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Feeding difficulty is a known complication of congenital heart surgery. Despite this, there is a relative sparsity in the available data regarding risk factors, incidence, associated symptoms, and outcomes.
In this retrospective chart review, patients aged 0–18 years who underwent congenital heart surgery at a single institution between January and December, 2017 were reviewed. Patients with feeding difficulties before surgery, multiple surgeries, and potentially abnormal recurrent laryngeal nerve anatomy were excluded. Data collected included patient demographics, feeding outcomes, post-operative symptoms, flexible nasolaryngoscopy findings, and rates of readmission within a 1-year follow-up period. Multivariable regression analyses were performed to evaluate the risk of an alternative feeding plan at discharge and length of stay.
Three-hundred and twenty-six patients met the inclusion criteria for this study. Seventy-two (22.09%) were discharged with a feeding tube and 70 (97.22%) of this subgroup were younger than 12 months at the time of surgery. Variables that increased the risk of being discharged with a feeding tube included patient age, The Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery score, procedure group, aspiration, and reflux. Speech-language pathology was the most frequently utilised consulting service for patients discharged with feeding tubes (90.28%) while other services were not frequently consulted. The median length of stay was increased from 4 to 10 days for patients who required an enteral feeding tube at discharge.
Multidisciplinary management protocol and interventions should be developed and standardised to improve feeding outcomes following congenital heart surgery.
Drug Safety Communications (DSCs) are used by the Food and Drug Administration (FDA) to inform health care providers, patients, caregivers, and the general public about safety issues related to FDA-approved drugs. To assess patient knowledge of the messaging contained in DSCs related to the sleep aids zolpidem and eszopiclone, we conducted a large, cross-sectional patient survey of 1,982 commercially insured patients selected by stratified random sampling from the Optum Research Database who had filled at least two prescriptions for either zolpidem or eszopiclone between July 1, 2012 and June 30, 2013. Among the 594 respondents (32.7% response rate), two-thirds reported hearing generally about drug safety information prior to starting a new drug, with the remaining one-third “rarely” or “never” hearing such information. Providers and pharmacists were primary sources of drug safety information. Two-thirds of zolpidem users and half of eszopiclone users reported having heard about the related DSC messages, ability to accurately identify the major factual messages was limited (overall median 2 correct out of 5, with men and those reporting higher educational level scoring higher [2/5 vs. 1/5, p=0.001]). Respondents reacted to new drug safety information about their sleep aids by reporting that they would want to learn about alternative ways to help them sleep (70%) and seek out more information about the safety of their specific sleeping pill (59-78%). Opportunities may exist for the FDA to work with providers and pharmacies to help ensure the DSC information is more widely received and is more fully understood by those taking the affected medications.
Choosing Wisely Canada (CWC) is a national initiative designed to encourage patient-clinician discussions about the appropriate, evidence-based use of medical tests, procedures and treatments. The Canadian Association of Emergency Physicians’ (CAEP) Choosing Wisely Canada (CWC) working group developed and released ten recommendations relevant to Emergency Medicine in June 2015 (items 1–5) and October 2016 (items 6–10). In November 2016, the CAEP CWC working group developed a process for updating the recommendations. This process involves: 1) Using GRADE to evaluate the quality of evidence, 2) reviewing relevant recommendations on an ad hoc basis as new evidence emerges, and 3) reviewing all recommendations every five years. While the full review of the CWC recommendations will be performed in 2020, a number of high-impact studies were published after our initial launch that prompted an ad hoc review of the relevant three of our ten recommendations prior to the full review in 2020. This paper describes the results of the CAEP CWC working group's ad hoc review of three of our ten recommendations in light of recent publications.
Choosing Wisely Canada (CWC) is an initiative to encourage patient-physician discussions about the appropriate, evidence based use of medical tests, procedures and treatments. We present the Canadian Association of Emergency Physicians’ (CAEP) top five list of recommendations, and the process undertaken to generate them.
The CAEP Expert Working Group (EWG) generated a candidate list of 52 tests, procedures, and treatments in emergency medicine whose value to care was questioned. This list was distributed to CAEP committee chairs, revised, and then divided and randomly allocated to 107 Canadian emergency physicians (EWG nominated) who voted on each item based on: action-ability, effectiveness, safety, economic burden, and frequency of use. The EWG discussed the items with the highest votes, and generated the recommendations by consensus.
The top five CAEP CWC recommendations are: 1) Don’t order CT head scans in adults and children who have suffered minor head injuries (unless positive for a validated head injury clinical decision rule); 2) Don’t prescribe antibiotics in adults with bronchitis/asthma and children with bronchiolitis; 3) Don’t order lumbosacral spinal imaging in patients with non-traumatic low back pain who have no red flags/pathologic indicators; 4) Don’t order neck radiographs in patients who have a negative examination using the Canadian C-spine rules; and 5) Don’t prescribe antibiotics after incision and drainage of uncomplicated skin abscesses unless extensive cellulitis exists.
