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Neonates and infants who undergo congenital cardiac surgery frequently have difficulty with feeding. The factors that predispose these patients to require a gastrostomy tube have not been well defined. We aimed to report the incidence and describe hospital outcomes and characteristics in neonates and infants undergoing congenital cardiac surgery who required gastrostomy tube placement.
Materials and method:
A retrospective review was performed on patients undergoing congenital cardiac surgery between October 2015 and December 2020. Patients were identified by International Classification of Diseases 10th Revision codes, utilising the performance improvement database Vizient® Clinical Data Base, and stratified by age at admission: neonates (<1 month) and infants (1–12 months). Outcomes were compared and comparative analysis performed between admissions with and without gastrostomy tube placement.
There were 11,793 admissions, 3519 (29.8%) neonates and 8274 (70.2%) infants. We found an increased incidence of gastrostomy tube placement in neonates as compared to infants following congenital cardiac surgery (23.1% versus 6%, p = <0.001). Outcomes in neonates and infants were similar with increased length of stay and cost in those requiring a gastrostomy tube. Gastrostomy tube placement was noted to be more likely in neonates and infants with upper airway anomalies, congenital abnormalities, hospital infections, and genetic abnormalities.
Age at hospitalisation for congenital cardiac surgery is a definable risk factor for gastrostomy tube requirement. Additional factors contribute to gastrostomy tube placement and should be used when counselling families regarding the potential requirement of a gastrostomy tube.
Thirty years after the discovery of an Early Neolithic timber hall at Balbridie in Scotland was reported in Antiquity, new analysis of the site's archaeobotanical assemblage, featuring 20 000 cereal grains preserved when the building burnt down in the early fourth millennium BC, provide new insights into early farming practices. The results of stable isotope analyses of cereals from Balbridie, alongside archaeobotanical and stable isotope results from three other sites, indicate that while cereals were successfully cultivated in well-established plots without manuring at Balbridie, a variety of manuring strategies was implemented at the other sites. These differences reinforce the picture of variability in cultivation practices across Neolithic North-west Europe.
The mammalian respiratory system or lung is a tree-like branching structure, and the main site of gas exchange with the external environment. Structurally, the lung is broadly classified into the proximal (or conducting) airways and the distal alveolar region, where the gas exchange occurs. In parallel with the respiratory tree, the pulmonary vasculature starts with large pulmonary arteries that subdivide rapidly ending in capillaries adjacent to alveolar structures to enable gas exchange. The NOTCH signalling pathway plays an important role in lung development, differentiation and regeneration post-injury. Signalling via the NOTCH pathway is mediated through activation of four NOTCH receptors (NOTCH1-4), with each receptor capable of regulating unique biological processes. Dysregulation of the NOTCH pathway has been associated with development and pathophysiology of multiple adult acute and chronic lung diseases. This includes accumulating evidence that alteration of NOTCH3 signalling plays an important role in the development and pathogenesis of chronic obstructive pulmonary disease, lung cancer, asthma, idiopathic pulmonary fibrosis and pulmonary arterial hypertension. Herein, we provide a comprehensive summary of the role of NOTCH3 signalling in regulating repair/regeneration of the adult lung, its association with development of lung disease and potential therapeutic strategies to target its signalling activity.
We investigated the efficacy and complication profile of intranasal dexmedetomidine for transthoracic echocardiography sedation in patients with single ventricle physiology and shunt-dependent pulmonary blood flow during the high-risk interstage period.
A single-centre, retrospective review identified interstage infants who received dexmedetomidine for echocardiography sedation. Baseline and procedural vitals were reported. Significant adverse events related to sedation were defined as an escalation in care or need for any additional/increased inotropic support to maintain pre-procedural haemodynamics. Minor adverse events were defined as changes from baseline haemodynamics that resolved without intervention. To assess whether sedation was adequate, echocardiogram reports were reviewed for completeness.
From September to December 2020, five interstage patients (age 29–69 days) were sedated with 3 mcg/kg intranasal dexmedetomidine. The median sedation onset time and duration time was 24 minutes (range 12–43 minutes) and 60 minutes (range 33–60 minutes), respectively. Sedation was deemed adequate in all patients as complete echocardiograms were accomplished without a rescue dose. When compared to baseline, three (60%) patients had a >10% reduction in heart rate, one (20%) patient had a >10% reduction in oxygen saturations, and one (20%) patient had a >30% decrease in blood pressure. Amongst all patients, no significant complications occurred and haemodynamic changes from baseline did not result in need for intervention or interruption of study.
Intranasal dexmedetomidine may be a reasonable option for echocardiography sedation in infants with shunt-dependent single ventricle heart disease, and further investigation is warranted to ensure efficacy and safety in an outpatient setting.
