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Thrombosis, especially in the Fontan pathway, is one of the major concerns in patients who underwent Fontan surgery, with reported prevalence of 5–33%. We report a case of thrombus in a rudimentary left ventricle in teenager with no arrhythmia or neurological complications. We also report the special concerns of silent thrombus and role of cardiac MRI in diagnosing an intracardiac thrombus.
Introduction: Adoption of a new Electronic Health Record (EHR) can introduce radical changes in task allocation, work processes, and efficiency for providers. In June 2019, The Ottawa Hospital transitioned from a primarily paper based EHR to a comprehensive EHR (Epic) using a “big bang” approach. The objective of this study was to assess the impact of the transition to Epic on Emergency Physician (EP) work activities in a tertiary care academic Emergency Department (ED). Methods: We conducted a time motion study of EPs on shift in low acuity areas of our ED (CTAS 3-5). Fifteen EPs representing a spectrum of pre-Epic baseline workflow efficiencies were directly observed in real-time during two 4-hour sessions prior to EHR implementation (May 2019) and again in go live (August 2019). Trained observers performed continuous observation and measured times for the following EP tasks: chart review, direct patient care, documentation, physical movement, communication, teaching, handover, and other (including breaks). We compared time spent on tasks pre Epic and during go live and report mean times for the EP tasks per patient and per shift using two tailed t-test for comparison. Results: All physicians had a 17% decrease in patients seen after Epic implementation (2.72/hr vs 2.24/hr, p < 0.01). EPs spent the same amount of time per patient on direct patient care and chart review (direct patient care: 9min06sec/pt pre vs 8min56sec/pt go live, p = 0.77; chart review: 2min47sec/pt pre vs 2min50sec/pt go live, p = 0.88), however, documentation time increased (5min28sec/pt pre vs 7min12sec/pt go live, p < 0.01). Time spent on shift teaching learners increased but did not reach statistical significance (31min26sec/shift pre vs 36min21sec/shift go live, p = 0.39), and time spent on non-patient-specific activities – physical movement, handover, team communication, and other – did not change (50min49sec/shift pre vs 50min53sec/shift go live, p = 0.99). Conclusion: Implementation of Epic did not affect EP time with individual patients - there was no change in direct patient care or chart review. Documentation time increased and EP efficiency (patients seen per hr on shift) decreased after go live. Patient volumes cannot be adjusted in the ED therefore anticipating the EHR impact on EP workflow is critical for successful implementation. EDs may consider up staffing 20% during go live. Findings from this study can inform how to best support EDs nationally through transition to EHR.
Effective management of uncertainty can lead to better, more informed decisions. However, many decision makers and their advisers do not always face up to uncertainty, in part because there is little constructive guidance or tools available to help. This paper outlines six Uncertainty Principles to manage uncertainty.
Face up to uncertainty
Deconstruct the problem
Don’t be fooled (un/intentional biases)
Models can be helpful, but also dangerous
Think about adaptability and resilience
Bring people with you
These were arrived at following extensive discussions and literature reviews over a 5-year period. While this is an important topic for actuaries, the intended audience is any decision maker or advisor in any sector (public or private).
Sheath blight caused by soil borne necrotrophic fungus Rhizoctonia solani [teleomorph-Thanatephorus cucumeris (Frank) Donk.] is a major disease of rice. The disease is increasing over the year in India and cause up to 69% yield loss under favourable conditions. A total of 67 accessions of Oryza nivara were screened to identify resistance against sheath blight during 2015. Out of these, 16 accessions were found moderately resistant (MR) which were further evaluated during the year 2016 and 2017. After three years of screening, 12 of them were found to have a consistent moderate resistant reaction whereas four of the O. nivara accessions namely, IRGC81941, IRGC102463C, CR100097 and CR100110A have shown moderately susceptible to susceptible reaction against sheath blight. A correlation study revealed that different disease variables measured were significantly (P < 0.05) correlated. All the genotypes and genotype × environment interaction had a significant (P < 0.001) effect on all the disease variables. Cluster analysis showed that all the accessions were clustered into four groups which showed resistant, MR, moderately susceptible and susceptible reactions. Among all the O. nivara accessions IRGC81941A showed the maximum potential against sheath blight due to a least relative lesion height of 22.80%. None of the accession had complete resistance to the disease. The identified promising accessions such as IRGC81835, IRGC81941A, CR100008 and CR100111B can be utilized in a sheath blight resistance breeding program.
