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Acute kidney injury leads to worse outcomes following paediatric cardiac surgery. There is a lack of literature focusing on acute kidney injury after the Hybrid stage 1 palliation for single ventricle physiology. Patients undergoing the Hybrid Stage 1, as a primary option, may have a lower incidence of kidney injury than previously reported. When present, kidney injury may increase the risk of post-operative morbidity and mortality.
A retrospective, single centre review was conducted in patients with hypoplastic left heart syndrome who underwent Hybrid Stage 1 from 2008 to 2018. Acute kidney injury was defined as a dichotomous yes (meeting any injury criteria) or no (no injury) utilising two different criteria utilised in paediatrics. The impact of kidney injury on perioperative characteristics and 30-day mortality was analysed.
The incidence of acute kidney injury is 13.4–20.7%, with a severe injury rate of 2.4%. Patients without a prenatal diagnosis of hypoplastic left heart syndrome have a higher incidence of kidney injury than those prenatally diagnosed, (40% versus 14.5%, p = 0.024). Patients with acute kidney injury have a significantly higher incidence of 30-day mortality, 27.3%, compared to without, 5.6% (p = 0.047).
The incidence of severe acute kidney injury after the Hybrid Stage 1 palliation is low. A prenatal diagnosis may be associated with a lower incidence of kidney injury following the Hybrid Stage 1. Though uncommon, severe acute kidney injury following Hybrid Stage 1 may be associated with higher 30-day mortality.
A survey of Veterans’ Affairs Medical Centers on control of carbapenem-resistant Enterobacteriaceae (CRE) and carbapenem-producing CRE (CP-CRE) demonstrated that most facilities use VA guidelines but few screen for CRE/CP-CRE colonization regularly or regularly communicate CRE/CP-CRE status at patient transfer. Most respondents were knowledgeable about CRE guidelines but cited lack of adequate resources.
Although there is growing interest in mental health problems in university students there is limited understanding of the scope of need and determinants to inform intervention efforts.
To longitudinally examine the extent and persistence of mental health symptoms and the importance of psychosocial and lifestyle factors for student mental health and academic outcomes.
Undergraduates at a Canadian university were invited to complete electronic surveys at entry and completion of their first year. The baseline survey measured important distal and proximal risk factors and the follow-up assessed mental health and well-being. Surveys were linked to academic grades. Multivariable models of risk factors and mental health and academic outcomes were fit and adjusted for confounders.
In 1530 students surveyed at entry to university 28% and 33% screened positive for clinically significant depressive and anxiety symptoms respectively, which increased to 36% and 39% at the completion of first year. Over the academic year, 14% of students reported suicidal thoughts and 1.6% suicide attempts. Moreover, there was persistence and overlap in these mental health outcomes. Modifiable psychosocial and lifestyle factors at entry were associated with positive screens for mental health outcomes at completion of first year, while anxiety and depressive symptoms were associated with lower grades and university well-being.
Clinically significant mental health symptoms are common and persistent among first-year university students and have a negative impact on academic performance and well-being. A comprehensive mental health strategy that includes a whole university approach to prevention and targeted early-intervention measures and associated research is justified.
Craving in negative emotional situations (negative craving) is commonly associated with relapse and heavy alcohol use. Elevated dynorphin levels were associated with negative emotions, while variations in the OPRK1 and PDYN genes encoding OPRK1 receptor and dynorphins were associated with alcohol dependence.
To investigate potential overlap in the genetic factors underlying, negative craving and alcohol dependence.
Examine the association of the negative craving and genetic variation in the OPRK1 and PDYN genes.
13 PDYN and 10 OPRK1 Single Nucleotide Polymorphisms (SNPs), including those previously reported to be associated with alcohol dependence were genotyped in 196 alcohol dependent subjects. The raw scores of the negative subscale of Inventory of Drug Taking Situations (IDTS) were utilized as a quantitative measure of negative craving. Logistic regression models were used to test for associations after controlling for age and gender.
Gene-level haplotype testing demonstrated significant association of negative craving with variation in PDYN (p < 0.05) but not OPRK1 gene. The rs2281285 - rs199794 haplotype showed significant association (p = 0.0236) with negative craving, while rs2235749 - rs10485703 haplotype showed marginally significant association (p = 0.055). This replicates previous findings of association between these haplotypes and alcohol dependence. Negative craving was also associated with PDYN rs2281285 variant (p = 0.012) with estimated effect size of 6.95 (SE = 2.75). This new association finding was not significant after correction for multiple testing (p = 0.18).
