines (ILs) derived from the G-6 population were evaluated for seed germination and seedling vigor in greenhouse conditions and for weed-competitive ability under field conditions (upland weed-free, upland weedy, and lowland weedy). Parents and checks were included for comparison. Selection pressure for weed competitiveness was relatively stronger in upland conditions than in lowland conditions. After three rounds of selection and based on their relative grain yield performances across conditions, a total of 21 most-promising introgression fixed lines showing superior traits and weed-competitive ability were identified. G-6-L2-WL-3, G-6-RF6-WL-3, G-6-L15-WU-1,G-6-Y16-WL-2, and G-6-L6-WU-3 were the top ILs in lowland weedy conditions, whereas G-6-Y7-WL-3, G-6-Y6-WU-3, G-6-Y3-WL-3, and G-6-Y8-WU-1 were the highest yielding in upland weedy conditions. The use of weed-competitive rice cultivars in African and Asian countries will be a highly effective strategy to reduce production costs and provide alternative solutions to the unavailability of herbicides. Competitive rice varieties will also significantly improve grain yields in aerobic rice systems and can become an important strategy for successful upland rice production.
Recently developed innovations may improve the economic and environmental sustainability of pig production systems. Generic models are needed to assess the impact of innovations on farm performance. Here we developed a stochastic bio-economic farm model for a typical farrow-to-finish pig farm to assess the impact of innovations on private and social profits. The model accounts for emissions of greenhouse gases from feed production and manure by using the shadow price of CO2, and for stochasticity of economic and biological parameters. The model was applied to assess the impact of using locally produced alternative feed sources (i.e. co-products) in the diets of finishing pigs on private and social profits of a typical Brazilian farrow-to-finish pig farm. Three cases were defined: a reference case (with a standard corn–soybean meal-based finishing diet), a macaúba case (with a macaúba kernel cake-based finishing diet) and a co-products case (with a co-products-based finishing diet). Pigs were assumed to be fed to equal net energy intakes in the three cases. Social profits are 34% to 38% lower than private profits in the three cases. Private and social profits are about 11% and 14% higher for the macaúba case than the reference case, whereas they are 3% and 7% lower for the co-products case, respectively. Environmental costs are higher under the alternative cases than the reference case suggesting that other benefits (e.g. costs and land use) should be considered to utilize co-products. The CV of farm profits is between 75% and 87% in the three cases following from the volatility of prices over time and variations in biological parameters between fattening pigs.
A large eddy simulation framework is used to explore the structure of the turbulent flow in a thermally stratified wind turbine array boundary layer. The flow field is driven by a constant geostrophic wind with time-varying surface boundary conditions obtained from a selected period of the CASES-99 field experiment. Proper orthogonal decomposition is used to extract coherent structures of the turbulent flow under the considered thermal stratification regimes. The flow structure is discussed in the context of three-dimensional representations of key modes, which demonstrate features ranging in size from the wind turbine wakes to the atmospheric boundary layer. Results demonstrate that structures related to the atmospheric boundary layer flow dominate over those introduced by the wind farm for the unstable and neutrally stratified regimes; large structures in atmospheric turbulence are beneficial for the wake recovery, and consequently the presence of the turbulent wind turbine wakes is diminished. Contrarily, the flow in the stably stratified case is fully dominated by the presence of the turbines and highly influenced by the Coriolis force. A comparative analysis of the test cases indicates that during the stable regime, higher-order modes contribute less to the overall character of the flow. Under neutral and unstable stratification, important turbulence dynamics are distributed over a larger range of basis functions. The influence of the wind turbines on the structure of the atmospheric boundary layer is mainly quantified via the turbulence kinetic energy of the first ten modes. Linking the new insights into structure of the wind turbine/atmospheric boundary layer and their interaction addressed here will benefit the formulation of new simplified models for commercial application.
