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Despite enormous strides in our field with respect to patient care, there has been surprisingly limited dialogue on how to train and educate the next generation of congenital cardiologists. This paper reviews the current status of training and evolving developments in medical education pertinent to congenital cardiology. The adoption of competency-based medical education has been lauded as a robust framework for contemporary medical education over the last two decades. However, inconsistencies in frameworks across different jurisdictions remain, and bridging gaps between competency frameworks and clinical practice has proved challenging. Entrustable professional activities have been proposed as a solution but integration of such activities into busy clinical cardiology practices will present its own challenges. Consequently, this pivot toward a more structured approach to medical education necessitates the widespread availability of appropriately trained medical educationalists; a development that will better inform curriculum development, instructional design, and assessment. Differentiation between superficial and deep learning, the vital role of rich formative feedback and coaching, should guide our trainees to become self-regulated learners, capable of critical reasoning yet retaining an awareness of uncertainty and ambiguity. Furthermore, disruptive innovations such as ‘technology enhanced learning’ may be leveraged to improve education, especially for trainees from low- and middle-income countries. Each of these initiatives will require resources, widespread advocacy and raised awareness, and publication of supporting data, and so it is especially gratifying that Cardiology in The Young has fostered a progressive approach, agreeing to publish one or two articles in each journal issue in this domain.
This paper describes a computational investigation of multimode instability growth and multimaterial mixing induced by multiple shock waves in a high-energy-density (HED) environment, where pressures exceed 1 Mbar. The simulations are based on a series of experiments performed at the National Ignition Facility (NIF) and designed as an HED analogue of non-HED shock-tube studies of the Richtmyer–Meshkov instability and turbulent mixing. A three-dimensional computational modelling framework is presented. It treats many complications absent from canonical non-HED shock-tube flows, including distinct ion and free-electron internal energies, non-ideal equations of state, radiation transport and plasma-state mass diffusivities, viscosities and thermal conductivities. The simulations are tuned to the available NIF data, and traditional statistical quantities of turbulence are analysed. Integrated measures of turbulent kinetic energy and enstrophy both increase by over an order of magnitude due to reshock. Large contributions to enstrophy production during reshock are seen from both the baroclinic source and enstrophy–dilatation terms, highlighting the significance of fluid compressibility in the HED regime. Dimensional analysis reveals that Reynolds numbers and diffusive Péclet numbers in the HED flow are similar to those in a canonical non-HED analogue, but conductive Péclet numbers are much smaller in the HED flow due to efficient thermal conduction by free electrons. It is shown that the mechanism of electron thermal conduction significantly softens local spanwise gradients of both temperature and density, which causes a minor but non-negligible decrease in enstrophy production and small-scale mixing relative to a flow without this mechanism.
This study investigated the impact of the Webinar on deep human learning of CHD.
Materials and methods:
This cross-sectional survey design study used an open and closed-ended questionnaire to assess the impact of the Webinar on deep learning of topical areas within the management of the post-operative tetralogy of Fallot patients. This was a quantitative research methodology using descriptive statistical analyses with a sequential explanatory design.
One thousand-three-hundred and seventy-four participants from 100 countries on 6 continents joined the Webinar, 557 (40%) of whom completed the questionnaire. Over 70% of participants reported that they “agreed” or “strongly agreed” that the Webinar format promoted deep learning for each of the topics compared to other standard learning methods (textbook and journal learning). Two-thirds expressed a preference for attending a Webinar rather than an international conference. Over 80% of participants highlighted significant barriers to attending conferences including cost (79%), distance to travel (49%), time commitment (51%), and family commitments (35%). Strengths of the Webinar included expertise, concise high-quality presentations often discussing contentious issues, and the platform quality. The main weakness was a limited time for questions. Just over 53% expressed a concern for the carbon footprint involved in attending conferences and preferred to attend a Webinar.
E-learning Webinars represent a disruptive innovation, which promotes deep learning, greater multidisciplinary participation, and greater attendee satisfaction with fewer barriers to participation. Although Webinars will never fully replace conferences, a hybrid approach may reduce the need for conferencing, reduce carbon footprint. and promote a “sustainable academia”.
