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Late detection of critical congenital heart disease (CCHD) is multifactorial and ill defined. We investigated the results of pulse oximetry screening (POS) and points in the care chain that contribute to delayed detection of CCHD. The medical records of 13 infants with delayed detection at a single pediatric cardiac center between 2013 and 2016 were identified and reviewed. Left heart obstructive lesions were the most common diagnosis (n = 8; 62%) and included coarctation of the aorta (n = 6), interrupted aortic arch with ventricular septal defect (n = 1), and critical aortic stenosis (n = 1). Tetralogy of Fallot (TOF) (n = 2), truncus arteriosus (n = 1), pulmonary atresia with ventricular septal defect (n = 1), and total anomalous pulmonary venous drainage (n = 1) made up the remainder of the conditions. Routine prenatal care was reported in most infants (10/13). Infants with late detection had either a true negative POS (10/13 infants) or no POS performed (3/13 infants). At the time of detection, 5/6 (83%) infants with coarctation had normal pulse oximetry values, whereas 6/7 (86%) infants with other CCHD developed abnormal pulse oximetry values. At diagnosis, 11/13 (85%) infants had significant signs or symptoms of clinical deterioration; only 2 infants were completely asymptomatic. Late detection of CCHD is uncommon and multifactorial. Eliminating late detection is dependent upon improving detection on screening obstetrical ultrasounds, enforcement of universal POS, and attention to the neonatal physical exam.

Background Frontotemporal lobar degeneration (FTLD) is a neuropathological construct with multiple clinical presentations, including the behavioural variant of frontotemporal dementia (bvFTD), primary progressive aphasia—both non-fluent variant (nfvPPA) and semantic variant (svPPA)—progressive supranuclear palsy (PSP) and corticobasal syndrome (CBS), characterised by the deposition of abnormal tau protein in the brain. A major challenge for treating FTLD is early diagnosis and accurate discrimination among different syndromes. The main goal here was to investigate the cortical architecture of FTLD syndromes using cortical diffusion tensor imaging (DTI) analysis and to test its power to discriminate between different clinical presentations. Methods A total of 271 individuals were included in the study: 87 healthy subjects (HS), 31 semantic variant primary progressive aphasia (svPPA), 37 behavioural variant (bvFTD), 30 non-fluent/agrammatic variant primary progressive aphasia (nfvPPA), 47 PSP Richardson’s syndrome (PSP-RS) and 39 CBS cases. 3T MRI T1-weighted images and DTI scans were analysed to extract three cortical DTI derived measures (AngleR, PerpPD and ParlPD) and mean diffusivity (MD), as well as standard volumetric measurements. Whole brain and regional data were extracted. Linear discriminant analysis was used to assess the group discrimination capability of volumetric and DTI measures to differentiate the FTLD syndromes. In addition, in order to further investigate differential diagnosis in CBS and PSP-RS, a subgroup of subjects with autopsy confirmation in the training cohort was used to select features which were then tested in the test cohort. Three different challenges were explored: a binary classification (controls vs all patients), a multiclass classification (HS vs bvFTD vs svPPA vs nfvPPA vs CBS vs PSP-RS) and an additional binary classification to differentiate CBS and PSP-RS using features selected in an autopsy confirmed subcohort. Results Linear discriminant analysis revealed that PerpPD was the best feature to distinguish between controls and all patients (ACC 86%). PerpPD regional values were able to classify correctly the different FTLD syndromes with an accuracy of 85.6%. The PerpPD and volumetric values selected to differentiate CBS and PSP-RS patients showed a classification accuracy of 85.2%. Conclusions (I) PerpPD achieved the highest classification power for differentiating healthy controls and FTLD syndromes and FTLD syndromes among themselves. (II) PerpPD regional values could provide an additional marker to differentiate FTD, PSP-RS and CBS.

To study the association of MRCP+ parameters with biochemical scoring systems and MR elastography (MRE) in primary sclerosing cholangitis (PSC). To evaluate the incremental value of combining MRCP+ with morphological scores in associating with biochemical scores. MRI images, liver stiffness measurements by MRE, and biochemical testing of 65 patients with PSC that were retrospectively enrolled between January 2014 and December 2015 were obtained. MRCP+ was used to post-process MRCP images to obtain quantitative measurements of the bile ducts and biliary tree. Linear regression analysis was used to test the associations. Bootstrapping was used as a validation method. The total number of segmental strictures had the strongest association with Mayo Risk Score (R2 = 0.14), minimum stricture diameter had the highest association with Amsterdam Oxford Prognostic Index (R2 = 0.12), and the percentage of duct nodes with width 0–3 mm had the strongest association with PSC Risk Estimate Tool (R2 = 0.09). The presence of Ducts with medians > 9 mm had the highest association with MRE (R2= 0.21). The strength of association of MRCP+ to Mayo Risk Score was similar to ANALI2 and weaker than MRE (R2 = 0.23, 0.24, 0.38 respectively). MRCP+ enhanced the association of ANALI 2 and MRE with the Mayo Risk Score. MRCP+ demonstrated a significant association with biochemical scores and MRE. The association of MRCP+ with the biochemical scores was generally comparable to ANALI scores. MRCP+ enhanced the association of ANALI2 and MRE with the Mayo Risk Score. • MRCP+ has the potential to act as a risk stratfier in PSC. • MRE outperformed MRCP+ for risk stratifcation. • Combination of MRCP+ with MRE and ANALI scores improved overall performace as risk stratifiers.

