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A 22q11 chromosome deletion is common in patients with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals. We sought to determine whether 22q11 chromosome deletion is associated with increased postoperative morbidity after unifocalisation surgery.
We included all patients with this diagnosis undergoing primary or revision unifocalisation ± ventricular septal defect closure at our institution from 2008 to 2016, and we excluded patients with unknown 22q11 status. Demographic and surgical data were collected. We compared outcomes between those with 22q11 chromosome deletion and those without using non-parametric analysis.
We included 180 patients, 41% of whom were documented to have a chromosome 22q11 deletion. Complete unifocalisation was performed in all patients, and intracardiac repair was performed with similar frequency regardless of 22q11 chromosome status. Duration of mechanical ventilation was longer in 22q11 deletion patients. This difference remained significant after adjustment for delayed sternal closure and/or intracardiac repair. Duration of ICU stay was longer in patients with 22q11 deletion, although no longer significant when adjusted for delayed sternal closure and intracardiac repair. Finally, length of hospital stay was longer in 22q11-deleted patients, but this difference was not significant on unadjusted or adjusted analysis.
Children with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals and 22q11 deletion are at risk for greater prolonged mechanical ventilation after unifocalisation surgery. Careful attention should be given to the co-morbidities of this population in the perioperative period to mitigate risks that may complicate the postoperative course.
A panel of emergency medicine (EM) leaders endeavoured to define the key elements of leadership and its models, as well as to formulate consensus recommendations to build and strengthen academic leadership in the Canadian EM community in the areas of mentorship, education, and resources.
The expert panel comprised EM leaders from across Canada and met regularly by teleconference over the course of 9 months. From the breadth of backgrounds and experience, as well as a literature review and the development of a leadership video series, broad themes for recommendations around the building and strengthening of EM leadership were presented at the CAEP 2015 Academic Symposium held in Edmonton, Alberta. Feedback from the attendees (about 80 emergency physicians interested in leadership) was sought. Subsequently, draft recommendations were developed by the panel through attendee feedback, further review of the leadership video series, and expert opinion. The recommendations were distributed to the CAEP Academic Section for further feedback and updated by consensus of the expert panel.
The methods informed the panel who framed recommendations around four themes: 1) leadership preparation and training, 2) self-reflection/emotional intelligence, 3) academic leadership skills, and 4) gender balance in academic EM leadership. The recommendations aimed to support and nurture the next generation of academic EM leaders in Canada and included leadership mentors, availability of formal educational courses/programs in leadership, self-directed education of aspiring leaders, creation of a Canadian subgroup with the AACEM/SAEM Chair Development Program, and gender balance in leadership roles.
These recommendations serve as a roadmap for all EM leaders (and aspiring leaders) to build on their success, inspire their colleagues, and foster the next generation of Canadian EM academic leaders.
Home equity release products have been promoted as a potential solution to residential long-term care costs for the elderly. Lower than expected utilisation of home equity release loans has prompted efforts to better model and price the no-negative-equity-guarantee (NNEG) built into the contracts, but loan rates are still widely perceived by homeowners as being unattractive. We propose the introduction of a new adjustable rate loan based on a regional house price index, with the NNEG being borne by a specially created intermediary. The proposed approach allows us to directly address and separately price the basis risk between individual house price returns and index returns. In addition, it offers the opportunity to create securities based on residential real estate that would be attractive to a wider class of investors. The alternative risk-sharing mechanism creates a more transparent and simple pricing structure for the loans. We then use house sales data to demonstrate the approach. We find in our sample that it would be possible to make higher loans than seen in previous literature using standard roll-up contracts. In the most favourable scenario for our simulations, the maximum loan is 89% of the appraised home value if the loan is advanced as a lump sum and 95% if the loan is advanced in instalments.
Research is essential for the development of evidence-based emergency medical services (EMS) systems of care. When resources are scarce and gaps in evidence are large, a national agenda may inform the growth of EMS research in Canada. This mixed methods consensus study explores current barriers and existing strengths within Canadian EMS research, provides recommendations, and suggests EMS topics for future study.
Purposeful sampling was employed to invite EMS research stakeholders from various roles across the country. Study phases consisted of 1) baseline interviews of a subsample, 2) roundtable discussion, and 3) an online Delphi survey, in which participants scored each statement for importance. Consensus was defined a priori and met if 80% scored a statement as “important” or “very important.”