Gravitational waves from coalescing neutron stars encode information about nuclear matter at extreme densities, inaccessible by laboratory experiments. The late inspiral is influenced by the presence of tides, which depend on the neutron star equation of state. Neutron star mergers are expected to often produce rapidly rotating remnant neutron stars that emit gravitational waves. These will provide clues to the extremely hot post-merger environment. This signature of nuclear matter in gravitational waves contains most information in the 2–4 kHz frequency band, which is outside of the most sensitive band of current detectors. We present the design concept and science case for a Neutron Star Extreme Matter Observatory (NEMO): a gravitational-wave interferometer optimised to study nuclear physics with merging neutron stars. The concept uses high-circulating laser power, quantum squeezing, and a detector topology specifically designed to achieve the high-frequency sensitivity necessary to probe nuclear matter using gravitational waves. Above 1 kHz, the proposed strain sensitivity is comparable to full third-generation detectors at a fraction of the cost. Such sensitivity changes expected event rates for detection of post-merger remnants from approximately one per few decades with two A+ detectors to a few per year and potentially allow for the first gravitational-wave observations of supernovae, isolated neutron stars, and other exotica.
To determine the radiological prevalence of frontal cells according to the International Frontal Sinus Anatomy Classification in patients undergoing computed tomography of the paranasal sinuses for clinical symptoms of chronic rhinosinusitis, and to examine the association between cell classification and frontal sinusitis development.
A total of 180 (left and right) sides of 90 patients were analysed. The prevalence of each International Frontal Sinus Anatomy Classification cell was assessed. Logistic regression analysis was used to compare the distribution of various cells in patients with and without frontal sinusitis.
The agger nasi cell was the most commonly occurring cell, seen in 95.5 per cent of patients. The prevalence rates for supra agger cells, supra agger frontal cells, supra bullar frontal cells, supra bullar cells, supra-orbital ethmoid cells and frontal septal cells were 33.3 per cent, 22.2 per cent, 21.1 per cent, 36.1 per cent, 39.4 per cent and 21.1 per cent, respectively. There was no significant difference in the occurrence of any of the cell types in patients with frontal sinusitis compared to those without (p > 0.05).
The presence of any of the International Frontal Sinus Anatomy Classification cells was not significantly associated with frontal sinusitis.
The catastrophic declines of three species of ‘Critically Endangered’ Gyps vultures in South Asia were caused by unintentional poisoning by the non-steroidal anti-inflammatory drug (NSAID) diclofenac. Despite a ban on its veterinary use in 2006 (India, Nepal, Pakistan) and 2010 (Bangladesh), residues of diclofenac have continued to be found in cattle carcasses and in dead wild vultures. Another NSAID, meloxicam, has been shown to be safe to vultures. From 2012 to 2018, we undertook covert surveys of pharmacies in India, Nepal and Bangladesh to investigate the availability and prevalence of NSAIDs for the treatment of livestock. The purpose of the study was to establish whether diclofenac continued to be sold for veterinary use, whether the availability of meloxicam had increased and to determine which other veterinary NSAIDs were available. The availability of diclofenac declined in all three countries, virtually disappearing from pharmacies in Nepal and Bangladesh, highlighting the advances made in these two countries to reduce this threat to vultures. In India, diclofenac still accounted for 10–46% of all NSAIDs offered for sale for livestock treatment in 2017, suggesting weak enforcement of existing regulations and a continued high risk to vultures. Availability of meloxicam increased in all countries and was the most common veterinary NSAID in Nepal (89.9% in 2017). Although the most widely available NSAID in India in 2017, meloxicam accounted for only 32% of products offered for sale. In Bangladesh, meloxicam was less commonly available than the vulture-toxic NSAID ketoprofen (28% and 66%, respectively, in 2018), despite the partial government ban on ketoprofen in 2016. Eleven different NSAIDs were recorded, several of which are known or suspected to be toxic to vultures. Conservation priorities should include awareness raising, stricter implementation of current bans, bans on other vulture-toxic veterinary NSAIDs, especially aceclofenac and nimesulide, and safety-testing of other NSAIDs on Gyps vultures to identify safe and toxic drugs.
To depict various temporal bone abnormalities on high-resolution computed tomography in congenital aural atresia patients, and correlate these findings with auditory function test results and microtia subgroup.