This chapter asks whether the Sustainable Development Goals have advanced planetary ecological integrity, that is, strengthened policies towards the preservation of global commons at various levels of governance. We start with a brief account of the concept of planetary integrity, before engaging in a theoretical debate about the potential role of the Sustainable Development Goals in advancing planetary integrity, drawing on a literature survey. Finally, we assess the transformative potential of the goals for planetary integrity by focusing on governance interventions at international, regional, local and transnational levels. Our research shows that while the Sustainable Development Goals have raised concern about environmental protection, they do not motivate transformative change towards planetary integrity. Specifically, the literature raises doubts about the actual steering effects of the goals owing to their poor additionality with respect to existing environmental agreements, their inherent contradictions, and their weak ambition when it comes to planetary integrity.
This article is a clinical guide which discusses the “state-of-the-art” usage of the classic monoamine oxidase inhibitor (MAOI) antidepressants (phenelzine, tranylcypromine, and isocarboxazid) in modern psychiatric practice. The guide is for all clinicians, including those who may not be experienced MAOI prescribers. It discusses indications, drug-drug interactions, side-effect management, and the safety of various augmentation strategies. There is a clear and broad consensus (more than 70 international expert endorsers), based on 6 decades of experience, for the recommendations herein exposited. They are based on empirical evidence and expert opinion—this guide is presented as a new specialist-consensus standard. The guide provides practical clinical advice, and is the basis for the rational use of these drugs, particularly because it improves and updates knowledge, and corrects the various misconceptions that have hitherto been prominent in the literature, partly due to insufficient knowledge of pharmacology. The guide suggests that MAOIs should always be considered in cases of treatment-resistant depression (including those melancholic in nature), and prior to electroconvulsive therapy—while taking into account of patient preference. In selected cases, they may be considered earlier in the treatment algorithm than has previously been customary, and should not be regarded as drugs of last resort; they may prove decisively effective when many other treatments have failed. The guide clarifies key points on the concomitant use of incorrectly proscribed drugs such as methylphenidate and some tricyclic antidepressants. It also illustrates the straightforward “bridging” methods that may be used to transition simply and safely from other antidepressants to MAOIs.
We consider the use of sparsity-promoting norms in obtaining localised forcing structures from resolvent analysis. By formulating the optimal forcing problem as a Riemannian optimisation, we are able to maximise cost functionals whilst maintaining a unit-energy forcing. Taking the cost functional to be the energy norm of the driven response results in a traditional resolvent analysis and is solvable by a singular value decomposition (SVD). By modifying this cost functional with the $L_1$-norm, we target spatially localised structures that provide an efficient amplification in the energy of the response. We showcase this optimisation procedure on two flows: plane Poiseuille flow at Reynolds number $Re=4000$, and turbulent flow past a NACA 0012 aerofoil at $Re=23\,000$. In both cases, the optimisation yields sparse forcing modes that maintain important features of the structures arising from an SVD in order to provide a gain in energy. These results showcase the benefits of utilising a sparsity-promoting resolvent formulation to uncover sparse forcings, specifically with a view to using them as actuation locations for flow control.
Scrub typhus is a common bacterial infection in Asia caused by Orientia tsutsugamushi. This serological cohort study estimated the incidence of infection in a rural population in South India. Participants were enrolled through systematic sampling in 46 villages at baseline, and revisited the following year. Blood samples were tested for IgG antibodies using ELISA, followed by indirect immunofluorescence assays (IFA) in those positive for ELISA at both rounds. A case was defined as sero-conversion (ELISA), or at least a 4-fold titre increase (IFA), between the two time points. In addition to crude incidence rate estimates, we used piecewise linear rates across calendar months, with rates proportional to the monthly incidence of local hospital cases to address seasonality and unequal follow-up times. Of 402 participants, 61.7% were female. The mean age was 46.7 years, (range 13–88). 21 participants showed evidence for serological infection. The estimated incidence was 4.4 per 100 person-years (95% CI 2.8–6.7). The piecewise linear rates approach resulted in a similar estimate of 4.6 per 100 person years (95% CI 2.9–6.9). Considering previous estimates of symptomatic scrub typhus incidence in the same study population, only about 2–5% of infections may result in clinically relevant disease.
Health related quality of life in children who have undergone the Ross procedure has not been well characterized. The aim of this study was to characterize HRQOL in this cohort and compare to children with other CHD.
In this cross sectional, single-center study, HRQOL was assessed in patients who underwent a non-neonatal Ross procedure using the Pediatric Quality of Life Inventory (PedsQL). Ross cohort scores were compared with healthy norms, patients with CHD requiring no surgical intervention or had curative surgery (Severity 2, S2), and patients who were surgically repaired with ≥ 1 surgical procedure and with significant residual lesion or need for additional surgery (Severity 3, S3). Associations between PedsQL score and patient factors were also examined.
68 patients completed surveys. Nearly 1/6 of patients had overall scores below the cut-off for at-risk status for impaired HRQOL. There was no difference in overall HRQOL score between the Ross cohort and healthy children (p=0.56) and S2 cohort (p=0.97). HRQOL was significantly higher in the Ross cohort compared to S3 cohort (p =0.02). This difference was driven by a higher psychosocial HRQOL in the Ross cohort as compared to S3 cohort (p =0.007). Anxiety scores were significantly worse in the Ross cohort compared to both S2 (p=0.001) and S3 (p=0.0017), respectively.
