16p12.2 microdeletion has been associated with congenital heart defects and developmental delay. In this case, we describe the rare association between tetralogy of Fallot with an absent pulmonary valve a right-sided aortic arch and a retro-aortic innominate vein associated with a 16p12.2 microdeletion and epilepsy.

The diatomic free radical methylidyne (CH) is an important tracer of the interstellar medium, and the study of it was critical to our earliest understanding of star formation. Although it is detectable across the electromagnetic spectrum, observations at radio frequencies allow for a study of the kinematics of the diffuse and dense gas in regions of new star formation. There is only two published (single-dish) detections of the low-frequency hyperfine transitions between 700 and 725 MHz, despite the precise frequencies being known. These low-frequency transitions are of particular interest as they are shown in laboratory experiments to be more sensitive to magnetic fields than their high-frequency counterparts (with more pronounced Zeeman splitting). In this work, we take advantage of the radio quiet environment and increased resolution of the Australian Square Kilometre Array Pathfinder (ASKAP) over previous searches to make a pilot interferometric search for CH at 724.7883 MHz (the strongest of the hyperfine transitions) in RCW 38. We found the band is clean of radio frequency interference, but we did not detect the signal from this transition to a five-sigma sensitivity limit of 0.09 Jy, which corresponds to a total column density upper limit of 1.9 $\times 10^{18}$ cm–2 for emission and 1.3 $\times 10^{14}$ cm–2 for absorption with an optical depth limit of 0.95. Achieved within 5 h of integration, this column density sensitivity should have been adequate to detect the emission or absorption in RCW 38, if it had similar properties to the only previous reported detections in W51.

This two-part article examines the global public health (GPH) information system deficits emerging in the coronavirus disease 2019 (COVID-19) pandemic. It surveys past, missed opportunities for public health (PH) information system and operational improvements, examines current megatrend changes to information management, and describes a new multi-disciplinary model for population-based management (PBM) supported by a GPH Database applicable to pandemics and GPH crises.

The catastrophic declines of three species of ‘Critically Endangered’ Gyps vultures in South Asia were caused by unintentional poisoning by the non-steroidal anti-inflammatory drug (NSAID) diclofenac. Despite a ban on its veterinary use in 2006 (India, Nepal, Pakistan) and 2010 (Bangladesh), residues of diclofenac have continued to be found in cattle carcasses and in dead wild vultures. Another NSAID, meloxicam, has been shown to be safe to vultures. From 2012 to 2018, we undertook covert surveys of pharmacies in India, Nepal and Bangladesh to investigate the availability and prevalence of NSAIDs for the treatment of livestock. The purpose of the study was to establish whether diclofenac continued to be sold for veterinary use, whether the availability of meloxicam had increased and to determine which other veterinary NSAIDs were available. The availability of diclofenac declined in all three countries, virtually disappearing from pharmacies in Nepal and Bangladesh, highlighting the advances made in these two countries to reduce this threat to vultures. In India, diclofenac still accounted for 10–46% of all NSAIDs offered for sale for livestock treatment in 2017, suggesting weak enforcement of existing regulations and a continued high risk to vultures. Availability of meloxicam increased in all countries and was the most common veterinary NSAID in Nepal (89.9% in 2017). Although the most widely available NSAID in India in 2017, meloxicam accounted for only 32% of products offered for sale. In Bangladesh, meloxicam was less commonly available than the vulture-toxic NSAID ketoprofen (28% and 66%, respectively, in 2018), despite the partial government ban on ketoprofen in 2016. Eleven different NSAIDs were recorded, several of which are known or suspected to be toxic to vultures. Conservation priorities should include awareness raising, stricter implementation of current bans, bans on other vulture-toxic veterinary NSAIDs, especially aceclofenac and nimesulide, and safety-testing of other NSAIDs on Gyps vultures to identify safe and toxic drugs.

Infant feeding guidelines worldwide recommend first foods to be Fe rich with no added sugars and that nutrient-poor discretionary foods are to be avoided. Feeding guidelines also recommend exposing infants to a variety of foods and flavours with increasingly complex textures. Here, we compare nutritional and textural properties of commercial infant and toddler foods available in Australia with established infant feeding guidelines. Nutrition information and ingredient lists were obtained from food labels, manufacturer and/or retailer websites. In total, 414 foods were identified, comprising mostly mixed main dishes, fruit and vegetable first foods and snacks. Most products were poor sources of Fe, and 80 % of first foods were fruit-based. Half of all products were purées in squeeze pouches, and one-third of all products were discretionary foods. The nutritional content of many products was inconsistent with guidelines, being low in Fe, sweet, smooth in consistency or classified as discretionary. Reformulation of products is warranted to improve Fe content, particularly in mixed main dishes, expand the range of vegetable-only foods and textural variety. Greater regulatory oversight may be needed to better inform parents and caregivers. Frequent consumption of commercial baby foods low in Fe may increase the risk of Fe deficiency. Excessive consumption of purées via squeeze pouches may also have implications for overweight and obesity risk.

