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Background: Pediatric craniocerebral gunshot wounds occur in the context of both accidental and intentional trauma. Unique physiologic factors merited research into prognostic factors and treatment priorities in the pediatric population. Methods: A systematic search of MEDLINE, EMBASE, Web of Science, LILACS, Cochrane Registered Trials and Systematic Reviews, ISRCTN, and ClinicalTrials.gov was conducted. Selection criteria included all studies published in any language since 2000 which described intracranial isolated gunshot wounds in a civilian individual or population of pediatric age. Post-mortem and epidemiological studies were excluded. Screening was conducted through Covidence. Results: Initial database search revealed 349 unique studies for abstract and title screening. Fifty studies were selected for full text screening. Nine studies were included in the final review. Study quality was assessed with the Newcastle-Ottawa Scale. Case series noted bullet migration, pituitary deficiency, neurovascular and neuropsychological concerns. Three single-center retrospective studies of 71, 30, and 48 pediatric patients suggested multiple negative prognostic signs on initial presentation. Early aggressive surgical treatment was recommended by some authors. Conclusions: This systematic review analyzed the best current understanding of evidence for prognostic factors and treatment considerations of intracranial gunshot wounds in the pediatric neurotrauma context. Areas for future research with larger multi-center studies were highlighted.
Background: Biallelic variants in POLR1C are associated with POLR3-related leukodystrophy (POLR3-HLD), or 4H leukodystrophy (Hypomyelination, Hypodontia, Hypogonadotropic Hypogonadism), and Treacher Collins syndrome (TCS). The clinical spectrum of POLR3-HLD caused by variants in this gene has not been described. Methods: A cross-sectional observational study involving 25 centers worldwide was conducted between 2016 and 2018. The clinical, radiologic and molecular features of 23 unreported and previously reported cases of POLR3-HLD caused by POLR1C variants were reviewed. Results: Most participants presented between birth and age 6 years with motor difficulties. Neurological deterioration was seen during childhood, suggesting a more severe phenotype than previously described. The dental, ocular and endocrine features often seen in POLR3-HLD were not invariably present. Five patients (22%) had a combination of hypomyelinating leukodystrophy and abnormal craniofacial development, including one individual with clear TCS features. Several cases did not exhibit all the typical radiologic characteristics of POLR3-HLD. A total of 29 different pathogenic variants in POLR1C were identified, including 13 new disease-causing variants. Conclusions: Based on the largest cohort of patients to date, these results suggest novel characteristics of POLR1C-related disorder, with a spectrum of clinical involvement characterized by hypomyelinating leukodystrophy with or without abnormal craniofacial development reminiscent of TCS.
Background: Continuous electroencephalographic (cEEG) monitoring is essential to diagnosing non-convulsive seizures (NCS), reported to occur in 7-46% of at-risk critically ill patients. However, cEEG is labour-intensive, and given scarcity of resources at most centres cEEG is feasible in only selected patients. We aim to evaluate the clinical utility of cEEG at our centre in order to optimize further cEEG allocation among critically ill patients. Methods: Using a clinical database, we identified critically ill children who underwent cEEG monitoring in 2016, 2017 and 2018. We abstracted underlying diagnoses, indication for cEEG monitoring, cEEG findings, and associated changes in management. Results: Over this three year period, 928 cEEGs were performed. Among the 100 studies analyzed to date, primary indications for monitoring were characterization of events of unclear etiology (32%), diagnosis of NCS (30%), and monitoring of therapy for seizures (17%). Seizures were captured in 31% of patients (22% subclinical only, 5% electroclinical only, 4% both), which resulted in a treatment change in 90% of cases. Non-epileptic events were captured in 26% of patients. Conclusions: cEEG yielded clinically meaningful information in 57% of cases, frequently resulting in management changes. Subgroup analyses by cEEG indication and ICU location will be presented.