Summary Care Sport Connectors (CSCs) have been appointed to create a connection between primary care and physical activity (PA) sectors to stimulate inactive residents into becoming physically active. Adequate recruitment strategies are necessary to reach the intended target group in order to foster the sustainability of lifestyle interventions. The objective of this study is to explore PA behavior and health characteristics of the target group reached by CSCs and if these characteristics differ between participants when grouped based on how they were recruited. Participants from lifestyle interventions were included between September 2014 and April 2016 using a purposive sampling method. Participants were recruited through CSCs via public relations (n = 135), a personal letter (n = 136), or a referral (n = 98) and compared based on their PA level, health-related quality of life, motivation, self-efficacy, morbidity and health-related fitness. Scores were analyzed with a multi-level (mixed model) analysis measured before the intervention. The three groups were different in PA level (p = 0.002). The outcomes regarding health-related quality of life, motivation, and number of somatic disorders were also significantly different for the three groups, except for the categories of mental health (p = 0.145) and self-efficacy (p = 0.464). For all dimensions, the referral group scored the least favorable. The investment in time and money for an active recruitment strategy like referrals is worthwhile because it provides CSCs the opportunity to reach people who are inactive and at risk of chronic disease. Future studies are necessary to reveal the effect on PA levels and health in the long-term.

Aims COVID-19 remains the major focus of healthcare provision. Managing orthopaedic emergencies effectively, while at the same time protecting patients and staff, remains a challenge. We explore how the UK lockdown affected the rate, distribution, and type of orthopaedic emergency department (ED) presentations, using the same period in 2019 as reference. This article discusses considerations for the ED and trauma wards to help to maintain the safety of patients and healthcare providers with an emphasis on more remote geography. Methods The study was conducted from 23 March 2020 to 5 May 2020 during the full lockdown period (2020 group) and compared to the same time frame in 2019 (2019 group). Included are all patients who attended the ED at Raigmore Hospital during this period from both the local area and tertiary referral from throughout the UK Highlands. Data was collected and analyzed through the ED Information System (EDIS) as well as ward and theatre records. Results A total of 1,978 patients presented to the ED during the lockdown period, compared to 4,777 patients in the same timeframe in 2019; a reduction of 58.6%. Orthopaedic presentations in 2020 and 2019 were 736 (37.2%) and 1,729 (36.2%) respectively, representing a 57.4% reduction. During the lockdown, 43.6% of operations were major procedures (n = 48) and 56.4% were minor procedures (n = 62), representing a significant proportional shift. Conclusion During the COVID- 19 lockdown period there was a significant reduction in ED attendances and orthopaedic presentations compared to 2019. We also observed that there was a proportional increase in fractures in elderly patients and in minor injuries requiring surgery. These represented the majority of the orthopaedic workload during the lockdown period of 2020. Given this shift towards smaller surgical procedures, we suggest that access to a minor operating theatre in or close to ED would be desirable in the event of a second wave or future crisis.