Silver nanowire-based contacts represent one of the major new directions in transparent contacts for opto-electronic devices with the added advantage that they can have Indium-Tin-Oxide-like properties at substantially reduced processing temperatures and without the use of vacuum-based processing. However, nanowires alone often do not adhere well to the substrate or other film interfaces; even after a relatively high-temperature anneal and unencapsulated nanowires show environmental degradation at high temperature and humidity. Here we report on the development of ZnO/Ag-nanowire composites that have sheet resistance below 10 Ω/sq and >90% transmittance from a solution-based process with process temperatures below 200 °C. These films have significant applications potential in photovoltaics and displays.
We compare the results of using a Random Forest Classifier with the results of using Nonparametric Discriminant Analysis to classify whether a filament channel (in the case of a filament eruption) or an active region (in the case of a flare) is about to produce an event. A large number of descriptors are considered in each case, but it is found that only a small number are needed in order to get most of the improvement in performance over always predicting the majority class. There is little difference in performance between the two classifiers, and neither results in substantial improvements over simply predicting the majority class.
To evaluate the success rate of dry and wet temporalis fascia grafts in type I underlay tympanoplasty.
A prospective, randomised study was conducted. One hundred adult patients (males and females) with chronic suppurative otitis media (mucosal type) were divided into 2 groups of 50 each: one group underwent dry graft tympanoplasty and the other underwent wet graft tympanoplasty. Fibroblast count was calculated in dry and wet grafts.
The dry graft and wet graft groups had overall surgical success rates of 82 and 90 per cent, respectively; this finding was not statistically significant. A statistically significant high fibroblast count was observed in wet grafts, but it did not correlate with surgical success.
A dry or wet temporalis fascia graft does not influence the outcome of tympanoplasty type I.
Individual-level measures of acculturation (e.g. age of immigration) have a complex relationship with psychiatric disorders. Fine-grained analyses that tap various acculturation dimensions and population subgroups are needed to generate hypotheses regarding the mechanisms of action for the association between acculturation and mental health.
Study participants were US Latinos (N = 6359) from Wave 2 of the 2004–2005 National Epidemiologic Survey of Alcohol and Related Conditions (N = 34 653). We used linear χ2 tests and logistic regression models to analyze the association between five acculturation dimensions and presence of 12-month DSM-IV mood/anxiety disorders across Latino subgroups (Mexican, Puerto Rican, Cuban, ‘Other Latinos’).
Acculturation dimensions associated linearly with past-year presence of mood/anxiety disorders among Mexicans were: (1) younger age of immigration (linear χ21 = 11.04, p < 0.001), (2) longer time in the United States (linear χ21 = 10.52, p < 0.01), (3) greater English-language orientation (linear χ21 = 14.57, p < 0.001), (4) lower Latino composition of social network (linear χ21 = 15.03, p < 0.001), and (5) lower Latino ethnic identification (linear χ21 = 7.29, p < 0.01). However, the associations were less consistent among Cubans and Other Latinos, and no associations with acculturation were found among Puerto Ricans.
The relationship between different acculturation dimensions and 12-month mood/anxiety disorder varies across ethnic subgroups characterized by cultural and historical differences. The association between acculturation measures and disorder may depend on the extent to which they index protective or pathogenic adaptation pathways (e.g. loss of family support) across population subgroups preceding and/or following immigration. Future research should incorporate direct measures of maladaptive pathways and their relationship to various acculturation dimensions.
This study was designed to study the variations in different geometrical and dosimetric parameters.
Materials and methods
In this study, two groups comprises 21 and 28 patients, who were treated with 9·5 Gy × 2 Fx and 7·5 Gy × 3 Fx, respectively, using microselectron high-dose rate (HDR) remote control unit. All patients were analysed using orthogonal radiographs to evaluate variations in different parameters.