Introduction: Individualizing risk for stroke following a transient ischemic attack (TIA) is a topic of intense research, as existing scores are context-dependent or have not been well validated. The Canadian TIA Score stratifies risk of subsequent stroke into low, moderate and high risk. Our objective was to prospectively validate the Canadian TIA Score in a new cohort of emergency department (ED) patients. Methods: We conducted a prospective cohort study in 14 Canadian EDs over 4 years. We enrolled consecutive adult patients with an ED visit for TIA or nondisabling stroke. Treating physicians recorded standardized clinical variables onto data collection forms. Given the ability of prompt emergency carotid endarterectomy (CEA) to prevent stroke (NNT = 3) in high risk patients, our primary outcome was the composite of subsequent stroke or CEA ≤7 days. We conducted telephone follow-up using the validated Questionnaire for Verifying Stroke Free Status at 7 and 90 days. Outcomes were adjudicated by panels of 3 local stroke experts, blinded to the index ED data collection form. Based on prior work, we estimated a sample size of 5,004 patients including 93 subsequent strokes, would yield 95% confidence bands of +/− 10% for sensitivity and likelihood ratio (LR). Our analyses assessed interval LRs (iLR) with 95% CIs. Results: We prospectively enrolled 7,569 patients with mean 68.4 +/−14.7 years and 52.4% female, of whom 107 (1.4%) had a subsequent stroke and 74 (1.0%) CEA ≤7 days (total outcomes = 181). We enrolled 81.2% of eligible patients; missed patients were similar to enrolled. The Canadian TIA Score stratified the stroke/CEA ≤7days risk as: Low (probability <0.2%, iLR 0.20 [95%CI 0.091-0.44]; Moderate (probability 1.3%, iLR 0.79 [0.68-0.92]; High (probability 2.6%, iLR 2.2 [1.9-2.6]. Sensitivity analysis for just stroke ≤7 days yielded similar results: Low iLR 0.17 [95%CI 0.056-0.52], Medium iLR 0.89 [0.75-1.1], High iLR 2.0 [1.6-2.4]. Conclusion: The Canadian TIA Score accurately identifies TIA patients risk for stroke/CEA ≤7 days. Patients classified as low risk can be safely discharged following a careful ED assessment with elective follow-up. Patients at moderate risk can undergo additional testing in the ED, have antithrombotic therapy optimized, and be offered early stroke specialist follow-up. Patients at high risk should in most cases be fully investigated and managed ideally in consultation with a stroke specialist during their index ED visit.
During tonsillectomy, one of the key concerns is establishing adequate haemostasis. Intra-operative haemorrhage from the upper pole of the tonsil fossae can be a challenge to deal with because of an inability to clearly visualise bleeding points. Laryngeal mirrors are readily available in an ENT operating theatre and routinely used for indirect visualisation of the post-nasal space during adenoidectomy.
This paper describes a technique, utilising a laryngeal mirror placed within the tonsil fossa (after having removed the palatine tonsil), to visualise the upper pole and any bleeding points.
Results and conclusion:
Laryngeal mirrors can be used with case to inspect the tonsil fossa post-tonsillectomy for bleeding points which may not be directly visible, so that these can be cauterised.
Mental health and wellbeing, including addressing impacts of historical trauma and substance use among young people, has been identified as a key priority by Indigenous communities and leaders across Canada and globally. Yet, research to understand mental health among young Indigenous people who have used drugs is limited.
To examine longitudinal risk and strengths-based factors associated with psychological distress among young Indigenous people who use drugs.
The Cedar Project is an ongoing cohort study involving young Indigenous people who use drugs in Vancouver, Prince George, and Chase, British Columbia, Canada. This study included participants who completed the Symptom Checklist-90-Revised, returned for follow-up between 2010 and 2012, and completed the Childhood Trauma Questionnaire. Adjusted linear mixed-effects models estimated effects of study variables on changes in area T-scores of psychological distress.
Of 202 eligible participants, 53% were women and the mean age was 28 years. Among men, childhood maltreatment (emotional abuse, physical abuse, sexual abuse, physical neglect), any drug use, blackouts from drinking, and sex work were associated with increased distress. Among women, childhood maltreatment (emotional abuse, physical abuse, physical neglect), blackouts from drinking, and sexual assault were associated with increased distress, while having attempted to quit using drugs was associated with reduced distress. Marginal associations were observed between speaking their traditional language and living by traditional culture with lower distress among men.
Culturally safe mental wellness interventions are urgently needed to address childhood trauma and harmful coping strategies that exacerbate distress among young Indigenous people who use drugs.