BACKGROUND: Osteofibrous dysplasia-like adamantinoma (OFD-AD) and classic adamantinoma (AD) are rare, neoplastic diseases with only limited data supporting current treatment protocols. We believe that our retrospective multicenter cohort study is the largest analysis of patients with adamantinoma to date. The primary purpose of this study was to describe the disease characteristics and evaluate the oncological outcomes. The secondary purpose was to identify risk factors for local recurrence after surgical treatment and propose treatment guidelines. METHODS: Three hundred and eighteen confirmed cases of OFD-AD and AD for which primary treatment was carried out between 1985 and 2015 were submitted by 22 tertiary bone tumor centers. Proposed clinical risk factors for local recurrence such as size, type, and margins were analyzed using univariable and multivariate Cox regression analysis. RESULTS: Of the 318 cases, 128 were OFD-AD and 190 were AD. The mean age at diagnosis was 17 years (median, 14.5 years) for OFD-AD and 32 years (median, 28 years) for AD; 53% of the patients were female. The mean tumor size in the OFD-AD and AD groups combined was 7.8 cm, measured histologically. Sixteen percent of the patients sustained a pathological fracture prior to treatment. Local recurrence was recorded in 22% of the OFD-AD cases and 24% of the AD cases. None of the recurrences in the OFD-AD group progressed to AD. Metastatic disease was found in 18% of the AD cases and fatal disease, in 11% of the AD cases. No metastatic or fatal disease was reported in the OFD-AD group. Multivariate Cox regression analysis demonstrated that uncontaminated resection margins (hazard ratio [HR] = 0.164, 95% confidence interval [CI] = 0.092 to 0.290, p < 0.001), pathological fracture (HR = 1.968, 95% CI = 1.076 to 3.600, p = 0.028), and sex (female versus male: HR = 0.535, 95% CI = 0.300 to 0.952, p = 0.033) impacted the risk of local recurrence. CONCLUSIONS: OFD-AD and AD are parts of a disease spectrum but should be regarded as different entities. Our results support reclassification of OFD-AD into the intermediate locally aggressive category, based on the local recurrence rate of 22% and absence of metastases. In our study, metastatic disease was restricted to the AD group (an 18% rate). We advocate wide resection with uncontaminated margins including bone and involved periosteum for both OFD-AD and AD. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: Social dysfunction is one of the most common signs of major neuropsychiatric disorders. The Default Mode Network (DMN) is crucially implicated in both psychopathology and social dysfunction, although the transdiagnostic properties of social dysfunction remains unknown. As part of the pan-European PRISM (Psychiatric Ratings using Intermediate Stratified Markers) project, we explored cross-disorder impact of social dysfunction on DMN connectivity. Methods: We studied DMN intrinsic functional connectivity in relation to social dysfunction by applying Independent Component Analysis and Dual Regression on resting-state fMRI data, among schizophrenia (SZ; N=48), Alzheimer disease (AD; N=47) patients and healthy controls (HC; N=55). Social dysfunction was operationalised via the Social Functioning Scale (SFS) and De Jong-Gierveld Loneliness Scale (LON). Results: Both SFS and LON were independently associated with diminished DMN connectional integrity within rostromedial prefrontal DMN subterritories (pcorrected range=0.02–0.04). The combined effect of these indicators (Mean.SFS + LON) on diminished DMN connectivity was even more pronounced (both spatially and statistically), independent of diagnostic status, and not confounded by key clinical or sociodemographic effects, comprising large sections of rostromedial and dorsomedial prefrontal cortex (pcorrected =0.01). Conclusions: These findings pinpoint DMN connectional alterations as putative transdiagnostic endophenotypes for social dysfunction and could aid personalised care initiatives grounded in social behaviour, The project leading to this application has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 115916. This Joint Undertaking receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA. This publication reflects only the author’s views and neither the IMI 2JU nor EFPIA nor the European Commission are liable for any use that may be made of the information contained therein

Magnetic resonance imaging with magnetic resonance cholangiopancreatography (MRI-MRCP) in primary sclerosing cholangitis (PSC) is currently based on qualitative assessment and has high interobserver variability. We investigated the utility and performance of quantitative metrics derived from a three-dimensional biliary analysis tool in adult patients with PSC. MRI-MRCP, blood-based biomarkers, and FibroScan were prospectively performed in 80 participants with large-duct PSC and 20 healthy participants. Quantitative analysis was performed using MRCP+ (Perspectum Ltd., United Kingdom), and qualitative reads were performed by radiologists. Inter-reader agreements were compared. Patients were classified into high risk or low risk for disease progression, using Mayo risk score (MRS), Amsterdam-Oxford model (AOM), upper limit of normal (ULN) alkaline phosphatase (ALP), disease distribution, and presence of dominant stricture. Performance of noninvasive tools was assessed using binomial logistic regressions and receiver operating characteristic curve analyses. Quantitative biliary metrics performed well to distinguish abnormal from normal bile ducts (P < 0.0001). Interobserver agreements for MRCP+ dilatation metrics (intraclass correlation coefficient, 0.90-0.96) were superior to modified Amsterdam intrahepatic stricture severity score (κ = 0.74) and Anali score (κ = 0.38). MRCP+ intrahepatic dilatation severity showed excellent performance to classify patients into high-risk and low-risk groups, using predictors of disease severity as the reference (MRS, P < 0.0001; AOM, P = 0.0017; 2.2 × ULN ALP, P = 0.0007; 1.5 × ULN ALP, P = 0.0225; extrahepatic disease, P = 0.0331; dominant stricture, P = 0.0019). MRCP+ intrahepatic dilatation severity was an independent predictor of MRS >0 (odds ratio, 31.3; P = 0.035) in the multivariate analysis. Conclusion: Intrahepatic biliary dilatation severity calculated using MRCP+ is elevated in patients with high-risk PSC and may be used as an adjunct for risk stratification in PSC. This exploratory study has provided the groundwork for examining the utility of novel quantitative biliary metrics in multicenter studies.

Background: Clinical trials with putative antidepressants can be difficult to execute as it can take up to 8 weeks before differences emerge between drug and placebo, and long expensive trials often fail. Implementation of early response biomarkers could aid this process significantly with potential to identify new treatments. Aims: In a secondary analysis, we examined the association of early effects on emotional processing with later clinical outcome following treatment with the novel NOP antagonist LY2940094 versus placebo. We hypothesised that early induction of positive bias would be associated with reduced severity of depression after 8 weeks of treatment. Methods: This was a multicentre, randomised, double-blind, parallel-group, fixed-dose, placebo-controlled, 8 week study to assess sensitivity of the facial emotional recognition task (FERT) to early changes in emotional bias induced by LY2940094. Patients who met diagnostic criteria for major depression were randomised to receive LY2940094 ( N = 70) or placebo ( N = 66). At week 1 and 6, the FERT was completed by 33 patients in the LY2940094 group and 34 in the placebo group. Results: Patients identified happy faces with higher accuracy (Wald χ2(1,33) = 14.25, p 2(1,32) = 0.83, p = 0.36) and this correlated with eventual treatment response measured by the Hamilton Depression Rating Scale 7 weeks later. Conclusion: These data suggest that emotional processing biomarkers may be sensitive to early effects of antidepressant treatment indicative of later clinical response. Further studies in this area may be useful in developing new treatments and clinical trial designs for predicting antidepressant response.

