To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Paediatric pulmonary hypertension has been described as a secondary complication of multiple diseases and their treatment. Limited information exists about the relationship between pulmonary hypertension and cancer in children. A review of charts was performed in all patients treated for cancer and developed pulmonary hypertension. A total of four patients developed pulmonary hypertension during treatment of cancer. All patients had solid tumors, had echocardiographic evidence of elevated right ventricular pressures, and required intensive care stays. Treatment courses included inhaled and oral pulmonary vasodilators along with systemic steroids. Each had normalisation of echocardiograms and resolution of pulmonary symptoms. Prompt diagnosis of pulmonary hypertension and treatment with pulmonary vasodilators and steroids are considered important measures followed by chemotherapy and radiation regimens.
Congenital complete tracheal rings are usually associated with pulmonary slings. We report a rare association of congenital complete tracheal rings with hypoplastic left heart variant. A term infant with diagnosis of a mildly hypoplastic mitral valve, unicuspid aortic valve, and moderately hypoplastic aortic arch with severe coarctation underwent a hybrid procedure initially. Upon failing extubation attempts, complete tracheal rings were seen on direct laryngoscopy. The combination of the lesions resulted in a poor outcome. In patients with failure of extubation post-cardiac surgery, a diagnosis of complete tracheal rings should be included in the differential and a direct laryngoscopy should be considered.
This paper presents an overview of the importance of oral health in complex emergencies. It highlights the importance of maintaining general and oral health in the acute, intermediate and long-term phases of such events which are increasing in frequency. The importance of oral health as an early warning sign for systemic disease and deprivation is also explored along with the crucial role of oral health in maintaining quality of life through adequate nutrition and speech. The overview of oral health in these situations identifies the need for training dental personnel as members of rehabilitation teams that set out to manage these disasters. They can quickly help in improving quality of life for victims by extracting carious and painful teeth as necessary, and also form part of an oral health education program for aid agencies. They can also be the first to identify systemic diseases like HIV and may also play a role in identifying victims of abuse, as non-accidental injuries can frequently present in the oro-facial region. The oral health overview concludes by describing the contents of innovative oral health packs that are tailored to prevention of dental diseases and that can be readily incorporated as part of food packs distributed by aid agencies. (Disaster Med Public Health Prepardness. 2018;12:772-777)
Parents may experience anxiety and stress when their children undergo cardiac catheterisation. The goal of this study was to assess the level of anxiety in parents of children undergoing cardiac catheterisation and to identify factors that were associated with level of anxiety.
This was a cross-sectional survey of parents of children who underwent cardiac catheterisation. Anxiety levels were measured using a validated self-report questionnaire – State-Trait Anxiety Inventory, which generates state anxiety scores on the current state of anxiety and trait anxiety scores on the stable aspects of anxiety proneness. One sample t-test was used to compare the data with normative data. Multiple linear regression was used to assess the factors associated with the state score.
A total of 113 parents completed the survey. The mean age of parents was 34.0±7.7 years and the mean age of children undergoing catheterisation was 6.7±5.7 years. Compared with normative data, mean state score was significantly higher in our cohort (p<0.05) despite no difference in the trait score. Final multivariate model showed that the state score was significantly associated with child age group (<1 year [coefficient β 7.2] and 10–18 years [6.3], compared to 1 to <10 years of age [reference]) and history of previous catheterisation (−5.2) (p<0.05).
Concurrent state anxiety level was high among parents of children undergoing cardiac catheterisation, whereas trait anxiety level was not. Higher anxiety was experienced by parents of infants and adolescents without a history of previous catheterisation.
To evaluate the success rate of dry and wet temporalis fascia grafts in type I underlay tympanoplasty.
A prospective, randomised study was conducted. One hundred adult patients (males and females) with chronic suppurative otitis media (mucosal type) were divided into 2 groups of 50 each: one group underwent dry graft tympanoplasty and the other underwent wet graft tympanoplasty. Fibroblast count was calculated in dry and wet grafts.
The dry graft and wet graft groups had overall surgical success rates of 82 and 90 per cent, respectively; this finding was not statistically significant. A statistically significant high fibroblast count was observed in wet grafts, but it did not correlate with surgical success.
A dry or wet temporalis fascia graft does not influence the outcome of tympanoplasty type I.
