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Amiodarone may be considered for patients with junctional ectopic tachycardia refractory to treatment with sedation, analgesia, cooling, and electrolyte replacements. There are currently no published pediatric data regarding the hemodynamic effects of the newer amiodarone formulation, PM101, devoid of hypotensive agents used in the original amiodarone formulation. We performed a single-center, retrospective, descriptive study from January 2012 to December 2020 in a pediatric ICU. Thirty-three patients were included (22 male and 11 female) between the ages of 1.1 and 1,460 days who developed post-operative junctional ectopic tachycardia or other tachyarrhythmias requiring PM101. Data analysis was performed on hemodynamic parameters (mean arterial pressures and heart rate) and total PM101 (mg/kg) from hour 0 of amiodarone administration to hour 72. Adverse outcomes were defined as Vasoactive-Inotropic Score >20, patients requiring ECMO or CPR, or patient death. There was no statistically significant decrease in mean arterial pressures within the 6 hours of PM101 administration (p > 0.05), but there was a statistically significant therapeutic decrease in heart rate for resolution of tachyarrhythmia (p < 0.05). Patients received up to 25 mg/kg in an 8-hour time for rate control. Average rate control was achieved within 11.91 hours and average rhythm control within 62 hours. There were four adverse events around the time of PM101 administration, with three determined to not be associated with the medication. PM101 is safe and effective in the pediatric cardiac surgical population. Our study demonstrated that PM101 can be used in a more aggressive dosing regimen than previously reported in pediatric literature with the prior formulation.
Pleistocene periglacial activity in eastern Australia was widespread and has been predicted to have extended along much of the east coast. This paper describes block deposits in the New England Tablelands, Australia, as far north as 30°S. These deposits are characterized by openwork blocks on slopes below the angle of repose. The deposits are positioned where frost cracking was significant and range in area up to 8 ha. Surface exposure dating using the cosmogenic nuclide 36Cl from four block deposits indicate all sites were active late during the last glacial cycle, with a concentration of activity between 15–30 ka. Modern temperature measurements from block deposits highlight the importance of local topography for promoting freezing. Periglacial deposits are likely to have been more extensive than previously recognized at these northern limits, and mean annual temperature more than 8°C colder than today.
To determine how engagement of the hospital and/or vendor with performance improvement strategies combined with an automated hand hygiene monitoring system (AHHMS) influence hand hygiene (HH) performance rates.
The study was conducted in 58 adult and pediatric inpatient units located in 10 hospitals.
HH performance rates were estimated using an AHHMS. Rates were expressed as the number of soap and alcohol-based hand rub portions dispensed divided by the number of room entries and exits. Each hospital self-assigned to one of the following intervention groups: AHHMS alone (control group), AHHMS plus clinician-based vendor support (vendor-only group), AHHMS plus hospital-led unit-based initiatives (hospital-only group), or AHHMS plus clinician-based vendor support and hospital-led unit-based initiatives (vendor-plus-hospital group). Each hospital unit produced 1–2 months of baseline HH performance data immediately after AHHMS installation before implementing initiatives.
Hospital units in the vendor-plus-hospital group had a statistically significant increase of at least 46% in HH performance compared with units in the other 3 groups (P ≤ .006). Units in the hospital only group achieved a 1.3% increase in HH performance compared with units that had AHHMS alone (P = .950). Units with AHHMS plus other initiatives each had a larger change in HH performance rates over their baseline than those in the AHHMS-alone group (P < 0.001).
AHHMS combined with clinician-based vendor support and hospital-led unit-based initiatives resulted in the greatest improvements in HH performance. These results illustrate the value of a collaborative partnership between the hospital and the AHHMS vendor.
This chapter presents different spinal pathologies and explains how to examine each case. The specific clinical tests and clinical signs are pointed out for each case. Cases covered include kyphosis, ankylosing spondylosis, cervical myelopathy, rheumatoid spine and spondylolisthesis, amongst others.
Existing mass vaccination clinic guidance calls for staffing and resource requirements that may not be achievable in smaller settings. Practical and scalable solutions to these problems were developed by a volunteer group of continuous improvement professionals, working to assist 2 non-governmental organizations engaged in coordinating refugee health services: the Somali Health Board of Seattle, WA and Community Health Services Inc. of Rochester, MN. Our shared goal was to get more shots in arms by bringing vaccines to small communities through pop-up clinics that are quick to set-up and require minimal resources. The clinics were developed using continuous improvement methods, thereby yielding a 2-minute vaccine administration time and an 8-fold improvement in productivity as a result of Federal Emergency Management Agency (FEMA) guidance. This report details our field-tested methods and achieved results. The relevance and benefits of this approach deserve attention as pandemic response needs continue to evolve and vaccines become more globally available.