Cardiac surgery for CHD was pioneered in Washington, DC by Charles Hufnagel and Edgar Davis working at Georgetown University and Children’s Hospital of the District of Columbia. Children’s Hospital, now Children’s National Hospital, had been established just 5 years after the end of the Civil War. In the 1950s, Davis and Hufnagel undertook many open-heart operations using the technique of surface cooling, hypothermia, and circulatory arrest. Hufnagel and Lewis Scott, who founded the cardiology department at Children’s, were trained in Boston by Gross and Nadas. Judson Randolph, also a trainee of Gross, introduced cardiac surgery using cardiopulmonary bypass and established the General Pediatric Surgery department at Children’s in the 1960s. The transition of hospital staffing from community-based private physicians to full-time hospital employees was often controversial but was complete by the turn of the millennium. The 21st century has seen continuing growth of the new Children’s National Heart Institute and consolidation of several congenital cardiac programmes in Washington, DC.

OBJECTIVES To evaluate newborn pulse oximetry screening (POS) outcomes at a large community hospital and the impact of the recommended revised POS algorithm. METHODS A retrospective cohort study was performed to evaluate the results of POS in the well-infant nursery between 2012 and 2020. The POS results were obtained from an electronic platform. Chart review was completed for newborns with failed screens. The recommended revision to POS, no second rescreen, was applied to the data to evaluate screening outcomes. RESULTS Of the total 65 414 infants admitted to the well-infant nursery during this 8-year period, >99% (n = 64 780) received POS. Thirty-one infants failed POS (4.6 per 10 000 screened). All infants who failed POS were found to have a disorder, with 12 (39%) having critical congenital heart disease (CCHD), 9 (29%) having non-CCHD requiring further follow-up, and 10 (32%) having noncardiac conditions. One false-negative screen result was identified through the Maryland Department of Health Newborn Screening Follow-up Program. The positive predictive value of POS for those screened was 39% for CCHD, with a specificity of 99.97%. Eliminating the second rescreen in the POS algorithm would have resulted in an additional 5 newborns without CCHD failing POS, increasing the false-positive rate from 0.03% to 0.04%. CONCLUSIONS POS is an effective tool for identifying CCHD and secondary conditions. POS was successfully implemented with few missed screens and was highly specific. Elimination of the second rescreen in the pulse oximetry algorithm would have resulted in a minimal increase in false-positive results and faster evaluation of newborns with CCHD.

Clostridioides difficile infection (CDI) is a common complication in the hematopoietic stem cell transplantation (HSCT) and hematologic malignancy (HM) population. CDI is associated with increased hospital length of stay, health care and societal costs, morbidity, and mortality. Identifying strategies for secondary prevention of CDI is of extreme importance in the HSCT/HM population. In this study, our primary objective was to evaluate the effectiveness and safety of an oral vancomycin prophylaxis (OVP) protocol for secondary prevention of CDI in a retrospective cohort of adult autologous/allogeneic HSCT recipients and patients with HM who did not undergo HSCT with a first CDI episode treated with concomitant broad-spectrum antibiotics (BSA). Patients were diagnosed and treated for CDI as inpatients and/or outpatients and were divided into 2 groups based on a preprotocol versus postprotocol analysis: the OVP group, comprising patients who received planned monotherapy with oral vancomycin 125 mg every 6 hours for 14 days for a first episode of CDI and subsequently received OVP posttreatment and a no OVP (NOVP) group, comprising patients who received planned monotherapy with oral vancomycin 125 mg every 6 hours for 14 days for a first episode of CDI and subsequently did not receive OVP posttreatment. OVP was defined as vancomycin 125 mg every 12 hours for up to 7 days after BSA discontinuation. The primary endpoint was recurrent CDI (rCDI), defined as symptoms of loose stools/diarrhea with high clinical suspicion for CDI prompting empiric therapy within 60 days of completion of treatment/prophylaxis for the first CDI episode. The incidence of vancomycin-resistant enterococcal (VRE) infection and 60-day mortality were also compared between the 2 groups. Multivariate logistic regression was created from associated variables to identify independent associations with rCDI. A total of 50 patients were included, 21 in the OVP group (42%) and 29 in the NOVP group (58%). The mean patient age was 58 years, and the cohort was 60% male and 86% Caucasian. HSCT was performed in 60% of the patients, and 76% of CDI cases were diagnosed during hospitalization. The rate of rCDI was significantly lower in the OVP group compared with the NOVP group (5% [1 of 21] versus 35% [10 of 29]; P= .016), with no subsequent increase in VRE infection rate (14% [3 of 21] versus 10% [3 of 29]; P = .686). By multivariable logistic regression, rCDI was inversely associated with OVP (odds ratio [OR], .14; 95% confidence interval [CI], .007 to .994; P = .049) and directly associated with outpatient CDI diagnosis (OR, 8.72; 95% CI, 1.816 to 49.158; P = .007). No between-group differences were found in 60-day mortality (10% [2 of 21] for OVP versus 7% [2 of 29] for NOVP; P > 0.999). OVP appears to be safe and effective for secondary prevention of CDI in the HSCT/HM population. Prospective trials are needed to validate the effectiveness of OVP in this vulnerable population to prevent rCDI.