Variations in different parameters are more in Group II patients than in Group I patients, which show that the variation in geometrical and dosimetrical parameters increases with increasing HDR number of fractions.
In the reporting of an outcome of multiple fractionation of HDR treatments resultant dosimetric parameters must be evaluated and must be used for clinical interpretation.
Ghumusar is an inadequately studied goat population of western region of Ganjam district of Orissa state. Sporadic information is available on its morphological traits but no information is found on its genetic variability. Therefore, an attempt was made to measure the genetic diversity in Ghumusar goat population using 25 microsatellite markers. Genomic DNA isolated from blood samples drawn at random from 50 individuals were utilized for this study. The average number of observed allele was 9.80 and the effective average number of allele was 4.28. The polymorphic information contents ranged from 0.53 to 0.91. The average observed and expected heterozygosity was 0.73 and 0.71, respectively. The values of Nei's gene diversity in Ghumusar goat population ranged from 0.11 to 0.87 with a mean of 0.69. The overall Fis value was observed to be 0.002, which is not significantly different from zero; hence indicating no global deficit of heterozygotes. Under sign test, expected number of loci with heterozygosity excess (Hee) was 14.88, 14.79 and 14.74 for the infinite allele model (IAM), stepwise mutation model (SMM) and two-phased model (TPM) of mutation, respectively. The observed number of loci with heterozygotic excess (He) was 14, 8 and 2 under these three models, respectively. Under all the three models, He was less than Hee and this deviation was significant under SMM and TPM models. There was no serious genetic reduction in effective population size as indicated by L-shaped curve in Ghumusar goat population.
Introduction: Radiographic findings of dengue fever have not yet been clearly elucidated in relation to clinical and serological findings, despite the fact that two-fifths of the world population lives in areas where the virus is endemic. The current study is a retrospective analyzis of ultrasonographic (USG) features of patients presenting with probable dengue fever during the outbreak of DF of 2006 in North India.
Methods: Case records of a 169 patients with probable dengue fiver were included. Ten individual sonographic parameters were reviewed vis-à-vis ascites, hepatomegaly, splenomegaly, gall bladder wall edema (GBWE), pleural effusion (right or left or both), pericardial effusion, pericholecystic collection, perinephric collection. Subjects who had GB wall thickness >3 mm as measured on ultrasound were identified as positive for GBWE. The cases were analyzed in view of their serological profile.
Results: The mean age of the subjects was 27.9 +/− 13.4 years. The mean value of the platelet count was 57.4 +/− 22.3 x 103/cmm. The most common ultrasonographic feature was ascites (126, 74.6%) followed by gall bladder wall edema (122, 72%), hepatomegaly (78, 46.2%), splenomegaly (66, 39.1%) and pericholecystic collection (63, 37.3%); 48 (28.4%) subjects demonstrated evidence of pleural effusion on the right side, while 19 (11.2%) had bilateral effusion. None of the subjects had an isolated left pleural effusion. Twenty-seven (16%) subjects reported bleeding manifestations in the form of petechiae and five (3%) developed renal dysfunction. Presence of pleural and pericardial effusions was found to be specific while ascites and GBWE were identified as highly sensitive markers for seropositive Primary DF.
Conclusions: Ultrasonographic evidence of ascites, pleuro-pericardial effusion, and gallbladder wall edema are rapidly aquired, non-invasive markers of dengue and can be helpful before serological investigations become available. These findings may indicate severity and may herald the onset of bleeding (petechiae) or predict the development of acute renal dysfunction.
Basic emergency care at primary, secondary and tertiary health care level in India is in its infancy. Lack of training in emergency care is an important factor. We designed AIIMS basic emergency care course (AIIMS BECC) to address the issue.
To improve the knowledge, skill and attitude of healthcare workers and laypersons in basic emergency care and to identify and train instructors.
