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IMPORTANCE: The use of valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) has been rapidly expanding as an alternative treatment to redo surgical aortic valve replacement (SAVR) for failed bioprosthetic valves despite limited long-term data. OBJECTIVE: To assess mortality and morbidity in patients undergoing intervention for failed bioprosthetic SAVR. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective population-based cohort analysis conducted between January 1, 2015, and December 31, 2020, with a median (IQR) follow-up time of 2.3 (1.1-4.0) years. A total of 1771 patients with a history of bioprosthetic SAVR who underwent ViV-TAVR or redo SAVR in California, New York, and New Jersey were included. Data were obtained from the California Department of Health Care Access and Information, the New York Statewide Planning and Research Cooperative System, and the New Jersey Discharge Data Collection System. Exclusion criteria included undergoing TAVR or redo SAVR within 5 years from initial SAVR, as well as infective endocarditis, concomitant surgical procedures, and out-of-state residency. Propensity matching yielded 375 patient pairs. Data were analyzed from January to December 2023. INTERVENTIONS: ViV-TAVR vs redo SAVR. MAIN OUTCOMES AND MEASUREMENTS: The primary outcome was all-cause mortality. Secondary outcomes were stroke, heart failure hospitalization, reoperation, major bleeding, acute kidney failure, new pacemaker insertion, and infective endocarditis. RESULTS: From 2015 through 2020, the proportion of patients undergoing ViV-TAVR vs redo SAVR increased from 159 of 451 (35.3%) to 498 or 797 (62.5%). Of 1771 participants, 653 (36.9%) were female, and the mean (SD) age was 74.4 (11.3) years. Periprocedural mortality and stroke rates were similar between propensity-matched groups. The ViV-TAVR group had lower periprocedural rates of major bleeding (2.4% vs 5.1%; P = .05), acute kidney failure (1.3% vs 7.2%; P < .001), and new pacemaker implantations (3.5% vs 10.9%; P < .001). The 5-year all-cause mortality rate was 23.4% (95% CI, 15.7-34.1) in the ViV-TAVR group and 13.3% (95% CI, 9.2-18.9) in the redo SAVR group. In a landmark analysis, no difference in mortality was observed up to 2 years (hazard ratio, 1.03; 95% CI, 0.59-1.78), but after 2 years, ViV-TAVR was associated with higher mortality (hazard ratio, 2.97; 95% CI, 1.18-7.47) as well as with a higher incidence of heart failure hospitalization (hazard ratio, 3.81; 95% CI, 1.57-9.22). There were no differences in 5-year incidence of stroke, reoperation, major bleeding, or infective endocarditis. CONCLUSIONS AND RELEVANCE: Compared with redo SAVR, ViV-TAVR was associated with a lower incidence of periprocedural complications and a similar incidence of all-cause mortality through 2 years’ follow-up. However, ViV-TAVR was associated with higher rates of late mortality and heart failure hospitalization. These findings may be influenced by residual confounding and require adjudication in a randomized clinical trial.

AbstractObjectives:The aim of the present study was to evaluate the levels of possible internet addiction, gaming addiction, gambling addiction and associated mental health difficulties in a secondary school population in Ireland.Methods:An online survey containing questions related to internet addiction, gaming addiction, gambling addiction and associated mental health difficulties was administered to secondary school adolescents in Ireland. Participants were self-selecting and answered questions on the characteristics of each topic and screening questionnaires for addiction to each behaviour, as well as their respective effects on mental health.Results:A total of 234 children participated in the survey (156 males; aged 12–18 years; average age of 14.2 years; S.D. 1.60). Internet addiction as assessed using the Chen Internet Addiction Scale was present for between 11.5% and 22.6% and levels of gaming addiction as assessed using by the Internet Gaming Disorder Scale–Short Form was present for between 0.5% and 1.6%. Weak positive correlations were found between time spent on the internet and time spent gaming with internet addiction and gaming addiction, respectively. There were weak positive correlations between higher internet addiction scores, higher gaming addiction scores, and increased depression and anxiety scores. Using the South Oaks Gambling Screen–Revised for Adolescents, two participants were classed as ‘at-risk’ for gambling addiction and one participant was classed as a problem gambler.Conclusions:The present study examined behavioural addictions and their effects on mental health on a self-selecting sample of schoolchildren at two schools in Ireland. A low number were identified as being at risk or problem gamblers.

The present study utilized structural equation modeling with secondary Fragile Families and Child Wellbeing Study data (N= 1,267) to examine the relations between paternal economic hardship, nonresident father involvement, and co-parenting. Findings showed that paternal economic hardship (Year 5) was associated with higher child-reported father–child closeness (p< .05), but lower father-reported co-parenting (p< .05), at Year 9. Higher mother-reported co-parenting (Year 9) was associated with increased mother-reported father involvement (p< .001) at Year 9. Findings underscore the importance of including multiple perspectives, and practical implications include the need for practitioners to foster healthy co-parenting relationships to concurrently increase nonresident father involvement among racially/ethnically diverse and low-income fathers.