BackgroundDepressed patients often focus on negative life events. Effective antidepressant therapy reverses this negative emotional bias (NEB) within 1 week. Clinical therapeutic effect usually requires 4–6 weeks. The value of implementing NEB monitoring for the personalisation of antidepressant therapy is unknown.ObjectiveTo estimate the likely outcome and cost consequences of adopting the P1vital Oxford Emotional Test Battery (ETB) for this purpose in routine primary care in England.MethodsA hybrid decision analytic model (decision tree plus Markov model) was developed to estimate the cost-effectiveness of ETB monitoring versus no ETB over 52 weeks using quality-adjusted life years (QALYs). Differences in depression severity, episode type and analytical perspectives were considered. Input data were derived from relevant guidelines, literature, national databases, expert opinion and the developers for the year 2013. Multiple sensitivity analyses addressed uncertainty.FindingsThe mean number of ETB tests is 2.162 per newly diagnosed patient and 2.166 per patient with recurrent depression. The incremental cost-effectiveness of ETB versus ‘no ETB’ is £4355/QALY from the healthcare perspective. From the broader societal perspective, ETB is more effective and cost saving.ConclusionsMonitoring negative emotional bias in primary care in England for personalised antidepressant treatment using ETB seems as an effective and cost-effective option under all considered scenarios (including worst case). Its main economic value seems to lie in reduced productivity loss as opposed to healthcare savings.Clinical implicationsThe test supports accelerated application of evidence-based depression care. Further optimisation and implementation in the ongoing European PReDicT trial is ongoing.

Despite numerous advances in medical and surgical management, congenital heart disease (CHD) remains the number one cause of death in the first year of life from congenital malformations. The current strategies used to approach improving outcomes in CHD are varied. This article will discuss the recent impact of pulse oximetry screening for critical CHD, describe the contributions of advanced cardiac imaging in the neonate with CHD, and highlight the growing importance of quality improvement and safety programs in the cardiac intensive care unit.

Aims: Chondrosarcoma, osteosarcoma and Ewing sarcoma form the majority of malignant primary tumours of bone. High-grade bone sarcomas require intensive treatment due to their rapid and invasive growth pattern and metastasising capabilities. This nationwide study covers overall incidence, treatment and survival patterns of bone sarcomas in a 15-year period (2000-2014) in the total population of the Netherlands.Patients and methods: Data for this study were derived from the Netherlands Cancer Registry, which receives primary notification from the national pathology database. Classification and categorisation was based on the ICD-O-3 classification and the WHO classification 2013 applied according to our clinicopathological expertise. Overall incidence over the 15-year-period was calculated as a rate per 100,000 person-years (using the European Standardised Rate, ESR). Survival was analysed with Kaplan-Meier curves and Cox proportional hazards regression.Results: Incidence for high-grade chondrosarcoma (n = 429) was estimated at 0.15 per 100,000 ESR, and 5-year overall survival at 65.9% (95% confidence interval (CI): 61.0%-70.4%). Incidence for high-grade central osteosarcoma (n = 605) was estimated at 0.25 per 100,000 ESR and 5-year survival at 53.9% (95% CI: 49.7%-58.0%). Ewing sarcoma incidence (n = 334) was estimated at 0.15 per 100,000 ESR and 5-year survival at 59.3% (95% CI: 53.5%-64.6%). For high-grade central osteosarcoma, treatment at a bone tumour centre was associated with better survival (HR 0.593).Conclusions: This study provides comprehensive incidence estimates for all the main primary bone sarcomas over a 15-year time period in a Northern European country with little migration. Centralisation of bone sarcoma care improves the clinical outcome in osteosarcoma.