Introduction: ED patient comorbidity is difficult to ascertain for research. Traditional surrogates such as triage acuity, admission rate, and age have been used to approximate patient complexity. Differences between EDs for the management of similar conditions are nevertheless difficult to reconcile. The Charlson Comorbidity Index (CCI) contains 19 categories and is a validated predictor of the ten-year mortality for a patient who may have a range of comorbid conditions. CCI is based on the International Classification of Diseases (ICD) diagnosis codes found in administrative data such as the Discharge Abstract Database (DAD). The DAD collects this, and other inpatient information, for all Canadian hospitals. We sought to develop a linkage between the regional ED database and the regional inpatient DAD in order to derive a CCI score for each ED patient as a surrogate of comorbidity. Methods: We used regional data from Vancouver Coastal Health (VCH) over a 2.5 year period from April 2013 - September 2015. An algorithm was created to identify CCI conditions in the regional DAD. Whenever a patient visited the ED a query was made to the DAD going back for 5 years to acquire CCI relevant diagnoses and enter these diagnoses as well as the CCI weighting into the ED database. Patient DAD records from VCH were utilized no matter in which ED a patient presented. No information from admissions outside the region was available. Results: There were 931,596 regional ED visits made by 446,579 unique patients in a total of 11 EDs (6 urban and 5 rural). In total there were 127,233 patients with a CCI score (13.7% of total visits). The average CCI was 0.40 (SD 1.31) with a range of 0.12 at the urban urgent care centre to 0.52 at the urban tertiary care centre. More isolated rural EDs tended to have higher percentages of patients with CCI scores than community urban EDs. Higher acuity, age, and ambulance arrival, ED death, all correlated to higher CCI scores. The most common CCI conditions were “diabetes with complications” (10/11 EDs) and was present in 35,816 (3.8%) visits and “cancer” (10/11 EDs) present in 34,624 (3.7%) ahead of COPD (26,451 visits) and CHF (25,233 visits). Conclusion: Use of the CCI is a novel way to passively capture patient comorbidities without reliance on a data entry technician. Limitations include the inability to link to hospitalization data outside a specific health region.
Individual-level measures of acculturation (e.g. age of immigration) have a complex relationship with psychiatric disorders. Fine-grained analyses that tap various acculturation dimensions and population subgroups are needed to generate hypotheses regarding the mechanisms of action for the association between acculturation and mental health.
Study participants were US Latinos (N = 6359) from Wave 2 of the 2004–2005 National Epidemiologic Survey of Alcohol and Related Conditions (N = 34 653). We used linear χ2 tests and logistic regression models to analyze the association between five acculturation dimensions and presence of 12-month DSM-IV mood/anxiety disorders across Latino subgroups (Mexican, Puerto Rican, Cuban, ‘Other Latinos’).
Acculturation dimensions associated linearly with past-year presence of mood/anxiety disorders among Mexicans were: (1) younger age of immigration (linear χ21 = 11.04, p < 0.001), (2) longer time in the United States (linear χ21 = 10.52, p < 0.01), (3) greater English-language orientation (linear χ21 = 14.57, p < 0.001), (4) lower Latino composition of social network (linear χ21 = 15.03, p < 0.001), and (5) lower Latino ethnic identification (linear χ21 = 7.29, p < 0.01). However, the associations were less consistent among Cubans and Other Latinos, and no associations with acculturation were found among Puerto Ricans.
The relationship between different acculturation dimensions and 12-month mood/anxiety disorder varies across ethnic subgroups characterized by cultural and historical differences. The association between acculturation measures and disorder may depend on the extent to which they index protective or pathogenic adaptation pathways (e.g. loss of family support) across population subgroups preceding and/or following immigration. Future research should incorporate direct measures of maladaptive pathways and their relationship to various acculturation dimensions.
The effect of Hybrid stage 1 palliation for hypoplastic left heart syndrome on right ventricular function is unknown. We sought to compare right ventricular function in normal neonates and those with hypoplastic left heart syndrome before Hybrid palliation and to assess the effect of Hybrid palliation on right ventricular function, using the right ventricular myocardial performance index and the ratio of systolic and diastolic durations.
We carried out a retrospective review of echocardiographic data on 23 infants with hypoplastic left heart syndrome who underwent Hybrid palliation and 35 normal controls. Data were acquired before Hybrid and after Hybrid palliation – post 1, 0–4 days; post 2, 1 week; post 3, 2–3 weeks; post 4, 1–1.5 months following Hybrid palliation.
Myocardial performance index and ratio of systolic and diastolic durations were higher in the pre-Hybrid hypoplastic left heart syndrome group (n=23) – 0.47±0.16 versus 0.25±0.07, p<0.001; 1.59±0.44 versus 1.09±0.14, p<0.0001 – compared with controls (n=35). There was no significant change in the myocardial performance index at any of the post-Hybrid time points. Ratio of systolic and diastolic durations increased significantly 2 weeks after Hybrid – post 3: 2.08±0.62 and post 4: 2.21±0.45 versus pre: 1.59±0.44, p=0.043 and 0.003. There were no significant differences in parameters between sub-groups of infants who died (n=10) and survivors (n=13).