Children who have undergone a Ross procedure report HRQOL equivalent to CHD not requiring therapy and superior to CHD with residual lesions. Despite these reassuring results, providers should be aware of potential anxiety among Ross patients.
The Homa Peninsula has been known to science since 1911, and fossil specimens from the area comprise many type specimens for common African mammalian paleospecies. Here we discuss the fauna and the paleoenvironmental information from the Homa Peninsula. The Homa Peninsula is a 200 km2 area in Homa Bay County, situated on the southern margin of the Winam Gulf of Lake Victoria in Kenya (Figure 29.1). Lake Victoria is estimated to be the third largest lake in the world, with a surface area of 68,900 km2 and a maximum length of approximately 616 km. Although its catchment is extensive, it is relatively shallow compared to any other lake of similar size, with a maximum depth of 84 m. Lake Victoria is located in a depression formed by the western and eastern branches of the East African Rift System (EARS), and is at an average elevation of 1135 m a.s.l. (Database for Hydrological Time Series of Inland Waters, 2017).
Background: Basilar artery stenting is a rescue therapy in the management of hyperacute stroke Published data on efficacy and safety are limited. Methods: A systematic review of published studies was performed in accordance with PRISMA guidelines. Inclusion criteria were adult patients with ischemic stroke with permanent basilar artery stent placement within 48 hours of onset. Data were extracted by two independent reviewers. Additional cases from our institution were identified via a local stroke registry. Results: Of 212 screened articles, patient-level data was reported in 35 studies (93 individuals) and six additional patients were included from our registry. Patients (n=99, 63% male; median age 64) most often presented with mid-basilar occlusion (52%) and 76% received treatment within 12 hours of onset. Favorable angiographic results occurred in 67%. The final modified Rankin Scale score (mRS) was 0-3 for 56% of patients; mortality was 29%. Those with complete flow post-procedure were more likely to have a final mRS of 0-3 (p=0.05). Conclusions: In 99 cases of basilar stenting in hyperacute stroke, favourable angiographic and functional outcomes were reported in 67% and 56% of patients, respectively. International multicenter registries are required to establish benefit and identify patient and technical factors that predict favorable outcomes.
Anxiety can interfere with attention and working memory, which are components that affect learning. Statistical models have been designed to study learning, such as the Bayesian Learning Model, which takes into account prior possibilities and behaviors to determine how much of a new behavior is determined by learning instead of chance. However, the neurobiological basis underlying how anxiety interferes with learning is not yet known. Accordingly, we aimed to use neuroimaging techniques and apply a Bayesian Learning Model to study learning in individuals with generalized anxiety disorder (GAD).
Participants were 25 controls and 14 individuals with GAD and comorbid disorders. During fMRI, participants completed a shape-button association learning and reversal task. Using a flexible factorial analysis in SPM, activation in the dorsolateral prefrontal cortex, basal ganglia, and hippocampus were compared between groups during First Reversal. Beta values from the peak of these regions were extracted for all learning conditions and submitted to repeated measures analyses in SPSS.
Individuals with GAD showed less activation in the basal ganglia and the hippocampus only in the First Reversal compared with controls. This difference was not present in the Initial Learning and Second Reversal.
Given that the basal ganglia is associated with initial learning, and the hippocampus with transfer of knowledge from short to long term memory, our results suggest that GAD may engage these regions to a lesser extent during early accommodation or consolidation of learning, but have no longer term effects in brain activation patterns during subsequent learning.
The year 2020 will be remembered as a moment of omni-crisis at the intersection of public health, politics, and economics. A global pandemic on a scale not seen in a century struck tens of millions and left a wake of devastation. Governments around the world responded in divergent ways, from competent and well organized to chaotic and inept, with predictable consequences for their citizens. Their economies suffered the consequences as well, with many facing skyrocketing rates of unemployment and business failure. Those at the low end of the income spectrum fared the worst: in the United States, employment in the foodservice industry dropped from 12 million to 6 million in a single month, leaving the equivalent of the population of Denmark out of work.
Typhoid fever is a major cause of illness and mortality in low- and middle-income settings. We investigated the association of typhoid fever and rainfall in Blantyre, Malawi, where multi-drug-resistant typhoid has been transmitting since 2011. Peak rainfall preceded the peak in typhoid fever by approximately 15 weeks [95% confidence interval (CI) 13.3, 17.7], indicating no direct biological link. A quasi-Poisson generalised linear modelling framework was used to explore the relationship between rainfall and typhoid incidence at biologically plausible lags of 1–4 weeks. We found a protective effect of rainfall anomalies on typhoid fever, at a two-week lag (P = 0.006), where a 10 mm lower-than-expected rainfall anomaly was associated with up to a 16% reduction in cases (95% CI 7.6, 26.5). Extreme flooding events may cleanse the environment of S. Typhi, while unusually low rainfall may reduce exposure from sewage overflow. These results add to evidence that rainfall anomalies may play a role in the transmission of enteric pathogens, and can help direct future water and sanitation intervention strategies for the control of typhoid fever.