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The inclusion of students with autism spectrum disorder (ASD) is increasing, but there have been no longitudinal studies of included students in Australia. Interview data reported in this study concern primary school children with ASD enrolled in mainstream classes in South Australia and New South Wales, Australia. In order to examine perceived facilitators and barriers to inclusion, parents, teachers, and principals were asked to comment on the facilitators and barriers to inclusion relevant to each child. Data are reported about 60 students, comprising a total of 305 parent interviews, 208 teacher interviews, and 227 principal interviews collected at 6-monthly intervals over 3.5 years. The most commonly mentioned facilitator was teacher practices. The most commonly mentioned barrier was intrinsic student factors. Other factors not directly controllable by school staff, such as resource limitations, were also commonly identified by principals and teachers. Parents were more likely to mention school- or teacher-related barriers. Many of the current findings were consistent with previous studies but some differences were noted, including limited reporting of sensory issues and bullying as barriers. There was little change in the pattern of facilitators and barriers identified by respondents over time. A number of implications for practice and directions for future research are discussed.
Many cryptocurrencies including Bitcoin are susceptible to a so-called double-spend attack, where someone dishonestly attempts to reverse a recently confirmed transaction. The duration and likelihood of success of such an attack depends on the recency of the transaction and the computational power of the attacker, and these can be related to the distribution of time for counts from one Poisson process to exceed counts from another by some desired amount. We derive an exact expression for this distribution and show how it can be used to obtain efficient simulation estimators. We also give closed-form analytic approximations and illustrate their accuracy.
Balloon aortic valvuloplasty and open surgical valvotomy are procedures to treat neonatal aortic stenosis, and there is controversy as to which method has superior outcomes.
We reviewed the records of patients at our institution since 2000 who had a balloon aortic valvuloplasty or surgical valvotomy via an open commissurotomy prior to 2 months of age.
Forty patients had balloon aortic valvuloplasty and 15 patients had surgical valvotomy via an open commissurotomy. There was no difference in post-procedure mean gradient by transthoracic echocardiogram, which were 25.8 mmHg for balloon aortic valvuloplasty and 26.2 mmHg for surgical valvotomy, p = 0.87. Post-procedure, 15% of balloon aortic valvuloplasty patients had moderate aortic insufficiency and 2.5% of patients had severe aortic insufficiency, while no surgical valvotomy patients had moderate or severe aortic insufficiency. The average number of post-procedure hospital days was 14.2 for balloon aortic valvuloplasty and 19.8 for surgical valvotomy (p = 0.52). Freedom from re-intervention was 69% for balloon aortic valvuloplasty and 67% for surgical valvotomy at 1 year, and 43% for balloon aortic valvuloplasty and 67% for surgical valvotomy at 5 years (p = 0.60).
Balloon aortic valvuloplasty and surgical valvotomy provide similar short-term reduction in valve gradient. Balloon aortic valvuloplasty has a slightly shorter but not statistically significant hospital stay. Freedom from re-intervention is similar at 1 year. At 5 years, it is slightly higher in surgical valvotomy, though not statistically different. Balloon aortic valvuloplasty had a higher incidence of significant aortic insufficiency. Long-term comparisons cannot be made given the lack of long-term follow-up with surgical valvotomy.
Encephalitis causes high morbidity and mortality. An incidence of 4.3 cases of encephalitis/100 000 population has been reported in the UK. We performed a retrospective evaluation of the diagnosis and management of adults admitted to hospital with a clinical diagnosis of encephalitis/meningoencephalitis. Clinical, laboratory and radiological data were collated from electronic records. Thirty-six patients, median age 55 years and 24 (67%) male were included. The aetiology was confirmed over nine months in 25 (69%) of whom 16 were infections (six viral, seven bacterial, two parasitic and one viral and parasitic co-infection); 7 autoimmune; 1 metabolic and 1 neoplastic. Of 24 patients with fever, 15 (63%) had an infection. The median time to computed topography, magnetic resonance imaging and electroencephalography (EEG) was 1, 8 and 3 days respectively. Neuroimaging was abnormal in 25 (69%) and 17 (89%) had abnormal EEGs. Only 19 (53%) received aciclovir treatment. Six (17%) made good recoveries, 16 (44%) had moderate disability, 8 (22%) severe disability and 6 (17%) died. Outcomes were worse for those with an infectious cause. In summary, a diagnosis was made in 69.4% of patients admitted with encephalitis/meningoencephalitis. Autoimmune causes are important to consider at an early stage due to a successful response to treatment. Only 53% of patients received aciclovir on admission. Neuroimaging and EEG studies were delayed. The results of this work resulted in further developing the clinical algorithm for managing these patients.