Right ventricular myocardial performance index and ratio of systolic and diastolic durations were significantly higher in infants with hypoplastic left heart syndrome before intervention compared with controls. The ratio of systolic and diastolic durations increased significantly 2 weeks after Hybrid palliation. Our data suggest that infants with hypoplastic left heart syndrome have right ventricular dysfunction before intervention, which worsens over 2 weeks after Hybrid palliation.
Since their introduction in 1977, the technology and surgical techniques surrounding the use and application of bone-anchored hearing devices have developed considerably.
This article reviews current developments in the use of bone-anchored hearing devices, looking at the possible options for patients, complications encountered and future possibilities.
Advances in surgical technique are described, with the move towards the use of linear incisions and no soft tissue reduction. Methods for preventing complications are analysed, with review of different abutments and the introduction of the active bone conduction implant.
Debilitating patient-related non-cardiac co-morbidity cumulatively increases risk for congenital heart surgery. At our emerging programme, flexible surgical strategies were used in high-risk neonates and infants generally considered in-operable, in an attempt to make them surgical candidates and achieve excellent outcomes.
Materials and methods
Between April, 2010 and November, 2013, all referred neonates (142) and infants (300) (average scores: RACHS 2.8 and STAT 3.0) underwent 442 primary cardiac operations: patients with bi-ventricular lesions underwent standard (n=294) or alternative (n=19) repair/staging strategies, such as pulmonary artery banding(s), ductal stenting, right outflow patching, etc. Patients with uni-ventricular hearts followed standard (n=96) or alternative hybrid (n=34) staging. The impact of major pre-operative risk factors (37%), standard or alternative surgical strategy, prematurity (50%), gestational age, low birth weight, genetic syndromes (23%), and major non-cardiac co-morbidity requiring same admission surgery (27%) was analysed on the need for extracorporeal membrane oxygenation, mortality, length of intubation, as well as ICU and hospital length of stays.
The need for extracorporeal membrane oxygenation (8%) and hospital survival (94%) varied significantly between surgical strategy groups (p=0.0083 and 0.028, respectively). In high-risk patients, alternative bi- and uni-ventricular strategies minimised mortality, but were associated with prolonged intubation and ICU stay. Major pre-operative risk factors and lower weight at surgery significantly correlated with prolonged intubation, hospital length of stay, and mortality.
In our emerging programme, flexible surgical strategies were offered to 53/442 high-risk neonates and infants with complex CHDs and significant non-cardiac co-morbidity, in order to buffer risk and achieve patient survival, although at the cost of increased resource utilisation.
The emergence of invasive fungal wound infections (IFIs) in combat casualties led to development of a combat trauma-specific IFI case definition and classification. Prospective data were collected from 1133 US military personnel injured in Afghanistan (June 2009–August 2011). The IFI rates ranged from 0·2% to 11·7% among ward and intensive care unit admissions, respectively (6·8% overall). Seventy-seven IFI cases were classified as proven/probable (n = 54) and possible/unclassifiable (n = 23) and compared in a case-case analysis. There was no difference in clinical characteristics between the proven/probable and possible/unclassifiable cases. Possible IFI cases had shorter time to diagnosis (P = 0·02) and initiation of antifungal therapy (P = 0·05) and fewer operative visits (P = 0·002) compared to proven/probable cases, but clinical outcomes were similar between the groups. Although the trauma-related IFI classification scheme did not provide prognostic information, it is an effective tool for clinical and epidemiological surveillance and research.
This paper reports on two rare cases of neonatal airway lesions with differing aetiology that were successfully managed by surgery, and provides a review of the literature on neonatal stridor and airway lesions.
In the first case report, a newborn presented with a nasopharyngeal teratoma. In the second case report, a newborn presented with a congenital laryngeal saccular cyst. Difficulties in the diagnosis of these lesions, and surgical and anaesthetic challenges in their management are discussed.
Every case of neonatal airway distress must be evaluated and the cause of stridor needs to be established. It is important that rare lesions such as teratomas and laryngeal cysts are not overlooked; a high index of suspicion for these congenital anomalies is necessary. These airway lesions should be managed in an institutional setting by a multidisciplinary team.
This review aimed to summarise present knowledge surrounding cochlear implants and neuroplasticity using positron emission tomography.
