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Monitoring cerebral and renal near-infrared spectroscopy for regional venous oxygenation is a common practice in the postoperative care of neonates recovering from surgery for CHD. In this study, we aimed to test the feasibility of using this technology for monitoring changes in splanchnic perfusion during feeds in infants recovering from cardiac surgery.
Methods:
We monitored renal and splanchnic near-infrared spectroscopy in 29 neonates once recovered from the critical postoperative state and tolerating full enteral nutrition. Infants were tested over 3 feeds for splanchnic regional oxygenation (rO2), arterial to splanchnic saturation difference and splanchnic to renal regional oxygenation ratio.
Result:
Splanchnic regional oxygenation data were obtained with no failure or interruptions. Interclass correlation for agreement between measurements suggested good repeatability: 0.84 at baseline and 0.82 at end of feed. Infants with physiologic repair (n = 19) showed a trend towards increased splanchnic regional oxygenation at the end of feeds and were more likely to achieve regional oxygenation > 50% compared to infants with shunt-dependent circulation (n = 10, p = 0.02). Calculating AVO2 and regional oxygenation index did not result in improved test sensitivity.
Conclusion:
Monitoring splanchnic regional oxygenation during feeds for infants recovering from congenital heart surgery is feasible and reliable. These results suggest that near-infrared spectroscopy could be further studied as a tool for bedside monitoring to assist in feeding management and prevention of necrotising enterocolitis in this sensitive patient population.
This study suggests that there may be considerable difficulties in providing accurate calendar age estimates in the Roman period in Europe, between ca. AD 60 and ca. AD 230, using the radiocarbon calibration datasets that are currently available. Incorporating the potential for systematic offsets between the measured data and the calibration curve using the ΔR approach suggested by Hogg et al. (2019), only marginally mitigates the biases in calendar date estimates observed. At present, it clearly behoves researchers in this period to “caveat emptor” and validate the accuracy of their calibrated radiocarbon dates and chronological models against other sources of dating information.
Background: Healthcare facilities have experienced many challenges during the COVID-19 pandemic, including limited personal protective equipment (PPE) supplies. Healthcare personnel (HCP) rely on PPE, vaccines, and other infection control measures to prevent SARS-CoV-2 infections. We describe PPE concerns reported by HCP who had close contact with COVID-19 patients in the workplace and tested positive for SARS-CoV-2. Method: The CDC collaborated with Emerging Infections Program (EIP) sites in 10 states to conduct surveillance for SARS-CoV-2 infections in HCP. EIP staff interviewed HCP with positive SARS-CoV-2 viral tests (ie, cases) to collect data on demographics, healthcare roles, exposures, PPE use, and concerns about their PPE use during COVID-19 patient care in the 14 days before the HCP’s SARS-CoV-2 positive test. PPE concerns were qualitatively coded as being related to supply (eg, low quality, shortages); use (eg, extended use, reuse, lack of fit test); or facility policy (eg, lack of guidance). We calculated and compared the percentages of cases reporting each concern type during the initial phase of the pandemic (April–May 2020), during the first US peak of daily COVID-19 cases (June–August 2020), and during the second US peak (September 2020–January 2021). We compared percentages using mid-P or Fisher exact tests (α = 0.05). Results: Among 1,998 HCP cases occurring during April 2020–January 2021 who had close contact with COVID-19 patients, 613 (30.7%) reported ≥1 PPE concern (Table 1). The percentage of cases reporting supply or use concerns was higher during the first peak period than the second peak period (supply concerns: 12.5% vs 7.5%; use concerns: 25.5% vs 18.2%; p Conclusions: Although lower percentages of HCP cases overall reported PPE concerns after the first US peak, our results highlight the importance of developing capacity to produce and distribute PPE during times of increased demand. The difference we observed among selected groups of cases may indicate that PPE access and use were more challenging for some, such as nonphysicians and nursing home HCP. These findings underscore the need to ensure that PPE is accessible and used correctly by HCP for whom use is recommended.
Healthcare personnel with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection were interviewed to describe activities and practices in and outside the workplace. Among 2,625 healthcare personnel, workplace-related factors that may increase infection risk were more common among nursing-home personnel than hospital personnel, whereas selected factors outside the workplace were more common among hospital personnel.
To evaluate the association between novel pre- and post-operative biomarker levels and 30-day unplanned readmission or mortality after paediatric congenital heart surgery.
