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The Residual Lesion Score is a novel tool for assessing the achievement of surgical objectives in congenital heart surgery based on widely available clinical and echocardiographic characteristics. This article describes the methodology used to develop the Residual Lesion Score from the previously developed Technical Performance Score for five common congenital cardiac procedures using the RAND Delphi methodology.
A panel of 11 experts from the field of paediatric and congenital cardiology and cardiac surgery, 2 co-chairs, and a consultant were assembled to review and comment on validity and feasibility of measuring the sub-components of intraoperative and discharge Residual Lesion Score for five congenital cardiac procedures. In the first email round, the panel reviewed and commented on the Residual Lesion Score and provided validity and feasibility scores for sub-components of each of the five procedures. In the second in-person round, email comments and scores were reviewed and the Residual Lesion Score revised. The modified Residual Lesion Score was scored independently by each panellist for validity and feasibility and used to develop the “final” Residual Lesion Score.
The Residual Lesion Score sub-components with a median validity score of ≥7 and median feasibility score of ≥4 that were scored without disagreement and with low absolute deviation from the median were included in the “final” Residual Lesion Score.
Using the RAND Delphi methodology, we were able to develop Residual Lesion Score modules for five important congenital cardiac procedures for the Pediatric Heart Network’s Residual Lesion Score study.
On 5 Nivôse of the Year II (Christmas Day, 1793), addressing the National Assembly on behalf of the Committee of Public Safety, Robespierre declared: “The theory of revolutionary government is as new as the revolution that has brought it about. It should not be sought in the books of political writers, who have not foreseen this revolution, nor in the laws of tyrants, who content to abuse their power, are little concerned to investigate its legitimacy.” It is tempting to suppose Robespierre is exaggerating. Whatever the relation of revolutionary government to “the laws of tyrants,” Robespierre's ties to the republican tradition in political philosophy, and especially to Rousseau, are striking and nearly everywhere acknowledged, not least by Robespierre himself. However, I am not concerned here with the question of Rousseau's influence upon Robespierre, but with the rather different question of conceptual affinity. Even if Robespierre's intent were just to put The Social Contract into practice (if need be, by despotic means), it is still appropriate to ask whether Robespierre is a Rousseauean.
For more than two decades, C. B. Macpherson has waged a relentless campaign to expose and critize the ‘possessive individualist’ assumptions of classical and liberal democratictheory. This new book —a collection of essays, including several not previously published —gives a clear focus to this campaign and provides the fullest expression to date of its positive side: the elaboration of a social philosophy incorporating liberal values but free from possessive individualist assumptions. What is defective in the assumptions is less the internal theoretical problems they generate than that they have become historically outmoded. For Macpherson, liberal democracy is historically — even politically — inadequate, before it is theoretically inadequate. It is inadequate for us — now — because it rests on assumptions we no longer need, assumptions that have ceased to be historically progressive. However, liberal democracy is not, as surgeons would say, beyond operation. On Macpherson's view, nearly everything that is attractive in liberal theory can be salvaged. Democratic Theory is appropriately subtitled: Essays in Retrieval.
While echocardiographic parameters are used to quantify ventricular function in infants with single ventricle physiology, there are few data comparing these to invasive measurements. This study correlates echocardiographic measures of diastolic function with ventricular end-diastolic pressure in infants with single ventricle physiology prior to superior cavopulmonary anastomosis.
Data from 173 patients enrolled in the Pediatric Heart Network Infant Single Ventricle enalapril trial were analysed. Those with mixed ventricular types (n = 17) and one outlier (end-diastolic pressure = 32 mmHg) were excluded from the analysis, leaving a total sample size of 155 patients. Echocardiographic measurements were correlated to end-diastolic pressure using Spearman’s test.
Median age at echocardiogram was 4.6 (range 2.5–7.4) months. Median ventricular end-diastolic pressure was 7 (range 3–19) mmHg. Median time difference between the echocardiogram and catheterisation was 0 days (range −35 to 59 days). Examining the entire cohort of 155 patients, no echocardiographic diastolic function variable correlated with ventricular end-diastolic pressure. When the analysis was limited to the 86 patients who had similar sedation for both studies, the systolic:diastolic duration ratio had a significant but weak negative correlation with end-diastolic pressure (r = −0.3, p = 0.004). The remaining echocardiographic variables did not correlate with ventricular end-diastolic pressure.
In this cohort of infants with single ventricle physiology prior to superior cavopulmonary anastomosis, most conventional echocardiographic measures of diastolic function did not correlate with ventricular end-diastolic pressure at cardiac catheterisation. These limitations should be factored into the interpretation of quantitative echo data in this patient population.
Using a commercial X-ray tomography instrument, we have obtained reconstructions of a graded-index optical fiber with voxels of edge length 1.05 µm at 12 tube voltages. The fiber manufacturer created a graded index in the central region by varying the germanium concentration from a peak value in the center of the core to a very small value at the core-cladding boundary. Operating on 12 tube voltages, we show by a singular value decomposition that there are only two singular vectors with significant weight. Physically, this means scans beyond two tube voltages contain largely redundant information. We concentrate on an analysis of the images associated with these two singular vectors. The first singular vector is dominant and images of the coefficients of the first singular vector at each voxel look are similar to any of the single-energy reconstructions. Images of the coefficients of the second singular vector by itself appear to be noise. However, by averaging the reconstructed voxels in each of several narrow bands of radii, we can obtain values of the second singular vector at each radius. In the core region, where we expect the germanium doping to go from a peak value at the fiber center to zero at the core-cladding boundary, we find that a plot of the two coefficients of the singular vectors forms a line in the two-dimensional space consistent with the dopant decreasing linearly with radial distance from the core center. The coating, made of a polymer rather than silica, is not on this line indicating that the two-dimensional results are sensitive not only to the density but also to the elemental composition.