The Ross procedure involves using the native pulmonary valve for aortic valve replacement then replacing the pulmonary valve with an allograft or xenograft. We aimed to compare our age-matched experience with the bovine jugular vein conduit and the pulmonary homograft for pulmonary valve replacement during the Ross procedure in children.
Between 1998 and 2016, 15 patients <18 years of age underwent a Ross procedure using the bovine jugular vein conduit (Ross-Bovine Jugular Vein Conduit) at our institution. These patients were age-matched with 15 patients who had the Ross operation with a standard pulmonary homograft for right ventricular outflow tract reconstruction (Ross-Pulmonary Homograft). Paper and electronic medical records were retrospectively reviewed.
The median age of the Ross-Bovine Jugular Vein Conduit and Ross-Pulmonary Homograft patients were 4.8 years (interquartile range 1.1–6.6) and 3.3 years (interquartile 1.2–7.6), respectively (p = 0.6). The median follow-up time for the Ross-Bovine Jugular Vein Conduit and Ross-Pulmonary Homograft groups were 1.7 years (interquartile range 0.5–4.9) and 6.8 years (interquartile range 1.9–13.4), respectively (p = 0.03). Overall, 5-year survival, freedom from redo aortic valve replacement, and freedom from pulmonary valve replacement were similar between groups.
The bovine jugular vein conduit and pulmonary homograft have favourable mid-term durability when used for right ventricular outflow tract reconstruction for the Ross operation. The bovine jugular vein conduit may be a suitable replacement for appropriately sized patients undergoing a Ross aortic valve replacement, though longer follow-up is needed.
Nudging in microbiology is an antimicrobial stewardship strategy to influence decision making through the strategic reporting of microbiology results while preserving prescriber autonomy. The purpose of this scoping review was to identify the evidence that demonstrates the effectiveness of nudging strategies in susceptibility result reporting to improve antimicrobial use.
A search for studies in Ovid MEDLINE, Embase, PsycINFO, and All EBM Reviews was conducted. All simulated and vignette studies were excluded. Two independent reviewers were used throughout screening and data extraction.
Of a total of 1,346 citations screened, 15 relevant studies were identified. Study types included pre- and postintervention (n = 10), retrospective cohort (n = 4), and a randomized controlled trial (n = 1). Most studies were performed in acute-care settings (n = 13), and the remainder were in primary care (n = 2). Most studies used a strategy to alter the default antibiotic choices on the antibiotic report. All studies reported at least 1 outcome of antimicrobial use: utilization (n = 9), appropriateness (n = 7), de-escalation (n = 2), and cost (n = 1). Moreover, 12 studies reported an overall benefit in antimicrobial use outcomes associated with nudging, and 4 studies evaluated the association of nudging strategy with subsequent antimicrobial resistance, with 2 studies noting overall improvement.
The number of heterogeneous studies evaluating the impact of applying nudging strategies to susceptibility result reports is small; however, most strategies do show promise in altering prescriber’s antibiotic selection. Selective and cascade reporting of targeted agents in a hospital setting represent the majority of current research. Gaps and opportunities for future research identified from our scoping review include performing prospective randomized controlled trials and evaluating other approaches aside from selective reporting.
Antimicrobial stewardship program (ASP) interventions, such as prospective audit and feedback (PAF), have been shown to reduce antimicrobial use and improve patient outcomes. However, the optimal approach to PAF is unknown.
We examined the impact of a high–intensity interdisciplinary rounds–based PAF compared to low–intensity PAF on antimicrobial use on internal medicine wards in a 400–bed community hospital.
Prior to the intervention, ASP pharmacists performed low–intensity PAF with a focus on targeted antibiotics. Recommendations were made directly to the internist for each patient. High–intensity, rounds–based PAF was then introduced sequentially to 5 internal medicine wards. This PAF format included twice–weekly interdisciplinary rounds, with a review of all internal medicine patients receiving any antimicrobial agent. Antibiotic use and clinical outcomes were measured before and after the transition to high–intensity PAF. An interrupted time–series analysis was performed adjusting for seasonal and secular trends.
With the transition from low–intensity to high–intensity PAF, a reduction in overall usage was seen from 483 defined daily doses (DDD)/1,000 patient days (PD) during the low–intensity phase to 442 DDD/1,000 PD in the high–intensity phase (difference, −42; 95% confidence interval [CI], −74 to −9). The reduction in usage was more pronounced in the adjusted analysis, in the latter half of the high intensity period, and for targeted agents. There were no differences seen in clinical outcomes in the adjusted analysis.