Methods:
Children aged 18 years or younger undergoing congenital heart surgery (n = 162) at Johns Hopkins Hospital from 2010 to 2014 were enrolled in the prospective cohort. Collected novel pre- and post-operative biomarkers include soluble suppression of tumorgenicity 2, galectin-3, N-terminal prohormone of brain natriuretic peptide, and glial fibrillary acidic protein. A model based on clinical variables from the Society of Thoracic Surgery database was developed and evaluated against two augmented models.
Results:
Unplanned readmission or mortality within 30 days of cardiac surgery occurred among 21 (13%) children. The clinical model augmented with pre-operative biomarkers demonstrated a statistically significant improvement over the clinical model alone with a receiver-operating characteristics curve of 0.754 (95% confidence interval: 0.65–0.86) compared to 0.617 (95% confidence interval: 0.47–0.76; p-value: 0.012). The clinical model augmented with pre- and post-operative biomarkers demonstrated a significant improvement over the clinical model alone, with a receiver-operating characteristics curve of 0.802 (95% confidence interval: 0.72–0.89; p-value: 0.003).
Conclusions:
Novel biomarkers add significant predictive value when assessing the likelihood of unplanned readmission or mortality after paediatric congenital heart surgery. Further exploration of the utility of these novel biomarkers during the pre- or post-operative period to identify early risk of mortality or readmission will aid in determining the clinical utility and application of these biomarkers into routine risk assessment.
In Scotland, the base of the Ballagan Formation has traditionally been placed at the first grey mudstone within a contiguous Late Devonian to Carboniferous succession. This convention places the Devonian–Carboniferous boundary within the Old Red Sandstone (ORS) Kinnesswood Formation. The consequences of this placement are that tetrapods from the Ballagan Formation were dated as late Tournaisian in age and that the ranges of typically Devonian fish found in the Kinnesswood Formation continued into the Carboniferous. The Pease Bay specimen of the fish Remigolepis is from the Kinnesswood Formation. Comparisons with its range in Greenland, calibrated against spores, show it was Famennian in age. Detailed palynological sampling at Burnmouth from the base of the Ballagan Formation proves that the early Tournaisian spore zones (VI and HD plus Cl 1) are present. The Schopfites species that occurs through most of the succession is Schopfites delicatus rather than Schopfites claviger. The latter species defines the late Tournaisian CM spore zone. The first spore assemblage that has been found in Upper ‘ORS' strata underlying the Ballagan Formation (Preston, Whiteadder Water), contains Retispora lepidophyta and is from the early latest Famennian LL spore zone. The spore samples are interbedded with volcaniclastic debris, which shows that the Kelso Volcanic Formation is, in part, early latest Famennian in age. These findings demonstrate that the Ballagan Formation includes most of the Tournaisian with the Devonian–Carboniferous boundary positioned close to the top of the Kinnesswood Formation. The Stage 6 calcrete at Pease Bay can be correlated to the equivalent section at Carham, showing that it represents a time gap equivalent to the latest Famennian glaciation(s). Importantly, some of the recently described Ballagan Formation tetrapods are older than previously dated and now fill the key early part of Romer's Gap.
The lower Mississippian Ballagan Formation of northern Britain is one of only two successions worldwide to yield the earliest known tetrapods with terrestrial capability following the end-Devonian mass extinction event. Studies of the sedimentary environments and habitats in which these beasts lived have been an integral part of a major research project into how, why and under what circumstances this profound step in the evolution of life on Earth occurred. Here, a new palaeogeographic map is constructed from outcrop data integrated with new and archived borehole material. The map shows the extent of a very low-relief coastal wetland developed along the tropical southern continental margin of Laurussia. Coastal floodplains in the Midland Valley and Tweed basins were separated from the marginal marine seaway of the Northumberland–Solway Basin to the south by an archipelago of more elevated areas. A complex mosaic of sedimentary environments was juxtaposed, and included fresh and brackish to saline and hypersaline lakes, a diverse suite of floodplain palaeosols and a persistent fluvial system in the east of the region. The strongly seasonal climate led to the formation of evaporite deposits alternating with flooding events, both meteoric and marine. Storm surges drove marine floods from the SW into both the western Midland Valley and Northumberland–Solway Basin; marine water also flooded into the Tweed Basin and Tayside in the east. The Ballagan Formation is a rare example in the geological record of a tropical, seasonal coastal wetland that contains abundant, small-scale evaporite deposits. The diverse sedimentary environments and palaeosol types indicate a network of different terrestrial and aquatic habitats in which the tetrapods lived.
