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Treatment of hypoplastic left heart syndrome varies across institutions. This study examined the impact of introducing a standardised programme.
This retrospective cohort study evaluated the effects of a comprehensive strategy on 1-year transplant-free survival with preserved ventricular and atrioventricular valve (AVV) function following a Norwood operation. This strategy included standardised operative and perioperative management and dedicated interstage monitoring. The post-implementation cohort (C2) was compared to historic controls (C1). Outcomes were assessed using logistic regression and Kaplan–Meier analysis.
The study included 105 patients, 76 in C1 and 29 in C2. Groups had similar baseline characteristics, including percentage with preserved ventricular (96% C1 versus 100% C2, p = 0.28) and AVV function (97% C1 versus 93% C2, p = 0.31). Perioperatively, C2 had higher indexed oxygen delivery (348 ± 67 ml/minute/m2 C1 versus 402 ± 102ml/minute/m2 C2, p = 0.015) and lower renal injury (47% C1 versus 3% C2, p = 0.004). The primary outcome was similar in both groups (49% C1 and 52% C2, p = 0.78), with comparable rates of death and transplantation (36% C1 versus 38% C2, p = 0.89) and ventricular (2% C1 versus 0% C2, p = 0.53) and AVV dysfunction (11% C1 versus 11% C2, p = 0.96) at 1-year. When accounting for cohort and 100-day freedom from hospitalisation, female gender (OR 3.7, p = 0.01) increased and ventricular dysfunction (OR 0.21, p = 0.02) and CPR (OR 0.11, p = 0.002) or ECMO use (OR 0.15, p = 001) decreased the likelihood of 1-year transplant-free survival.
Standardised perioperative management was not associated with improved 1-year transplant-free survival. Post-operative ventricular or AVV dysfunction was the strongest predictor of 1-year mortality.
A compact antenna module with a single band notch at wireless local area network (WLAN) (5.725–5.825 GHz) for ultra-wideband (UWB) multiple input multiple output (MIMO) applications is proposed. Proposed antenna which acquires size of 0.299 λ × 0.413 λ × 0.005 λ mm3 at 3.1 GHz consists of two symmetrical radiators placed side by side on global merchandise link (GML) 1000 substrate (εr = 3.2, tan δ = 0.004). Isolation between the antenna elements is >18 dB in the whole UWB band, which is achieved by introducing the vertical stub and H-slot between the monopole radiators in the ground plane. The simulated and measured results of the antenna system are in good agreement. The proposed antenna covers entire UWB with impedance bandwidth (|S11| < −15 dB) from 3.1 to 11 GHz except at WLAN notched band. The designed antenna module bears low envelope correlation coefficient and minimal multiplexing efficiency hence fulfilling criteria suitable for various wireless MIMO applications.
Chronic aflatoxin exposure has been associated with childhood stunting (length-for-age/height-for-age < –2 sd), while data lacks for Bangladesh, a country with substantial burden of childhood stunting. This paper examined the association between aflatoxin exposure and childhood stunting in a slum setting of Dhaka city.
In this MAL-ED aflatoxin birth cohort study, plasma samples were assayed for aflatoxin B1-lysine adduct (AFB1-lys) by MS at 7, 15, 24 and 36 months of age for 208, 196, 173 and 167 children to assess chronic aflatoxin exposure. Relationship between aflatoxin exposure and anthropometric measures was examined by mixed-effects logistic regression models.
Setting and participants:
The study was conducted in Mirpur, Dhaka, where children were followed from birth to 36 months.
Prevalence of stunting increased from 21 % at 7 months to 49 % at 36 months of age. Mean AFB1-lys concentrations at 7, 15, 24 and 36 months were 1·30 (range 0·09–5·79), 1·52 (range 0·06–6·35), 3·43 (range 0·15–65·60) and 3·70 (range 0·09–126·54) pg/mg albumin, respectively, and the percentage of children with detectable AFB1-lys was 10, 21, 18 and 62 %, respectively. No association was observed between aflatoxin exposure and stunting in multivariable analyses. Factors associated with childhood stunting were age, low birth weight, maternal height, stool myeloperoxidase and number of people sleeping in one room.
A relatively lower exposure to aflatoxin may not influence the linear growth of children. This finding indicates a threshold level of exposure for linear growth deficit and further investigation in other areas where higher concentrations of aflatoxin exposure exist.