High–intensity PAF was associated with a reduction in antibiotic use compared to a low–intensity approach without any adverse impact on patient outcomes. A decision to implement high–intensity PAF approach should be weighed against the increased workload required.
The initial classic Fontan utilising a direct right atrial appendage to pulmonary artery anastomosis led to numerous complications. Adults with such complications may benefit from conversion to a total cavo-pulmonary connection, the current standard palliation for children with univentricular hearts.
A single institution, retrospective chart review was conducted for all Fontan conversion procedures performed from July, 1999 through January, 2017. Variables analysed included age, sex, reason for Fontan conversion, age at Fontan conversion, and early mortality or heart transplant within 1 year after Fontan conversion.
A total of 41 Fontan conversion patients were identified. Average age at Fontan conversion was 24.5 ± 9.2 years. Dominant left ventricular physiology was present in 37/41 (90.2%) patients. Right-sided heart failure occurred in 39/41 (95.1%) patients and right atrial dilation was present in 33/41 (80.5%) patients. The most common causes for Fontan conversion included atrial arrhythmia in 37/41 (90.2%), NYHA class II HF or greater in 31/41 (75.6%), ventricular dysfunction in 23/41 (56.1%), and cirrhosis or fibrosis in 7/41 (17.1%) patients. Median post-surgical follow-up was 6.2 ± 4.9 years. Survival rates at 30 days, 1 year, and greater than 1-year post-Fontan conversion were 95.1, 92.7, and 87.8%, respectively. Two patients underwent heart transplant: the first within 1 year of Fontan conversion for heart failure and the second at 5.3 years for liver failure.
Fontan conversion should be considered early when atrial arrhythmias become common rather than waiting for severe heart failure to ensue, and Fontan conversion can be accomplished with an acceptable risk profile.
OBJECTIVES/SPECIFIC AIMS: Engaging patients and consumers in research is a complex process where innovative strategies are needed to effectively translate scientific discoveries into improvements in the public’s health (Wilkins et. al., 2013; Terry et. al., 2013). The Clinical Translational Science Awards (CTSA)—supported by the National Institute of Health (NIH) under the auspices of the National Center for Advancing Translational Sciences (NCATS)—aim to provide resources and support needed to strengthen our nation’s clinical and translational research (CTR) enterprise. In 2008, Stanford University was awarded a CTSA from the NIH, establishing Spectrum (Stanford Center for Clinical and Translational Research and Education) and its Community Engagement (CE) Program aimed at building long-standing community-academic research partnerships for translational research in the local area surrounding Stanford University. To date, the CE Pilot Program has funded 38 pilot projects from the 2009-2017 calendar year. The purpose of this study was to understand, through a unique pilot program, the barriers, challenges, and facilitators to community-engaged research targeting health disparities as well as community-academic partnerships. METHODS/STUDY POPULATION: Investigators conducted a qualitative study of the community engagement pilot program. Previous pilot awardees were recruited via email and phone to participate in a one-hour focus group to discuss their pilot project experience—describing any barriers, challenges, and facilitators to implementing their pilot project. RESULTS/ANTICIPATED RESULTS: The focus group revealed that community engage research through the pilot program was not only appreciated by faculty, but projects were successful, and partnerships developed were sustained after funding. Specifically, the pilot program has seen success in both traditional and capacity building metrics: the initial investment of $652,250.00 to fund 38 projects has led to over $11 million dollars in additional grant funding. In addition, pilot funding has led to peer-reviewed publications, data resources for theses and dissertations, local and national presentations/news articles, programmatic innovation, and community-level impact. Challenges and barriers were mainly related to timing, grant constraints, and university administrative processes. DISCUSSION/SIGNIFICANCE OF IMPACT: The Community Engagement Pilot Program demonstrates an innovative collaborative approach to support community-academic partnerships. This assessment highlights the value and importance of pilot program to increase community engaged research targeting health disparities. Challenges are mainly administrative in nature: pilot awardees mentioned difficulties working on university quarterly timelines, challenges of subcontracting or sharing money with community partners, onerous NIH prior approval process, and limitations to carryover funding. However, pilot grants administered through the program strengthen the capacity to develop larger scale community-based research initiatives.
Stone tool producers in the Maya Lowlands had several types of raw materials from which to choose. Limestone, chert, and obsidian are the most naturally abundant, whereas chert and obsidian outnumber limestone in archaeological contexts. The presence of flaked-stone tools made of limestone is typically attributed to the scarcity of more suitable raw materials. Nevertheless, in chert-rich areas, such as the upper Belize River valley, limestone bifaces and production debitage are present. To understand their presence, we examine limestone biface production and use at Buenavista del Cayo.
