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We evaluated the safety and feasibility of high-intensity interval training via a novel telemedicine ergometer (MedBIKE™) in children with Fontan physiology.
The MedBIKE™ is a custom telemedicine ergometer, incorporating a video game platform and live feed of patient video/audio, electrocardiography, pulse oximetry, and power output, for remote medical supervision and modulation of work. There were three study phases: (I) exercise workload comparison between the MedBIKE™ and a standard cardiopulmonary exercise ergometer in 10 healthy adults. (II) In-hospital safety, feasibility, and user experience (via questionnaire) assessment of a MedBIKE™ high-intensity interval training protocol in children with Fontan physiology. (III) Eight-week home-based high-intensity interval trial programme in two participants with Fontan physiology.
There was good agreement in oxygen consumption during graded exercise at matched work rates between the cardiopulmonary exercise ergometer and MedBIKE™ (1.1 ± 0.5 L/minute versus 1.1 ± 0.5 L/minute, p = 0.44). Ten youth with Fontan physiology (11.5 ± 1.8 years old) completed a MedBIKE™ high-intensity interval training session with no adverse events. The participants found the MedBIKE™ to be enjoyable and easy to navigate. In two participants, the 8-week home-based protocol was tolerated well with completion of 23/24 (96%) and 24/24 (100%) of sessions, respectively, and no adverse events across the 47 sessions in total.
The MedBIKE™ resulted in similar physiological responses as compared to a cardiopulmonary exercise test ergometer and the high-intensity interval training protocol was safe, feasible, and enjoyable in youth with Fontan physiology. A randomised-controlled trial of a home-based high-intensity interval training exercise intervention using the MedBIKE™ will next be undertaken.
Little is known about the determinants of community integration (i.e. recovery) for individuals with a history of homelessness, yet such information is essential to develop targeted interventions.
We recruited homeless Veterans with a history of psychotic disorders and evaluated four domains of correlates of community integration: perception, non-social cognition, social cognition, and motivation. Baseline assessments occurred after participants were engaged in supported housing services but before they received housing, and again after 12 months. Ninety-five homeless Veterans with a history of psychosis were assessed at baseline and 53 returned after 12 months. We examined both cross-sectional and longitudinal relationships with 12-month community integration.
The strongest longitudinal association was between a baseline motivational measure and social integration at 12 months. We also observed cross-sectional associations at baseline between motivational measures and community integration, including social, work, and independent living. Cross-lagged panel analyses did not suggest causal associations for the motivational measures. Correlations with perception and non-social cognition were weak. One social cognition measure showed a significant longitudinal correlation with independent living at 12 months that was significant for cross-lagged analysis, consistent with a causal relationship and potential treatment target.
The relatively selective associations for motivational measures differ from what is typically seen in psychosis, in which all domains are associated with community integration. These findings are presented along with a partner paper (Study 2) to compare findings from this study to an independent sample without a history of psychotic disorders to evaluate the consistency in findings regarding community integration across projects.
In an initial study (Study 1), we found that motivation predicted community integration (i.e. functional recovery) 12 months after receiving housing in formerly homeless Veterans with a psychotic disorder. The current study examined whether the same pattern would be found in a broader, more clinically diverse, homeless Veteran sample without psychosis.
We examined four categories of variables as potential predictors of community integration in non-psychotic Veterans: perception, non-social cognition, social cognition, and motivation at baseline (after participants were engaged in a permanent supported housing program but before receiving housing) and a 12-month follow-up. A total of 82 Veterans had a baseline assessment and 41 returned for testing after 12 months.
The strongest longitudinal association was between an interview-based measure of motivation (the motivation and pleasure subscale from the Clinical Assessment Interview for Negative Symptoms) at baseline and measures of social integration at 12 months. In addition, cross-lagged panel analyses were consistent with a causal influence of general psychiatric symptoms at baseline driving social integration at 12 months, and reduced expressiveness at baseline driving independent living at 12 months, but there were no significant causal associations with measures of motivation.
The findings from this study complement and reinforce those in Veterans with psychosis. Across these two studies, our findings suggest that motivational factors are associated at baseline and at 12 months and are particularly important for understanding and improving community integration in recently-housed Veterans across psychiatric diagnoses.
Emergency Medical Services (EMS) systems have developed protocols for prehospital activation of the cardiac catheterization laboratory for patients with suspected ST-elevation myocardial infarction (STEMI) to decrease first-medical-contact-to-balloon time (FMC2B). The rate of “false positive” prehospital activations is high. In order to decrease this rate and expedite care for patients with true STEMI, the American Heart Association (AHA; Dallas, Texas USA) developed the Mission Lifeline PreAct STEMI algorithm, which was implemented in Los Angeles County (LAC; California USA) in 2015. The hypothesis of this study was that implementation of the PreAct algorithm would increase the positive predictive value (PPV) of prehospital activation.
This is an observational pre-/post-study of the effect of the implementation of the PreAct algorithm for patients with suspected STEMI transported to one of five STEMI Receiving Centers (SRCs) within the LAC Regional System. The primary outcome was the PPV of cardiac catheterization laboratory activation for percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The secondary outcome was FMC2B.
A total of 1,877 patients were analyzed for the primary outcome in the pre-intervention period and 405 patients in the post-intervention period. There was an overall decrease in cardiac catheterization laboratory activations, from 67% in the pre-intervention period to 49% in the post-intervention period (95% CI for the difference, -14% to -22%). The overall rate of cardiac catheterization declined in post-intervention period as compared the pre-intervention period, from 34% to 30% (95% CI, for the difference -7.6% to 0.4%), but actually increased for subjects who had activation (48% versus 58%; 95% CI, 4.6%-15.0%). Implementation of the PreAct algorithm was associated with an increase in the PPV of activation for PCI or CABG from 37.9% to 48.6%. The overall odds ratio (OR) associated with the intervention was 1.4 (95% CI, 1.1-1.8). The effect of the intervention was to decrease variability between medical centers. There was no associated change in average FMC2B.