Approximately, 1.7 million individuals in the United States have been infected with SARS-CoV-2, the virus responsible for the novel coronavirus disease-2019 (COVID-19). This has disproportionately impacted adults, but many children have been infected and hospitalised as well. To date, there is not much information published addressing the cardiac workup and monitoring of children with COVID-19. Here, we share the approach to the cardiac workup and monitoring utilised at a large congenital heart centre in New York City, the epicentre of the COVID-19 pandemic in the United States.
Innovation Concept: The Orange Book (OB) identifies drugs approved on the basis of safety and effectiveness by the FDA and serves as the gold standard reference for correct pharmacological therapies. It ties in closely with Choosing Wisely Canada (CWC) modelling good stewardship in antimicrobial prescriptions. The book focuses on passive didactic learning instead of active learning, which was shown to have a greater influence on prescribing behaviour. Educational video games, a form of active learning, have been shown to improve clinical skills in medical training. Contagion is a role-playing video game providing an active way of teaching antimicrobial components of the OB and CWC guidelines. Method: Phase I of Contagion was qualitatively tested on students and physicians at McMaster University for teaching effectiveness, applicability to real-life scenarios, and enjoyability. Post-game play 12 participants scored different aspects of the game on a Likert scale. Curriculum, Tool, or Material: The player is a rural physician treating infections in various communities. Each round, the player is given a crate of antibiotics. As communities are infected, the player is provided with clinical symptoms the patients present with. The player must identify the pathology and then correctly treat the communities. The player can treat empirically or order tests to identify the infectious organism. The player strategically navigates which communities to treat as there are limited actions per turn and the player must prevent communities from dying or infecting neighboring regions. Communities tend to build antibiotic resistance over time making first-line treatments unviable, thus careful strategizing and stewardship is essential. Active learning will occur when players are tasked with finding the correct answer to different presentations. After each turn, players will learn about the infecting organism, its phenotypes, and common infectious symptoms. This is considered passive learning. Conclusion: Contagion was well-received by physicians and medical students as an active learning tool to teach the OB and CWC guidelines. On preliminary user testing Contagion scored 5 in effectiveness in teaching treatments and 4.6 in teaching stewardship. An objective of this project is to perform large scale testing across schools to demonstrate the effectiveness of the learning components of the game. We hope to eventually create a tool that can be incorporated in continuing medical education for physicians.
Diabetes mellitus is a syndrome with disordered metabolism and inappropriate hyperglycaemia due to either the deficiency of insulin secretion or to a combination of insulin resistance and inadequate insulin secretion to compensate. Depressive disorders have been found to occur at increased prevalence rates among patients with Type 1 and Type 2 Diabetes Mellitus 9. Depression has the additional importance in diabetes because of its association with poor compliance with diabetic treatment, poor glycemic control and an increased risk of micro and macro vascular complications. An accurate estimate of depression prevalence is needed to keep and gauge the potential impact of depression management in patients with co-morbid diabetes 22. Better recognition and better treatment of depression are important in themselves but they could also improve medical outcome by substantial portion in patients of diabetes
Total of 527 cases of Diabetes were screened for major depressive disorder (MDD) by using DSMIV based criteria system. Montgomeny Asberg Depression rating scale (MADRS) and Clinical Global Impression (Severity) (CGI) scale to access severity.
1. Major depressive disorder is inordinately high among the sample of adult diabetic patients occurring at the rates of 2 - 6 times greater than those observed in general population.
2. Majority of patients with diabetes who have major depressive disorder have depression of moderate severity and not just mild depressive symptomatology.
3. The presence of major depressive disorder is significantly associated with poorer glycemic control.
UK mental health services envisage that patients with a first presentation of psychosis are seen by an ad hoc assertive service for the first three years and then are transferred for further follow up to a community mental health team or to primary care.
We have reported on the three year outcomes of 62 patients who were treated in such an assertive service, compared to 62 patients who received treatment as usual. Outcomes in all domains were significantly better with the assertive service. These domains included employment, education, family life, relapses, readmission and concordance with medication.
We now report on an audit of outcomes at the end of the fourth year in both groups of patients; the exercise will be repeated at the end of the fifth year.
A note audit is being carried out on the two groups of patients.
Work on the audit is in progress at the time of writing. Early results indicate that some patients have had significant relapses since leaving the assertive service. This has led to significant bed usage by some patients. Other patients appear to have remained stable.
Relapse leads to a reduction of quality of life for the patients. Thus, in some cases there appears to be a reduction in the more advantageous quality of life outcomes once patients are referred to the community mental health team. This mirrors five year outcomes of first psychosis patients reported by the OPUS project.