Despite the benefits of exercise, a large percentage of the older population in South Africa continue to lead sedentary lifestyles. This study aimed to determine the effects of a structured group exercise programme on functional fitness of older persons living in old-age homes. A quasi-experimental design was used to compare the effects of a 12-week group exercise programme. Twenty participants each were selected from five old-age homes. Participants were randomly allocated into either an experimental group or a comparison group at each site. The experimental group participated in the exercise intervention three times weekly, while the comparison group received the same intervention twice weekly for 12 weeks. The intervention programme included warm-up, balance, endurance, resistance and cool-down components. Assessments of upper and lower body strength and flexibility, aerobic endurance, agility and balance were conducted before and after the intervention programme using the Senior Functional Test. Comparisons of baseline and post-intervention measures showed greater improvements in upper and lower body strength and flexibility, as well as aerobic endurance capacity (p < 0.05). Training frequency revealed no significant difference in functional fitness measures between both groups following the 12-week intervention programme. Twelve weeks of multifaceted group exercise training, at least twice a week, can be used as an effective strategy to promote functional fitness in this population.
High-fidelity simulation (HFS) is a relatively new teaching modality, which is gaining widespread acceptance in medical education. To date, dozens of studies have proven the usefulness of HFS in improving student, resident, and attending physician performance, with similar results in the allied health fields. Although many studies have analyzed the utility of simulation, few have investigated why it works. A recent study illustrated that permissive failure, leading to simulated mortality, is one HFS method that can improve long-term performance. Critics maintain, however, that the use of simulated death is troubling and excessive. Given the controversy regarding simulated death, we consider the data about the educational value and the emotional harms associated with them, expecting that evidence could be useful in resolving the question. The goal of this narrative review is to explore the argument against simulated mortality and provide educators with an imperative as to why it can be safely utilized.
A few studies have evaluated the impact of clinical trial results on practice in paediatric cardiology. The Infant Single Ventricle (ISV) Trial results published in 2010 did not support routine use of the angiotensin-converting enzyme inhibitor enalapril in infants with single-ventricle physiology. We sought to assess the influence of these findings on clinical practice.
A web-based survey was distributed via e-mail to over 2000 paediatric cardiologists, intensivists, cardiothoracic surgeons, and cardiac advance practice nurses during three distribution periods. The results were analysed using McNemar’s test for paired data and Fisher’s exact test.
The response rate was 31.5% (69% cardiologists and 65% with >10 years of experience). Among respondents familiar with trial results, 74% reported current practice consistent with trial findings versus 48% before trial publication (p<0.001); 19% used angiotensin-converting enzyme inhibitor in this population “almost always” versus 36% in the past (p<0.001), and 72% reported a change in management or improved confidence in treatment decisions involving this therapy based on the trial results. Respondents familiar with trial results (78%) were marginally more likely to practise consistent with the trial results than those unfamiliar (74 versus 67%, p=0.16). Among all respondents, 28% reported less frequent use of angiotensin-converting enzyme inhibitor over the last 3 years.
Within 5 years of publication, the majority of respondents was familiar with the Infant Single Ventricle Trial results and reported less frequent use of angiotensin-converting enzyme inhibitor in single-ventricle infants; however, 28% reported not adjusting their clinical decisions based on the trial’s findings.
Background: Spinal cord stimulation (SCS) is a well-established treatment for chronic neuropathic pain in the lower limbs. Upper limb pain comprises a significant proportion of neuropathic pain patients, but is often difficult to target specifically and consistently with paresthesias. We hypothesized that the use of dorsal nerve root stimulation (DNRS), as an option along with SCS, would help us better relieve pain in these patients. Methods: All 35 patients trialed with spinal stimulation for upper limb pain between July 1, 2011, and October 31, 2013, were included. We performed permanent implantation in 23/35 patients based on a visual analogue scale pain score decrease of ≥50% during trial stimulation. Results: Both the SCS and DNRS groups had significant improvements in average visual analogue scale pain scores at 12 months compared with baseline, and the majority of patients in both groups obtained ≥50% pain relief. The majority of patients in both groups were able to reduce their opioid use, and on average had improvements in Short Form-36 quality of life scores. Complication rates did not differ significantly between the two groups. Conclusions: Treatment with SCS or DNRS provides meaningful long-term relief of chronic neuropathic pain in the upper limbs.
Objectives: Blast explosions are the most frequent mechanism of traumatic brain injury (TBI) in recent wars, but little is known about their long-term effects. Methods: Functional connectivity (FC) was measured in 17 veterans an average of 5.46 years after their most serious blast related TBI, and in 15 demographically similar veterans without TBI or blast exposure. Subcortical FC was measured in bilateral caudate, putamen, and globus pallidus. The default mode and fronto-parietal networks were also investigated. Results: In subcortical regions, between-groups t tests revealed altered FC from the right putamen and right globus pallidus. However, following analysis of covariance (ANCOVA) with age, depression (Center for Epidemiologic Studies Depression Scale), and posttraumatic stress disorder symptom (PTSD Checklist – Civilian version) measures, significant findings remained only for the right globus pallidus with anticorrelation in bilateral temporal occipital fusiform cortex, occipital fusiform gyrus, lingual gyrus, and cerebellum, as well as the right occipital pole. No group differences were found for the default mode network. Although reduced FC was found in the fronto-parietal network in the TBI group, between-group differences were nonsignificant after the ANCOVA. Conclusions: FC of the globus pallidus is altered years after exposure to blast related TBI. Future studies are necessary to explore the trajectory of changes in FC in subcortical regions after blast TBI, the effects of isolated versus repetitive blast-related TBI, and the relation to long-term outcomes in veterans. (JINS, 2016, 22, 631–642)