The Global Muon Detector Network (GMDN) is composed by four ground cosmic ray detectors distributed around the Earth: Nagoya (Japan), Hobart (Australia), Sao Martinho da Serra (Brazil) and Kuwait city (Kuwait). The network has operated since March 2006. It has been upgraded a few times, increasing its detection area. Each detector is sensitive to muons produced by the interactions of ~50 GeV Galactic Cosmic Rays (GCR) with the Earth′s atmosphere. At these energies, GCR are known to be affected by interplanetary disturbances in the vicinity of the earth. Of special interest are the interplanetary counterparts of coronal mass ejections (ICMEs) and their driven shocks because they are known to be the main origins of geomagnetic storms. It has been observed that these ICMEs produce changes in the cosmic ray gradient, which can be measured by GMDN observations. In terms of applications for space weather, some attempts have been made to use GMDN for forecasting ICME arrival at the earth with lead times of the order of few hours. Scientific space weather studies benefit the most from the GMDN network. As an example, studies have been able to determine ICME orientation at the earth using cosmic ray gradient. Such determinations are of crucial importance for southward interplanetary magnetic field estimates, as well as ICME rotation.
A novel method to estimate unsteady aerodynamic force coefficients from pointwise velocity measurements is presented. As opposed to other existing methodologies, time-resolved full velocity fields are not required. The methodology is based on a resolvent-based reduced-order model which requires the mean flow to obtain physical flow structures and pointwise measurement to calibrate their amplitudes. A computationally affordable time-stepping methodology to obtain resolvent modes in non-trivial flow domains is introduced and compared with previous existing matrix-free and matrix-forming strategies. The technique is applied to the unsteady flow around an inclined square cylinder at low Reynolds number. The potential of the methodology is demonstrated through good agreement between the fluctuating pressure distribution on the cylinder and the temporal evolution of the unsteady lift and drag coefficients predicted by the model and those computed by direct numerical simulation.
Bagasse and rice husk are two important agro-industrial by-products that are used as fuel in the sugar and rice mill industries, thus producing large quantities of bagasse ash (BA; 0·05 of bagasse) and rice husk ash (0·20 of rice husk) as waste material. Applying BA and rice husk ash (RHA) to agricultural land improves yield, nutrient uptake and chemical fertility of soil, particularly with special reference to available phosphorus (P) and potassium (K). The present field experiment was conducted for 3 years to evaluate the P fertilizer value of these agro-industrial waste materials in a wheat–rice system (WRS). The experiment was laid out in a split-plot design with RHA and BA applied at 10 t/ha and including a no-amendment control as the main plot treatments and three levels of fertilizer P (0, 13 and 26 kg P/ha; designated P0, P13 and P26, respectively) as sub-plot treatments to wheat in WRS. Application of fertilizer P increased the wheat grain yield up to P26 in the un-amended control treatment. However, a significant response of wheat to fertilizer P was also observed up to P13 in the presence of BA and RHA, thereby saving 50% of fertilizer P. Both RHA and BA increased wheat productivity by 12 and 16%, respectively, over the un-amended control. The subsequent rice crop also produced 14% higher paddy yield when the two ashes were applied along with P13 to the previous wheat crop. The increases in grain yield were accompanied by significant increases in the uptake of P and K, and P content (Olsen P) in the soil. The application of recommended P (P26) in un-amended plots resulted in a negative P balance of 9·3 kg P/ha/year. On the other hand, the application of BA alone and RHA along with P13 resulted in neutral/slightly positive P balance. A strong linear relationship (R2 = 0·98) was observed between P balance and Olsen-P build up in the soil. It may be concluded that application of BA and RHA has the potential to increase system productivity and reduce the cost of inputs in terms of reduced application of fertilizer P to wheat and rice.
Many medications administered to patients with schizophrenia possess anticholinergic properties. When aggregated, pharmacological treatments may result in a considerable anticholinergic burden. The extent to which anticholinergic burden has a deleterious effect on cognition and impairs ability to participate in and benefit from psychosocial treatments is unknown.
Seventy patients were followed for approximately 3 years. The MATRICS consensus cognitive battery (MCCB) was administered at baseline. Anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale. Ability to benefit from psychosocial programmes was measured using the DUNDRUM-3 Programme Completion Scale (D-3) at baseline and follow-up. Psychiatric symptoms were measured using the PANSS. Total antipsychotic dose was measured using chlorpromazine equivalents. Functioning was measured using the Social and Occupational Functioning Assessment Scale (SOFAS).