Forty patients (56 ears) with congenital malformation of the auricle and/or external auditory canal were evaluated. Auricles were graded according to Marx's classification, divided into subgroups of minor (grades I and II) and major (III and IV) microtia. Other associated anomalies of the external auditory canal, tympanic cavity, ossicular status, oval and round windows, facial nerve, and inner ear were evaluated.
Minor and major microtia were observed in 53.6 and 46.4 per cent of ears respectively. Mean hearing levels were 62.47 and 62.37 dB respectively (p = 0.98). The malleus was the most commonly dysplastic ossicle (73.3 vs 80.8 per cent of ears respectively, p = 0.53). Facial nerve (mastoid segment) abnormalities were associated (p = 0.04) with microtia subgroup (80 vs 100 per cent in minor vs major subgroups).
Microtia grade was not significantly associated with mean hearing levels or other ear malformations, except for external auditory canal and facial nerve (mastoid segment) anomalies. High-resolution computed tomography is essential in congenital aural atresia, before management strategy is decided.
To assess the coverage of the adolescent weekly iron and folic acid supplementation (WIFS) programme in rural West Bengal, India.
We conducted a population-based cross-sectional survey of intended WIFS programme beneficiaries (in-school adolescent girls and boys and out-of-school adolescent girls).
Birbhum Health and Demographic Surveillance System.
A total of 4448 adolescents 10–19 years of age participated in the study.
The percentage of adolescents who reported taking four WIFS tablets during the last month as intended by the national programme was 9·4 % among in-school girls, 7·1 % for in-school boys and 2·3 % for out-of-school girls. The low effective coverage was due to the combination of large deficits in WIFS provision and poor adherence. A large proportion of adolescents reported they were not provided any WIFS tablets in the last month: 61·7 % of in-school girls, 73·3 % of in-school boys and 97·1 % of out-of-school girls. In terms of adherence, only 41·6 % of in-school girls, 38·1 % of in-school boys and 47·4 % of out-of-school girls reported that they consumed all WIFS tablets they received. Counselling from teachers, administrators and school staff was the primary reason adolescents reported taking WIFS tablets, whereas the major reasons for non-adherence were lack of perceived benefit, peer suggestion not to take WIFS and a reported history of side effects.
The effective coverage of the WIFS programme for in-school adolescents and out-of-school adolescent girls is low in rural Birbhum. Integrated supply- and demand-side strategies appear to be necessary to increase the effective coverage and potential benefits of the WIFS programme.
The widespread evolution of herbicide resistance in weed populations has become an increasing concern for no-tillage (NT) growers in semiarid regions of the U.S. Great Plains. Lack of cost-effective and alternative new herbicide sites of action further exacerbates the problem of herbicide-resistant (HR) weeds and threatens the long-term sustainability of prevailing cropping systems in the region. A recent decline in commodity prices and increasing herbicide costs to manage HR weeds has spurred research efforts to build a strong rationale for developing ecologically based integrated weed management (IWM) strategies in the U.S. Great Plains. Integration of cover crops (CCs) in NT dryland production systems potentially offers several ecosystem services, including weed control, soil health improvement, decline in selective pest pressure, and overall reduction in pest management inputs. This review article aims to document the role of CCs for IWM, with emphasis on exploring emerging weed issues; ecological, economic, and agronomic benefits of growing CCs; and constraints preventing adoption of CCs in NT cropping systems in the semiarid Great Plains. We attempt to focus on changes in weed management practices, their long-term impacts on weed seedbanks, weed shifts, and herbicide-resistance evolution in the most common weed species in the region. We also highlight current knowledge gaps and propose new research priorities based on an improved understanding of CC management strategies that will ultimately aid in achieving sustainable weed management goals and preserving natural resources in water-limited environments.
The aim of this study was to evaluate contact endoscopy in detecting local treatment failures post-radiotherapy in squamous cell carcinoma of the upper aerodigestive tract.
A total of 135 consecutive patients with suspected residual or recurrent cancer after definitive radiotherapy underwent contact endoscopy before biopsy. Contact endoscopy findings were compared with histopathological examination findings. Contact endoscopy could not be completed in 7 patients (5.9 per cent) and histopathological examination was inconclusive in 5 patients (3.7 per cent). The findings of the remaining 123 patients were compared.