Cochlear implants are an established device for severe sensorineural hearing loss. However, the outcomes following a cochlear implant are variable and unpredictable. Furthermore, despite increasing numbers of implantations taking place, there are still uncertainties regarding how individuals learn to process speech using an implant. Functional neuroimaging studies using techniques such as positron emission tomography provide an insight into the cortical changes that take place in patients with cochlear implants.
Only when the underlying mechanisms responsible for speech processing in implantees are understood can appropriate rehabilitation for those with poor speech perception be provided and outcomes improved.
The present investigation was carried out to evaluate the hepatoprotective effect of probiotic fermented milk (FM) containing Lactobacillus rhamnosus GG and Lactobacillus casei strain Shirota, alone as well as in combination with chlorophyllin (CHL) as an antioxidant agent in male Wistar rats administered aflatoxin-B1 (AFB1). AFB1 was injected intraperitoneally at the rate of 450 μg/kg body weight per animal twice a week for 6 weeks, maintaining an equal time interval between the two consecutive AFB1 administrations. A total of 125 male Wistar rats were randomly allocated to five groups, each group having twenty-five animals. Group I was offered FM containing L. rhamnosus GG and L. casei strain Shirota. Group II was administered AFB1 and served as the control group; group III was administered FM-AFB1, in which besides administering AFB1, FM was also offered. Group IV was offered CHL and AFB1, and group V was offered both FM and CHL along with AFB1. The rats were euthanised at the 15th and 25th week of the experiment and examined for the biochemical and hepatopathological profile. A significant reduction in thiobarbituric acid-reactive substances (TBARS) was observed in the FM–CHL–AFB1 group compared with the AFB1 control group. FM alone or in combination with CHL was found to show a significant (P < 0·05) hepatoprotective effect by lowering the levels of TBARS and by enhancing the activities of antioxidant enzymes such as glutathione peroxidase, superoxide dismutase, catalase and glutathione-S-transferase, indicating that probiotic FM alone or in combination with CHL possesses a potent protective effect against AFB1-induced hepatic damage.
Basic emergency care at primary, secondary and tertiary health care level in India is in its infancy. Lack of training in emergency care is an important factor. We designed AIIMS basic emergency care course (AIIMS BECC) to address the issue.
To improve the knowledge, skill and attitude of healthcare workers and laypersons in basic emergency care and to identify and train instructors.
Prospective study conducted over a period of one and half years. The target groups were medical, police, fire fighter, paramilitary forces, teachers, school children of India. Provider AIIMS BECC is of one day duration. The contents of the course are cardio-pulmonary resuscitation, chocking and special scenarios like trauma, electrocution, drowning, hypothermia, pregnancy, etc. Course was disseminated via lectures, audio-visual and hands on training. The participants were evaluated by pre and post test questions. Subjects had to score 80% to be successful and those who scored more than 90% were eligible for instructor course. The confidence levels at baseline and at the end of the course were evaluated in policecourses were evaluated on course clarity, course delivery and trainers quality on a likert scale (1 = worst, 5 = excellent).
1614 subjects were trained. 99.81% became providers and 2.6% were trained as instructors. 83.1% were non-medical and16.9% were medical personals. 76.14% were police, paramilitary 0.8%, teachers 1.6%, students 2.1% and mixed groups were 2.6%. The average and modal increase in confidence level among police were 66.14% and 62.49%. Likert scale of ≥ 4 was observed in 90.7% in course clarity, 91.28% in course delivery and 95.26% in trainer quality.
Knowledge, skill and attitude of healthcare care and laypersons in providing basic emergency care improved by community emergency care initiative. Instructors were identified for further dissemination of the course. The confidence levels increased among police.
Isotope hydrology investigations were carried out with the aim to study isotope variability in mineral and thermal waters (MTW) of Slovakia. The aquifers of MTW were formed by Triassic limestones and dolomites, which are found in the mountains as well as in the pre-Tertiary substratum of depressions and lowlands. The MTW were of artesian and/or open structures. At present, there are only boreholes available, as natural outflows have already been captured by them. Large spatial isotope variability (14C between 2 and 33.6 pMC, δ18O between −11.8‰ and −9.8‰, and δ13C between −12.7‰ and +3.4‰ for bicarbonates and −21‰ and –4.9‰ for free CO2) and heterogeneity of MTW was observed, indicating different origins of MTW. Corrected radiocarbon apparent ages of MTW indicate that they mostly infiltrated during the Würm and Holocene periods.
To assess the outcome of conservative management of vestibular schwannoma.