Mediation analysis found that the influence of anticholinergic burden on ability to participate and benefit from psychosocial programmes was completely mediated by the MCCB. For every 1-unit increase on the ACB scale, change scores for DUNDRUM-3 decreased by −0.27 points. This relationship appears specific to anticholinergic burden and not total antipsychotic dose. Moreover, mediation appears to be specific to cognition and not psychopathology. Baseline functioning also acted as mediator but only when MCCB was not controlled for.
Anticholinergic burden has a significant impact on patients’ ability to participate in and benefit from psychosocial treatment programmes. Physicians need to be mindful of the cumulative effect that medications can have on patient cognition, functional capacity and ability to benefit from psychosocial treatments.
The State of Qatar experienced a sandstorm on the night of April 1, 2015, lasting approximately 12 hours, with winds of more than 100 km/h and average particulate matter of approximately 10 μm in diameter. The emergency department (ED) of the main tertiary hospital in Qatar managed 62% of the total emergency calls and those of higher triage order. The peak load of patients during the event manifested approximately 6 hours after the onset. The Major Emergency Command Centre of the hospital ensured the department was maximally organized in terms of disaster management, and established protocols were brought into action. Multiple timely meetings were convened in efforts to effectively execute plans that included rapid emergency medical services handover time, resourcing staff, maximizing bed space, preventing dust entry in the ED, bypassing certain administrative processes, canceling day-surgeries that did not affect inpatient morbidity, and procuring additional respiratory equipment. Patients arrived mainly with exacerbations of asthma and respiratory distress, ophthalmic emergencies, and vehicular trauma; surprisingly, the incidence of pedestrian injuries did not vary. (Disaster Med Public Health Preparedness. 2017;11:227–238)
A novel reduced-order model for time-varying nonlinear flows arising from a resolvent decomposition based on the time-mean flow is proposed. The inputs required for the model are the mean-flow field and a small set of velocity time-series data obtained at isolated measurement points, which are used to fix relevant frequencies, amplitudes and phases of a limited number of resolvent modes that, together with the mean flow, constitute the reduced-order model. The technique is applied to derive a model for the unsteady three-dimensional flow in a lid-driven cavity at a Reynolds number of 1200 that is based on the two-dimensional mean flow, three resolvent modes selected at the most active spanwise wavenumber, and either one or two velocity probe signals. The least-squares full-field error of the reconstructed velocity obtained using the model and two point velocity probes is of the order of 5 % of the lid velocity, and the dynamical behaviour of the reconstructed flow is qualitatively similar to that of the complete flow.
Background: Burst-suppression is an electroencephalographic pattern observed during coma and reflects severe encephalopathy. We investigated the reactivity of burst-suppression to photic stimulation in children with acquired brain injury. Methods: Intensive care unit electroencephalographic monitoring recordings containing burst-suppression were obtained from 5 comatose children with acquired brain injury of various etiologies. Intermittent photic stimulation was performed at 1 Hz for 1 minute to assess reactivity. We quantified reactivity by measuring the change in the burst ratio (fraction of time in burst) following photic stimulation. Results: Photic stimulation evoked bursts in all patients, resulting in a transient increase in the burst ratio, while the mean heart rate remained unchanged. The regression slope of the change in burst ratio, referred to as the standardized burst ratio reactivity, correlated with subjects’ Glasgow Coma Scale scores. Conclusions: Reactivity of the burst-suppression pattern to photic stimulation occurs across diverse coma etiologies. Standardized burst ratio reactivity appears to reflect coma severity. Measurement of burst ratio reactivity may represent a simple bedside tool to monitor coma severity in critically ill children.
The effect of streamwise-varying steady transpiration on turbulent pipe flow is examined using direct numerical simulation at fixed friction Reynolds number
. The streamwise momentum equation reveals three physical mechanisms caused by transpiration acting in the flow: modification of Reynolds shear stress, steady streaming and generation of non-zero mean streamwise gradients. The influence of these mechanisms has been examined by means of a parameter sweep involving transpiration amplitude and wavelength. The observed trends have permitted identification of wall transpiration configurations able to reduce or increase the overall flow rate
, respectively. Energetics associated with these modifications are presented. A novel resolvent formulation has been developed to investigate the dynamics of pipe flows with a constant cross-section but with time-mean spatial periodicity induced by changes in boundary conditions. This formulation, based on a triple decomposition, paves the way for understanding turbulence in such flows using only the mean velocity profile. Resolvent analysis based on the time-mean flow and dynamic mode decomposition based on simulation data snapshots have both been used to obtain a description of the reorganization of the flow structures caused by the transpiration. We show that the pipe flows dynamics are dominated by a critical-layer mechanism and the waviness induced in the flow structures plays a role on the streamwise momentum balance by generating additional terms.