IMPORTANCE: Patients with left main coronary artery disease presenting with an acute coronary syndrome (ACS) represent a high-risk and understudied subgroup of patients with atherosclerosis. OBJECTIVE: To assess clinical outcomes after PCI vs CABG in patients with left main disease with vs without ACS. DESIGN, SETTING, AND PARTICIPANTS: Data were pooled from 4 trials comparing PCI with drug-eluting stents vs CABG in patients with left main disease who were considered equally suitable candidates for either strategy (SYNTAX, PRECOMBAT, NOBLE, and EXCEL). Patients were categorized as presenting with or without ACS. Kaplan-Meier event rates through 5 years and Cox model hazard ratios were generated, and interactions were tested. Patients were enrolled in the individual trials from 2004 through 2015. Individual patient data from the trials were pooled and reconciled from 2020 to 2021, and the analyses pertaining to the ACS subgroup were performed from March 2022 through February 2023. MAIN OUTCOMES AND MEASURES: The primary outcome was death through 5 years. Secondary outcomes included cardiovascular death, spontaneous myocardial infarction (MI), procedural MI, stroke, and repeat revascularization. RESULTS: Among 4394 patients (median [IQR] age, 66 [59-73] years; 3371 [76.7%] male and 1022 [23.3%] female) randomized to receive PCI or CABG, 1466 (33%) had ACS. Patients with ACS were more likely to have diabetes, prior MI, left ventricular ejection fraction less than 50%, and higher SYNTAX scores. At 30 days, patients with ACS had higher all-cause death (hazard ratio [HR], 3.40; 95% CI, 1.81-6.37; P &lt; .001) and cardiovascular death (HR, 3.21; 95% CI, 1.69-6.08; P &lt; .001) compared with those without ACS. Patients with ACS also had higher rates of spontaneous MI (HR, 1.70; 95% CI, 1.25-2.31; P &lt; .001) through 5 years. The rates of all-cause mortality through 5 years with PCI vs CABG were 10.9% vs 11.5% (HR, 0.93; 95% CI, 0.68-1.27) in patients with ACS and 11.3% vs 9.6% (HR, 1.19; 95% CI, 0.95-1.50) in patients without ACS (P = .22 for interaction). The risk of early stroke was lower with PCI vs CABG (ACS: HR, 0.39; 95% CI, 0.12-1.25; no ACS: HR, 0.35; 95% CI, 0.16-0.75), whereas the 5-year risks of spontaneous MI and repeat revascularization were higher with PCI vs CABG (spontaneous MI: ACS: HR, 1.74; 95% CI, 1.09-2.77; no ACS: HR, 3.03; 95% CI, 1.94-4.72; repeat revascularization: ACS: HR, 1.57; 95% CI, 1.19-2.09; no ACS: HR, 1.90; 95% CI, 1.54-2.33), regardless of ACS status. CONCLUSION AND RELEVANCE: Among largely stable patients undergoing left main revascularization and with predominantly low to intermediate coronary anatomical complexity, those with ACS had higher rates of early death. Nonetheless, rates of all-cause mortality through 5 years were similar with PCI vs CABG in this high-risk subgroup. The relative advantages and disadvantages of PCI vs CABG in terms of early stroke and long-term spontaneous MI and repeat revascularization were consistent regardless of ACS status. TRIAL REGISTRATION: ClinicalTrials.gov Identifiers: NCT00114972, NCT00422968, NCT01496651, NCT01205776

Objectives:There are no data relating to gambling advertisements shown during live sporting events in Ireland. The aim of the present study was to analyze gambling advertisements shown during live sporting events broadcast in Ireland and to assess these advertisements for responsible gambling (RG) practices.Methods:Sixty-five live televised sporting events comprising Association Football (soccer), Rugby Union, and Gaelic Athletic Association (GAA) matches broadcast in Ireland were analyzed. Pre-match (up to 30 minutes before kick-off), half-time, and post-match (up to 30 minutes after the match has ended) advertisement breaks were analyzed for gambling advertisements, including in-game fixed (static advertising) and dynamic (electronic advertisements changing at regular intervals) pitch-side advertising. Gambling advertisements were studied for evidence of RG practices.Results:A total of 3602 television advertisements, 618 dynamic advertisements, and 394 static advertisements were analyzed. Gambling advertisements were shown in 75.4% (n= 49) games and were the seventh most commonly televised advertisement shown overall. Gambling advertising was more common in football (fourth most common advertisement) compared to rugby (12th most common) and GAA (13th most common). Static and dynamic gambling advertising were common during football matches (second and first most common advertisements, respectively). The majority of advertisements contained RG messaging, an age limit, and an RG organization. No advertisements showing responsible gambling tools were observed.Conclusions:Gambling advertisements are commonly shown during live televised sporting broadcasts in Ireland, especially during live football matches and typically before the adult television watershed. Gambling legislation is required to minimize harm to vulnerable groups including children.