Introduction: Paramedics commonly administer intravenous dextrose to severely hypoglycemic patients. Typically, the treatment provided is a 25g ampule of 50% dextrose (D50). This dose of D50 is meant to ensure a return to consciousness. However, this dose may be unnecessary and lead to harm or difficulties regulating blood glucose post treatment. We hypothesize that a lower dose such as dextrose 10% (D10) or titrating the D50 to desired level of consciousness may be optimal and avoid adverse events. Methods: We systematically searched Medline, Embase, CINAHL and Cochrane Central on June 5th 2019. PRISMA guidelines were followed. The GRADE methods and risk of bias assessments were applied to determine the certainty of the evidence. We included primary literature investigating the use of intravenous dextrose in hypoglycemic diabetic patients presenting to paramedics or the emergency department. Outcomes of interest were related to the safe and effective reversal of symptoms and blood glucose levels (BGL). Results: 660 abstracts were screened, 40 full text articles, with eight studies included. Data from three randomized controlled trials and five observational studies were analyzed. A single RCT comparing D10 to D50 was identified. The primary significant finding of the study was an increased post-treatment glycemic profile by 3.2 mmol/L in the D50 group; no other outcomes had significant differences between groups. When comparing pooled data from all the included studies we find higher symptom resolution in the D10 group compared to the D50 group; at 99.8% and 94.9% respectively. However, the mean time to resolution was approximately 4 minutes longer in the D10 group (4.1 minutes (D50) and 8 minutes (D10)). There was more need for subsequent doses in the D10 group at 23.0% versus 16.5% in the D50 group. The post treatment glycemic profile was lower in the D10 group at 5.9 mmol/L versus 8.5 mmol/L in the D50 group. Both treatments had nearly complete resolution of hypoglycemia; 98.7% (D50) and 99.2% (D10). No adverse events were observed in the D10 group (0/871) compared to 12/133 adverse events in the D50 group. Conclusion: D10 may be as effective as D50 at resolving symptoms and correcting hypoglycemia. Although the desired effect can take several minutes longer there appear to be fewer adverse events. The post treatment glycemic profile may facilitate less challenging ongoing glucose management by the patients.

Introduction: Medicine demands a sacrifice of physicians’ personal life, but culture has slowly changed towards valuing a balanced work life. Parental leave is linked to better physical and mental health, but policies and culture surrounding parental leave are largely unstudied in the Canadian Emergency Medicine landscape. Anecdotally, experiences vary widely. This study was designed to determine what proportion of Canadian Emergency Departments have formal parental leave policies (maternity, paternity, and other ex. adoption) and what proportion of Canadian EM physicians are satisfied with their department's parental leave policies. Methods: Two surveys were generated; one to assess attitudes and experiences of emergency physicians, and a second survey for department chiefs assessed the policies and their features. These were approved by the UBC REB and distributed through the CAEP Research Committee. Primary outcomes were physician satisfaction with their department's parental leave policy (4-5/5 Likert Scale), and departments with a formal parental leave policy (Y/N). Results: 38% (8/21) of department chiefs reported having a formal policy for maternity leave, 29% (6/21) for paternity leave, and 24% (5/21) other. The survey of Emergency Physicians revealed similar rates at 48% (90/187) maternity, 40% (70/184) paternity, 29% (53/181) other. Among physicians who were aware of them, 69% (62/90) were somewhat or very satisfied with the maternity leave policies, 58% (51/88) with paternity leave policies, and 48% (39/81) with other parental leave. Less than 10% were somewhat or very dissatisfied with any of these. Several department chiefs commented that they had never refused anyone parental leave, but have no formal policy. However, 87% (147/187) of physicians reported a formal maternity leave policy was somewhat or very important to them; similarly 80% (134/187) paternity leave. Less than 15% felt each was somewhat or extremely unimportant. Conclusion: Presence and type of parental leave policy varies across the country. Most physicians were satisfied with the support they had available, but the vast majority felt that a formal maternity and paternity leave policy itself was important. This study would suggest that, without actually changing practice, the introduction of a formal parental leave policy is of value. Our research group will use this data to collaborate on a template parental leave policy to be made available for this purpose.

