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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.
To describe the clinical impact of healthcare-associated (HA) respiratory syncytial virus (RSV) in hospitalized adults.
Retrospective cohort study within a prospective, population-based, surveillance study of RSV-infected hospitalized adults during 3 respiratory seasons: October 2017–April 2018, October 2018–April 2019, and October 2019–March 2020.
The study was conducted in 2 academically affiliated medical centers.
Each HA-RSV patient (in whom RSV was detected by PCR test ≥4 days after hospital admission) was matched (age, sex, season) with 2 community-onset (CO) RSV patients (in whom RSV was detected ≤3 days of admission).
Risk factors and outcomes were compared among HA-RSV versus CO-RSV patients using conditional logistic regression. Escalation of respiratory support associated with RSV detection (day 0) from day −2 to day +4 was explored among HA-RSV patients.
In total, 84 HA-RSV patients were matched to 160 CO-RSV patients. In HA-RSV patients, chronic kidney disease was more common, while chronic respiratory conditions and obesity were less common. HA-RSV patients were not more likely to be admitted to an ICU or require mechanical ventilation, but they more often required a higher level of care at discharge compared with CO-RSV patients (44% vs 14%, respectively). Also, 29% of evaluable HA-RSV patients required respiratory support escalation; these patients were older and more likely to have respiratory comorbidities, to have been admitted to intensive care, and to die during hospitalization.
HA-RSV in adults may be associated with escalation in respiratory support and an increased level of support in living situation at discharge. Infection prevention and control strategies and RSV vaccination of high-risk adults could mitigate the risk of HA-RSV.
To describe the association between duration of antimicrobial prophylaxis (AMP) and 30-day surgical site infection (SSI), 7-day acute kidney injury (AKI), 90-day Clostridioides difficile infection (CDI), prolonged hospitalization, and 30-day reoperation after lumbar spine surgery for noninfectious indications, and to report adherence to current guidelines.
Participants and setting:
The study cohort comprised 6,198 patients who underwent lumbar spine surgery for noninfectious indications across 137 Veterans’ Health Administration surgery centers between 2016 and 2020.
Used univariate and multivariate logistic regression to determine the association between type and duration of AMP with 30-day SSI, 7-day AKI, 90-day CDI, prolonged hospitalization, and 30-day reoperation.
Only 1,160 participants (18.7%) received the recommended duration of AMP. On multivariate analysis, the use of multiple prophylactic antimicrobials was associated with increased odds of 90-day CDI (adjusted odds ratio [aOR], 5.5; 95% confidence interval [CI], 1.1–28.2) and 30-day reoperation (aOR, 2.3; 95% CI, 1.2–4.4). Courses of antimicrobials ≥3 days were associated with increased odds of prolonged hospitalization (aOR,1.8; 95% CI, 1.4–2.3) and 30-day reoperation (aOR, 3.5; 95% CI, 2.2–5.7). In univariate analysis, increasing days of AMP was associated with a trend toward increasing odds of 90-day CDI (cOR, 1.4; 95% CI, 1.0–1.8 per additional day; P = .056).
Longer courses of AMP after lumbar spine surgery were associated with higher odds of CDI, prolonged hospitalization, and reoperation, but not with lower odds of SSI. However, adherence to the recommended duration of AMP is very low, hinting at a wide evidence-to-practice gap that needs to be addressed by spine surgeons and antimicrobial stewardship programs.
Contrasting the well-described effects of early intervention (EI) services for youth-onset psychosis, the potential benefits of the intervention for adult-onset psychosis are uncertain. This paper aims to examine the effectiveness of EI on functioning and symptomatic improvement in adult-onset psychosis, and the optimal duration of the intervention.
360 psychosis patients aged 26–55 years were randomized to receive either standard care (SC, n = 120), or case management for two (2-year EI, n = 120) or 4 years (4-year EI, n = 120) in a 4-year rater-masked, parallel-group, superiority, randomized controlled trial of treatment effectiveness (Clinicaltrials.gov: NCT00919620). Primary (i.e. social and occupational functioning) and secondary outcomes (i.e. positive and negative symptoms, and quality of life) were assessed at baseline, 6-month, and yearly for 4 years.