• Younger (aged 25-49) White men had a consistent advantage in the labour market between 1991 and 2011 compared with those in other ethnic groups, who were more likely to be not working or working in less secure employment.
• White women aged 25-49 also had a consistent employment advantage over the last 20 years compared with women in other ethnic groups.
• Exceptions to the pattern of White advantage were Indian and Chinese men, whose initial high unemployment and self-employment rates converged with those of the White group over the 20-year period. Black Caribbean women had similar labour market participation rates to White women from 1991 to 2011.
• At older ages (50-74), Black African men and women had the highest rates of labour market participation over the past 20 years. This is likely due to the age structure of the Black African group, where there are relatively few people aged over 65.
• Younger Pakistani and Bangladeshi men saw large falls in unemployment rates over the period 1991-2011 (respectively, from 25 to 10 per cent and from 26 to 11 per cent), but unemployment rates for these groups remain much higher than for White men.
• Black Caribbean and Black African younger men had rates of unemployment consistently more than double those of White men throughout the period 1991-2011.
• For Bangladeshi men, the fall in unemployment was balanced by a rise in part-time work; the 11-fold increase in part-time work for this group between 1991 and 2011 was larger than for any other ethnic group. In 2011, over one-third of Bangladeshi working men were employed part time.
• Pakistani and Bangladeshi women were the least likely, in the 25- to 49-year-old age group, to be in the labour market, but also experienced the highest rises in rates of economic activity between 1991 and 2011 (from 24 to 43 per cent for Pakistani women and from 17 to 40 per cent for Bangladeshi women).
• In the 50- to 74-year-old age group Pakistani and Bangladeshi women were the least likely to be in the labour market. From 1991 to 2011, these were the only groups that had increases in the proportion of women out of the labour market due to sickness.
• The advantage of younger White women in relation to unemployment reduced over the period, but was still present in 2011.
Response to lithium in patients with bipolar disorder is associated with clinical and transdiagnostic genetic factors. The predictive combination of these variables might help clinicians better predict which patients will respond to lithium treatment.
To use a combination of transdiagnostic genetic and clinical factors to predict lithium response in patients with bipolar disorder.
This study utilised genetic and clinical data (n = 1034) collected as part of the International Consortium on Lithium Genetics (ConLi+Gen) project. Polygenic risk scores (PRS) were computed for schizophrenia and major depressive disorder, and then combined with clinical variables using a cross-validated machine-learning regression approach. Unimodal, multimodal and genetically stratified models were trained and validated using ridge, elastic net and random forest regression on 692 patients with bipolar disorder from ten study sites using leave-site-out cross-validation. All models were then tested on an independent test set of 342 patients. The best performing models were then tested in a classification framework.
The best performing linear model explained 5.1% (P = 0.0001) of variance in lithium response and was composed of clinical variables, PRS variables and interaction terms between them. The best performing non-linear model used only clinical variables and explained 8.1% (P = 0.0001) of variance in lithium response. A priori genomic stratification improved non-linear model performance to 13.7% (P = 0.0001) and improved the binary classification of lithium response. This model stratified patients based on their meta-polygenic loadings for major depressive disorder and schizophrenia and was then trained using clinical data.
Using PRS to first stratify patients genetically and then train machine-learning models with clinical predictors led to large improvements in lithium response prediction. When used with other PRS and biological markers in the future this approach may help inform which patients are most likely to respond to lithium treatment.
Application of a self-practice self-reflection (SP/SR) framework to clinical training programmes for those learning cognitive behavioural therapy (CBT) have demonstrated positive outcomes. These programmes have typically resulted in reports of enhanced learning, improved clinical skills, heightened empathy, improved interpersonal skills, increased self-awareness, and self-development for those undertaking such training. However, the utility of specific activities within this framework for enhancing trainees’ learning still requires exploration. This study sought to explore the use of a low frustration tolerance (LFT) exercise to enhance trainee’s learning around issues relating to frustration and discomfort tolerance. It also further explored the possible application of SP/SR as a form of competency-based assessment. The study was based on 41 student trainees that engaged in a self-directed LFT exercise. Written reflections on these exercises were then thematically analysed. From a competency basis, the exercise provided an approach for observing the trainee’s competency with formulation skills, intervention planning, and self-reflective capacity. Participants reported both personal and professional development outcomes from the exercise. These included a ‘deepened’ understanding of cognitive behavioural principles related to their experiences, both in terms of principles relating to maintenance of dysfunction and to creating change. Increased self-awareness and learning outcomes relating to the development of interpersonal skills were also commonly reported by trainees.
