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Following stage 1 palliation, delayed sternal closure may be used as a technique to enhance thoracic compliance but may also prolong the length of stay and increase the risk of infection.
We reviewed all neonates undergoing stage 1 palliation at our institution between 2010 and 2017 to describe the effects of delayed sternal closure.
During the study period, 193 patients underwent stage 1 palliation, of whom 12 died before an attempt at sternal closure. Among the 25 patients who underwent primary sternal closure, 4 (16%) had sternal reopening within 24 hours. Among the 156 infants who underwent delayed sternal closure at 4 [3,6] days post-operatively, 11 (7.1%) had one or more failed attempts at sternal closure. Patients undergoing primary sternal closure had a shorter duration of mechanical ventilation and intensive care unit length of stay. Patients who failed delayed sternal closure had a longer aortic cross-clamp time (123±42 versus 99±35 minutes, p=0.029) and circulatory arrest time (39±28 versus 19±17 minutes, p=0.0009) than those who did not fail. Failure of delayed sternal closure was also closely associated with Technical Performance Score: 1.3% of patients with a score of 1 failed sternal closure compared with 18.9% of patients with a score of 3 (p=0.0028). Among the haemodynamic and ventilatory parameters studied, only superior caval vein saturation following sternal closure was different between patients who did and did not fail sternal closure (30±7 versus 42±10%, p=0.002). All patients who failed sternal closure did so within 24 hours owing to hypoxaemia, hypercarbia, or haemodynamic impairment.
When performed according to our current clinical practice, sternal closure causes transient and mild changes in haemodynamic and ventilatory parameters. Monitoring of SvO2 following sternal closure may permit early identification of patients at risk for failure.
The optimal approach to unifocalisation in pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (pulmonary artery/ventricular septal defect/major aortopulmonary collaterals) remains controversial. Moreover, the impact of collateral vessel disease burden on surgical decision-making and late outcomes remains poorly defined. We investigated our centre’s experience in the surgical management of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals.
Materials and methods
Between 1996 and 2015, 84 consecutive patients with pulmonary artery/ventricular septal defect/major aortopulmonary collaterals underwent unifocalisation. In all, 41 patients received single-stage unifocalisation (Group 1) and 43 patients underwent multi-stage repair (Group 2). Preoperative collateral vessel anatomy, branch pulmonary artery reinterventions, ventricular septal defect status, and late right ventricle/left ventricle pressure ratio were evaluated.
Median follow-up was 4.8 compared with 5.7 years for Groups 1 and 2, respectively, p = 0.65. Median number of major aortopulmonary collaterals/patient was 3, ranging from 1 to 8, in Group 1 compared with 4, ranging from 1 to 8, in Group 2, p = 0.09. Group 2 had a higher number of lobar/segmental stenoses within collateral vessels (p = 0.02). Group 1 had fewer catheter-based branch pulmonary artery reinterventions, with 5 (inter-quartile range from 1 to 7) per patient, compared with 9 (inter-quartile range from 4 to 14) in Group 2, p = 0.009. Among patients who achieved ventricular septal defect closure, median right ventricle/left ventricle pressure was 0.48 in Group 1 compared with 0.78 in Group 2, p = 0.03. Overall mortality was 6 (17%) in Group 1 compared with 9 (21%) in Group 2.
Single-stage unifocalisation is a promising repair strategy in select patients, achieving low rates of reintervention for branch pulmonary artery restenosis and excellent mid-term haemodynamic outcomes. However, specific anatomic substrates of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals may be better suited to multi-stage repair. Preoperative evaluation of collateral vessel calibre and function may help inform more patient-specific surgical management.
Clinical formulation was introduced in its present form a little over 30 years ago and is, in essence, a concise summary of the origins and nature of a person's problems, together with opinion on what may go wrong in the future and what steps should be taken to improve matters. In our article we discuss how, in recent times, the task of preparing a clinical formulation has rightly become a multidisciplinary exercise involving the whole clinical team and, even more important, that nowadays the patient – the subject of the clinical formulation – together with their carers should also be actively involved in the process and feel some ownership of the conclusions and decisions. In addition, we compare these developments in clinical formulation with similar developments, arising for the same reasons, in clinical teaching and education.