Our findings support association of PDYN sequence variation with negative craving in alcohol dependent subjects. Future studies should investigate functional mechanisms of this association.
Generative neural networks (GNNs) have successfully used human-created designs to generate novel 3D models that combine concepts from disparate known solutions, which is an important aspect of design exploration. GNNs automatically learn a parameterization (or latent space) of a design space, as opposed to alternative methods that manually define a parameterization. However, GNNs are typically not evaluated using an explicit notion of physical performance, which is a critical capability needed for design. This work bridges this gap by proposing a method to extract a set of functional designs from the latent space of a point cloud generating GNN, without sacrificing the aforementioned aspects of a GNN that are appealing for design exploration. We introduce a sparsity preserving cost function and initialization strategy for a genetic algorithm (GA) to optimize over the latent space of a point cloud generating autoencoder GNN. We examine two test cases, an example of generating ellipsoid point clouds subject to a simple performance criterion and a more complex example of extracting 3D designs with a low coefficient of drag. Our experiments show that the modified GA results in a diverse set of functionally superior designs while maintaining similarity to human-generated designs in the training data set.
Lithium-treated patients with polyuria are at increased risk of lithium toxicity. We aimed to describe the clinical benefits and risks of different management strategies for polyuria in community lithium-treated patients.
This is a naturalistic, observational, prospective 12-month cohort study of lithium-treated patients with polyuria attending a community mental health service in Dublin, Ireland. When polyuria was detected, management changed in one of four ways: (a) no pharmacological change; (b) lithium dose decrease; (c) lithium substitution; or (d) addition of amiloride.
Thirty-four participants were diagnosed with polyuria and completed prospective data over 12 months. Mean 24-hour urine volume decreased from 4852 to 4344 ml (p = 0.038). Mean early morning urine osmolality decreased from 343 to 338 mOsm/kg (p = 0.823). Mean 24-hour urine volume decreased with each type of intervention but did not attain statistical significance for any individual intervention group. Mean early morning urine osmolality decreased in participants with no pharmacological change and increased in participants who received a change in medication but these changes did not attain statistical significance. Only participants who discontinued lithium demonstrated potentially clinically significant changes in urine volume (mean decrease 747 ml in 24 hours) and early morning urine osmolality (mean increase 31 mOsm/kg) although this was not definitively proven, possibly owing to power issues.
Managing polyuria by decreasing lithium dose does not appear to substantially improve objective measures of renal tubular dysfunction, whereas substituting lithium may do so. Studies with larger numbers and longer follow-up would clarify these relationships.
Disease surveillance in wildlife populations presents a logistical challenge, yet is critical in gaining a deeper understanding of the presence and impact of wildlife pathogens. Erinaceus coronavirus (EriCoV), a clade C Betacoronavirus, was first described in Western European hedgehogs (Erinaceus europaeus) in Germany. Here, our objective was to determine whether EriCoV is present, and if it is associated with disease, in Great Britain (GB). An EriCoV-specific BRYT-Green® real-time reverse transcription PCR assay was used to test 351 samples of faeces or distal large intestinal tract contents collected from casualty or dead hedgehogs from a wide area across GB. Viral RNA was detected in 10.8% (38) samples; however, the virus was not detected in any of the 61 samples tested from Scotland. The full genome sequence of the British EriCoV strain was determined using next generation sequencing; it shared 94% identity with a German EriCoV sequence. Multivariate statistical models using hedgehog case history data, faecal specimen descriptions and post-mortem examination findings found no significant associations indicative of disease associated with EriCoV in hedgehogs. These findings indicate that the Western European hedgehog is a reservoir host of EriCoV in the absence of apparent disease.
In Cameroon, there is a national programme engaged in the control of schistosomiasis and soil-transmitted helminthiasis. In certain locations, the programme is transitioning from morbidity control towards local interruption of parasite transmission. The volcanic crater lake villages of Barombi Mbo and Barombi Kotto are well-known transmission foci and are excellent context-specific locations to assess appropriate disease control interventions. Most recently they have served as exemplars of expanded access to deworming medications and increased environmental surveillance. In this paper, we review infection dynamics through time, beginning with data from 1953, and comment on the short- and long-term success of disease control. We show how intensification of local control is needed to push towards elimination and that further environmental surveillance, with targeted snail control, is needed to consolidate gains in preventive chemotherapy as well as empower local communities to take ownership of interventions.