Tertiary referral centre.
Four hundred and thirty-six patients with vestibular schwannoma (490 tumours), including 327 sporadic tumours and 163 tumours in 109 patients with neurofibromatosis type two.
Main outcome measures:
The relationship of tumour growth to tumour size at presentation, and to certain demographic features.
The initial tumour size was significantly larger in the neurofibromatosis type two group (11 mm) than in the sporadic vestibular schwannoma group (5.1 mm). In both groups, 68 per cent of tumours did not grow during follow up (mean 3.6 years; range one to 14 years). The mean growth rate was 1.1 mm/year (range 0–15 mm/year) for sporadic tumours and 1.7 mm/year (range 0–18 mm/year) for neurofibromatosis type two tumours. The tumour growth rate correlated positively with tumour size in the sporadic tumour group, and correlated negatively with age in the neurofibromatosis type two group.
Two-thirds of vestibular schwannomas did not grow. Radiological surveillance is an acceptable approach in carefully selected patients. Once a sporadic vestibular schwannoma reaches 2 cm in intracranial diameter, it is likely to continue growing. We do not recommend conservative management for sporadic tumours with an intracranial diameter of 1.5 cm or more. Vestibular schwannoma management is more complex in patients with neurofibromatosis type two.
Oral submucous fibrosis is a chronic disease characterised by progressive inability to open the mouth. Various treatment modalities are available for its management, but these have largely been ineffective.
Materials and methods:
Nine cases of oral submucous fibrosis underwent a release procedure using a KTP-532 laser, from March 2005 to January 2006, within the ENT – head and neck surgery department of a tertiary centre.
Pre- and post-operative mouth-opening was compared using the Wilcoxon signed rank test, and a significant difference observed (Z = −2.690, p = 0.007). Follow up over an average period of 12 months showed encouraging results.
This preliminary study indicated that adequate release of oral submucous fibrosis can be achieved by using a KTP-532 laser release procedure, with minimal morbidity and satisfactory results. These promising results should encourage more widespread use of this technique in the management of this condition.
The first of several cases of meningococcal meningitis was reported in April 2005, in New Delhi, India. Subsequent to this the Government declared an outbreak, which persisted for two periods, from April–July 2005 and January–March 2006. The National Institute of Communicable Diseases (NICD) recommended using WHO criteria for diagnosis of disease. During the outbreak 380 clinically suspected cases were investigated. Of 55 cases diagnosed as confirmed/probable the mortality rate was 14·6%. Meningitis was reported in 60% of cases and meningococcaemia in 40%. Microscopy of petechial rash was positive in 87·5%, CSF Gram stain positive in 68·3%, and latex agglutination test of CSF positive in 64·9% of samples. Neisseria meningitidis (serogroup A) was isolated from 37·7% of cases, 57·7% from CSF. Blood culture was positive in 10·4% of cases. CrgA polymerase chain reaction for N. meningitidis confirmed the isolates. All isolates were susceptible to third-generation cephalosporins, azithromycin and rifampicin, with increasing resistance to ceftriaxone. Penicillin resistance was encountered in 15·4% of strains. Resistance to quinolones was very high at 100% for levofloxacin, 84·6% for ofloxacin and 65·4% for ciprofloxacin. All patients with penicillin-resistant organisms (4) or intermediate sensitivity (4) succumbed to the disease. These patients also had a higher minimum inhibitory concentration to ceftriaxone.
Fourteen strains of S. Typhi (n=13) and S. Paratyphi A (n=1) resistant to ciprofloxacin were compared with 30 ciprofloxacin decreased-susceptibility strains on the basis of qnr plasmid analysis, and nucleotide substitutions at gyrA, gyrB, parC and parE. In ciprofloxacin-resistant strains, five S. Typhi and a single S. Paratyphi A showed triple mutations in gyrA (Ser83→Phe, Asp87→Asn, Glu133→Gly) and a novel mutation outside the quinolone resistance determining region (QRDR) (Met52→Leu). Novel mutations were also discovered in an isolate (minimum inhibitory concentration 8 μg/ml) in gyrA gene Asp76→Asn and outside the QRDR Leu44→Ile. Out of 30 isolates with reduced susceptibility, single mutation was found in 12 strains only. Genes encoding qnr plasmid (qnr A, qnr B, AAC1-F) were not detected in ciprofloxacin-resistant or decreased-susceptibility strains. Antimicrobial surveillance coupled with molecular analysis of fluoroquinolone resistance is warranted for reconfirming novel and established molecular patterns of resistance, which is quintessential for reappraisal of enteric fever therapeutics.