• Understand the core principles of formulation
• Know how to prepare a formulation within a clinical team
• Understand the role that formulation plays in the effective management of patients
The cat flea, Ctenocephalides felis, is a major pest species on companion animals thus of significant importance to the animal health industry. The aim of this study was to develop sampling and storage protocols and identify stable reference genes for gene expression studies to fully utilize the growing body of molecular knowledge of C. felis. RNA integrity was assessed in adult and larvae samples, which were either pierced or not pierced and stored in RNAlater at ambient temperature. RNA quality was maintained best in pierced samples, with negligible degradation evident after 10 days. RNA quality from non-pierced samples was poor within 3 days. Ten candidate reference genes were evaluated for their stability across four group comparisons (developmental stages, genders, feeding statuses and insecticide-treatment statuses). Glyceraldehyde 3 phosphate dehydrogenase (GAPDH), 60S ribosomal protein L19 (RPL19) and elongation factor-1α (Ef) were ranked highly in all stability comparisons, thus are recommended as reference genes under similar conditions. Employing just two of these three stable reference genes was sufficient for accurate normalization. Our results make a significant contribution to the future of gene expression studies in C. felis, describing validated sample preparation procedures and reference genes for use in this common pest.
Risk assessment and management is an integral part of modern clinical practice. In this article we discuss best practice in the assessment and management of risk of harm to others. Unstructured clinical judgement methods have been used for many years, but it is only more recently that actuarial and structured clinical judgement methods have been introduced. These methods are discussed and compared. We describe a process that could be followed by a clinical team and give an illustrative case example. Last, we reflect on aspects of current practice and consider the possible direction of developments in the field.
The Risk Management Authority (RMA), Scotland's new body which oversees the conduct of assessments of convicted offenders placed on risk assessment orders, recently held its first annual lecture. This was given by Scotland's new Solicitor General, who observed that risk assessment orders are likely to be reserved for ‘extraordinary crimes committed by extraordinary people’. The first risk assessment orders have been made by Scottish courts and the risk assessors' reports are awaited with interest, not least in England, which has taken a different approach to dangerous offenders (Darjee & Crichton, 2002). It seems timely to review the more novel aspects of the Scottish system and the issues they raise for forensic psychiatry.
Optical melting was used to determine the stabilities of 11
small RNA oligomers of defined secondary structure as a function
of magnesium ion concentration. The oligomers included helices
composed of Watson–Crick base pairs, GA tandem base pairs,
GU tandem base pairs, and loop E motifs (both eubacterial and
eukaryotic). The effect of magnesium ion concentration on stability
was interpreted in terms of two simple models. The first assumes
an uptake of metal ion upon duplex formation. The second assumes
nonspecific electrostatic attraction of metal ions to the RNA
oligomer. For all oligomers, except the eubacterial loop E,
the data could best be interpreted as nonspecific binding of
metal ions to the RNAs. The effect of magnesium ions on the
stability of the eubacterial loop E was distinct from that seen
with the other oligomers in two ways. First, the extent of
stabilization by magnesium ions (as measured by either change
in melting temperature or free energy) was three times greater
than that observed for the other helical oligomers. Second,
the presence of magnesium ions produces a doubling of the enthalpy
for the melting transition. These results indicate that magnesium
ion stabilizes the eubacterial loop E sequence by chelating
the RNA specifically. Further, these results on a rather small
system shed light on the large enthalpy changes observed upon
thermal unfolding of large RNAs like group I introns. It is
suggested that parts of those large enthalpy changes observed
in the folding of RNAs may be assigned to variations in the
hydration states and types of coordinating atoms in some
specifically bound magnesium ions and to an increase in the
observed cooperativity of the folding transition due to the
binding of those magnesium ions coupling the two stems together.
Brownian dynamic simulations, carried out to visualize the metal
ion binding sites, reveal rather delocalized ionic densities
in all oligomers, except for the eubacterial loop E, in which
precisely located ion densities were previously calculated.
The association between, and stability of, clinical diagnosis and diagnosis derived
from the Autism Diagnostic Interview-Revised (ADI-R; Lord, Rutter, & Le Couteur, 1994) was
examined in a sample of prospectively identified children with childhood autism and other
pervasive developmental disorders assessed at the age of 20 months and 42 months. Clinical
diagnosis of autism was stable, with all children diagnosed with childhood autism at age 20
months receiving a diagnosis of childhood autism or a related pervasive developmental
disorder (PDD) at age 42 months. Clinical diagnosis of childhood autism was also
reasonably sensitive, with all children who went on to receive a clinical diagnosis of
childhood autism at 42 months being identified as having autism or PDD at 20 months.