ObjectivesThe aim of this study was to carry out the first ever study of gaming characteristics of individuals engaging in online gaming in Ireland and to ascertain whether features of gaming disorder are present in this population.MethodsAn online survey (comprising 21 questions – 3 demographic questions and 18 questions related to gaming and gaming disorder) was distributed on numerous Irish online gaming forums and Irish online gaming communities. Participants were self-selected and invited to compete the online survey containing questions related to gaming behaviours (age of onset, hours played on weekdays/weekends, type of device used), mobile gaming, motives for online gaming, use of microtransactions, engagement in esports, and a screening tool for the presence of gaming disorder.ResultsA total of 166 participants engaged in the online survey. Among this study population of regular gamers in Ireland, 2.4% of the study population were classified as having gaming disorder, with up to 5.4% showing some evidence of disordered gaming. The main motivation for online gaming in the non-disordered gaming group was recreation (13.3, sd= 2.7) but only the fourth main motivation in the disordered gaming group behind competition (16.3, sd= 3.7), escape (16.2, sd= 4.3), and coping (15.1, sd= 3.7). Increased hours of gameplay on weekdays and weekends were noted in the disordered gaming group compared to non-disordered gamers.ConclusionsA small percentage of gamers in Ireland demonstrate disordered gaming characteristics and gaming disorder, consistent with data from other international studies. Epidemiological studies are required in Ireland to enhance our knowledge of this disorder.

ABSTRACTObjectivesWeight classifications are used in boxing and other combat sports to match opponents of similar size. Professional boxers commonly engage in a potentially harmful practice known as rapid weight loss or ‘weight cutting’ to make weight the day prior to competition before rehydrating and refueling. This investigation describes the prevalence and magnitude of rapid weight gain in boxers following weigh-in as well as differences in practice with respect to weight class and promotion.MethodsThis analysis describes official weight data from male professional boxers collected by the California State Athletic Commission between 2015 and 2018. A total of 399 athletes were included in the study.ResultsAmong included athletes, 389 (97.5%) athletes gained weight between official weigh-in and competition. Total absolute body mass gained was 4.4 ± 2.2 kg corresponding to a total relative body mass gain of 7.2 ± 3.5%. Boxers competing in international promotions gained significantly more body mass than regional competitors (8.0 ± 3.0% vs. 6.6 ± 3.7%; p < 0.001). In total, 82 (20.6%) athletes gained 10% body mass or more before competition. More international competitors reached this 10% threshold than regional competitors (25.3% vs. 17.4%; p = 0.03).ConclusionsThese findings indicate high prevalence and magnitude of RWG in professional boxing, particularly in boxers competing in elite international promotions.

COVID-19 was declared a pandemic by the World Health Organization on March 11th, 2020. Global social lockdowns were instigated to reduce spread and prevent health-services from becoming overwhelmed. People having treatment for cancer are known to have heightened psychological/emotional burden. The combined impact of managing pandemic regulations alongside this may present additional burden. The purpose of this systematic review is to examine current evidence of the psychological and emotional impact of COVID-19 on people with cancer, early in the pandemic.

Gaming disorder is set to be included in the International Statistical Classification of Diseases and Related Health Problemsalongside other behavioural addictions (gambling disorder) and substance-related addictions. Given the popularity of online gaming, this is set to become an increasingly common presentation to general mental health professionals, addiction specialists, and general practitioners. This article briefly examines online gaming and describes the characteristics of gaming disorder. Some features of online gaming that have addictive potential and similarities to other addictive behaviours such as gambling disorder are discussed. Finally, the article examines treatment options available for gaming disorder and treatment going forward from an Irish perspective.