In the USA, 68% of adults and 31% of children are overweight or obese. Obesity doubles mortality rates and has significant associated medical costs with an average obese person spending $1500 or more per year. In addition, 10% of all adults and 23% of adults over 60 years have type 2 diabetes, with an average person spending $2257 or more per year. In 2009, 1 out of every 10 healthcare dollars was spent on type 2 diabetes, totalling $174 billion. People with serious and persistent mental illness die on average 25 years earlier than the general population. Cardiovascular disease is the primary cause of death in persons with mental illness and accounts for 60% of the increased mortality. Furthermore, 46.24% of individuals with cardiometabolic risk factors who are also on antipsychotic medications take high- to moderate-risk antipsychotics. The cluster of cardiometabolic syndrome includes: type 2 diabetes, hypertension, dyslipidemia, obesity and pre-existing cardiovascular disease. There are, however, modifiable risk factors including smoking cessation, diet change, physical activity, medical care and choice of antipsychotic medication (on which the physician has direct control). More information is therefore needed on various antipsychotic medications and their associated cardiometabolic risk factors in order to educate physicians. In this review article, we examined 10 articles on antipsychotic medications, and their effect on the 5 domains, including type 2 diabetes, hypertension, dyslipidemia, obesity and pre-existing cardiovascular disease. Overall, there was a clear trend, which found a significant difference in the associated risk factors amongst various antipsychotic medications.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Familial risk for psychosis may interact with environmental risk factors.
We are studying a large birth cohort of children of mothers with psychotic disorders, themselves at high risk of developing a psychotic illness, to understand the developmental aetiology of psychotic illness.
Our aim is to examine whether exposure to environmental stressors in childhood, including timing of exposure, is a risk factor for psychotic illness, independent of familial liability. Specificity to maternal schizophrenia is explored.
We used record-linkage across state-wide registers (midwives, psychiatric, child protection and mortality, among others) to identify 15,486 offspring born in Western Australia 1980–2001 to mothers with a lifetime history of psychotic illness (case children) and compared them with 452,459 offspring born in the same period to mothers with no known psychiatric history (comparison children).
A total of 4.1% of case children had developed a psychotic illness compared to 1.1% of comparison children. Exposure to environmental risk factors including obstetric complications, aboriginality, lower socioeconomic status, discontinuity in parenting and childhood abuse significantly increased risk of psychotic illness in offspring. Length and age at time of discontinuity in parenting impacted on risk. At the same time, case children were also significantly more likely than comparison children to be at risk of experiencing these adverse life events.
Exposure to environmental stressors is associated with psychotic illness, and timing of exposure is important. However, children already at increased familial risk for psychotic illness are also at increased risk of experiencing these environmental stressors.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
As plasmonic materials transition from three-dimensional to two-dimensional (2D) form, unique optical and electronic phenomena arise that are unattainable in bulk materials and conventional thin films. Exceptional sensitivity to external perturbations, including electrical biasing and optical excitation as well as quantum effects, are expected to emerge, as has been demonstrated in graphene. Similarly, metallic or plasmonic films with thicknesses down to a few monolayers, called transdimensional materials (TDMs), are predicted to exhibit remarkably strong tunability of their optical response. The unique properties of 2D materials and TDMs have established them as promising platforms for dynamic nanophotonic devices. While novel 2D materials have been widely explored for nanophotonic devices, until recently, there have been minimal studies on the evolution of the optical properties of plasmonic TDMs. In this article, we highlight progress in exploring the thickness-dependent optical response of plasmonic materials as they approach the 2D regime. Experimental and theoretical investigations of the plasmonic properties of 2D materials, such as graphene and tungsten diselenide, TDMs, and plasmonic thin films, are discussed, with a focus on prospects for their utilization in dynamically tunable flat optical devices or metasurfaces.
Insurance industry practitioners have deep knowledge of their industry, but there is a lack of a simple-to-understand, practical blueprint on applying distributed ledger technology solutions, including blockchain. This paper provides a practical guide for actuaries, risk professionals, insurance companies and their Boards on blockchain, including an education piece to provide an understanding of the technology. Examples of real-world applications and use cases in insurance are provided to illustrate the capability of the technology. The current risks and challenges in adopting the technology are also considered. Finally, a checklist of issues to consider in adopting a blockchain solution for insurance business problems is provided.
Associations between childhood abuse and various psychotic illnesses in adulthood are commonly reported. We aim to examine associations between several reported childhood adverse events (sexual abuse, physical abuse, emotional abuse, neglect and interpersonal loss) among adults with diagnosed psychotic disorders and clinical and psychosocial outcomes.