Key learning aims
(1) To understand the usefulness of a behavioural experiment [a low frustration tolerance (LFT) exercise] for training within a SP/SR framework.
(2) To examine the potential for using SP/SR as a form of competency-based training.
(3) To demonstrate the benefits of experiential learning through SP/SR in training CBT.
Studying phenotypic and genetic characteristics of age at onset (AAO) and polarity at onset (PAO) in bipolar disorder can provide new insights into disease pathology and facilitate the development of screening tools.
To examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.
Genome-wide association studies (GWASs) and polygenic score (PGS) analyses of AAO (n = 12 977) and PAO (n = 6773) were conducted in patients with bipolar disorder from 34 cohorts and a replication sample (n = 2237). The association of onset with disease characteristics was investigated in two of these cohorts.
Earlier AAO was associated with a higher probability of psychotic symptoms, suicidality, lower educational attainment, not living together and fewer episodes. Depressive onset correlated with suicidality and manic onset correlated with delusions and manic episodes. Systematic differences in AAO between cohorts and continents of origin were observed. This was also reflected in single-nucleotide variant-based heritability estimates, with higher heritabilities for stricter onset definitions. Increased PGS for autism spectrum disorder (β = −0.34 years, s.e. = 0.08), major depression (β = −0.34 years, s.e. = 0.08), schizophrenia (β = −0.39 years, s.e. = 0.08), and educational attainment (β = −0.31 years, s.e. = 0.08) were associated with an earlier AAO. The AAO GWAS identified one significant locus, but this finding did not replicate. Neither GWAS nor PGS analyses yielded significant associations with PAO.
AAO and PAO are associated with indicators of bipolar disorder severity. Individuals with an earlier onset show an increased polygenic liability for a broad spectrum of psychiatric traits. Systematic differences in AAO across cohorts, continents and phenotype definitions introduce significant heterogeneity, affecting analyses.
The coronavirus disease 2019 (COVID-19) pandemic has resulted in shortages of personal protective equipment (PPE), underscoring the urgent need for simple, efficient, and inexpensive methods to decontaminate masks and respirators exposed to severe acute respiratory coronavirus virus 2 (SARS-CoV-2). We hypothesized that methylene blue (MB) photochemical treatment, which has various clinical applications, could decontaminate PPE contaminated with coronavirus.
The 2 arms of the study included (1) PPE inoculation with coronaviruses followed by MB with light (MBL) decontamination treatment and (2) PPE treatment with MBL for 5 cycles of decontamination to determine maintenance of PPE performance.
MBL treatment was used to inactivate coronaviruses on 3 N95 filtering facepiece respirator (FFR) and 2 medical mask models. We inoculated FFR and medical mask materials with 3 coronaviruses, including SARS-CoV-2, and we treated them with 10 µM MB and exposed them to 50,000 lux of white light or 12,500 lux of red light for 30 minutes. In parallel, integrity was assessed after 5 cycles of decontamination using multiple US and international test methods, and the process was compared with the FDA-authorized vaporized hydrogen peroxide plus ozone (VHP+O3) decontamination method.
Overall, MBL robustly and consistently inactivated all 3 coronaviruses with 99.8% to >99.9% virus inactivation across all FFRs and medical masks tested. FFR and medical mask integrity was maintained after 5 cycles of MBL treatment, whereas 1 FFR model failed after 5 cycles of VHP+O3.
MBL treatment decontaminated respirators and masks by inactivating 3 tested coronaviruses without compromising integrity through 5 cycles of decontamination. MBL decontamination is effective, is low cost, and does not require specialized equipment, making it applicable in low- to high-resource settings.
Traditional histories of German philosophy often present the development of German Idealism as a linear, teleological progression from Kant, through Fichte and Schelling, to Hegel. This approach originates in Hegel’s own history of philosophy, which portrays the history of German Idealism as a cumulative, dialectical progression that terminates – rather conveniently – in Hegel’s own absolute idealism. Over the past twenty years, there has been a growth of scholarship on the development of post-Kantian idealism, and a reappraisal of figures who were afforded only minor, supporting roles in the traditional narrative (figures such as K. L. Reinhold, S. Maimon, F. Schlegel, and Novalis). The effects of this revisionary scholarship have been salutary: it has resulted in a more nuanced picture of the development of German Idealism that challenges the standard Hegelian narrative; it has led to the recovery of important philosophical arguments and insights; it has made salient previously neglected continuities with earlier traditions (e.g., the Leibnizian-Wolffian and Spinozist traditions); and it has led to a deeper understanding of the philosophies of Fichte, Schelling, and Hegel by revealing their positions to be responses to hitherto unnoticed debates and questions.