However, clinical diagnosis for PDD and Asperger's syndrome lacked sensitivity at 20
months, with several children who subsequently received these diagnoses at 42 months
receiving diagnoses of language disorder or general developmental delay, as well as in two
cases being considered clinically normal, at the earlier timepoint. The ADI-R was found to
have good specificity but poor sensitivity at detecting childhood autism at 20 months;
however, the stability of diagnosis from 20 to 42 months was good. In addition, the ADI-R
at age 20 months was not sensitive to the detection of related PDDs or Asperger's syndrome.
The continuity and discontinuity between behavioural abnormalities identified at both
timepoints in the three domains of impairment in autism was examined, both in children who
met final clinical criteria for an autistic spectrum disorder, and for children with language
disorder who did not, as well as for a small sample of typically developing children.
Investigation to see if there are key psychological risk indicators for autism in a random population study of children at 18 months of age; and to assess how well these discriminate children who receive a diagnosis of autism from other forms of developmental delay.
Sixteen thousand children in the southeast of England were screened for autism by their health visitor or GP, during their routine 18-month-old developmental check-up, using the CHAT (Checklist for Autism in Toddlers). From a previous high-risk study we predicted that children at 18 months of age who failed three items (‘protodeclarative pointing‘, ‘gaze-monitoring‘, and ‘pretend play’) would be at risk for receiving a diagnosis of autism. From other evidence, we further predicted that those 18-month-olds who failed one or two of the key items (either pretend play, or protodeclarative pointing and pretend play) would be at risk for developmental delay without autism.
Twelve children out of the total population of 16 000 consistently failed the three key items. Of these, 10 (83.3%) received a diagnosis of autism. Thus, the false positive rate was 16.6% (2 out of 12 cases), and even these 2 cases were not normal. When the 10 children with autism were reassessed at 3.5 years of age, their diagnosis remained the same. Thus the false positive rate among the cases diagnosed with autism was zero. In contrast, of 22 children who consistently failed either protodeclarative pointing and/or pretend play, none received a diagnosis of autism, but 15 (68.2%) received a diagnosis of language delay.
Consistent failure of the three key items from the CHAT at 18 months of age carries an 83.3% risk of autism; and this pattern of risk indicator is specific to autism when compared to other forms of developmental delay.
In the ordinary application of the time-lag method to the measurement of the diffusion coefficient of a gas passing through a plane sheet of an inert solid, the gas is pressurized on one side of the sheet and evacuated on the other. After decay of transients, the cumulative amount, Q(t), of gas diffused through the sheet in time, t, assumes the “time-lag” form, Q(t) = A(t - L). Measurements of the slope, A, and the intercept, L, can be used to determine the diffusion coefficient and the solubility of the gas in the solid. We have rederived this law for the case of a solid which is actively evolving this same gas at an arbitrary rate and have used it to predict the rate of outgasing of the solid upon standing. Practical applications of the theory include radioactive decay of minerals, rejection of plasticizers by plastics, and the decomposition of solid rocket propellants.
A complete classification is given of harmonic morphisms to a surface and conformal foliations by geodesics, with or without isolated singularities, of a simply-connected space form. The method is to associate to any such a holomorphic map from a Riemann surface into the space of geodesics of the space form. Properties such as nonintersecting fibres (or leaves) are translated into conditions on the holomorphic mapping which show it must have a simple form corresponding to a standard example.
Sulfometuron, when applied as a foliar and/or soil application, prevented regrowth of bahiagrass. Sulfometuron application did not reduce regrowth of centipedegrass regardless of method of application. Sulfometuron was absorbed by the roots and foliage of centipedegrass and bahiagrass. Symplasmic translocation of the herbicide was evident in both species. Translocation of foliar-applied sulfometuron increased from approximately 1% at 48 h after application to 23% at 72 h in bahiagrass. Metabolism of sulfometuron was greater in centipedegrass (69% of foliar-applied, 10% of root-applied) at 72 h after application than in bahiagrass (30% of foliar-applied and 4% of root-applied). Tolerance of centipedegrass to sulfometuron appeared to be related to a high degree of herbicide metabolism in this species.