Within a large epidemiological study, the 2010 Australian National Survey of Psychosis (Survey of High Impact Psychosis, SHIP), we used logistic regression to model childhood adverse events (any and specific types) on 18 clinical and psychosocial outcomes.
Eighty percent of SHIP participants (1466/1825) reported experiencing adverse events in childhood (sexual abuse, other types of abuse and interpersonal loss). Participants reporting any form of childhood adversity had higher odds for 12/18 outcomes we examined. Significant associations were observed with all psychosocial outcomes (social dysfunction, victimisation, offending and homelessness within the previous 12 months, and definite psychosocial stressor within 12 months of illness onset), with the strongest association for homelessness (odds ratio (OR) = 2.82). Common across all adverse event types was an association with lifetime depression, anxiety and a definite psychosocial stressor within 12 months of illness onset. When adverse event types were non-hierarchically coded, sexual abuse was associated with 11/18 outcomes, other types of abuse 13/18 and, interpersonal loss occurring in the absence of other forms of abuse was associated with fewer of the clinical and psychosocial outcomes, 4/18. When adverse events types were coded hierarchically (to isolate the effect of interpersonal loss in the absence of abuse), interpersonal loss was associated with lower odds of self-reproach (OR = 0.70), negative syndrome (OR = 0.75) and victimisation (OR = 0.82).
Adverse childhood experiences among people with psychosis are common, as are subsequent psychosocial stressors. Mental health professionals should routinely enquire about all types of adversities in this group and provide effective service responses. Childhood abuse, including sexual abuse, may contribute to subsequent adversity, poor psychosocial functioning and complex needs among people with psychosis. Longitudinal research to better understand these relationships is needed, as are studies which evaluate the effectiveness of preventative interventions in high-risk groups.
To examine factors that influence decision-making, preferences, and plans related to advance care planning (ACP) and end-of-life care among persons with dementia and their caregivers, and examine how these may differ by race.
13 geographically dispersed Alzheimer’s Disease Centers across the United States.
431 racially diverse caregivers of persons with dementia.
Survey on “Care Planning for Individuals with Dementia.”
The respondents were knowledgeable about dementia and hospice care, indicated the person with dementia would want comfort care at the end stage of illness, and reported high levels of both legal ACP (e.g., living will; 87%) and informal ACP discussions (79%) for the person with dementia. However, notable racial differences were present. Relative to white persons with dementia, African American persons with dementia were reported to have a lower preference for comfort care (81% vs. 58%) and lower rates of completion of legal ACP (89% vs. 73%). Racial differences in ACP and care preferences were also reflected in geographic differences. Additionally, African American study partners had a lower level of knowledge about dementia and reported a greater influence of religious/spiritual beliefs on the desired types of medical treatments. Notably, all respondents indicated that more information about the stages of dementia and end-of-life health care options would be helpful.
Educational programs may be useful in reducing racial differences in attitudes towards ACP. These programs could focus on the clinical course of dementia and issues related to end-of-life care, including the importance of ACP.
Background: SMA is a neurodegenerative disease caused by biallelic deletion/mutation of the survival motor neuron (SMN1) gene. In the phase 1 trial (NCT02122952), SMN GRT onasemnogene abeparvovec (AVXS-101) improved outcomes of 15 symptomatic SMA1 patients (3 at a lower dose [cohort 1] and 12 at the proposed therapeutic dose [cohort 2]). This report describes long-term follow-up study design and data from the phase 1 study. Methods: Patients in the phase 1 study could rollover into a long-term follow-up study (NCT03421977). The primary objective is to collect long-term safety data (serious adverse events, hospitalizations, and adverse events of special interest). Annual follow-up will occur for 15 years. Additionally, patient record transfers from local clinician(s) will be requested. Safety assessments include medical history and record review, physical examination, clinical laboratory evaluation, and pulmonary assessments. Efficacy assessments include physical examination to assess developmental milestones. Results: As of September 27, 2018, the oldest patients are 59.2 (cohort 1) and 52.1 (cohort 2) months old and free of permanent ventilation. Preliminary data, including survival and developmental milestones, will be presented. Conclusions: Patients treated with a one-time dose of AVXS-101 continue to gain strength, develop, and achieve new milestones, demonstrating a long-term, durable response.