Compared with SC, patients with 4-year EI had better Role Functioning Scale (RFS) immediate [interaction estimate = 0.008, 95% confidence interval (CI) = 0.001–0.014, p = 0.02] and extended social network (interaction estimate = 0.011, 95% CI = 0.004–0.018, p = 0.003) scores. Specifically, these improvements were observed in the first 2 years. Compared with the 2-year EI group, the 4-year EI group had better RFS total (p = 0.01), immediate (p = 0.01), and extended social network (p = 0.05) scores at the fourth year. Meanwhile, the 4-year (p = 0.02) and 2-year EI (p = 0.004) group had less severe symptoms than the SC group at the first year.
Specialized EI treatment for psychosis patients aged 26–55 should be provided for at least the initial 2 years of illness. Further treatment up to 4 years confers little benefits in this age range over the course of the study.
Perceived discrimination is associated with worse mental health. Few studies have assessed whether perceived discrimination (i) is associated with the risk of psychotic disorders and (ii) contributes to an increased risk among minority ethnic groups relative to the ethnic majority.
We used data from the European Network of National Schizophrenia Networks Studying Gene-Environment Interactions Work Package 2, a population-based case−control study of incident psychotic disorders in 17 catchment sites across six countries. We calculated odds ratios (OR) and 95% confidence intervals (95% CI) for the associations between perceived discrimination and psychosis using mixed-effects logistic regression models. We used stratified and mediation analyses to explore differences for minority ethnic groups.
Reporting any perceived experience of major discrimination (e.g. unfair treatment by police, not getting hired) was higher in cases than controls (41.8% v. 34.2%). Pervasive experiences of discrimination (≥3 types) were also higher in cases than controls (11.3% v. 5.5%). In fully adjusted models, the odds of psychosis were 1.20 (95% CI 0.91–1.59) for any discrimination and 1.79 (95% CI 1.19–1.59) for pervasive discrimination compared with no discrimination. In stratified analyses, the magnitude of association for pervasive experiences of discrimination appeared stronger for minority ethnic groups (OR = 1.73, 95% CI 1.12–2.68) than the ethnic majority (OR = 1.42, 95% CI 0.65–3.10). In exploratory mediation analysis, pervasive discrimination minimally explained excess risk among minority ethnic groups (5.1%).
Pervasive experiences of discrimination are associated with slightly increased odds of psychotic disorders and may minimally help explain excess risk for minority ethnic groups.
Non-communicable chronic diseases (NCCDs) are the main cause of morbidity and mortality globally. Demographic aging has resulted in older populations with more complex healthcare needs. This necessitates a multilevel rethinking of healthcare policies, health education and community support systems with digitalization of technologies playing a central role. The European Innovation Partnership on Active and Healthy Aging (A3) working group focuses on well-being for older adults, with an emphasis on quality of life and healthy aging. A subgroup of A3, including multidisciplinary stakeholders in health care across Europe, focuses on the palliative care (PC) model as a paradigm to be modified to meet the needs of older persons with NCCDs. This development paper delineates the key parameters we identified as critical in creating a public health model of PC directed to the needs of persons with NCCDs. This paradigm shift should affect horizontal components of public health models. Furthermore, our model includes vertical components often neglected, such as nutrition, resilience, well-being and leisure activities. The main enablers identified are information and communication technologies, education and training programs, communities of compassion, twinning activities, promoting research and increasing awareness amongst policymakers. We also identified key ‘bottlenecks’: inequity of access, insufficient research, inadequate development of advance care planning and a lack of co-creation of relevant technologies and shared decision-making. Rethinking PC within a public health context must focus on developing policies, training and technologies to enhance person-centered quality life for those with NCCD, while ensuring that they and those important to them experience death with dignity.
Fewer than 200 radiocarbon (14C) dates with secure contextual information are available for Cuba, making it challenging to reconstruct Caribbean indigenous population dynamics, their identities and interactions. In this paper, we discussed 21 accelerator mass spectrometry (AMS) 14C dates from two mounds (M1 and M2) at the Playa del Mango site (Granma province, Cuba), traditionally associated with the Banwaroid stone tool tradition. The ΔR calculated for the site was –132.0 ± 176 and –164.0 ± 68. The chronology of burials from the peripheral area of M2 suggested that the cemetery was continuously used from at least cal BC 116–AD 241 (2 σ). The domestic area of M2 was used at minimum between cal BC 55–AD 435 (2 σ), which encompasses the use of the funerary areas. An isolated human tooth from M1 [cal AD 125–435 (2 σ)] suggested that this funerary area is later than the one at the periphery of M2, and possibly contemporaneous with the later formation of the M2 shell midden. The archaeological assemblage of the “Banwaroid tradition” is widely distributed in Cuba, and mixed with other archaeological traditions, supporting that a complex web of human interactions took place in the Caribbean in precolonial times.