IMPORTANCE: Impaired myocardial flow reserve (MFR) and stress myocardial blood flow (MBF) on positron emission tomography (PET) myocardial perfusion imaging may identify adverse myocardial characteristics, including myocardial stress and injury in aortic stenosis (AS). OBJECTIVE: To investigate whether MFR and stress MBF are associated with LV structure and function derangements, and whether these parameters improve after aortic valve replacement (AVR). DESIGN, SETTING, AND PARTICIPANTS: In this single-center prospective observational study in Boston, Massachusetts, from 2018 to 2020, patients with predominantly moderate to severe AS underwent ammonia N13 PET myocardial perfusion imaging for myocardial blood flow (MBF) quantification, resting transthoracic echocardiography (TTE) for assessment of myocardial structure and function, and measurement of circulating biomarkers for myocardial injury and wall stress. Evaluation of health status and functional capacity was also performed. A subset of patients underwent repeated assessment 6 months after AVR. A control group included patients without AS matched for age, sex, and summed stress score who underwent symptom-prompted ammonia N13 PET and TTE within 90 days. EXPOSURES: MBF and MFR quantified on ammonia N13 PET myocardial perfusion imaging. MAIN OUTCOMES AND MEASURES: LV structure and function parameters, including echocardiographic global longitudinal strain (GLS), circulating high-sensitivity troponin T (hs-cTnT), N-terminal pro–B-type natriuretic peptide (NT-pro BNP), health status, and functional capacity. RESULTS: There were 34 patients with AS (1 mild, 9 moderate, and 24 severe) and 34 matched control individuals. MFR was independently associated with GLS and LV ejection fraction, (β,−0.31; P = .03; β, 0.41; P = .002, respectively). Stress MBF was associated with hs-cTnT (unadjusted β, −0.48; P = .005) and log NT-pro BNP (unadjusted β, −0.37; P = .045). The combination of low stress MBF and high hs-cTnT was associated with higher interventricular septal thickness in diastole, relative wall thickness, and worse GLS compared with high stress MBF and low hs-cTnT (12.4 mm vs 10.0 mm; P = .008; 0.62 vs 0.46; P = .02; and −13.47 vs −17.11; P = .006, respectively). In 9 patients studied 6 months after AVR, mean (SD) MFR improved from 1.73 (0.57) to 2.11 (0.50) (P = .008). CONCLUSIONS AND RELEVANCE: In this study, in AS, MFR and stress MBF were associated with adverse myocardial characteristics, including markers of myocardial injury and wall stress, suggesting that MFR may be an early sensitive marker for myocardial decompensation.

The optimal revascularisation strategy for patients with left main coronary artery disease is uncertain. We therefore aimed to evaluate long-term outcomes for patients treated with percutaneous coronary intervention (PCI) with drug-eluting stents versus coronary artery bypass grafting (CABG).

Among the estimated 6.2 million Americans living with heart failure (HF), ≈5%/y may progress to advanced, or stage D, disease. Advanced HF has a high morbidity and mortality, such that early recognition of this condition is important to optimize care. Delayed referral or lack of referral in patients who are likely to derive benefit from an advanced HF evaluation can have important adverse consequences for patients and their families. A 2-step process can be used by practitioners when considering referral of a patient with advanced HF for consideration of advanced therapies, focused on recognizing the clinical clues associated with stage D HF and assessing potential benefits of referral to an advanced HF center. Although patients are often referred to an advanced HF center to undergo evaluation for advanced therapies such as heart transplantation or implantation of a left ventricular assist device, there are other reasons to refer, including access to the infrastructure and multidisciplinary team of the advanced HF center that offers a broad range of expertise. The intent of this statement is to provide a framework for practitioners and health systems to help identify and refer patients with HF who are most likely to derive benefit from referral to an advanced HF center.

ABSTRACTThis study examined whether various types of father-figure presence in Mexican (n= 414)- and Dominican- American (n= 336) households measured at baseline predicted child mental health functioning one year later. Results of linear regression analyses showed that the impact of household structure on child functioning was significant and differed by ethnicity. For Mexican-American children, residing with a step-father or other adult male predicted increased externalizing problems compared to children residing their biological father. For Dominican-American children, residing with no father figure predicted increased externalizing problems compared to children residing with a biological father. Implications for practice and future research are discussed.

This paper argues that a range of current AI systems have learned how to deceive humans. We define deception as the systematic inducement of false beliefs in the pursuit of some outcome other than the truth. We first survey empirical examples of AI deception, discussing both special-use AI systems (including Meta’s CICERO) and general-purpose AI systems (including large language models). Next, we detail several risks from AI deception, such as fraud, election tampering, and losing control of AI. Finally, we outline several potential solutions: first, regulatory frameworks should subject AI systems that are capable of deception to robust risk-assessment requirements; second, policymakers should implement bot-or-not laws; and finally, policymakers should prioritize the funding of relevant research, including tools to detect AI deception and to make AI systems less deceptive. Policymakers, researchers, and the broader public should work proactively to prevent AI deception from destabilizing the shared foundations of our society.

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Spinal cord stimulation (SCS) is used in the treatment of many chronic pain conditions. This study investigates racial and socioeconomic disparities in SCS among Medicare patients with chronic pain. Patients over the age of 18 with a primary diagnosis of postlaminectomy syndrome (ICD‐10 M96.1) or chronic pain syndrome (ICD‐10 G89.4) were identified in the Center for Medicare and Medicaid Services (CMS) Medicare Claims Limited Data Set. We defined our outcome as SCS therapy by race and socioeconomic status. Multivariable logistic regression was used to determine the variables associated with SCS. We identified 1,244,927 patients treated between 2016 and 2019 with a primary diagnosis of postlaminectomy syndrome (PLS) or chronic pain syndrome (CPS). Of these patients, 59,182 (4.8%) received SCS. Multivariable logistic regression analysis revealed that, compared with White patients, Black (OR [95%CI], 0.62 [0.6–0.65], p< 0.001), Asian (0.66 [0.56–0.76], p< 0.001), Hispanic (0.86 [0.8–0.93], p< 0.001), and North American Native (0.62 [0.56–0.69], p< 0.001) patients were significantly less likely to receive SCS. In addition, patients who were dual‐eligible for Medicare and Medicaid were significantly less likely to receive SCS than those eligible for Medicare only (OR = 0.38 [95% CI: 0.37–0.39], p< 0.001). This study suggests that racial and socioeconomic disparities exist in SCS among Medicare and Medicaid patients with PLS and CPS. Further work is required to elucidate the complex etiology underlying these findings.