The Eastern Gangetic Plain is among the world's most intensively farmed regions, where rainfed and irrigated agriculture coexist. While the region and especially Bangladesh is a major producer of rice (Oryza sativa L. ssp. indica), there is potential to further develop sustainable rice production systems. Specifically, there is scope to include a replacement crop for the short fallow between rice crops in the dominant cropping pattern of rainfed monsoon rice harvest followed by irrigated spring rice. The aim of the current research was to identify a suitable cool-season legume crop – pea (Pisum sativum L.) or lentil (Lens culinaris Medik. ssp. culinaris) – that could be grown in the brief period between rice crops. The study comprised four crop sequence experiments comparing legume cultivars differing in maturity grown in between both long and short duration rice cultivars. These experiments were done at the Bangladesh Rice Research Institute regional station at Rajshahi over three cropping cycles. This was followed by an evaluation of pea vs. fallow between rice crops on three farmers’ fields in one cropping cycle. Here it is demonstrated that green pod vegetable pea is one of the best options to intensify the rainfed monsoon rice–fallow–spring irrigated rice cropping system, notwithstanding other remunerative rabi cropping options that could displace boro rice. The inclusion of an extra crop, pea as green pod vegetable, increased farm productivity by 1·4-fold over the dominant cropping sequence (rice–fallow–rice) and farm net income by fourfold. The study highlighted the advantages in total system productivity and monetary return of crop intensification with the inclusion of a pea crop between successive rice crops instead of a fallow period.
Objectives: To compare growth patterns of nonfunctioning and prolactin-producing pituitary macroadenomas, and to find whether their specific growth patterns are associated with clinically significant effects on vision. Materials and Methods: From our comprehensive provincial neuropituitary registry, we retrospectively identified 35 randomly selected patients each with nonfunctioning adenomas and prolactinomas >10 mm in any dimension. MRI scans were analyzed to determine the superior and inferior growth, volume, and maximum craniocaudal height of the adenomas. Patients underwent visual field testing at diagnosis. Continuous variables were compared using Student’s t test, the Mann–Whitney U test, and ANOVA. Categorical variables were compared using the chi-square test. Results: The mean height of prolactinomas (23.2±11.3 mm) was similar to nonfunctioning adenomas (22.3±9.3 mm, p=0.8), and so were mean tumor volumes (prolactinoma=5.9±8 ml vs. nonfunctioning adenoma=4.8±5 ml, p=0.47). However, the mean suprasellar growth for prolactinomas was 2.9±5.3 mm and 7.3±4.7 mm for nonfunctioning adenomas (p<0.001), and the mean infrasellar growth was 10.2±8.0 and 5.0±6.6 mm, respectively (p=0.04). The inferior growth pattern of prolactinomas was associated with a significantly lower likelihood of having visual field abnormalities (11.4 vs. 57.1%, p<0.001). Conclusions: Prolactinomas have predominantly inferior growth compared to nonfunctioning adenomas and are less likely to cause vision changes.
Every year the growth of the poultry industry is severely threatened by a number of infectious viral, bacterial and parasitic diseases. There are a number of vaccines to control these diseases including inactivated virus vaccines, attenuated virus vaccines, live virus vaccines, and subunit vaccines, but they are often relatively expensive and require cold storage and trained people to administer them, especially in developing countries. Plant-based vaccines provide a better option to control these diseases in low profit margin poultry industry. Still there are some challenges in the field of plant-based, so called ‘green’ vaccines. Injection-based oral priming is a big challenge for commercialisation of green vaccines so, new techniques are needed in the field of plant-based vaccine to pass these barriers for commercialisation. This discusses the potential for plant-based vaccines and whether they are good option to control poultry diseases.
Introduction: Appropriate pain management relies on the use of valid, reliable and age-appropriate tools that are validated in the setting in which they are intended to be used. The aim of the study was to assess the psychometric properties of pain scales commonly used in children presenting to the pediatric emergency department (PED) with an acute musculoskeletal injury. Methods: Convergent validity was assessed by determining the Spearman’s correlations and the agreement using the Bland-Altman method between the Visual Analogue Scale (VAS), Faces Pain Scale-Revised (FPS-R) and Color Analogue Scale (CAS). Responsiveness to change was determined by performing the Wilcoxon signed-rank test between the pre-post analgesia mean scores. Reliability of the scales was estimated using relative (Spearman’s correlation, Intraclass Correlation Coefficient) and absolute indices (Coefficient of Reliability). Results: A total of 495 participants was included in the analyses. Mean age was 11.9 ±2.7 years and participants were mainly boys (55.3%). Correlation between each pair of scales was 0.79 (VAS/FPS-R), 0.92 (VAS/CAS) and 0.81 (CAS/FPS-R). Limits of agreement (80%CI) were -2.71 to 1.27 (VAS/FPS-R), -1.13 to 1.15 (VAS/CAS) and -1.45 to 2.61 (CAS/FPS-R). Responsiveness to change was demonstrated by significant differences in mean pain scores, among the three scales, between pre- and post-medication administration (p<0.0001). ICC and CR estimates suggested acceptable reliability for the three scales at 0.79 and ±1.49 for VAS, 0.82 and ±1.35 for CAS, and 0.76 and ±1.84 for FPS-R. Conclusion: The scales demonstrated good psychometric properties with a large sample of children with acute pain in the PED. The VAS and CAS showed a stronger convergent validity, while FPS-R was not in agreement with the other scales. Clinically, VAS and CAS scales can be used interchangeably to assess pain intensity of children with acute pain.
