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Children of mothers with adverse childhood experiences (ACEs) are at increased risk for developmental problems. However, the mechanisms through which a mother's experience of ACEs are transmitted to her offspring are understudied. The current study investigates potential modifiable mediators (maternal psychopathology and parenting) of the association between maternal ACEs and children's behavioral problems.
We utilized data from a pregnancy cohort study (N = 1030; CANDLE study) to investigate longitudinal associations between maternal ACEs, postpartum anxiety, observed parenting behavior, and child internalizing behaviors (meanage = 4.31 years, s.d.age = 0.38) in a racially diverse (67% Black; 33% White/Other) sample. We used structural equation modeling to test for direct associations between maternal ACEs and children's internalizing behaviors, as well as indirect associations via two simple mediations (maternal anxiety and parenting), and one serial mediation (sequence of maternal anxiety to parenting).
Simple mediation results indicated that maternal anxiety and cognitive growth fostering behaviors independently mediated the association between maternal ACEs and child internalizing. We observed no evidence of a serial mediation from ACEs to internalizing via the effects of maternal anxiety on parenting.
This study supports and refines extant literature by confirming the intergenerational association between maternal ACEs and child internalizing behaviors in a large, diverse sample, and identifies potential modifiable mediators: maternal anxiety and parenting behaviors related to fostering cognitive development. Findings may inform interventions targeting mothers who have experienced ACEs and suggest that providing support around specific parenting behaviors and addressing maternal anxiety may reduce internalizing behaviors in children.
The coronavirus disease 2019 pandemic resulted in the cessation of elective surgery. The continued provision of complex head and neck cancer surgery was extremely variable, with some UK centres not performing any cancer surgery. During the pandemic, Guy's and St Thomas’ NHS Foundation Trust received high numbers of coronavirus disease 2019 admissions. This paper presents our experience of elective complex major head and neck cancer surgery throughout the pandemic.
A head and neck cancer surgery hub was set up that provided a co-ordinated managed care pathway for cancer patients during the pandemic; the Guy's Cancer Centre provided a separate, self-enclosed coronavirus-free environment within the hospital campus.
Sixty-nine head and neck cancer patients were operated on in two months, and 13 patients had a microvascular free tissue transfer. Nosocomial infection with coronavirus disease 2019 was detected in two cases (3 per cent), neither required critical care unit admission. Both patients made a complete recovery and were discharged home. There were no deaths.
Performing major head and neck surgery, including free flap surgery, is possible during the pandemic; however, significant changes to conventional practice are required to achieve desirable patient outcomes.
Infantile hemiplegia due to brain injury is associated with poor attention span, which critically affects the learning and acquisition of new skills, especially among children with left-sided infantile hemiplegia (LSIH). This study aimed to improve the selective visual attention (SVA) of children with LSIH through transcranial direct current stimulation (tDCS).
A total of 15 children participated in this randomized, double-blinded, pilot study; of them, 10 experienced LSIH, and the remaining 5 were healthy age-matched controls. All the children performed the Computerized Stroop Color-Word Test (CSCWT) at baseline, during the 5th and 10th treatment sessions, and at follow-up. The experimental (n = 5) and control groups (n = 5) received tDCS, while the sham group (n = 5) received placebo tDCS. All three groups received cognitive training on alternate days, for 3 weeks, with the aim to improve SVA.
Two-way repeated measures analysis of variance (ANOVA) showed a statistically significant change in the mean scores of CSCWT between time points (baseline, 5th and 10th sessions, and follow-up) within-subject factor, group (experimental, sham) between-subject factor and interaction (time points X group) (p < 0.005). Furthermore, a one-way repeated measures ANOVA showed significant differences between time point (p < 0.005) for the experimental and control group but not the sham group.
These pilot results suggest that future research should be conducted with adequate samples to enable conclusions to be drawn.
Tracheostomy for coronavirus disease 2019 pneumonitis patients requiring prolonged invasive mechanical ventilation remains a matter of debate. This study analysed the timing and outcomes of percutaneous tracheostomy, and reports our experience of a dedicated ENT–anaesthetics department led tracheostomy team.