We detail tentative detections of low-frequency carbon radio recombination lines from within the Orion molecular cloud complex observed at 99–129 MHz. These tentative detections include one alpha transition and one beta transition over three locations and are located within the diffuse regions of dust observed in the infrared at 100 μm, the Hα emission detected in the optical, and the synchrotron radiation observed in the radio. With these observations, we are able to study the radiation mechanism transition from collisionally pumped to radiatively pumped within the H ii regions within the Orion molecular cloud complex.
To determine the scope, source, and mode of transmission of a multifacility outbreak of extensively drug-resistant (XDR) Acinetobacter baumannii.
SETTING AND PARTICIPANTS
Residents and patients in skilled nursing facilities, long-term acute-care hospital, and acute-care hospitals.
A case was defined as the incident isolate from clinical or surveillance cultures of XDR Acinetobacter baumannii resistant to imipenem or meropenem and nonsusceptible to all but 1 or 2 antibiotic classes in a patient in an Oregon healthcare facility during January 2012–December 2014. We queried clinical laboratories, reviewed medical records, oversaw patient and environmental surveillance surveys at 2 facilities, and recommended interventions. Pulsed-field gel electrophoresis (PFGE) and molecular analysis were performed.
We identified 21 cases, highly related by PFGE or healthcare facility exposure. Overall, 17 patients (81%) were admitted to either long-term acute-care hospital A (n=8), or skilled nursing facility A (n=8), or both (n=1) prior to XDR A. baumannii isolation. Interfacility communication of patient or resident XDR status was not performed during transfer between facilities. The rare plasmid-encoded carbapenemase gene blaOXA-237 was present in 16 outbreak isolates. Contact precautions, chlorhexidine baths, enhanced environmental cleaning, and interfacility communication were implemented for cases to halt transmission.
Interfacility transmission of XDR A. baumannii carrying the rare blaOXA-237 was facilitated by transfer of affected patients without communication to receiving facilities.
Select units in the military have improved combat medic training by integrating their functions into routine clinical care activities with measurable improvements in battlefield care. This level of integration is currently limited to special operations units. It is unknown if regular Army units and combat medics can emulate these successes. The goal of this project was to determine whether US Army combat medics can be integrated into routine emergency department (ED) clinical care, specifically medication administration.
This was a quality assurance project that monitored training of combat medics to administer parenteral medications and to ensure patient safety. Combat medics were provided training that included direct supervision during medication administration. Once proficiency was demonstrated, combat medics would prepare the medications under direct supervision, followed by indirect supervision during administration. As part of the quality assurance and safety processes, combat medics were required to document all medication administrations, supervising provider, and unexpected adverse events. Additional quality assurance follow-up occurred via complete chart review by the project lead.
During the project period, the combat medics administered the following medications: ketamine (n=13), morphine (n=8), ketorolac (n=7), fentanyl (n=5), ondansetron (n=4), and other (n=6). No adverse events or patient safety events were reported by the combat medics or discovered during the quality assurance process.
In this limited case series, combat medics safely administered parenteral medications under indirect provider supervision. Future research is needed to further develop this training model for both the military and civilian setting.
SchauerSG, CunninghamCW, FisherAD, DeLorenzoRA. A Pilot Project Demonstrating that Combat Medics Can Safely Administer Parenteral Medications in the Emergency Department. Prehosp Disaster Med. 2017;32(6):679–681.
Planets form in disks around young stars. The planet formation process may start when the protostar and disk are still deeply embedded within their infalling envelope. However, unlike more evolved protoplanetary disks, the physical and chemical structure of these young embedded disks are still poorly constrained. We have analyzed ALMA data for 13CO, C18O and N2D+ to constrain the temperature structure, one of the critical unknowns, in the disk around L1527. The spatial distribution of 13CO and C18O, together with the kinetic temperature derived from the optically thick 13CO emission and the non-detection of N2D+, suggest that this disk is warm enough (≳ 20 K) to prevent CO freeze-out.