Africa is experiencing a rapid increase in adult obesity and associated cardiometabolic diseases (CMDs). The H3Africa AWI-Gen Collaborative Centre was established to examine genomic and environmental factors that influence body composition, body fat distribution and CMD risk, with the aim to provide insights towards effective treatment and intervention strategies. It provides a research platform of over 10 500 participants, 40–60 years old, from Burkina Faso, Ghana, Kenya and South Africa. Following a process that involved community engagement, training of project staff and participant informed consent, participants were administered detailed questionnaires, anthropometric measurements were taken and biospecimens collected. This generated a wealth of demographic, health history, environmental, behavioural and biomarker data. The H3Africa SNP array will be used for genome-wide association studies. AWI-Gen is building capacity to perform large epidemiological, genomic and epigenomic studies across several African counties and strives to become a valuable resource for research collaborations in Africa.
Aneurysm of the sinus of Valsalva is a rare congenital cardiac anomaly. It occurs as an outpouching that progresses like a windsock, and it may rupture producing aortic regurgitation, cardiac tamponade, congestive heart failure, conduction abnormalities, and stroke. We describe a case of rupture of the sinus of Valsalva into the interventricular septum producing a large dissecting aneurysm. Despite the location, it did not produce a conduction abnormality.
Coronary artery anomalies are a heterogeneous group of congenital disorders presenting with a wide spectrum of symptoms, ranging from vague chest pain to sudden cardiac death. Despite available data, there is no consensus about the classification, nomenclature, and outcomes of coronary anomalies in the normally connected heart. In this study, we aimed to investigate clinical and angiographic characteristics of coronary arterial anomalies, as well as the frequency of atherosclerotic involvement in anomalous coronaries, diagnosed at a tertiary referral centre.
We retrospectively reviewed coronary angiograms performed between 2011 and 2015 for the presence of a coronary anomaly. A total of 111 patients with a final diagnosis of coronary anomaly were included in the study group. We also recruited 110 age- and sex-matched patients who underwent coronary angiography because of symptomatic coronary artery disease as controls.
Among 36,893 coronary angiograms, 111 (0.30%) major coronary anomalies were found. Compared with controls, the prevalence of significant atherosclerotic coronary disease was lower in patients with coronary anomalies and stable symptoms (p=0.02); however, the prevalence of significant coronary atherosclerosis was similar among patients admitted with unstable angina or myocardial infarction (p>0.05). Compared with controls, patients with an anomalous left anterior descending coronary artery had significantly less atherosclerotic involvement than those in whom the left anterior descending artery was not anomalous (p=0.005).
Although coronary artery anomalies are cited as a cause for myocardial ischaemia, atherosclerotic coronary artery disease is also frequent and may offer an alternative explanation to ischaemic symptoms. No predisposition to accelerated atherosclerosis was found, however, and atherosclerotic involvement was less frequent in some anomalous vessels.
The primary extracardiac inferior cavopulmonary connection is an unusual novel palliation for single-ventricle physiology, which we first performed in the setting of unfavourable upper-body systemic venous anatomy for a standard bi-directional Glenn, and in lieu of leaving our patient with shunt-dependent physiology. After an initial 16-month satisfactory follow-up, increasing cyanosis led to the discovery of a veno-venous collateral that was coiled, but, more importantly, to impressive growth of a previously diminutive superior caval vein, which allowed us to perform completion Fontan with a good outcome. Performing the single-ventricle staging in a reverse manner, first from below with a primary inferior cavopulmonary connection, followed by Fontan completion from above with a standard superior caval vein bi-directional Glenn, is also possible when deemed necessary.