Mental health problems can lead to costs and benefits in other sectors (e.g. in the education sector) in addition to the healthcare sector. These related costs and benefits are known as intersectoral costs and benefits (ICBs). Although some ICBs within the education sector have been identified previously, little is known about their extensiveness and transferability, which is crucial for their inclusion in health economics research.
The aim of this study was to identify ICBs in the education sector, to validate the list of ICBs in a broader European context, and to categorize the ICBs using mental health as a case study.
Previously identified ICBs in the education sector were used as a basis for this study. Additional ICBs were extracted from peer-reviewed literature in PubMed and grey literature from six European countries. A comprehensive list of unique items was developed based on the identified ICBs. The list was validated by surveying an international group of educational experts. The survey results were used to finalize the list, which was categorized according to the care atom.
Additional ICBs in the education sector were retrieved from ninety-six sources. Fourteen experts from six European countries assessed the list for completeness, clarity, and relevance. The final list contained twenty-four ICBs categorized into input, throughput, and output.
By providing a comprehensive list of ICBs in the education sector, this study laid further foundations for the inclusion of important societal costs in health economics research in the broader European context.
To investigate changes in socio-economic inequalities in growth in height, weight, BMI and grip strength in children born during 1955–1993 in Guatemala, a period of marked socio-economic-political change.
We modelled longitudinal data on height, weight, BMI and hand grip strength using Super-Imposition by Translation and Rotation (SITAR). Internal Z-scores summarising growth size, timing and intensity (peak growth velocity, e.g. cm/year) were created to investigate inequalities by socio-economic position (SEP; measured by school attended). Interactions of SEP with date of birth were investigated to capture secular changes in inequalities.
Urban and peri-urban schools in the region of Guatemala City, Guatemala.
Participants were 40 484 children and adolescents aged 3–19 years of Ladino and Maya ancestry (nobservations 157 067).
The difference in height (SITAR size) between lowest and highest SEP decreased from −2·0 (95 % CI −2·2, −1·9) sd to −1·4 (95 % CI −1·5, −1·3) sd in males, and from −2·0 (95 % CI −2·1, −1·9) sd to −1·2 (95 % CI −1·3, −1·2) sd in females over the study period. Inequalities also reduced for weight, BMI and grip strength, due to greater secular increases in lowest-SEP groups. The puberty period was earlier and shorter in higher-SEP individuals (earlier SITAR timing and higher SITAR intensity). All SEP groups showed increases in BMI intensity over time.
Inequality narrowed between the 1960s and 1990s. The lowest-SEP groups were still >1 sd shorter than the highest. Risks remain for reduced human capital and poorer population health for urban Guatemalans.
We present a numerical methodology for construction of reduced-order models (ROMs) of fluid flows through the combination of flow modal decomposition and regression analysis. Spectral proper orthogonal decomposition is applied to reduce the dimensionality of the model and, at the same time, filter the proper orthogonal decomposition temporal modes. The regression step is performed by a deep feedforward neural network (DNN), and the current framework is implemented in a context similar to the sparse identification of nonlinear dynamics algorithm. A discussion on the optimization of the DNN hyperparameters is provided for obtaining the best ROMs and an assessment of these models is presented for a canonical nonlinear oscillator and the compressible flow past a cylinder. Then the method is tested on the reconstruction of a turbulent flow computed by a large eddy simulation of a plunging airfoil under dynamic stall. The reduced-order model is able to capture the dynamics of the leading edge stall vortex and the subsequent trailing edge vortex. For the cases analysed, the numerical framework allows the prediction of the flow field beyond the training window using larger time increments than those employed by the full-order model. We also demonstrate the robustness of the current ROMs constructed via DNNs through a comparison with sparse regression. The DNN approach is able to learn transient features of the flow and presents more accurate and stable long-term predictions compared to sparse regression.
Although relapse in psychosis is common, a small proportion of patients will not relapse in the long term. We examined the proportion and predictors of patients who never relapsed in the 10 years following complete resolution of positive symptoms from their first psychotic episode.
Patients who previously enrolled in a 12-month randomized controlled trial on medication discontinuation and relapse following first-episode psychosis (FEP) were followed up after 10 years. Relapse of positive symptoms was operationalized as a change from a Clinical Global Impression scale positive score of <3 for at least 3 consecutive months to a score of ⩾3 (mild or more severe). Baseline predictors included basic demographics, premorbid functioning, symptoms, functioning, and neurocognitive functioning.