ABSTRACTHeart Teams have come to occupy a prominent place in modern cardiovascular disease. While the concept is intuitively obvious - bringing together specialties of diverse backgrounds to focus on care of the individual patient - they have been harder to actually implement in clinical practice and it has been difficult to define metrics of success. One documented metric has been the design, implementation, and end result of randomized clinical trials that were conducted with co-investigators of both interventional cardiology and cardiovascular surgery which resulted in pivotal presentations of outcomes in specific patient groups. This metric, however, has come under scrutiny because of trial performance, conclusions, and implications for practice. The resulting controversies should not result in retreat from the concept of the Heart Team which should be at the heart of optimizing care for individual patients based upon scientific evidence and expert consensus on the issues of optimal cardiovascular care. The widespread use of telemedicine can play a major role in enhancing decision making by the Heart Team.Abbreviations: IC: Interventional Cardiology; CVS: Cardiovascular Surgery; CABG: Coronary artery bypass grafting; PCI: Percutaneous coronary intervention; CAD: Coronary artery disease; TAVR: Transcatheter aortic valve replacement; SAVR: Surgical aortic valve replacement; RCTs: Randomized clinical trials; CMS: Centers for Medicare and Medicaid Services; FDA: Food and Drug Administration

Objective: To identify quantitative and qualitative differences in the velopharyngeal musculature and surrounding structures between children with submucous cleft palate (SMCP) and velopharyngeal insufficiency (VPI) and noncleft controls with normal anatomy and normal speech.Methods: Magnetic resonance imaging was used to evaluate the velopharyngeal mechanism in 20 children between 4 and 9 years of age; 5 with unrepaired SMCP and VPI. Quantitative and qualitative measures of the velum and levator veli palatini in participants with symptomatic SMCP were compared to noncleft controls with normal velopharyngeal anatomy and normal speech.Results: Analysis of covariance revealed that children with symptomatic SMCP demonstrated increased velar genu angle (15.6°, P= .004), decreased α angle (13.2°, P= .37), and longer (5.1 mm, P= .32) and thinner (4 mm, P= .005) levator veli palatini muscles compared to noncleft controls. Qualitative comparisons revealed discontinuity of the levator muscle through the velar midline and absence of a musculus uvulae in children with symptomatic SMCP compared to noncleft controls.Conclusions: The levator veli palatini muscle is longer, thinner, and discontinuous through the velar midline, and the musculus uvulae is absent in children with SMCP and VPI compared to noncleft controls. The overall velar configuration in children with SMCP and VPI is disadvantageous for achieving adequate velopharyngeal closure necessary for nonnasal speech compared to noncleft controls. These findings add to the body of literature documenting levator muscle, musculus uvulae, and velar and craniometric parameters in children with SMCP.

IMPORTANCE: Women with aortopathy conditions are at risk for pregnancy-related aortic dissection, and these conditions may not be recognized until after the aortic dissection occurs. OBJECTIVE: To examine the clinical characteristics, imaging features, and outcomes in women with pregnancy-related acute aortic dissection. DESIGN, SETTING, AND PARTICIPANTS: A cohort study, comprising data from the International Registry of Acute Aortic Dissection (IRAD) (February 1, 1998, to February 28, 2018). The multicenter referral center study included 29 women with aortic dissection during pregnancy or less than 12 weeks post partum in IRAD from 1998 to 2018. MAIN OUTCOMES AND MEASURES: Clinical features of pregnancy-related aortic dissection to be studied included underlying aortopathy, aortic size, type of aortic dissection, timing of dissection, hypertension, and previous aortic surgery. RESULTS: A total of 29 women (mean [SD] age, 32 [6] years) had pregnancy-related aortic dissection, representing 0.3% of all aortic dissections and 1% of aortic dissection in women in the IRAD. Among women younger than 35 years, aortic dissection was related to pregnancy in 20 of 105 women (19%). Thirteen women (45%) had type A aortic dissection, and 16 women (55%) had type B. Aortic dissection onset was known in 27 women (93%): 15 during pregnancy, 4 in the first trimester, and 11 in the third trimester; 12 were post partum, occurring a mean (SD) of 12.5 (14) days post partum. At type A aortic dissection diagnosis, the mean (SD) aortic diameters were sinus of Valsalva, 54.5 (5) mm and ascending aorta, 54.7 (6) mm. At type B aortic dissection diagnosis, the mean (SD) descending aortic diameter was 32.5 (5) mm. Twenty women (69%) had an aortopathy condition or a positive family history: 13 women (65%) with Marfan syndrome, 2 women (10%) with Loeys-Dietz syndrome, 2 women (10%) with bicuspid aortic valves, 2 women (10%) with a family history of aortic disease, and 1 woman (5%) with familial thoracic aortic aneurysm. Aortopathy was not recognized until after aortic dissection in 47% of the women. Twenty-eight women (97%) survived aortic dissection hospitalization. CONCLUSIONS AND RELEVANCE: Aortic dissection complicating pregnancy is rare. Most pregnancy-related aortic dissection is due to an aortopathy often not diagnosed until after aortic dissection. In this study, type A aortic dissections were associated with a dilated aorta, and type B aortic dissections often were not. Recognition of underlying conditions and risks for aortic dissection may improve management of pregnancy in women with aortopathy.