The Dark Energy Survey is undertaking an observational programme imaging 1/4 of the southern hemisphere sky with unprecedented photometric accuracy. In the process of observing millions of faint stars and galaxies to constrain the parameters of the dark energy equation of state, the Dark Energy Survey will obtain pre-discovery images of the regions surrounding an estimated 100 gamma-ray bursts over 5 yr. Once gamma-ray bursts are detected by, e.g., the Swift satellite, the DES data will be extremely useful for follow-up observations by the transient astronomy community. We describe a recently-commissioned suite of software that listens continuously for automated notices of gamma-ray burst activity, collates information from archival DES data, and disseminates relevant data products back to the community in near-real-time. Of particular importance are the opportunities that non-public DES data provide for relative photometry of the optical counterparts of gamma-ray bursts, as well as for identifying key characteristics (e.g., photometric redshifts) of potential gamma-ray burst host galaxies. We provide the functional details of the DESAlert software, and its data products, and we show sample results from the application of DESAlert to numerous previously detected gamma-ray bursts, including the possible identification of several heretofore unknown gamma-ray burst hosts.
Healthcare provider hands are an important source of intraoperative bacterial transmission events associated with postoperative infection development.
OBJECTIVE
To explore the efficacy of a novel hand hygiene improvement system leveraging provider proximity and individual and group performance feedback in reducing 30-day postoperative healthcare-associated infections via increased provider hourly hand decontamination events.
DESIGN
Randomized, prospective study.
SETTING
Dartmouth-Hitchcock Medical Center in New Hampshire and UMass Memorial Medical Center in Massachusetts.
PATIENTS
Patients undergoing surgery.
METHODS
Operating room environments were randomly assigned to usual intraoperative hand hygiene or to a personalized, body-worn hand hygiene system. Anesthesia and circulating nurse provider hourly hand decontamination events were continuously monitored and reported. All patients were followed prospectively for the development of 30-day postoperative healthcare-associated infections.
RESULTS
A total of 3,256 operating room environments and patients (1,620 control and 1,636 treatment) were enrolled. The mean (SD) provider hand decontamination event rate achieved was 4.3 (2.9) events per hour, an approximate 8-fold increase in hand decontamination events above that of conventional wall-mounted devices (0.57 events/hour); P<.001. Use of the hand hygiene system was not associated with a reduction in healthcare-associated infections (odds ratio, 1.07 [95% CI, 0.82–1.40], P=.626).
CONCLUSIONS
The hand hygiene system evaluated in this study increased the frequency of hand decontamination events without reducing 30-day postoperative healthcare-associated infections. Future work is indicated to optimize the efficacy of this hand hygiene improvement strategy.
The 2013 Infection Prevention and Control (IP&C) Guideline for Cystic Fibrosis (CF) was commissioned by the CF Foundation as an update of the 2003 Infection Control Guideline for CF. During the past decade, new knowledge and new challenges provided the following rationale to develop updated IP&C strategies for this unique population:
1. The need to integrate relevant recommendations from evidence-based guidelines published since 2003 into IP&C practices for CF. These included guidelines from the Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC), the World Health Organization (WHO), and key professional societies, including the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA). During the past decade, new evidence has led to a renewed emphasis on source containment of potential pathogens and the role played by the contaminated healthcare environment in the transmission of infectious agents. Furthermore, an increased understanding of the importance of the application of implementation science, monitoring adherence, and feedback principles has been shown to increase the effectiveness of IP&C guideline recommendations.
2. Experience with emerging pathogens in the non-CF population has expanded our understanding of droplet transmission of respiratory pathogens and can inform IP&C strategies for CF. These pathogens include severe acute respiratory syndrome coronavirus and the 2009 influenza A H1N1. Lessons learned about preventing transmission of methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant gram-negative pathogens in non-CF patient populations also can inform IP&C strategies for CF.