Out of 178 first-episode patients, 37 (21%) never relapsed during the 10-year period. Univariate predictors (p ⩽ 0.1) of patients who never relapsed included a duration of untreated psychosis (DUP) ⩽30 days, diagnosed with non-schizophrenia spectrum disorders, having less severe negative symptoms, and performing better in logical memory immediate recall and verbal fluency tests. A multivariate logistic regression analysis further suggested that the absence of any relapsing episodes was significantly related to better short-term verbal memory, shorter DUP, and non-schizophrenia spectrum disorders.
Treatment delay and neurocognitive function are potentially modifiable predictors of good long-term prognosis in FEP. These predictors are informative as they can be incorporated into an optimum risk prediction model in the future, which would help with clinical decision making regarding maintenance treatment in FEP.
There is a large literature linking current BMI to levels of cardiovascular risk biomarkers, but it is unknown whether measures of BMI earlier in the life course and maximum BMI are predictive of current levels of biomarkers. The objective of the current study was to determine how current, maximum and age-25 BMI among individuals over the age of 60 years are associated with their current levels of cardiovascular risk biomarkers.
Cross-sectional study with retrospective recall.
Costa Rica (n 821) and the USA (n 4110).
Nationally representative samples of adults aged 60 years or over.
We used regression models to examine the relationship between multiple meaures of BMI with four established cardiovascular risk biomarkers. The most consistent predictor of current levels of systolic blood pressure, TAG and HDL-cholesterol was current BMI. However, maximum BMI was the strongest predictor of glycosylated Hb (HbA1c) and was also related to HDL-cholesterol and TAG. HbA1c was independent of current BMI. We found that these relationships are consistent between Costa Rica and the USA for HbA1c and for HDL-cholesterol.
Current levels of cardiovascular risk biomarkers are not only the product of current levels of BMI, but also of maximum lifetime BMI, particularly for levels of HbA1c and for HDL-cholesterol. Managing maximum obtained BMI over the life course may be most critical for maintaining the healthiest levels of cardiovascular risk.
This essay considers the development of Cuban American literature, which can be traced to the first part of the nineteenth century, when Cubans fled the Spanish colony to live and write in the United States. The early works were written in Spanish about island concerns. This critic argues that a US perspective is also discernable in these works. In its most recent manifestation, Cuban American literature refers to works produced by exiles fleeing Castro’s rise to power, living mainly in Miami but also in other US cities. Written in Spanish and English, these works take issues with events unfolding at home and in the adopted country. They combine two perspective, two geographic spaces, two cultures, and two languages. In the United States, women, gay, and lesbian writers explore uncomfortable topics known to their parents’ culture. Cuban American literature is rich and varied, and speaks to the changing perspectives of the Cuban American experience.
Two female snapper-choking isopods Cymothoa excisa (body length 11 and 14 mm) were in the buccal cavity of two invasive lionfish Pterois volitans (total length 294 and 301 mm) collected in Alacranes Reef, southern Gulf of Mexico. This is the first record of C. excisa parasitizing invasive lionfish P. volitans in coral reefs of the Western Atlantic, where these isopods appear to have infected the host through adult prey-predator transfer.
Field experiments were established in 1989 and 1990 at the Southern Piedmont Conservation Research Center near Watkinsville, GA, to determine effects of coastal bermudagrass density on cotton in a conservation tillage system. Cotton height, canopy width, leaf area indices, and seed cotton yields were determined at coastal bermudagrass densities of 0 to 3600 kg ha−1 as achieved by herbicide inputs. Soil water measurements were recorded in cotton plots with a range of coastal bermudagrass densities using time domain reflectometry. Cotton growth and yields were reduced by coastal bermudagrass competition both years of the study. At the highest coastal bermudagrass density of 3600 kg ha−1, cotton height was reduced compared to cotton alone as early as 5 wk after planting. Seed cotton yields were reduced 25% at the highest coastal bermudagrass densities both years of the study. At the 15-cm soil depth, coastal bermudagrass significantly reduced soil water in cotton. Soil water in cotton at 30, 45, and 60 cm was not affected by coastal bermudagrass.