Prospective study conducted over a period of one and half years. The target groups were medical, police, fire fighter, paramilitary forces, teachers, school children of India. Provider AIIMS BECC is of one day duration. The contents of the course are cardio-pulmonary resuscitation, chocking and special scenarios like trauma, electrocution, drowning, hypothermia, pregnancy, etc. Course was disseminated via lectures, audio-visual and hands on training. The participants were evaluated by pre and post test questions. Subjects had to score 80% to be successful and those who scored more than 90% were eligible for instructor course. The confidence levels at baseline and at the end of the course were evaluated in policecourses were evaluated on course clarity, course delivery and trainers quality on a likert scale (1 = worst, 5 = excellent).
1614 subjects were trained. 99.81% became providers and 2.6% were trained as instructors. 83.1% were non-medical and16.9% were medical personals. 76.14% were police, paramilitary 0.8%, teachers 1.6%, students 2.1% and mixed groups were 2.6%. The average and modal increase in confidence level among police were 66.14% and 62.49%. Likert scale of ≥ 4 was observed in 90.7% in course clarity, 91.28% in course delivery and 95.26% in trainer quality.
Knowledge, skill and attitude of healthcare care and laypersons in providing basic emergency care improved by community emergency care initiative. Instructors were identified for further dissemination of the course. The confidence levels increased among police.
To assess the outcome of conservative management of vestibular schwannoma.
Tertiary referral centre.
Four hundred and thirty-six patients with vestibular schwannoma (490 tumours), including 327 sporadic tumours and 163 tumours in 109 patients with neurofibromatosis type two.
Main outcome measures:
The relationship of tumour growth to tumour size at presentation, and to certain demographic features.
The initial tumour size was significantly larger in the neurofibromatosis type two group (11 mm) than in the sporadic vestibular schwannoma group (5.1 mm). In both groups, 68 per cent of tumours did not grow during follow up (mean 3.6 years; range one to 14 years). The mean growth rate was 1.1 mm/year (range 0–15 mm/year) for sporadic tumours and 1.7 mm/year (range 0–18 mm/year) for neurofibromatosis type two tumours. The tumour growth rate correlated positively with tumour size in the sporadic tumour group, and correlated negatively with age in the neurofibromatosis type two group.
Two-thirds of vestibular schwannomas did not grow. Radiological surveillance is an acceptable approach in carefully selected patients. Once a sporadic vestibular schwannoma reaches 2 cm in intracranial diameter, it is likely to continue growing. We do not recommend conservative management for sporadic tumours with an intracranial diameter of 1.5 cm or more. Vestibular schwannoma management is more complex in patients with neurofibromatosis type two.
The problem of the two-stream instability in warm, collisionless, field-free plasmas is investigated for arbitrary direction of propagation vector, using the moment equations. It is found that the configurations characterized by (i) a beam of electrons with ions immobile, and (ii) all electrons moving through mobile ions, are stable for subsonic interpenetration speeds. For supersonic speeds, however, the configurations are unstable both for electrostatic and electromagnetic perturbations. The former instability is restricted only to a cone of propagation about the streaming direction, while the latter exists for all angles, and has growth rates that are even larger than the electrostatic growth rates in the limit of long-wavelength perturbations.
Oral submucous fibrosis is a chronic disease characterised by progressive inability to open the mouth. Various treatment modalities are available for its management, but these have largely been ineffective.
Materials and methods:
Nine cases of oral submucous fibrosis underwent a release procedure using a KTP-532 laser, from March 2005 to January 2006, within the ENT – head and neck surgery department of a tertiary centre.
Pre- and post-operative mouth-opening was compared using the Wilcoxon signed rank test, and a significant difference observed (Z = −2.690, p = 0.007). Follow up over an average period of 12 months showed encouraging results.
This preliminary study indicated that adequate release of oral submucous fibrosis can be achieved by using a KTP-532 laser release procedure, with minimal morbidity and satisfactory results. These promising results should encourage more widespread use of this technique in the management of this condition.