Background Parental support is an important element in overweight prevention programs for children. The purpose of this study was to examine everyday life situations in which mothers encounter difficulties encouraging healthy energy balance–related behavior in their school-age children. Methods We formed four focus groups containing 6–9 participants each. The participants were mothers of Dutch, Turkish, or Moroccan descent with a child 8–13 years of age. All focus group sessions were recorded, transcribed, and coded. Content was analyzed conventionally using ATLAS.ti 6. Results Twenty-seven difficult everyday life situations were identified in 14 settings. The five most frequently reported situations were a daily struggle regarding eating vegetables, eating breakfast on time before going to school, eating candy and snacks between meals, and spending excessive time watching television and using the computer. A perceived loss of parental control, the inability to establish rules and the failure to consistently enforce those rules were the most commonly cited reasons for why the mothers experience these situations as being difficult. Conclusions We identified five difficult everyday life situations related to healthy energy balance-related behavior. These five difficult situations were used as the input for developing a web-based parenting program designed to prevent children from becoming overweight. We reasoned that if we use these situations and the underlying reasons, many parents would recognize these situations and are willing to learn how to deal with them and complete the e-learning. Electronic supplementary material The online version of this article (10.1186/s12889-019-6826-x) contains supplementary material, which is available to authorized users.

Objectives The authors sought to investigate long-term outcomes after revascularization with and without use of cardiopulmonary bypass and hypothesized that off-pump would be comparable with on-pump. The primary outcome of interest was survival, and secondary outcomes were need for reintervention for revascularization or new diagnosis of myocardial infarction occurring any time after surgery during the 8- to 12-year follow-up period. Design Retrospective cohort analysis. Setting Veterans Affairs Medical Center. Participants All patients undergoing primary isolated coronary bypass between January 1, 2004, and December 31, 2008 (n = 555). Interventions Coronary artery bypass on-pump (n = 238) or off-pump (n = 317). Measurements and Main Results Demographic and clinical variables were documented, including information on mortality, new myocardial infarction, and need for reintervention in the 8- to 12-year period after surgery. The on-pump and off-pump groups were similar regarding all demographic and clinical variables (p > 0.05), except for higher incidence of prior percutaneous coronary intervention in the off-pump group. There were more perioperative complications in the on-pump group (p = 0.007) and a greater number of grafts used (p = 0.000). Kaplan-Meier survival analysis demonstrated no significant difference (p > 0.05) in overall survival, reintervention-free survival, or postoperative myocardial infarction–free survival between patients who underwent bypass grafting on-pump or off-pump over extended follow-up averaging 10years. Conclusions The present study's data did not show differences in key long-term outcomes between patients who underwent revascularization with or without cardiopulmonary bypass, supporting the idea that both methods achieve similar late results regarding overall survival, need for reintervention, and postoperative myocardial infarction.

Background It is helpful for collaboration if professionals from the field of health and social welfare and the field of city planning are aware of each other’s concepts of what a healthy living environment entails and what its components are. This study examined perceptions about creating a healthy living environment of professionals from these two fields, as well as the differences between them. Methods We recruited 95 professionals from Nijmegen, the Netherlands who worked in the fields of health, social welfare and city planning in governmental and non-governmental capacities. We used the concept mapping method to collect and analyse their thoughts on healthy living environments. Participants first submitted statements on this subject in a brainstorming session, using an online mapping tool. Then they sorted these statements and rated them on priorities and opportunities within urban planning processes. Results During the brainstorm, 43 professionals generated 136 statements. After the elimination of duplicates, 92 statements were individually sorted by 32 professionals. Concept mapping software was used to create an overall map, in which the statements were sorted into ten clusters. Each of these clusters represented one of the main features of a healthy living environments. After 36 participants rated these statements, it emerged that professionals from both fields agreed on priorities and opportunities for the clusters ‘Spatial quality’ and ‘Conducive to exercise’. Professionals also agreed on which three clusters had the fewest priorities and possibilities (‘Promotes personal wellbeing’, ‘Encourages healthy choices’, ‘Conducive to social connections’). Conclusion We found that professionals in health and social welfare and city planning have similar views concerning the most and least important features of a healthy living environment in urban planning process. This could indicate that the differences between the two fields may be more nuanced and specific than previously thought. This knowledge offers perspectives for professionals to strengthen their collaboration and to come to a joint result in urban planning projects.

Depressed patients often do not respond to the first antidepressant prescribed, resulting in sequential trials of different medications. Personalised medicine offers a means of reducing this delay; however, the clinical effectiveness of personalised approaches to antidepressant treatment has not previously been tested. We assessed the clinical effectiveness of using a predictive algorithm, based on behavioural tests of affective cognition and subjective symptoms, to guide antidepressant treatment. We conducted a multicentre, open-label, randomised controlled trial in 913 medication-free depressed patients. Patients were randomly assigned to have their antidepressant treatment guided by a predictive algorithm or treatment as usual (TaU). The primary outcome was the response of depression symptoms, defined as a 50% or greater reduction in baseline score of the QIDS-SR-16 scale, at week 8. Additional prespecified outcomes included symptoms of anxiety at week 8, and symptoms of depression and functional outcome at weeks 8, 24 and 48. The response rate of depressive symptoms at week 8 in the PReDicT (55.9%) and TaU (51.8%) arms did not differ significantly (odds ratio: 1.18 (95% CI: 0.89-1.56), P = 0.25). However, there was a significantly greater reduction of anxiety in week 8 and a greater improvement in functional outcome at week 24 in the PReDicT arm. Use of the PReDicT test did not increase the rate of response to antidepressant treatment estimated by depressive symptoms but did improve symptoms of anxiety at week 8 and functional outcome at week 24. Our findings indicate that personalisation of antidepressant treatment may improve outcomes in depressed patients. This project received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 696802.