A prospective single-centre observational study was conducted of patients undergoing tracheostomy, who had been diagnosed with coronavirus disease 2019 pneumonitis, between 21st March and 20th May 2020.
Eighty-one patients underwent tracheostomy after a median (interquartile range) of 16 (13–20) days of invasive mechanical ventilation. Median follow-up duration was 32 (23–40) days. Of patients, 86.7 per cent were successfully liberated from invasive mechanical ventilation in a median (interquartile range) of 12 (7–16) days. Moreover, 68.7 per cent were subsequently discharged from hospital. On univariate analysis, there was no difference in outcomes between early (before day 14) and late (day 14 or later) tracheostomy. The mortality rate was 8.6 per cent and no deaths were tracheostomy related.
Outcomes appear favourable when patients are carefully selected. Percutaneous tracheostomy performed via a multidisciplinary approach, with appropriate training, was safe and optimised healthcare resource utilisation.
September 11 will long be associated with unthinkable violence. The sheer magnitude of the terrorist attacks, the visual imagery of the collapsing towers of the World Trade Center, and the extensive media attention given to the victims have defined the violence of September 11 in unitary terms. But in the aftermath of the terrorist attacks, another form of violence spread across the country: in the days and weeks after September 11, over 1,000 bias incidents against Arabs, Muslims, and South Asians were reported. These incidents, including the murders of as many as 19 people, assaults on scores of others, vandalism of homes, businesses, and places of worship, and verbal harassment of countless individuals, form part of the subterranean history of September 11. While the violence of September 11 itself is largely thought to have been incomprehensible, post–September 11 hate violence is remarkable precisely because it is something we can understand. Although condemned as individual acts of criminality, the phenomenon of hate violence toward Arabs, Muslims, and South Asians is one that appeared to need little explanation; it was accepted as a regrettable but expected response to the terrorist attacks. As early as September 12, 2001, major newspapers reported predictions of the violence against these communities.
Studies have shown higher rate of various psychiatric disorders among individuals with substance abuse / dependence. There is little data in developing countries, such as Pakistan, on prevalence of psychiatric co-morbidity in this population and impact on treatment.
To assess the psychiatric co-morbidity among individuals with substance dependence and to determine its demographic associations in patients with substance dependence in Pakistan.
This was a descriptive study conducted at a tertiary care hospital in Pakistan. Participants were 588 individuals with substance dependence admitted to a tertiary care hospital in Pakistan, mainly in male inpatient substance dependence unit. The patients were assessed for psychiatric co-morbidity using DSM IV criteria. Informed consent was obtained. The study was approved by the Institutional Research Committee. The results were obtained by using chi square test on SPSS 17.
Out of 588, 200 patients (34%) were found co-morbid with other psychiatric disorders along with substance dependence. Reason of first substance use and history of previous substance dependence were observed to be significantly associated with co-morbid psychiatric disorders, x2 (48, n = 549) = 112.396, p < 0.01 and x2 (18, n = 588) = 29.66, p = 0.041 respectively.
1. There was high rate of psychiatric co-morbidity among individuals with substance dependence in this sample.
2. Depression, personality disorders and anxiety disorders were the major co-morbid diagnosis among this population.
Cold dissection is the most commonly used tonsillectomy technique, with low post-operative haemorrhage rates. Coblation is an alternative technique that may cause less pain, but could have higher post-operative haemorrhage rates.
This study evaluated the peri-operative outcomes in paediatric tonsillectomy patients by comparing coblation and cold dissection techniques.
A systematic review was conducted of all comparative studies of paediatric coblation and cold dissection tonsillectomy, up to December 2018. Any studies with adults were excluded. Outcomes such as pain, operative time, and intra-operative, primary and secondary haemorrhages were recorded.
Seven studies contributed to the summative outcome. Coblation tonsillectomy appeared to result in less pain, less intra-operative blood loss (p < 0.01) and a shorter operative time (p < 0.01). There was no significant difference between the two groups for post-operative haemorrhage (p > 0.05).
The coblation tonsillectomy technique may offer better peri-operative outcomes when compared to cold dissection, and should therefore be offered in paediatric cases, before cold dissection tonsillectomy.