The implementation of the PreAct algorithm in the LAC EMS system was associated with an overall increase in the PPV of cardiac catheterization laboratory activation.
This book examines the ways the Syrian conflict has served as the genesis of new rules of customary international law. Though it has only been nine years since the conflict began, Syria has already brought about profound changes to international law.
To set the stage for the chapters that follow, this chapter traces the historic roots of the strife in Syria as well as the major events during the conflict from 2011 to 2019. It also describes the major actors within and outside of Syria that have played a significant role in the fray. Finally, it discusses the sources of international law applicable to the Syrian conflict.
Since 2011, Syria has been engulfed in a protracted civil war that began as part of the wave of Arab Spring protests against Middle East tyrants. The Syrian conflict has seen the rise and fall of the ISIS terrorist organization, the largest refugee migration since World War II, and the repeated use of chemical weapons against a civilian population. The situation is complicated by the fact that Russia, Syria’s long-time ally, has repeatedly used its veto in the UN Security Council to prevent the Council from taking actions related to the crisis. With all that, Syria has become a dynamic laboratory for the rapid creation of new international law.
As the Syrian civil war presses on, the need for accountability for atrocities committed by Syrian officials, rebel commanders, and terrorist leaders grows. As documented by the UN Human Rights Council’s Independent and International Commission of Inquiry, the atrocities in Syria are among the worst in history. They include mass executions, widespread rapes, systematic torture, intentionally targeting hospitals, and repeated use of chemical weapons against civilians. The vast majority of international crimes have been committed in a methodical fashion by the Syrian government, encouraged by the long-standing culture of impunity. These crimes require prosecution to bring justice for the victims, deter vigilantism, and prevent recurrence.
In 2014, a militant group calling itself the Islamic State (ISIS) rapidly took over more than 30 percent of the territory of Syria and Iraq. In the process, it captured billions of dollars (US) worth of oil fields and refineries, bank assets and antiquities, tanks, and armaments, and became one of the greatest threats to peace and security in the Middle East. In an effort to “degrade and defeat” ISIS, the United States, assisted by a handful of other Western and Arab countries, launched thousands of bombing sorties and cruise missile attacks against ISIS targets in Iraq and Syria since August 2014. While the Iraqi government had consented to foreign military action against ISIS within Iraq, the Syrian government did not. Rather, Syria protested that the air strikes in Syrian territory were an unjustifiable violation of international law.
As the above chapters have described, the UN High Commissioner for Refugees has recognized the Syrian refugee crisis as the world’s single largest refugee crisis since World War II. This chapter will analyze how the international community has attempted to deal with more than six million Syrians who have sought refuge around the globe while still protecting against the infiltration of terrorists. The global approach to the Syrian migration crisis, described in this chapter, includes novel legislation, executive and judicial actions, as well as new policy approaches related to the rights of Syrian refugees. This chapter will also examine how the Syrian refugee crisis affected the negotiation of the Global Compact on Refugees and the Global Compact on Safe, Orderly and Regular Migration, which were adopted in 2018. Finally, this chapter will assess whether the Syrian migration crisis has contributed to the development of new Grotian moments.
Historically, crystallization of new rules of customary international law was viewed as a protracted process that took decades, if not centuries, to complete. But, sometimes, during periods of sweeping geopolitical change, customary international law can ripen quite rapidly. Often those periods correspond with major wars. Named in honor of Hugo Grotius, whose masterpiece De Jure Belli ac Pacis helped usher in the modern system of international law at the end of the Eighty Years’ War, “Grotian moments” are transformative developments that generate the unique conditions for accelerated formation of customary international law. Has this book proved that the Syrian conflict was a Grotian moment? And, if so, what will the legacy of Syria be?
This chapter examines whether the allied air strikes against Syria on April 14, 2018 may have crystalized an emerging customary norm of humanitarian intervention, thereby representing a historic development in international law.
Carbapenem-resistant Enterobacterales (CRE) are common causes of healthcare-associated infections and are often multidrug resistant with limited therapeutic options. Additionally, CRE can spread within and between healthcare facilities, amplifying potential harms.
To better understand the burden, risk factors, and source of acquisition of carbapenemase genes in clinical Escherichia coli and Klebsiella spp isolates from patients in Washington to guide prevention efforts.
Multicenter prospective surveillance study.
Escherichia coli and Klebsiella spp isolates meeting the Washington state CRE surveillance case definition were solicited from clinical laboratories and tested at Washington Public Health Laboratories using polymerase chain reaction (PCR) for the 5 most common carbapenemase genes: blaKPC, blaNDM, blaIMP, blaVIM, and blaOXA-48. Case patients positive by PCR were investigated by the public health department.
From October 2012 through December 2017, 363 carbapenem-resistant E. coli and Klebsiella spp isolates were tested. Overall, 45 of 115 carbapenem-resistant K. pneumoniae (39%), 1 of 8 K. oxytoca (12.5%), and 28 of 239 carbapenem-resistant E. coli (11.7%) were carbapenemase positive. Of 74 carbapenemase-positive isolates, blaKPC was most common (47%), followed by blaNDM (30%), blaOXA-48 (22%), and blaIMP (1%). Although all cases had healthcare exposure, blaKPC acquisition was associated with US health care, whereas non-blaKPC acquisition was associated with international health care or travel.
We report that blaKPC, the most prevalent carbapenemase in the United States, accounts for nearly half of carbapenemase cases in Washington state and that most KPC-cases are likely acquired through in-state health care.