Aims Congenital heart disease (CHD) is the most common congenital malformation. Despite the worldwide burden to patient wellbeing and health system resource utilization, tracking of long-term outcomes is lacking, limiting the delivery and measurement of high-value care. To begin transitioning to value-based healthcare in CHD, the International Consortium for Health Outcomes Measurement aligned an international collaborative of CHD experts, patient representatives, and other stakeholders to construct a standard set of outcomes and risk-adjustment variables that are meaningful to patients. Methods and results The primary aim was to identify a minimum standard set of outcomes to be used by health systems worldwide. The methodological process included four key steps: (i) develop a working group representative of all CHD stakeholders; (ii) conduct extensive literature reviews to identify scope, outcomes of interest, tools used to measure outcomes, and case-mix adjustment variables; (iii) create the outcome set using a series of multi-round Delphi processes; and (iv) disseminate set worldwide. The Working Group established a 15-item outcome set, incorporating physical, mental, social, and overall health outcomes accompanied by tools for measurement and case-mix adjustment variables. Patients with any CHD diagnoses of all ages are included. Following an open review process, over 80% of patients and providers surveyed agreed with the set in its final form. Conclusion This is the first international development of a stakeholder-informed standard set of outcomes for CHD. It can serve as a first step for a lifespan outcomes measurement approach to guide benchmarking and improvement among health systems.

This chapter delves into common mistakes made when positioning a patient for intubation. It starts with the three key requirements to ensuring optimal intubation positioning, also known as the sniffing position. Next it discusses techniques and materials for creating a ramp for larger patients who would be otherwise suboptimally positioned and reviews common patient factors or environments where it is difficult to position a patient well. This includes intubating outside of the operating room, intubating in a gurney or ICU bed, intubating obese patients, and intubating under cervical spine precautions.

Monitored anesthesia care (MAC) is a term used to describe an anesthetic that is not a general anesthetic, although it is important to remember that all anesthesia provided by an anesthesiologist is carefully monitored from the preoperative to intraoperative to postoperative period. MAC is best paired with some type of nerve blockade, whether that is local anesthetic infiltration, a peripheral nerve block, or a neuraxial block such as an epidural or spinal. MAC is additionally typically paired with some form of IV sedation, but this is not a requirement. It is important to remember when performing MAC that it is a spectrum from mild to moderate (i.e., conscious) to deep sedation. As the degree of sedation progresses, there is an increasing risk of hypotension and, perhaps more importantly, an increasing degree of upper airway obstruction, hypoventilation, and eventually apnea.

Femoral veins are the second most common location for central line placement after internal jugular veins. As with subclavian and internal jugular central lines, ultrasound is a useful tool to correctly identifying the femoral vein. The femoral vein can be challenging to identify using anatomic landmarks particularly in patients with obese body habitus. Ultrasound guidance can help reduce the risk of nerve injury and hematoma from accidental puncture of surrounding neurovascular structures. However, ultrasound is not always available, so it is important for an anesthesiologist to know how to place femoral lines without ultrasound guidance.

Jet ventilation is a valuable technique for airway management in airway surgeries. It enables the ENT surgeon to operate uninterrupted and unimpeded by an endotracheal tube or laryngeal mask airway. It does not require the anesthesiologist to keep a patient spontaneously ventilating. However, it is a nuanced technique that requires careful coordination between the ENT surgeon and anesthesiologist. There are careful requirements that must be maintained in order to prevent potentially catastrophic complications, particularly barotrauma, pneumothorax, subcutaneous infiltration of air, severe hypercarbia, and interference with surgery. These are outlined in this chapter on jet ventilation for ENT surgery.

This book is an alphabetical directory of drugs, listed by generic name. Thus, the book will have 26 chapters - one chapter per letter (chapter 1 will have all drugs starting with the letter "A", chapter 2 with drugs starting with letter "B", etc.).

This chapter reviews how to perform a detailed preoperative evaluation of a patient’s airway including a twelve-step approach to assessing the teeth, palate, oropharynx, neck, and range of motion of the head and neck. It also reviews critical structures of the airway, broken down into the components of nasopharynx, oropharynx, larynx, and tracheobronchial tree. It also outlines important distances within the airway which can be used to assess appropriate depth of endotracheal tube positioning.

Combined spinal-epidurals are an excellent technique for surgeries of uncertain duration where the anesthesiologist has determined that monitored anesthesia care with neuraxial blockade would be better for the patient than a general anesthetic. This is commonly done in cesarean sections where typically a single shot spinal block would be placed or an in situ labor epidural would be re-dosed to achieve a desired level of sensory and motor blockade. This chapter highlights indications, insertion, and management of combined spinal-epidural blocks.