The first of several cases of meningococcal meningitis was reported in April 2005, in New Delhi, India. Subsequent to this the Government declared an outbreak, which persisted for two periods, from April–July 2005 and January–March 2006. The National Institute of Communicable Diseases (NICD) recommended using WHO criteria for diagnosis of disease. During the outbreak 380 clinically suspected cases were investigated. Of 55 cases diagnosed as confirmed/probable the mortality rate was 14·6%. Meningitis was reported in 60% of cases and meningococcaemia in 40%. Microscopy of petechial rash was positive in 87·5%, CSF Gram stain positive in 68·3%, and latex agglutination test of CSF positive in 64·9% of samples. Neisseria meningitidis (serogroup A) was isolated from 37·7% of cases, 57·7% from CSF. Blood culture was positive in 10·4% of cases. CrgA polymerase chain reaction for N. meningitidis confirmed the isolates. All isolates were susceptible to third-generation cephalosporins, azithromycin and rifampicin, with increasing resistance to ceftriaxone. Penicillin resistance was encountered in 15·4% of strains. Resistance to quinolones was very high at 100% for levofloxacin, 84·6% for ofloxacin and 65·4% for ciprofloxacin. All patients with penicillin-resistant organisms (4) or intermediate sensitivity (4) succumbed to the disease. These patients also had a higher minimum inhibitory concentration to ceftriaxone.
Fourteen strains of S. Typhi (n=13) and S. Paratyphi A (n=1) resistant to ciprofloxacin were compared with 30 ciprofloxacin decreased-susceptibility strains on the basis of qnr plasmid analysis, and nucleotide substitutions at gyrA, gyrB, parC and parE. In ciprofloxacin-resistant strains, five S. Typhi and a single S. Paratyphi A showed triple mutations in gyrA (Ser83→Phe, Asp87→Asn, Glu133→Gly) and a novel mutation outside the quinolone resistance determining region (QRDR) (Met52→Leu). Novel mutations were also discovered in an isolate (minimum inhibitory concentration 8 μg/ml) in gyrA gene Asp76→Asn and outside the QRDR Leu44→Ile. Out of 30 isolates with reduced susceptibility, single mutation was found in 12 strains only. Genes encoding qnr plasmid (qnr A, qnr B, AAC1-F) were not detected in ciprofloxacin-resistant or decreased-susceptibility strains. Antimicrobial surveillance coupled with molecular analysis of fluoroquinolone resistance is warranted for reconfirming novel and established molecular patterns of resistance, which is quintessential for reappraisal of enteric fever therapeutics.
Barium copper sulfur fluoride thin films with a face-centered cubic phase in the Fm3m space group were synthesized via RF magnetron sputtering. The results of a detailed optical and electronic characterization of the films are presented. As-deposited, they exhibit degenerate p-type conductivity at room temperature of approximately 260 S/cm – higher than that of any previously reported p-TC. Their conductivity after post-deposition processing increases to as high as 800 S/cm. The films exhibit bandgaps ranging from 1.45-1.75 eV. They are typically deposited with a substrate temperature between room temperature and 100°C, making them suitable for deposition on plastic as well as glass or crystalline substrates. It was found that a silica protective layer reduces degradation in film transparency that is caused by exposure to air.
Elongated styloid process is a relatively common cause of facial and neck pain, but it is often misdiagnosed due to its varied clinical presentation. Since an elongated styloid process is often confirmed by radiological means, it would be helpful to find a more accurate mode of depicting the styloid process.
In this prospective study, 39 cases were evaluated. A three-dimensional computed tomography (3D CT) reconstruction of the styloid process was performed in 18 cases. In these patients, we compared the length and medial angulation of the symptomatic styloid process as viewed on an orthopantomogram and a 3D CT reconstruction.
It was noted that a 3D CT reconstruction was more accurate in depicting the styloid process. This investigation can be considered as the ‘gold standard’ in the radiological diagnosis of an elongated styloid process.
There is marked diversity in the reported success rates for achieving an intact tympanic membrane following myringoplasty. Controversy exists about the factors thought to influence surgical outcome. Both of these facts have important implications for obtaining informed consent prior to surgery.
This study reviews the factors thought to determine the likelihood of achieving complete closure of the tympanic membrane following surgical closure.