In order to further define the molecular content of planetary nebulae (PNe), we have conducted searches for HCN, HCO+, HNC, and CCH at millimeter wavelengths in a sample of seventeen PNe using the new 12 m and Sub-Millimeter Telescopes of the Arizona Radio Observatory (ARO). HCN and HCO+ were identified in 75% of the PNe, with corresponding fractional abundances of f(HCN/H2) ~ 0.1-9.1 × 10−7 and f(HCO+/H2) ~ 0.04-7.4 × 10−7. HNC was subsequently identified in twelve PNe with f(HNC/H2) ~ 0.02-2.2 × 10−7. The [HCN]/[HNC] ratio was found to be ~1-8 in nebulae observed. CCH was also detected in eight PNe. The abundances for all molecules were found to remain relatively constant with nebular age across 10,000 years, in contrast to model predictions. They are also 10-100 greater than those observed in diffuse clouds, and suggest that molecular material from PNe seed the diffuse ISM.
The eastern bettong Bettongia gaimardi, a potoroid marsupial, has been extinct on the Australian mainland since the 1920s. Sixty adult bettongs were reintroduced from the island of Tasmania to two predator-free fenced reserves on mainland Australia. We examined baseline health parameters (body weight, haematology and biochemistry, parasites and infectious disease exposure) in a subset of 30 (13 male, 17 female) individuals at translocation and again at 12–24 months post-reintroduction. The mean body weight increased significantly post-reintroduction but there were no significant differences in body weight between the two reintroduction sites or between the sexes in response to reintroduction. Differences were evident in multiple haematological and biochemical variables post-reintroduction but there were few differences between the two reintroduced populations or between the sexes in response to reintroduction. Ectoparasite assemblages differed, with five of 13 species failing to persist, and an additional four species were identified post-reintroduction. None of the bettongs had detectable antibodies to the alphaherpesviruses Macropodid herpesvirus 1 and 2 post-reintroduction, including one individual that was seropositive at translocation. Similarly, the novel gammaherpesvirus potoroid herpesvirus 1 was not detected by polymerase chain reaction (PCR) in any of the bettongs post-reintroduction, including one individual that was PCR-positive at translocation. None of the bettongs had detectable antibodies to Toxoplasma gondii either at translocation or post-reintroduction. Our data demonstrate changing baseline health parameters in eastern bettongs following reintroduction to the Australian mainland are suggestive of improved health in the reintroduced populations, and provide additional metrics for assessing the response of macropodoids to reintroduction.
Although ethics is an essential component of undergraduate medical education, research suggests that current medical ethics curricula face considerable challenges in improving students’ ethical reasoning. This article discusses these challenges and introduces a promising new mode of graduate and professional ethics instruction for overcoming them. We begin by describing common ethics curricula, focusing in particular on established problems with current approaches. Next, we describe a novel method of ethics education and assessment for medical students that we have devised: the Medical Ethics Bowl (MEB). Finally, we suggest the pedagogical advantages of the MEB when compared to other ethics curricula.
We present the first measurement of the anisotropy parameter β using 3D kinematic information outside of the solar neighborhood. Our sample consists of 13 Milky Way halo stars with measured proper motions and radial velocities in the line of sight of M31. Proper motions were measured using deep, multi-epoch HST imaging, and radial velocities were measured from Keck II/DEIMOS spectra. We measure β = −0.3−0.9+0.4, which is consistent with isotropy, and inconsistent with measurements in the solar neighborhood. We suggest that this may be the kinematic signature of a relatively early, massive accretion event, or perhaps several such events.
Dynamical effects of non-conservative forces in long, defect free atomic wires are investigated. Current flow through these wires is simulated and we find that during the initial transient, the kinetic energies of the ions are contained in a small number of phonon modes, closely clustered in frequency. These phonon modes correspond to the waterwheel modes determined from preliminary static calculations. The static calculations allow one to predict the appearance of non-conservative effects in advance of the more expensive real-time simulations. The ion kinetic energy redistributes across the band as non-conservative forces reach a steady state with electronic frictional forces. The typical ion kinetic energy is found to decrease with system length, increase with atomic mass, and its dependence on bias, mass and length is supported with a pen and paper model. This paper highlights the importance of non-conservative forces in current carrying devices and provides criteria for the design of stable atomic wires.