The CWC recommendations for emergency medicine were selected using a mixed methods approach. This top 5 list was released at the CAEP Conference in June 2015 and should form the basis for future implementation efforts.
Efficient contracting predicts that ex ante severance pay contracts are offered to chief executive officers (CEOs) as protection against downside risk and to encourage investment in risky projects with a positive net present value (NPV). Consistent with this prediction, we find that ex ante contracted severance pay is positively associated with proxies for a CEO’s risk of dismissal and costs the CEO would incur from dismissal. Additionally, we show that the contracted severance payment amount is positively associated with CEO risk taking and the extent to which a CEO invests in projects that have a positive NPV. Overall, our findings imply that ex ante severance pay contracts are consistent with efficient contracting.
Allotment food gardens represent important sources of food security for urban residents. Since urban gardeners rarely receive formal agricultural education and have extremely limited space, they may be relying on readily available gardening advice (e.g., seed packet instructions), inventing cultural strategies that consider inter-specific competitive dynamics, or making poor planting decisions. Knowledge of garden crop diversity and planting arrangements can aid in designing strategies for productive urban gardens and food systems. We surveyed 96 individual plots in 10 allotment gardens in the Toronto region, assessed crop diversity within gardens and recorded planting practices used by urban gardeners by measuring the proximity of individual plants relative to similar or different crop species. We also compared planting densities used by urban gardeners with those recommended by major seed distributers. Collectively, Toronto urban agriculture contributes substantially to urban plant diversity (108 crops), but each plot tends to be relatively depauperate. Carrots and lettuce were three to five times more likely to be planted in clusters than intermingled with other crops (P < 0.05); whereas gardeners did not appear to use consistent planting arrangements for tomatoes or zucchini. Gardeners tended to plant tomatoes and zucchini 56–62.5% more densely than recommended by seed distributers (P < 0.001), whereas they planted 147 times fewer carrots in a given area than recommended (P < 0.05). Furthermore, neither crop planting density nor crop diversity changed with plot size. The planting arrangements we have documented suggest gardeners using allotment plots attempt plant densely in extremely limited space, and are employing cultural strategies that intensify competitive dynamics within gardens. Future research should assess the absolute and relative effect of altered cultural practices on yield, such that any modifications can be prioritized by their impact on yield.
A new dromomerycine palaeomerycid artiodactyl, Surameryx acrensis new genus new species, from upper Miocene deposits of the Amazon Basin documents the first and only known occurrence of this Northern Hemisphere group in South America. Osteological characters place the new taxon among the earliest known dromomerycine artiodactyls, most similar to Barbouromeryx trigonocorneus, which lived in North America during the early to middle Miocene, 20–16 Ma. Although it has long been assumed that the Great American Biotic Interchange (GABI) began with the closure of the Isthmus of Panama in the late Pliocene, or ca. 3.0–2.5 Ma, the presence of this North American immigrant in Amazonia is further evidence that terrestrial connections between North America and South America through Panama existed as early as the early late Miocene, or ca. 9.5 Ma. This early interchange date was previously indicated by approximately coeval specimens of proboscideans, peccaries, and tapirs in South America and ground sloths in North America. Although palaeomerycids apparently never flourished in South America, proboscideans thrived there until the end of the Pleistocene, and peccaries and tapirs diversified and still live there today.
Previously unknown ontogenies of five lichid genera, Dicranopeltis, Platylichas, Borealarges, Dicranogmus and Radiolichas, are described and placed in the context provided by a review of known lichid ontogenies. Lichid phylogenies have been based on holaspid morphology alone without reference to ontogeny. To broaden knowledge of lichid phylogeny, an analysis, based on the last protaspid instar of lichids and possible sister group taxa, is conducted. The results of this analysis show that, within the lichids, the traditional subfamily groupings are not supported, and the sister group of lichids is more likely to be found within the Proetida than the Odontopleurida. Tubercles, a prominent feature of lichid morphology, have not been considered taxonomically significant. An examination suggests that tubercle arrangement and the pattern of change of tubercle arrangement through ontogeny could be important in defining taxa. It is recommended that future work on lichid phylogeny include ontogenetic information and patterns of change in development.
Discrete current switching is induced in carbon nanotubes by electron beam irradiation. Switching amplitudes of 3% to 6% are observed at room temperature. Switching is created by electron beam exposure with dosage as low as 1000 pC/cm. Relative switching amplitude remains constant as the bias voltage varies, suggesting that current fluctuation is dominated by mobility fluctuation. Changes in the noise power spectral density following electron beam exposure will be discussed.