The Coronavirus Disease 2019 (COVID-19) pandemic has undoubtedly had a major impact on the provision of physical healthcare in Ireland and worldwide. The mental health impact of this pandemic cannot be underestimated, particularly relating to patients suffering from addiction. Heightened public stress and anxiety levels, increasing isolation and the physical consequences of addiction play a large role in the proliferation and ongoing relapse of substance misuse and behavioural addiction. Service provision is an ongoing challenge not only due to the increasing need for services given the increased mental health burden of COVID-19 but also the restrictions in place in clinical areas to achieve social distancing. The necessary adaptations to service provision provide opportunities for the analysis of current processes used in our addiction unit and the introduction of new processes to our service. The current crisis tests the sustainability of the service to provide the high standard of care required for these patients.

ABSTRACTAlthough aortic valve replacement with implantation of a bioprosthesis has been widely performed for more than 50 years, appreciation of the development of bioprosthetic leaflet thrombosis has increased recently with the emergence of transcatheter aortic valve replacement (TAVR) and the use of advanced imaging modalities, such as 4-dimensional computed tomographic angiography. Recent observational and randomized studies have demonstrated how this condition could affect patients treated with either TAVR or surgical aortic valve replacement (SAVR). The clinical relevance of bioprosthetic valve thrombosis and the optimal antithrombotic strategies to prevent this condition in patients treated with SAVR or TAVR are still a matter of debate, while anticoagulation is considered effective treatment to address bioprosthetic valve thrombosis once it is diagnosed. This review provides an overview on timing and mechanism of bioprosthetic valve thrombosis, its prevalence and clinical impact in patients treated with TAVR or SAVR, and how the different designs of various types of bioprostheses could influence the risk of thrombosis.

Acoustic triangulation is a unique, relatively noninvasive monitoring approach that can inform our understanding of a species’ distribution in time and space. Acoustic triangulation relies on standard triangulation techniques to determine the location of an acoustic event. Howl surveys are frequently used to survey wolves (Canis lupus) and other canids. We evaluated the efficacy of acoustic triangulation for estimating the location of wolves. We measured precision and accuracy of acoustic triangulation using an experimental mock howl survey and field data collected with wild wolves in northern Wisconsin, USA (2014–2018). Precision of acoustic triangulation was similar to triangulation with ground‐based radiotelemetry for both pooled data and individual wolves at specific times, although the 2 techniques did not result in similar predicted locations. Distance from the howl source was the most consistently significant factor influencing the efficacy of acoustic triangulation. Error ellipse size was 33 times smaller at distances <1 km. Wind speed also reduced the accuracy of acoustic triangulation for mock howl surveys. Precision for modified howl surveys with wild wolves improved with the number of bearings. We estimated a mean bearing error of 13.2° (±2.1, 95% CI) for single bearings and a maximum distance of 1.76 km (range = 0.96–1.76 km; x¯= 1.41 km) detection for audible anthropogenic howls. Such information can be applied to howl survey data to generate more fine‐scale location information for wolf‐pack home sites. Acoustic triangulation of wolves can provide high‐quality location information in areas where wolves are not monitored with radiocollars. © 2020 The Wildlife Society. Acoustic triangulation is an accurate and precise noninvasive technique for determining location information of howling wolves. Acoustic triangulation may help managers protect wolf home sites or better understand the landscape characteristics or behaviors associated with home site use.

This study investigated differences between patients <65 and ≥65 years of age following lumbar microdecompression.