In various scenarios, the motion of a tracked object, for example, a pointing apparatus, pedestrian, animal, vehicle, and others, is driven by achieving a premeditated goal such as reaching a destination. This is albeit the various possible trajectories to this endpoint. This paper presents a generic Bayesian framework that utilizes stochastic models that can capture the influence of intent (viz., destination) on the object behavior. It leads to simple algorithms to infer, as early as possible, the intended endpoint from noisy sensory observations, with relatively low computational and training data requirements. This framework is introduced in the context of the novel predictive touch technology for intelligent user interfaces and touchless interactions. It can determine, early in the interaction task or pointing gesture, the interface item the user intends to select on the display (e.g., touchscreen) and accordingly simplify as well as expedite the selection task. This is shown to significantly improve the usability of displays in vehicles, especially under the influence of perturbations due to road and driving conditions, and enable intuitive contact-free interactions. Data collected in instrumented vehicles are shown to demonstrate the effectiveness of the proposed intent prediction approach.
Transient neurological symptoms often present a difficult diagnostic dilemma. It is often difficult to tell if the transient symptoms were due to ischemia or due to something else (see Chapter 1). Usually, by the time the physician sees the patient, the neurological exam has returned to normal. On the other hand, it is critically important not to miss the diagnosis of transient ischemic attack (TIA). TIAs may provide an opportunity for physicians to intervene and prevent an ischemic stroke and subsequent disability, and must be taken seriously. The search for an etiology must be done expeditiously. Just as angina may serve as a warning for future myocardial infarction, a TIA is often a warning sign of an impending stroke.
As acute stroke therapies have developed, the context in which stroke care is provided has become more important. Creating and maintaining the organization of stroke care within a region or even a hospital requires much commitment and effort. High-quality stroke care requires coordination and communication between multiple stakeholders in the prehospital and in-hospital settings in what the American Heart Association (AHA) and American Stroke Association (ASA) term the “stroke chain of survival” (Table 14.1).
It is never too early to begin to educate the patient and family about lifestyle changes and medical treatments to prevent another stroke. These need to be reinforced throughout the hospital and rehabilitation stay, and in the outpatient stroke clinic.
After a major stroke, both the family and the patient go through a grief reaction that at first includes denial and disbelief, and sometimes anger. In particular, the need to insert a PEG is often a crisis point when the family finally comes to terms with the severe disability and prolonged recovery that lies ahead. At this stage, which is usually when the patient is in the acute stroke unit, mainly supportive measures are indicated.
In this chapter, we discuss mainly secondary prevention for stroke, although many of the measures, especially control of risk factors and lifestyle changes such as not smoking, controlling blood pressure, etc., are also important measures to avoid a first stroke.
Initially, we discuss a tailored diagnostic work-up, then general measures for secondary prevention of ischemic stroke, and finally recommendations for specific conditions that are associated with a high risk of recurrent stroke.
The following initial measures apply to all stroke patients. They are necessary to stabilize and assess the patient, and prepare for definitive therapy. All current and, probably, future stroke therapies for both ischemic and hemorrhagic stroke are best implemented as fast as possible, so these things need to be done quickly. This is the general order to do things, but in reality, in order to speed the process, these measures are usually dealt with simultaneously. They are best addressed in the ED, where urgent care pathways for stroke should be established and part of the routine (see Chapter 14).
This chapter covers the diagnosis and management of spontaneous subarachnoid hemorrhage due to rupture of intracranial aneurysms. At the end of the chapter we also discuss unruptured intracranial aneurysms. Much SAH management is not based on good-quality evidence. Much of what is recommended here comes from published practice guidelines and what is commonly practiced. Options for therapy might be limited by the availability and experience of persons performing surgery, endovascular therapy, and neurointensive care.
In this chapter, we consider spontaneous hemorrhage into the brain parenchyma and ventricles (intracerebral hemorrhage, ICH). Non-traumatic bleeding into the subarachnoid space (subarachnoid hemorrhage, SAH) is covered in Chapter 13. Traumatic subdural and epidural hemorrhages are not covered in this book.
Intracerebral hemorrhage is associated with very high morbidity and mortality. It is important to realize that, as with acute ischemic strokes, time is of the essence in ICH. The reason for this is that the blood accumulates rapidly, and the volume of the hematoma is the most important determinant of outcome.