The sensitivity, specificity and accuracy of contact endoscopy were 88.75, 88.72 and 86.99 per cent, respectively, with similar results across various sites of upper aerodigestive tract. Inter-observer kappa value was 0.86 (95 per cent confidence interval: 0.79–0.93). The intra-observer kappa value was 0.93 (95 per cent confidence interval: 0.87–1.00) for the first observer and 0.95 (95 per cent confidence interval: 0.90–1.00) for second and third observers.
Contact endoscopy showed the same high sensitivity and specificity with low inter- and intra-observer variability in detecting post-radiotherapy failures in cancer of the upper aerodigestive tract as has been shown in non-irradiated tissues in earlier studies.
Preoperative mechanical ventilation is associated with morbidity and mortality following CHD surgery, but prior studies lack a comprehensive analysis of how preoperative respiratory support mode and timing affects outcomes.
We retrospectively collected data on children <18 years of age undergoing cardiac surgery at an academic tertiary care medical centre. Using multivariable regression, we examined the association between modes of preoperative respiratory support (nasal cannula, high-flow nasal cannula/noninvasive ventilation, or invasive mechanical ventilation), escalation of preoperative respiratory support, and invasive mechanical ventilation on the day of surgery for three outcomes: operative mortality, postoperative length of stay, and postoperative complications. We repeated our analysis in a subcohort of neonates.
A total of 701 children underwent 800 surgical procedures, and 40% received preoperative respiratory support. Among neonates, 243 patients underwent 253 surgical procedures, and 79% received preoperative respiratory support. In multivariable analysis, all modes of preoperative respiratory support, escalation in preoperative respiratory support, and invasive mechanical ventilation on the day of surgery were associated with increased odds of prolonged length of stay in children and neonates. Children (odds ratio = 3.69, 95% CI 1.2–11.4) and neonates (odds ratio = 8.97, 95% CI 1.31–61.14) on high-flow nasal cannula/noninvasive ventilation had increased odds of operative mortality compared to those on room air.
Preoperative respiratory support is associated with prolonged length of stay and mortality following CHD surgery. Knowing how preoperative respiratory support affects outcomes may help guide surgical timing, inform prognostic conversations, and improve risk stratification models.
To compare round window niche visibility as seen endoscopically during cochlear implant surgery with pre-operative high-resolution computed tomography of the temporal bone.
Nineteen patients scheduled for cochlear implantation, aged 2–20 years, were referred for computed tomography from October 2016 to March 2018. Angles were measured between the lines passing through the mid-sagittal plane and cochlear basal turn on the scans. Endoscopic round window niche visibility during posterior tympanotomy was categorised as: type I = 100 per cent, type IIa = more than 50 per cent, type IIb = less than 50 per cent or type III = 0 per cent. Pre-operative computed tomography measurements were used to predict round window niche visibility before surgery and correlated with intra-operative findings.
The mean (range) of pre-operative angles on computed tomography for endoscopic visibility types I, IIa and IIb, were 64.06° (61.16–69.37°), 63.81° (58.61–71.35°) and 56.48° (50.37–59.05°), respectively, a statistically significant finding (one-way analysis of variance test, p = 0.016).
Pre-operative high-resolution temporal bone computed tomography measurements are useful in predicting round window niche visualisation as viewed endoscopically during posterior tympanotomy. The angle was more acute in type IIb compared to type I.
Fracture of crystalline silicon (c-Si) solar cells in photovoltaic modules is a big concern to the photovoltaics (PV) industry. Cell cracks cause performance degradation and warranty issues to the manufacturers. The roots of cell fractures lie in the manufacturing and integration process of the cells and modules as they go through a series of elevated temperature and pressure processes, involving bonding of dissimilar materials, causing residual stresses. Evaluation of the exact physical mechanisms leading to these thermomechanical stresses is highly essential to quantify them and optimize the PV modules to address them. We present a novel synchrotron X-ray microdiffraction based techniques to characterize the stress and fracture in the crystalline silicon PV modules. We show the detailed stress state after soldering and lamination process, using the synchrotron X-ray microdiffraction experiments. We also calculate the maximum tolerable microcrack size in the c-Si cells to sustain the residual stress after lamination. We further demonstrate the effect of these residual stresses on the cell fractures using the widely accepted fracture (4-point bending) tests. These test results show that the soldering and lamination induced localized residual stresses indeed reduce the load-carrying capacity of the c-Si cells.