Fifty-three stakeholders participated, representing researchers (37.7%), EMS administrators (24.6%), clinicians/ providers (20.7%), and educators (17.0%). Participation rates were as follows: interviews, 13 of 13 (100%); roundtable, 47 of 53 (89%); survey round 1, 50 of 53 (94%); survey round 2, 47 of 53 (89%); and survey round 3, 40 of 53 (75%). A total of 141 statements were identified as important: 20 barriers, 54 strengths/opportunities, 31 recommendations, and 36 suggested topics for future research. Like statements were synthesized, resulting in barriers (n 5 10), strengths/opportunities (n 5 24), and recommendations (n 5 19), which were categorized as time, opportunities, and funding; education and mentorship; culture of research and collaboration; structure, process, and outcome of research; EMS and paramedic practice; and the future of the EMS Research Agenda.
Consensus-based key messages from this agenda should be considered when designing, funding, and publishing EMS research and will advance EMS research locally, regionally, and nationally.
The human prion diseases have traditionally been classified into Creutzfeldt-Jakob disease (CJD), Gerstmann-Sträussler syndrome (GSS) and kuru. The clinically defined categories: CJD, GSS, and kuru may be divided further into three etiological categories: sporadic, acquired, and inherited. The coding sequences of mammalian prion protein genes are highly conserved in a similar way to other structural proteins, presumably by deleterious selection of coding mutations. Symptomatic treatment of various neurological and psychiatric features can be provided and a range of supportive services are likely to be required in the later stages of the disease. A number of approaches to rational therapeutics are being studied in experimental models. Anti-PrP antibodies have been shown to block progression of peripheral prion propagation in mouse models, and humanized versions of these antibodies could, in principle, be developed and used for both post-exposure prophylaxis and during established clinical disease.
We determined the after-tax income required to finance basic needs for Canadian elders living with different circumstances in terms of age, gender, city of residence, household size, homeowner or renter status, means of transportation, and health status. Using 2001 as our base year, we priced the typical expenses for food, shelter, medical, transportation, miscellaneous basic living items and home-based long-term care for elders living in five Canadian cities. This is the first Canadian study of basic living expenses tailored to elders instead of adults in general, prepared on an absolute rather than a relative basis. We also accounted for an individual’s unique life circumstances and established the varying effect that they have on the cost of basic expenses, particularly for home care. We found that the maximum Guaranteed Income Supplement and Old Age Security benefit did not meet the cost of basic needs for an elder living in poor circumstances.
We have obtained metallicities from near-infrared calcium triplet spectroscopy for nearly a thousand red giants in 28 fields spanning a range of radial distances from the center of the bar to near the tidal radius. We have used these data to investigate the radius-metallicity and age-metallicity relations. A powerful application of these data is in conjunction with the analysis of deep HST color–magnitude diagrams (CMDs). Most of the power in determining a robust star-formation history from a CMD comes from the main-sequence turnoff and subgiant branches. The age-metallicity degeneracy that results is largely broken by the red giant branch color, but theoretical model RGB colors remain uncertain. By incorporating the observed metallicity distribution function into the modelling process, a star-formation history with massively increased precision and accuracy can be derived. We incorporate the observed metallicity distribution of the LMC bar into a maximum-likelihood analysis of the bar CMD, and present a new star formation history and age–metallicity relation for the bar. The bar is certainly younger than the disk as a whole, and the most reliable estimates of its age are in the 5–6 Gyr range, when the mean gas abundance of the LMC had already increased to [Fe/H] ≳ −0.6. There is no obvious metallicity gradient among the old stars in the LMC disk out to a distance of 8–10 kpc, but the bar is more metal-rich than the disk by ≈0.1–0.2 dex. This is likely to be the result of the bar's younger average age. In both disk and bar, 95% of the red giants are more metal-rich than [Fe/H] = −1.2.
Numerous patients are assessed in the emergency department (ED) for chest pain suggestive of acute coronary syndrome (ACS) and subsequently discharged if found to be at low risk. Exercise stress testing is frequently advised as a follow-up investigation for low-risk patients; however, compliance with such recommendations is poorly understood. We sought to determine if compliance with follow-up for exercise stress testing is higher in patients for whom the investigation is ordered at the time of ED discharge, compared with patients who are advised to arrange testing through their family physician (FP).
Low-risk chest pain patients being discharged from the ED for outpatient exercise stress test and FP follow-up were randomized into 2 groups. ED staff ordered an exercise stress test for the intervention group, and the control group was advised to contact their FP to arrange testing. The primary outcome was completion of an exercise stress test at 30 days, confirmed through both patient contact and stress test results. Patients were unaware that our primary interest was their compliance with the exercise stress testing recommendations.