The recording and analysis of a burnt mound and adjacent palaeochannel deposits on the floodplain of the River Soar in Leicestershire revealed that the burnt mound was in use, possibly for a number of different purposes, at the transition from the Neolithic to the Bronze Age. An extensive radiocarbon dating programme indicated that the site was revisited. Human remains from the palaeochannel comprised the remains of three individuals, two of whom pre-dated the burnt mound by several centuries while the partial remains of a third, dating from the Late Bronze Age, provided evidence that this individual had met a violent death. These finds, along with animal bones dating to the Iron Age, and the remains of a bridge from the early medieval period, suggest that people were drawn to this location over a long period of time.
International criminal tribunals were created for prosecuting individuals responsible for the grossest violations of international humanitarian law embodied in the Universal Declaration of Human Rights, the International Covenant on Civil and Political Rights, the Hague Conventions, Geneva Conventions, the Genocide Convention, and the Convention against Torture and Cruel, Inhuman and Degrading Treatment and Punishment. This chapter examines the continued development of international tribunals from the Nuremberg and Tokyo Trials to Criminal Tribunal for the former Yugoslavia, Criminal Tribunal for Rwanda, and the hybrid courts including East Timor, Sierra Leone Special Court, and the Cambodian Extraordinary Chambers.
THE NUREMBERG TRIBUNAL
More than sixty million persons, primarily civilians, lost their lives during World War II. The German military was accused of the premeditated murder of civilian populations. After the war, leaders of the Allied nations – United States, France, Great Britain, and the USSR – drafted the Nuremberg Charter creating the International Military Tribunal for the “just and prompt trial and punishment of the major war criminals of the European Axis” powers (Ball, 1999). The Chief Prosecutor was Robert H. Jackson, Associate Justice of the United States Supreme Court. The trial was conducted in Nuremberg, Germany.
In 1815, the Treaty of Vienna, a multilateral treaty, banished Napoleon Bonaparte after his brutal invasion of Europe. This treaty was a sanction as well as a preventive measure against future aggression, and acted as precedent for the treatment of another sovereign, Wilhelm II of Hohenzollarne, the Kaiser of Germany (1859–1941), who was accused of committing horrific acts against civilians during World War I (Romano, Nollkaemper, & Kleffner, 2004). The Treaty of Versailles, signed in 1919, established a tribunal guided by international policy and international morality of that era to try Wilhelm II for crimes against the laws and customs of war. Kaiser Wilhelm argued that he was a victim of ex post facto or acts made criminal after the fact, and fled. The Netherlands, where he took refuge, refused to extradite Wilhelm (Jorgenson, 1999). Despite the failure to directly punish Kaiser Wilhelm, The Treaty of Versailles was evidence that under certain circumstances the world community would place limits on national sovereignty by international agreement or treaty.
The 1969 Vienna Convention defines a treaty as “an international agreement concluded between States in written form and governed by international law, whether embodied in a single instrument or in two or more related instruments and whatever its particular designation.” The 1986 Vienna Convention extends the definition of treaties to include international agreements involving international organizations as parties. Treaties are binding bilateral agreements, as between two States or multilateral agreements, as between several States. These agreements represent one area within the complex system of courts, agreements, customs, principles, and national laws that comprise international law.
“The new age proclaims itself to be fleet of foot, with wings on its soles; the dawn has put on seven-league boots - Long has lightning flashed on the horizon of poetry; the heavens have collected their stormy might into a powerful cloud; now the thunder has resounded mightily, now it has retreated and flashed only in the distance, now it has returned yet more fearsomely: but soon we shall speak not of a single storm, but the entire sky will break out into flame, and then all your petty lightning rods will avail no longer. Then the nineteenth century begins in earnest . . . Then there will be readers who can read.” Friedrich Schlegel, “On Incomprehensibility” / The readers of this volume will find Arthur O. Lovejoy's famous essay “On the Discrimination of Romanticisms” amply confirmed: Romanticism cannot be defined. To include an essay called “Romanticism and Enlightenment” seems to be an impossibility compounded. On any reasonably comprehensive view the eighteenth century was not dramatically more uniform than the early nineteenth. Indeed, in one crucial respect it was less so, for no fact so inescapably galvanized the Enlightenment mind as that of revolution did the mind of Romanticism. There are many versions of Enlightenment - aristocratic and bourgeois, rationalist and empiricist, modernist and classicist, mercantilist and laissez-faire, urban and pastoral, religious and secular. Properly speaking, this chapter should be entitled “Romanticisms and Enlightenments,” a multiplicity that leaves the student no hook except the little word “and” to hang a hat on.