Introduction: Accurate forecasting of emergency department (ED) patient visits can inform better resource matching. Calendar variables such as day of week and time of day are routinely used as predictors of ED volume. Further improvement in forecasting will likely come from dynamic variables. The effect of snowfall on ED volumes in colder climates remains poorly understood. We sought to determine whether accounting for snowfall improves ED patient volume forecasting. Our secondary objective was to characterize the magnitude of effect of snowfall on ED volume. Methods: This was a retrospective observational study using historical patient volume data and local snowfall records from April 1st, 2011 to March 31st, 2018 (2,542 days) at a single urban ED. We fit a series of four generalized linear models: a baseline model which included calendar variables and three different snowfall models which contained the variables in the baseline model plus an indicator variable for modelling snowfall. Each snowfall model had a different daily threshold for its indicator variable: any snowfall ( >0cm), moderate snowfall ( > = 1 cm), or high snowfall ( > = 5 cm). We modeled daily ED volume as the dependent variable using a Poisson distribution. To evaluate model fit, we examined the Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC) in each of the four models. In both cases, a lower number indicates better model fit. Incident rate ratios were calculated to determine the effect of snowfall. We used the delta method to calculate confidence intervals. Results: A total of 2542 days were used to develop the model. All three snowfall models demonstrated improved model fit compared to the baseline model with lower AIC and BIC values. The best fitting model included a binary variable for moderate snowfall ( > = 1cm/day). This model showed a statistically significant decrease in ED volume of 2.65% (95% CI: 1.23% -4.00%) on snowfall days, representing 5.4 (95% CI: 2.5 -8.2) patients per day at our hospital with an average daily volume of 205 patients. Conclusion: The addition of a snowfall variable results in improved forecasting model performance in ED volume forecasting with optimal threshold set at 1 cm of snow in our setting. Snowfall is associated with a modest, but statistically significant reduction in ED volume.
Shunt-related adverse events are frequent in infants after modified Blalock–Taussig despite use of acetylsalicylic acid prophylaxis. A higher incidence of acetylsalicylic acid-resistance and sub-therapeutic acetylsalicylic acid levels has been reported in infants. We evaluated whether using high-dose acetylsalicylic acid can decrease shunt-related adverse events in infants after modified Blalock–Taussig.
In this single-centre retrospective cohort study, we included infants ⩽1-year-old who underwent modified Blalock–Taussig placement and received acetylsalicylic acid in the ICU. We defined acetylsalicylic acid treatment groups as standard dose (⩽7 mg/kg/day) and high dose (⩾8 mg/kg/day) based on the initiating dose.
There were 34 infants in each group. Both groups were similar in age, gender, cardiac defect type, ICU length of stay, and time interval to second stage or definitive repair. Shunt interventions (18 versus 32%, p=0.16), shunt thrombosis (14 versus 17%, p=0.74), and mortality (9 versus 12%, p=0.65) were not significantly different between groups. On multiple logistic regression analysis, single-ventricle morphology (odds ratio 5.2, 95% confidence interval of 1.2–23, p=0.03) and post-operative red blood cells transfusion ⩾24 hours [odds ratio 15, confidence interval of (3–71), p<0.01] were associated with shunt-related adverse events. High-dose acetylsalicylic acid treatment [odds ratio 2.6, confidence interval of (0.7–10), p=0.16] was not associated with decrease in these events.
High-dose acetylsalicylic acid may not be sufficient in reducing shunt-related adverse events in infants after modified Blalock–Taussig. Post-operative red blood cells transfusion may be a modifiable risk factor for these events. A randomised trial is needed to determine appropriate acetylsalicylic acid dosing in infants with modified Blalock–Taussig.
When Hurricane Harvey landed along the Texas coast on August 25, 2017, it caused massive flooding and damage and displaced tens of thousands of residents of Harris County, Texas. Between August 29 and September 23, Harris County, along with community partners, operated a megashelter at NRG Center, which housed 3365 residents at its peak. Harris County Public Health conducted comprehensive public health surveillance and response at NRG, which comprised disease identification through daily medical record reviews, nightly “cot-to-cot” resident health surveys, and epidemiological consultations; messaging and communications; and implementation of control measures including stringent isolation and hygiene practices, vaccinations, and treatment. Despite the lengthy operation at the densely populated shelter, an early seasonal influenza A (H3) outbreak of 20 cases was quickly identified and confined. Influenza outbreaks in large evacuation shelters after a disaster pose a significant threat to populations already experiencing severe stressors. A holistic surveillance and response model, which consists of coordinated partnerships with onsite agencies, in-time epidemiological consultations, predesigned survey tools, trained staff, enhanced isolation and hygiene practices, and sufficient vaccines, is essential for effective disease identification and control. The lessons learned and successes achieved from this outbreak may serve for future disaster response settings. (Disaster Med Public Health Preparedness. 2019;13:97-101)