IMPORTANCE: Questions have recently arisen as to whether 30-day mortality is a reasonable metric for understanding institutional practice differences after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). OBJECTIVE: To examine the utility of 30-day vs 90-day mortality after TAVR and SAVR as a mortality quality metric. DESIGN, SETTING, AND PARTICIPANTS: This nationally representative, multicenter, cohort study analyzed data from Medicare beneficiaries undergoing TAVR and SAVR procedures from January 1, 2012, to December 31, 2015. Concomitant coronary artery bypass grafting and other heart valve or other major open-heart procedures were excluded. Hospitals that performed fewer than 50 TAVR or 70 SAVR procedures per year were excluded to ensure reliable estimates and to reduce the risks of inflated results because of small institutional sample sizes. Data were analyzed from October 2018 to August 2019. EXPOSURES: Hospitals were ranked into top- (10%), middle- (80%), and bottom-performing (10%) groups based on their 4-year mean 30-day mortality. MAIN OUTCOMES AND MEASURES: Changes in hospital performance rankings at 90 days and 1 year and correlation of 30- and 90-day mortality with 1-year mortality were examined. RESULTS: A total of 30 329 TAVR admissions at 184 hospitals and 26 021 SAVR admissions at 191 hospitals were evaluated. For TAVR, 40 hospitals (21.7%) changed performance rankings at 90 days: 13 (48.1%) in the top-performing group and 8 (29.6%) in the bottom-performing group. At 1 year, 56 hospitals (30.4%), which included 21 (77.8%) in the top-performing group and 12 (44.4%) in the bottom-performing group, changed rankings. Similar findings were observed for SAVR, with an overall 90-day conversion rate of 17.3% and a 1-year rate of 30.3%. These findings persisted after adjusting for the differences in patient risk profiles among the 3 groups. Capturing 90-day events was also more robustly informative regarding expected 1-year outcomes after both TAVR and SAVR, largely owing to the observed plateau in the instantaneous hazard observed beyond this point. CONCLUSIONS AND RELEVANCE: The findings suggest that evaluation of hospital performance based on 30-day mortality may underestimate outcomes and therefore substantially misrepresent institutional performance after TAVR and SAVR compared with 90-day mortality, even after risk adjustment. Although 30-day mortality has been validated, 90-day mortality may be a more reliable outcome metric for measuring hospital performance and capturing procedure-related mortality.

This study investigated sex-based differences in outcomes after mitral valve (MV) surgery for severe ischemic mitral regurgitation (SIMR).

ObjectivesThe aim of this study is to look at an Irish population in relation to the online gambling activities people are engaging with, the reasons for gambling online, their attitudes to online gambling and the financial/mental health consequences of online gambling.MethodsThe outline for this study was adapted from a study by McCormack et al. (2014) in relation to online gambling, with the aim of replicating this study in an Irish population. An online survey consisting of 11 categories related to online gambling was advertised online over a 7-month period. Participants answered on activities gambled online, devices used, duration of time gambling, as well mental health/financial consequences of their gambling.ResultsA total of 208 users participated in the online survey. The most popular gambling activity played was Sports Betting (26.9%) and the most commonly used device was Mobile app (68.6%). The main reason for gambling online was ‘To win money’ (84.6%), the main reason for ending gambling sessions – ‘Had something else to do’ (67.3%) and the most prominent emotion experienced – Excitement (60.6%). There were findings related to the severity of gambling addiction (75% – had to borrow or sell to fund gambling) and their attitudes towards online gambling (strongly agreed – 39.9% – The potential dangers of gambling should be advertised).ConclusionsOnline gamblers in Ireland share similar behavioural profiles to online gamblers in the United Kingdom and worldwide. The majority of participants in this research have been adversely affected from both a mental and financial perspective due to their gambling behaviours.

To perform a pilot study using transcutaneous electrical nerve stimulation (TENS) on the dorsal genital nerve and the posterior tibial nerve for improving symptoms of female sexual dysfunction (FSD) in women without bladder problems. We hypothesize that this therapy will be effective at improving genital arousal deficits. Nine women with general FSD completed the study. Subjects received 12 sessions of transcutaneous dorsal genital nerve stimulation (DGNS; n= 6) or posterior tibial nerve stimulation (PTNS; n= 3). Stimulation was delivered for 30 min at 20 Hz. Sexual functioning was evaluated with the female sexual functioning index (FSFI), and surveys were also given on general health, urological functioning, and the Patients’ Global Impression of Change (PGIC) after treatment. Surveys were given before treatment (baseline), after 6 and 12 weeks of treatment, and 6 weeks after the completion of stimulation sessions. The average total FSFI score across all subjects significantly increased from 15.3 ± 4.8 at baseline to 20.3 ± 7.8 after six sessions, 21.7 ± 7.5 after 12 sessions, and 21.3 ± 7.1 at study completion (p< 0.05 for all time points). Increases were observed in both DGNS and PTNS subjects. Significant FSFI increases were seen in the subdomains of lubrication, arousal, and orgasm, each of which is related to genital arousal. Bladder and general health surveys did not change across the study. PGIC had a significant increase. This study provides evidence that transcutaneous stimulation of peripheral nerves has the potential to be a valuable therapeutic tool for women with FSD.