Introduction: The Prehospital Evidence-based Practice (PEP) program is an online, freely accessible, continuously updated repository of appraised EMS research evidence. This report is an analysis of published evidence for EMS interventions used to assess and treat patients suffering from hypoglycemia. Methods: PubMed was systematically searched in June 2019. One author screened titles, abstracts and full-texts for relevance. Trained appraisers reviewed full text articles, scored each on a three-point Level of Evidence (LOE) scale (based on study design and quality) and three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing findings for each intervention's primary outcome), abstracted the primary outcome, setting and assigned an outcome category (patient or process). Second party appraisal was conducted for all included studies. The level and direction of each intervention was plotted in an evidence matrix, based on appraisals. Results: Twenty-nine studies were included and appraised for seven interventions: 5 drugs (Dextrose 50% (D50), Dextrose 10% (D10), glucagon, oral glucose and thiamine), one assessment tool (point-of-care (POC) glucose testing) and one call disposition (treat-and-release). The most frequently reported study primary outcomes were related to: clinical improvement (n = 15, 51.7%), feasibility/safety (n = 8, 27.6%), and diagnostics (n = 6, 20.7%). The majority of outcomes were patient focused (n = 18, 62.0%). Conclusion: EMS interventions for treating hypoglycemia are informed by high-quality supportive evidence. Both D50 and D10 are supported by high-quality evidence; suggesting D10 may be an effective alternative to the standard D50. “Treat-and-release” practices for hypoglycemia are supported by moderate-quality evidence for the patient related outcomes of relapse, patient preference and complications. This body of evidence is high-quality, patient-focused and conducted in the prehospital setting thus generalizable paramedic practice.

It is now well established that CBT for chronic insomnia is as efficacious as hypnotic medication and is also likely to be better at maintaining improved sleep. Most studies have looked at the use of individual CBT; there have been only a few studies looking at CBT for insomnia given in a group format.

For nearly ten years the Bristol Insomnia Group has offered cognitive behavioural management and support for people with chronic insomnia.

The seven group sessions are led by up to three members of a team consisting of a doctor (sleep specialist), an occupational therapist and a research sleep scientist. Components of the group intervention include education about sleep science, information on insomnia medication, sleep hygiene, relaxation, and cognitive therapy. To assess efficacy participants complete sleep diaries, a quality of life scale (SF36) and the dysfunctional beliefs and attitudes scale (DBAS) pre and post group.

Sleep diaries (n=68) showed significant differences in Total Sleep Time (TST), Sleep Onset Latency (SOL) and Sleep Quality (SQ). Approximately half of the participants had clinically significant improvements in their TST (increased by 30 minutes) and about a third had a clinically significant decrease (by 30 minutes) in their SOL. SF36 scores showed statistically improved scores in all nine domains, DBAS scores showed statistically significant decreased scores post group.

These results demonstrate promising sleep parameter and quality of life improvements after attendance at the group. CBT for insomnia is a clinically and cost effective approach for the treatment of chronic insomnia.

We know from neurological diseases that there is not only one way to hallucinate. This might also be the case in the psychiatric field. During a trial on refractory verbal hallucinations, we rediscovered a subgroup described under several names in France (Délire chronique d’évolution systématique 1882, Psychose Hallucinatoire Chronique 1911-1953), England (Late Paraphrenia, 1954) and Germany (Affective Paraphrenia - AP, 1968). Roughly, AP can be viewed as the core of paranoid schizophrenia.

We compared 10 AP patients with refractory hallucinations to 35 healthy controls with structural and functional MRI (fMRI). We looked for regions that presented with both grey matter deficit relative to controls and with hallucination-related activity. The lateral orbito-frontal cortex (LOF) was bilaterally involved both anatomically and functionally.

Using fMRI, we studied whole brain functional connectivity, both as a trait factor, i.e. hallucinators vs controls, and as a state factor, i.e. ON vs OFF hallucinations in the same patient. As a trait, functional connectivity was significantly increased between left and right LOF in patients relative to controls; however as a state, functional connectivity dropped to zero between left LOF, left and right superior temporal sulcus (STS) when ON relative to OFF hallucination.

In a larger group of AP patients without ongoing hallucinations, the LOF was still disconnected from the cingulate and temporal regions, in comparison not only to controls, but also relative to non AP type schizophrenias, most of whom also hallucinate during episodes.

We will discuss the “LOF-story hypothesis” for AP patients and their hallucinations.

Authors recently have suggested that family enrneshment is not synonymous with high levels of closeness or cohesion. A model proposed by Green and Werner clarifies the cohesion-enmeshment domain by distinguishing between closeness-caregiving and intrusiveness as separate relationship processes. This paper examines the cross-cultural applicability of this perspective through a study of 61 married couples in France. The French version of the California Inventory for Family Assessment (CIFA), a self-report measure designed to assess clinically relevant marital dimensions, was employed. In general, spouses' reports of their marital process demonstrated high internal consistency reliabilities. Factor analysis showed meaningful factor structures distinguishing closeness-caregiving and intrusiveness, as predicted, as well as openness of communication. Significant correlations were obtained between CIFA scales and scores on the Marital Adjustment Test. These results are similar for French and American couples. Research implications for studying relationships among French-speaking couples are underlined.