Social wasps can face many challenges during their colony cycle, including the presence of parasites. The order Strepsiptera is among the main parasites of the wasp genus Polistes. The aim of this study was to evaluate the effect of an endoparasite species on the host Polistes ferreri, with the hypothesis that females of this social wasp would undergo morphophysiological alterations as well as changes in their cuticular chemical profile caused by the obligate endoparasite. On average, parasitism was found in 10% of the colonies studied. All the parasitized females showed filamentous ovarioles without developing oocytes, which indicates a physiological castration. Moreover, the endoparasites present in the gaster of females caused its volume to increase, and the presence of endoparasites changed the cuticular chemical profiles of females, confirming our hypothesis. It is likely that this parasitism effect could hamper the maintenance of wasp colonies.
Tidal rhythmites of the Tonganoxie Sandstone Member (Stranger Formation, Douglas Group) at Buildex Quarry, eastern Kansas, contain a relatively diverse ichnofauna. The assemblage includes arthropod locomotion (Dendroidichnites irregulare, Diplichnites gouldi types A and B, Diplopodichnus biformis, Kouphichnium isp., Mirandaichnium famatinense, and Stiaria intermedia), resting (Tonganoxichnus buildexensis) and feeding traces (Stiallia pilosa, Tonganoxichnus ottawensis); grazing traces (Gordia indianaensis, Helminthoidichnites tenuis, Helminthopsis hieroglyphica); feeding structures (Circulichnis montanus, Treptichnus bifurcus, Treptichnus pollardi, irregular networks), fish traces (Undichna britannica, Undichna simplicitas), tetrapod trackways, and root traces. The taxonomy of some of these ichnotaxa is briefly reviewed and emended diagnoses for Gordia indianaensis and Helminthoidichnites tenuis are proposed. Additionally, the combined name Dendroidichnites irregulare is proposed for nested chevron trackways. Traces previously regarded as produced by isopods are reinterpreted as myriapod trackways (D. gouldi type B). Trackways formerly interpreted as limulid crawling and swimming traces are assigned herein to Kouphichnium isp and Dendroidichnites irregulare, respectively.
Taphonomic analysis suggests that most grazing and feeding traces were formed before the arthropod trackways and resting traces. Grazing/feeding traces were formed in a soft, probably submerged substrate. Conversely, the majority of trackways and resting traces probably were produced subaerially in a firmer, dewatered and desiccated sediment.
The Buildex Quarry ichnofauna records the activity of a terrestrial and freshwater biota. The presence of this assemblage in tidal rhythmites is consistent with deposition on tidal flats in the most proximal zone of the inner estuary, between the maximum landward limit of tidal currents and the salinity limit further towards the sea.
A new genus, Popenoeum, is proposed for a clade of Upper Cretaceous through lower Eocene pseudolivine gastropods found in North and South America, West Greenland, western Europe, and southern India. Popenoeum n. gen. is characterized by tabulate whorls with a prominent subsutural canal, collabral costae that terminate as tubercles on the body whorl shoulder, and closely spaced fine to strong spiral cords.
The type species, Popenoeum maritimus n. sp., is from the lower Paleocene (Danian) portion of the San Francisquito Formation, southern California, and from the upper Paleocene (Thanetian) Sepultura Formation, Baja California. Popenoeum maritimus bajaensis n. subsp. is also present in the Sepultura Formation.
Other species and subspecies in the clade include Popenoeum sp. (Toulmin) and P. scalina Heilprin from Alabama; P. mutabilis mutabilis (Woods) and P. mutabilis woodsi (Olsson) from northwestern Peru; P. aff. P. maritimus from West Greenland; P. brevis (Doncieux) and P. prima (Defiance) from France; P. chavani (Glibert), P. robusta (Briart and Cornet) and P. briarti (Vincent) from Belgium; and P. subcostata (Stoliczka) from southern India. The earliest species is P. subcostata, and it is the only Cretaceous species. The youngest form is P. mutabilis woodsi, and it is the only Eocene species. The new genus reached its peak during the Paleocene.
We present the observed “continuum” levels of polarization as a function of time for four well-observed Type II-Plateau supernovae (SNe II-P; Fig. 1), the class of SNe decisively determined to arise from red supergiant stars (Smartt 2009). All four objects show temporally increasing degrees of polarization through the end of the photospheric phase, with some exhibiting early-time polarization that challenge existing models (e.g., Dessart and Hillier 2011) to reproduce. A fundamental ejecta asymmetry is present in this photometrically diverse sample of type II SNe, and it probably takes different forms (e.g., 56Ni blobs/fingers, large scale deformation). We acknowledge support from NSF grants AST-1009571 and AST-1210311.