Objective: The objective of this study was to investigate the impact of international adoption (IA), age at palatoplasty (PR age), and velopharyngeal sufficiency (VPS) on articulation outcomes.Design: This was a cross-sectional, prospective, observational study.Setting: Outpatient hospital clinic.Participants: Fifty-one IA and 65 not-adopted (NA) children between the ages of 3 and 9 with nonsyndromic cleft palate with or without cleft lip.Main Outcome Measure(s): The Goldman-Fristoe Test of Articulation—2nd Edition (GFTA-2) standard score and cleft-related articulation errors (CREs).Results: Articulation impairment was observed for 40% to 76% of NA children and 71% to 92% IA children, depending on age. PR age mean IA = 2.07 (0.86) years; NA = 1.23 (0.71) years. Children who were IA had poorer performance on the GFTA-2 (B= −13.82, P= .015). Children who were IA were not significantly more likely to make CRE; rather, age at the time of assessment (B= −.10, P= .002) and VPS (B= .24, P= .021) were associated with CRE.Conclusions: Children who were IA demonstrated poorer articulation skills. Although primary palatoplasty was accomplished later among children who were IA, age at assessment and VP status (not PR age) were significantly correlated with articulation outcomes. Implications for timing of surgical intervention are discussed.

Photonics is a promising platform for implementing universal quantum information processing. Its main challenges include precise control of massive circuits of linear optical components and effective implementation of entangling operations on photons. By using large-scale silicon photonic circuits to implement an extension of the linear combination of quantum operators scheme, we realize a fully programmable two-qubit quantum processor, enabling universal two-qubit quantum information processing in optics. The quantum processor is fabricated with mature CMOS-compatible processing and comprises more than 200 photonic components. We programmed the device to implement 98 different two-qubit unitary operations (with an average quantum process fidelity of 93.2 ± 4.5%), a two-qubit quantum approximate optimization algorithm, and efficient simulation of Szegedy directed quantum walks. This fosters further use of the linear-combination architecture with silicon photonics for future photonic quantum processors. A fully programmable two-qubit quantum processor with more than 200 components is demonstrated by using silicon photonic circuits. A two-qubit quantum approximate optimization algorithm and simulation of Szegedy quantum walks are implemented.

ObjectivesThere are conflicting reports on the levels of anxiety and depression in individuals with alcohol problems and whether these conditions are substance-related or independent of the alcohol problem. The aim of this study was to characterise rates of co-morbid psychiatric symptoms among a group of individuals commencing treatment for alcohol dependence, and to examine the stability of these symptoms following treatment of the alcohol problem.MethodsSymptoms of anxiety and depression were examined in a group of individuals (n=93) undergoing residential treatment for alcohol dependence. Symptoms were measured at treatment entry and again at treatment completion using the Beck Anxiety Inventory and the Beck Depression Inventory – II.ResultsHigh levels of anxiety and depressive symptoms were reported at treatment entry, but on completion of treatment (28 days later) the majority of participants were no longer reporting symptoms suggestive of a possible co-morbid condition.ConclusionsThe significant change in rates of reported symptoms following completion of treatment suggests that a large proportion of symptoms reported at treatment entry were substance related. Diagnosing co-morbid conditions is best left until after a period of abstinence during which the alcohol problem has been treated. Assessing for co-morbidity at time of treatment seeking is likely to result in inappropriate co-morbid diagnoses being made and inappropriate or unnecessary treatments being prescribed for such individuals.

Supplemental Digital Content is available in the text.Acute aortic dissection (AAD) is a life-threatening condition associated with high morbidity and mortality rates, and it remains a challenge to diagnose and treat. The International Registry of Acute Aortic Dissection was established in 1996 with the mission to raise awareness of this condition and provide insights to guide diagnosis and treatment. Since then, >7300 cases have been included from >51 sites in 12 countries. Although presenting symptoms and physical findings have not changed significantly over this period, the use of computed tomography in the diagnosis has increased, and more patients are managed with interventional procedures: surgery in type A AAD and endovascular therapy in type B AAD; with these changes in care, there has been a significant decrease in overall in-hospital mortality in type A AAD but not in type B AAD. Herein, we summarized the key lessons learned from this international registry of patients with AAD over the past 20 years.

ObjectiveDescribe the extent to which tobacco industry marketing tactics incorporated American Indian culture and traditional tobacco.MethodsA keyword search of industry documents was conducted using document archives from the Truth Tobacco Documents Library. Tobacco industry documents (n=76) were analysed for themes.ResultsTobacco industry marketing tactics have incorporated American Indian culture and traditional tobacco since at least the 1930s, with these tactics prominently highlighted during the 1990s with Natural American Spirit cigarettes. Documents revealed the use of American Indian imagery such as traditional headdresses and other cultural symbols in product branding and the portrayal of harmful stereotypes of Native people in advertising. The historical and cultural significance of traditional tobacco was used to validate commercially available tobacco.ConclusionsThe tobacco industry has misappropriated culture and traditional tobacco by misrepresenting American Indian traditions, values and beliefs to market and sell their products for profit. Findings underscore the need for ongoing monitoring of tobacco industry marketing tactics directed at exploiting Native culture and counter-marketing tactics that raise awareness about the distinction between commercial and traditional tobacco use. Such efforts should be embedded within a culturally sensitive framework to reduce the burden of commercial tobacco use.