Two-hundred and thirty-one patients were enrolled and baseline characteristics were similar between the 2 groups. Completion of an exercise stress test at 30 days occurred in 87 out of 120 (72.5%) patients in the intervention group and 60 out of 107 (56.1%) patients in the control group. The difference in compliance rates (16.4%) between the 2 groups was statistically significant (χ2 = 6.69, p < 0.001) with a relative risk of 1.29 (95% confidence interval 1.18–1.40), and the results remained significant after a “worst case” sensitivity analysis involving 4 control group cases lost to follow-up. When subjects were contacted by telephone 30 days after the ED visit, 60% of those who were noncompliant patients felt they did not have a heart problem and that further testing was unnecessary.
When ED staff order an outpatient exercise stress test following investigation for potential ACS, patients are more likely to complete the test if it is booked for them before ED discharge. After discharge, many low-risk chest pain patients feel they are not at risk and do not return to their FP for further testing in a timely manner as advised. Changing to a strategy of ED booking of exercise stress testing may help earlier identification of patients with coronary heart disease.
We present results from a project aimed at better understanding the kinematics and metallicities of populous clusters in the LMC. In an effort to update previous [Fe/H] determinations, we have utilized FORS2 on the VLT to obtain infrared spectra for more than 200 stars in 28 LMC clusters. The absorption lines of the calcium II triplet were then used to calculate radial velocities and [Fe/H] for a sample of clusters spanning a large range of ages (~ 1-13 Gyr) and metallicities (−0.3 >[Fe/H]> − 2.0). We determine mean cluster velocities to typically 1.6 km s−1 and mean metallicities to 0.04 dex (random error). For eight of these clusters, we report the first spectroscopically determined metallicities based on individual cluster stars, and six of these eight have no published radial velocity measurements. Combining our data with archival HST/WFPC2 photometry, we find the newly measured cluster, NGC 1718, is one of the most metal-poor ([Fe/H] ~ −0.80), intermediate age (~ 2 Gyr) inner disk clusters in the LMC. Similar to what was found by previous authors, this cluster sample has motions consistent with that of a single rotating disk system, with no indication that the newly reported clusters exhibit halo kinematics. Additionally, our findings confirm previous results which show that the LMC lacks the metallicity gradient typically seen in non-barred spiral galaxies, suggesting that the bar is driving the mixing of stellar populations in the LMC. However, in contrast to previous work, we find that the higher metallicity clusters (≥−1.0 dex) in our sample show a very tight distribution (mean [Fe/H] = −0.48, σ = 0.09), with no tail toward solar metallicities. The cluster distribution is similar to what has been found for red giant stars in the bar, which indicates that the bar and the intermediate age clusters have similar star formation histories. This is in good agreement with recent theoretical models that suggest the bar and intermediate age clusters formed as a result of a close encounter with the SMC ~ 4 Gyr ago.
In situ transmission electron microscopy is an established experimental technique that permits direct observation of the dynamics and mechanisms of dislocation motion and deformation behavior. In this article, we detail the development of a novel specimen goniometer that allows real-time observations of the mechanical response of materials to indentation loads. The technology of the scanning tunneling microscope is adopted to allow nanometer-scale positioning of a sharp, conductive diamond tip onto the edge of an electron-transparent sample. This allows application of loads to nanometer-scale material volumes coupled with simultaneous imaging of the material’s response. The emphasis in this report is qualitative and technique oriented, with particular attention given to sample geometry and other technical requirements. Examples of the deformation of aluminum and titanium carbide as well as the fracture of silicon will be presented.
To study the natural outcome of patients refusing prehospital transportation (PT).
A total of 188 consecutive patients who refused PT in an urban, advanced life support (ALS), emergency medical services (EMS) system were studied. Of these, 77 (41 %) were male, and the average age was 51 years. Patients were entered into the study group only once.
Only 94 (50%) patients could be reached by telephone follow-up. Seven (7%) of these 94 patients had abnormal vital signs, 33 (35%) had cardiopulmonary complaints, 16 (17%) had an altered level of consciousness, nine (10%) were involved in accidents, and eight (8%) had abdominal pain. Six (6%) patients were admitted to the hospital, two (2 %) received ALS-level treatment by the paramedics and then refused conveyance, and 31 (33 %) either saw or contacted a physician. Consultation with an EMS physician was initiated for nine (5%) refusals. Of all the patients contacted, six (6%) needed PT for hospitalization.
As only 50% of the patients refusing prehospital transportation could be reached using follow-up telephone calls, the 6% figure probably underestimates the true number of patients requiring PT. Telephone follow-up is an inadequate means of determining the natural outcome for this patient population. The ALS nature of many of the complaints combined with the lack of consistent physician consultation, exposes the EMS system to an undefined medico-legal liability risk.
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