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Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline.
A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus
60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations.
Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.
Approximately, 1.7 million individuals in the United States have been infected with SARS-CoV-2, the virus responsible for the novel coronavirus disease-2019 (COVID-19). This has disproportionately impacted adults, but many children have been infected and hospitalised as well. To date, there is not much information published addressing the cardiac workup and monitoring of children with COVID-19. Here, we share the approach to the cardiac workup and monitoring utilised at a large congenital heart centre in New York City, the epicentre of the COVID-19 pandemic in the United States.
This paper compares the U.S. Environmental Protection Agency’s (EPA) ex ante compliance cost estimates for the 2004 Automobile and Light-Duty Truck Surface Coating National Emission Standards for Hazardous Air Pollutants to ex post evidence on the actual costs of compliance based on ex post cost data gathered from a subset of the industry via pilot survey and follow-up interviews. Unlike many prior retrospective studies on the cost of regulatory compliance, we use this newly gathered information to identify the key drivers of any differences between the ex ante and ex post estimates. We find that the U.S. EPA overestimated the cost of compliance for the plants in our sample and that overestimation was driven primarily by differences in the method of compliance rather than differences in the per-unit cost associated with a given compliance approach. In particular, the U.S. EPA expected facilities to install pollution abatement control technologies in their paint shops to reduce emissions of hazardous air pollutants, but instead these plants complied by reformulating coatings.
Researchers, product registration personnel, and growers desire the ability to chemically detect residual amounts of herbicides in soil at concentrations below those necessary to cause phytotoxicity to sensitive nontarget or rotational crop plants. Alfalfa, cotton, soybean, and sunflower, crops sensitive to low concentrations of aminocyclopyrachlor in soil, were planted at field test sites approximately 1 yr after aminocyclopyrachlor methyl was applied. Soil samples were collected when rotational crops were planted and were analyzed for aminocyclopyrachlor by a method based on high performance liquid chromatography tandem mass spectrometry (HPLC/MS/MS), with a limit of detection (LOD) of 0.1 part per billion (ppb) (soil oven-dry weight basis). Loglogistic dose–response analysis correlated visual phytotoxic plant responses to residual concentrations of aminocyclopyrachlor in the soil. Concentrations of aminocyclopyrachlor estimated to cause 25% phytotoxicity to alfalfa, cotton, soybean, and sunflower were 5.4, 3.2, 2.0, and 6.2 ppb, respectively, 20 to 60 times greater than the LOD of the analytical method available for soil analysis. Results from these studies suggest this HPLC/MS/MS method of analysis can be used to indicate potential risk and severity of plant response for alfalfa, cotton, soybean, and sunflower, and for other plant species once dose–response curves for these additional species are established. This chemical assay may be particularly important if researchers desire to study the concentration, movement, and dissipation of aminocyclopyrachlor in soil or as part of a forensic investigation to better understand the cause of an unanticipated or undesirable plant response.
An infant with residual severe mitral regurgitation following mitral commissurotomy developed cardiogenic unilateral pulmonary oedema and subsegmental atelectasis that resolved with mechanical mitral valve replacement.
Literature on food environments has expanded rapidly, yet most research focuses on stores and community characteristics without integrating customer-level data. The present study combines customer shopping behaviour with store food inventory data.
Face-to-face interviews were conducted with customers shopping in corner stores to measure food shopping behaviour, household food security and demographics. Store inventories were conducted to measure availability of healthy food in corner stores. Multilevel logistic regression models estimated the probability of customers purchasing a food item given the availability of that item in the store.
Nineteen corner stores in Hartford, CT, USA, average size 669 ft2 (62·15 m2).
Sample of 372 customers.
The majority of customers were Black or Hispanic (54 % and 40 %, respectively) and 61 % experienced food insecurity. For each additional type of fruits or vegetables available in the store, the estimated odds of a customer purchasing fruits increased by 12 % (P = 0·03) and the odds for purchasing vegetables increased by 15 % (P = 0·01). Customers receiving the Supplemental Nutrition Assistance Program (SNAP) were 1·7 times as likely to purchase fruit as those not receiving SNAP (P = 0·04). Greater availability of reduced-fat milk was not associated with increased likelihood of customers purchasing reduced-fat milk.
There is a positive association between fruit and vegetable variety and the probability that a customer purchases fruits and vegetables. Increasing the selection of produce in corner stores may increase their consumption by food-insecure and low-income residents at risk for health disparities. These findings have implications for future store interventions and food policies.
To develop and evaluate computer algorithms with high negative predictive values that augment traditional surveillance for central line–associated bloodstream infection (CLABSI).
Barnes-Jewish Hospital, a 1,250-bed tertiary care academic hospital in Saint Louis, Missouri.
We evaluated all adult patients in intensive care units who had blood samples collected during the period from July 1, 2005, to June 30,2006, that were positive for a recognized pathogen on culture. Each isolate recovered from culture was evaluated using the definitions for nosocomial CLABSI provided by the National Healthcare Safety Network of the Centers for Disease Control and Prevention. Using manual surveillance by infection prevention specialists as the gold standard, we assessed the ability of various combinations of dichotomous rules to determine whether an isolate was associated with a CLABSI. Sensitivity, specificity, and predictive values were calculated.
Infection prevention specialists identified 67 cases of CLABSI associated with 771 isolates recovered from blood samples. The algorithms excluded approximately 40%-62% of the isolates from consideration as possible causes of CLABSI. The simplest algorithm, with 2 dichotomous rules (ie, the collection of blood samples more than 48 hours after admission and the presence of a central venous catheter within 48 hours before collection of blood samples), had the highest negative predictive value (99.4%) and the lowest specificity (44.2%) for CLABSI. Augmentation of this algorithm with rules for common skin contaminants confirmed by another positive blood culture result yielded in a negative predictive value of 99.2% and a specificity of 68.0%.
An automated approach to surveillance for CLABSI that is characterized by a high negative predictive value can accurately identify and exclude positive culture results not representing CLABSI from further manual surveillance.
Trivalent chromium (Cr3+) is an essential trace element involved in insulin function. Cr deficiencies result in decreased insulin sensitivity, glucose intolerance and an increased risk of diabetes. Cr status decreases with age suggesting that the elderly may be at high risk of Cr deficiency. This study aimed to provide information about the Cr content of foods in France and the Cr intake in French free-living elderly. We measured the food Cr content and daily Cr intake of freely chosen diets for 3 d in twelve French free-living elderly people and their Cr excretion and plasma hormonal related variables, leptin, insulin and cortisol. Considering the relationship between insulin resistance and oxidative stress, we also determined plasma thiobarbituric acid reactive substance, thiol groups and total and reduced glutathione. Although these subjects had well-balanced diets, their daily Cr intakes did not reach the French recommendations. The low Cr intakes were due to the low Cr density of the foods. We found a negative correlation between Cr intakes and insulin, BMI and leptin.