Grewia tenax locally known as ‘Gangerun’, is an important multipurpose underutilized shrub and potentially threaten species of the Thar Desert of India. Owing to its importance, naturally available germplasm was collected and evaluated for its sustainable utilization in future. Data on individual mother plant, seed characters and soil profile were investigated. Habitat occurrence of G. tenax was found in patches with dominant association of Euphorbia caducifolia across the four districts of western Rajasthan. Individual plant on unprotected area portrayed far lower average height (0.95 m) and canopy area (1.75 m2) than protected area (2.63 m and 13.89 m2) signifying level of browsing pressure on this species in Jaisalmer. Soil samples belonging to Pali region have high organic carbon and low electrical conductivity content than Jaisalmer and Jodhpur. The statistical analysis of seed characters revealed the presence of high coefficient of variation (%) in 100-seed weight (HSW; 27.36) followed by seed length (SL; 8.06) and least in seed breadth (SB; 5.85). The range and mean values of HSW, SL, SB and length:breadth ratio (LBR) were (2.02–7.00 and 3.34 g), (4.36–6.15 and 5.36 mm), (3.73–4.68 and 4.25 mm) and (1.11–1.44 and 1.27), respectively. Significantly positive correlation was observed between SL and LBR (0.73) followed by HSW and SL (0.66). Along with these findings, its economic importance, utilization and conservation are detailed in this paper as to hasten further research on its various aspects for its successful conservation and utilization.
Unilateral total facial palsy is a debilitating condition that can affect an individual's physical, social and emotional wellbeing. When this occurs bilaterally, the severity of impact is extreme, with significant cosmetic disfigurement and functional morbidity. A variety of facial reanimation techniques have been used for unilateral facial weakness of varying House–Brackmann grades, and these are also applicable in bilateral cases. In bilateral cases, it is difficult to gauge successful improvement in comparison to the contralateral side, which also is afflicted.
This paper presents our experience with a bilateral facial paralysis patient who had a complex otological history. The patient, who presented with bilateral debilitating grade VI facial palsy, achieved a good result from bilateral facial reanimation with sequential hypoglossal–facial anastomosis. This is considered a reasonable option in cases of bilateral facial paralysis.
This study was conducted to characterize new plant type (NPT) traits among 650 genetically diverse rice genotypes of tropical japonica and indica and to establish an initial core set for NPT traits. Analysis of variance revealed highly significant differences among the genotypes for all the traits assessed except flag length and width and leaf angles. Dendrogram categorized the genotypes into five distinct duration groups. Genotypes viz., Pumphamah, IRGC5097, IRGC37015, IRGC43741, IRGC50448, IRGC53089, IRGC39111, IRGC18021, Haorei Machang, IRGC44069, IRGC8269, Thangmoi, IRGC33130 and IRGC29772 were identified as possessing strong culm. Long panicles with a length of more than 35 cm were found in IRGC8269, IRGC9147, IRGC14694, IRGC19642, IRGC27435, IRGC39111, IRGC31051, IRGC26011and IRGC25892. Ideal leaf angle of NPT genotypes of 5°, 10° and 20° of flag leaf, 1st and 2nd leaves was not found in any genotype but with a combination of 5°, 10° and 10° was observed in IRGC63102 and IRGC66644. NPT flag leaf length and width of 50 and 2 cm, respectively, was seen in ‘Kemenya Kepeu’ and ‘IRGC29772’. High grain number of more than 350 was observed in IRGC53089, IRGC31063 and Azhoghi. A total of 72 genotypes were found with a combination of one or more ideal plant type traits of which, hierarchical cluster analysis based on genetic distances selected 32 as NPT core set. This core set will serve as an ideal genetic resource for breeding programs aimed at NPT development.
A number of complex systems arising in diverse disciplines may have certain quantitative features that are surprisingly similar which are classified under the paradigm of “universality”. The non-extensive Tsallis stastical mechanics and Lévy flight patterns provide a novel basis for analyzing non-equilibrium complex systems that may exhibit long-range correlations. The present work studies the scope of employing non-extensive Gutenberg-Richter (G-R) type law for the magnitude distribution of energy of solar wind, in order to investigate the existence of a universal behavior as well as to compute the relations of degree of non-extensivity and Lévy statistics in solar wind turbulence with heliographic distance during different solar cycles.