The biological domain has the potential to offer a rich source of analogies to solve engineering design problems. However, due to the complexity embedded in biological systems, adding to the lack of structured, detailed, and searchable knowledge bases, engineering designers find it hard to access the knowledge in the biological domain, which therefore poses challenges in understanding the biological concepts in order to apply these concepts to engineering design problems. In order to assist the engineering designers in problem-solving, we report, in this paper, a web-based tool called Idea-Inspire 4.0 that supports analogical design using two broad features. First, the tool provides access to a number of biological systems using a searchable knowledge base. Second, it explains each one of these biological systems using a multi-modal representation: that is, using function decomposition model, text, function model, image, video, and audio. In this paper, we report two experiments that test how well the multi-modal representation in Idea-Inspire 4.0 supports understanding and application of biological concepts in engineering design problems. In one experiment, we use Bloom's method to test “analysis” and “synthesis” levels of understanding of a biological system. In the next experiment, we provide an engineering design problem along with a biological-analogous system and examine the novelty and requirement-satisfaction (two major indicators of creativity) of resulting design solutions. In both the experiments, the biological system (analogue) was provided using Idea-Inspire 4.0 as well as using a conventional text-image representation so that the efficacy of Idea-Inspire 4.0 is tested using a benchmark.
The goal of this paper is to examine meaning as a component of creativity. We take a demand-based approach for conceptualizing meaning, and propose that it emerges from user needs instead of emerging from already existing creative solutions. Meaning is proposed as a third component of creativity, alongside novelty and usefulness. We test this proposition in a pre-study, and two empirical studies. In the pre-study, designers define creativity and provide examples of solutions that they deem creative. The results of the pre-study yield a 24-item scale for assessing creativity. Then, we conduct two empirical studies, in which we utilize the created scale for measuring creativity, and for examining the components arising thereof. In the first study, we ask creators (design engineering students) to generate ideas for one of two design briefs. Afterwards, creators were asked to rate their own creations, on the 24-item creativity scale. Here, we find a four-factor solution for creative outcomes, consisting of the dimensions novelty, usefulness, cleverness, and meaning. In the second study, we ask independent evaluators (individuals with related and relevant degrees) to assess the creators’ work on the creativity scale. Here, we find a three-factor solution for creative outcomes, consisting of the dimensions novelty, usefulness, and meaning. In both studies, meaning emerged as a separate component of creativity. Additionally, in both studies, it accounted for variance that was unaccounted for by novelty and usefulness, thereby increasing the overall explanatory power of creative solutions. These findings strongly speak of meaning as a third component of creativity.
Traditionally, design opportunities and directions are conceived based on expertise, intuition, or time-consuming user studies and marketing research at the fuzzy front end of the design process. Herein, we propose the use of the total technology space map (TSM) as a visual ideation aid for rapidly conceiving high-level design opportunities. The map is comprised of various technology domains positioned according to knowledge proximity, which is measured based on a large quantity of patent data. It provides a systematic picture of the total technology space to enable stimulated ideation beyond the designer's knowledge. Designers can browse the map and navigate various technologies to conceive new design opportunities that relate different technologies across the space. We demonstrate the process of using TSM as a rapid ideation aid and then analyze its applications in two experiments to show its effectiveness and limitations. Furthermore, we have developed a cloud-based system for computer-aided ideation, that is, InnoGPS, to integrate interactive map browsing for conceiving high-level design opportunities with domain-specific patent retrieval for stimulating concrete technical concepts, and to potentially embed machine-learning and artificial intelligence in the map-aided ideation process.
Design problems are often presented as structured briefs with detailed constraints and requirements, suggesting a fixed definition. However, past studies have identified the importance of exploring design problems for creative design outcomes. Previous protocol studies of designers has shown that problems can “co-evolve” with the development of solutions during the design process. But to date, little evidence has been provided about how designers systematically explore presented problems to create better solutions. In this study, we conducted a qualitative analysis of 252 design problems collected from publically available sources, including award-winning product designs and open-source design competitions. This database offers an independent sample of presented problems, designers’ alternative problem descriptions, and innovative solutions. We report the results of this large-scale qualitative analysis aimed at characterizing changes to problems during the design process. Inductive coding was used to identify content patterns in “discovered” problem descriptions, with qualitative codes reliably scored by two independent coders. A total of 32 distinct patterns of problem exploration were identified across designers and presented problems. Each pattern is described in the form of a generalized strategy to guide designers as they explore problem spaces. The exploration patterns identified in this study are the first empirical evidence of problem exploration in independent design problems. Further, the presence of exploration patterns in discovered problems is associated with the selection of the corresponding solution as a challenge finalist. These empirically identified strategies for problem exploration may be useful for computational tools supporting designers.