To investigate the assessment and management of paediatric snoring and obstructive sleep apnoea in UK otolaryngology departments.
A telephone questionnaire survey of UK otolaryngology departments was conducted over a 16-week period.
The response rate was 61 per cent (85 out of 139 trusts). Use of pre-operative pulse oximetry was reported by 84 per cent of respondents, mainly to diagnose obstructive sleep apnoea (73 per cent) or stratify post-operative risk (46 per cent). Thirty-one per cent of respondents reported using post-operative pulse oximetry. Twenty-five per cent of respondents have a dedicated management protocol for paediatric obstructive sleep apnoea and snoring. Thirty-four per cent require prior clinical commissioning group approval before performing surgery. Fifty-eight per cent of respondents reported following up their obstructive sleep apnoea patients after surgery. The mean follow-up period (±standard deviation) was 6.8 ± 1.2 weeks.
There is variation in the assessment and management of paediatric snoring and obstructive sleep apnoea across the UK, particularly in the use of pre- and post-operative pulse oximetry monitoring, and further guidelines regarding this are necessary.
In search of a suitable resource conservation technology under pigeonpea (Cajanus cajan L.)–wheat (Triticum aestivum L.) system in the Indo-Gangetic Plains, the effects of conservation agriculture (CA) on crop productivity and water-use efficiency (WUE) were evaluated during a 3-year study. The treatments were: conventional tillage (CT), zero tillage (ZT) with planting on permanent narrow beds (PNB), PNB with residue (PNB + R), ZT with planting on permanent broad beds (PBB) and PBB + R. The PBB + R plots had higher pigeonpea grain yield than the CT plots in all 3 years. However, wheat grain yields under all plots were similar in all years except for PBB + R plots in the second year, which had higher wheat yield than CT plots. The contrast analysis showed that pigeonpea grain yield of CA plots was significantly higher than CT plots in the first year. However, both pigeonpea and wheat grain yields during the last 2 years under CA and CT plots were similar. The PBB + R plots had higher system WUE than the CT plots in the second and third years. Plots under CA had significantly higher WUE and significantly lower water use than CT plots in these years. The PBB + R plots had higher WUE than PNB + R and PNB plots. Also, the PBB plots had higher WUE than PNB in the second and third years, despite similar water use. The interactions of bed width and residue management for all parameters in the second and third years were not significant. Those positive impacts under PBB + R plots over CT plots were perceived to be due to no tillage and significantly higher amount of estimated residue retention. Thus, both PBB and PBB + R technologies would be very useful under a pigeonpea–wheat cropping system in this region.
Expressed sequence tag-simple sequence repeat (EST-SSR) markers were used to analyse genetic diversity among three Lens species. The SSR loci amplified successfully in wild species, with 94·82% transferability in Lens culinaris subsp. orientalis, 95·4% in Lens nigricans, 98·81% in L. culinaris subsp. odemensis, 94·82% in L. culinaris subsp. tomentosus and 96·55% in Lens ervoides. Ninety-nine alleles (average 3·41 alleles/locus) were detected by 29 SSR markers. Based on the unweighted pair group method with arithmetic mean cluster analysis, all the genotypes were grouped into three clusters at a similarity level of 0·30. The diversity analysis indicated no species-specific clustering of the wild and cultivated species. Wild species L. nigricans and L. culinaris subsp. odemensis, L. culinaris subsp. orientalis and L. ervoides were grouped in Cluster I, whereas the Mediterranean land races of L. culinaris subsp. culinaris and L. culinaris subsp. tomentosus formed a separate group in Cluster II A. Cluster II B comprised L. ervoides, L. culinaris subsp. orientalis and L. culinaris subsp. culinaris. Clusters II C, II D and II F included cultivated Indian lentil genotypes. Cluster II E comprised Indian and Mediterranean germplasm lines. Cluster II F included three early maturing germplasm lines, whereas Cluster III included only two germplasm lines. The functional annotation of SSR-containing unigenes revealed that a majority of genes were involved in an important transport-related function or were a component of metabolic pathways. A high level of polymorphism of EST-SSRs and their transferability to related wild species indicated that these markers could be used for molecular screening, map construction, comparative genomic studies and marker-assisted selection.