Double-lumen endotracheal tubes (ETTs) are typically used in the operating room in surgeries that require one-lung ventilation. They can be challenging to insert due to their large size relative to the pharynx and larynx, especially when compared to traditional single-lumen endotracheal tubes. This chapter details indications for one-lung ventilation, factors for appropriately sizing double-lumen ETTs, advantages and disadvantages to double-lumen ETTs, necessary equipment for intubating with a double-lumen ETT, and how to insert, manage, and troubleshoot double-lumen ETTs.

Central lines can be placed in several locations, most commonly internal jugular or femoral. Subclavian central lines are less common due to concern for iatrogenic pneumothorax. However, they are an important skill because there are situations in which internal jugular and femoral access are not available. Subclavian central lines are typically placed without ultrasound using anatomical landmarks. Special precautions are taken to minimize the risk of pneumothorax, secondary to accidental pleural puncture, and hemothorax, secondary to unintentional puncture of the subclavian artery. This chapter outlines equipment, positioning, and instructions for placing a subclavian central line without ultrasound using anatomical landmarks.

Ultrasound guidance has become more popular as technology has improved and anesthesiology residencies have increased ultrasound teaching in their training programs. Ultrasound is an invaluable tool because it helps providers accurately identify critical structures and avoid complications such as pneumothorax, hematoma, and nerve injury. However, as with all technology, ultrasound machines can malfunction or may not be readily available. Therefore, it is important for anesthesiologists to be adept at placing central lines without ultrasound in case it is unavailable. This chapter reviews how to place an internal jugular central line without ultrasound using anatomical landmarks. Internal jugular vein is the most common location to attempt central line placement due to ease of access. In certain patients, the internal jugular vein can be difficult to identify using anatomical landmarks, such as in the setting of a large, thick neck, trauma, and edema.

Total IV anesthetics are an excellent analgesic commonly used for neurosurgeries involving neuromonitoring or given to patients at risk for elevated intracranial pressure. Compared to inhaled anesthetics, TIVA requires some additional setup with multiple infusions, careful monitoring of one’s peripheral IV, and adjustment of IV anesthetic dosing timed appropriately to efficient emergence and extubation. This chapter highlights indications for TIVA and reviews common IV medications used to achieve TIVA. It then reviews potential complications of TIVA, how to avoid them, and discusses a possible technique for TIVA.

Background: Congenital heart disease (CHD) is the leading cause of morbidity and mortality from birth defects worldwide. We report an overview of trends in CHD mortality in 204 countries and territories over the past 30 years and associations with age, period, and birth cohort. Methods: Cause-specific CHD mortality estimates were derived from the Global Burden of Disease study 2019. We utilized an age-period-cohort model to estimate overall annual percentage changes in mortality (net drifts), annual percentage changes from 0-4 to 65-69 years (local drifts), period and cohort relative risks (period/cohort effects) between 1990 and 2019. This approach allows for the examination and differentiation of age, period and cohort effects in the mortality trends, with the potential to identify disparities and treatment gaps in cardiac care. Findings: CHD is the leading cause of deaths from non-communicable diseases in those under 20 years. Global CHD deaths in 2019 were 217,000 (95% uncertainty interval: 177,000, 262,000).There were 129 countries with at least 50 deaths. India, China, Pakistan and Nigeria had the highest mortality accounting for 39.7% of deaths globally. Between 1990 and 2019, the reduction in CHD all-age mortality ranged from –71.3% [–74.7 to –64.6] in high-sociodemographic index (SDI) countries to –42.1% [–61.9 to 12.1] in low-SDI countries. Globally, there was an emerging transition in the age distribution of deaths from pediatric to adult population, except for an increasing trend of mortality in 10~34 years in Mexico and Pakistan. During the past 30 years, favorable mortality reductions were generally found in most high-SDI countries like South Korea (net drift = –4.0% [95% confidence interval: –4.8 to –3.1] per year) and United States (–2.3% [–2.5 to –2.0]), and also in many middle-SDI countries like Brazil (–2.7% [–3.1 to 2.4]) and South Africa (–2.5% [–3.2 to –1.8]) and a few low-SDI countries like Ethiopia (–2.3% [–3.0 to –1.6]). However, 52 out of 129 countries had either increasing trends (net drifts≥0.0%) or stagnated reductions (≥–0.5%) in mortality. The relative risk of mortality generally showed improving trends over time and in successively younger birth cohorts among high- and high-middle SDI countries with the exceptions of Saudi Arabia and Kazakhstan. Fourteen middle-SDI countries such as Ecuador and Mexico, and sixteen low-middle-SDI countries including India and twenty low-SDI countries including Pakistan, had unfavorable or worsening risks for recent periods and birth cohorts. Interpretation: CHD mortality is an accessible metric that can be used to track trends and levels in the provision of congenital cardiac care for low- and middle-income countries. Improvements in the treatment of CHD should reduce the risk for successively younger cohorts and shift the risk for all age groups over time. Although there were gains in CHD mortality globally over the past three decades, unfavorable period and cohort effects were found in many countries, raising questions about adequacy of their health care for CHD patients across all age-groups. These failings carry significant implications for the likelihood of achieving the Sustainable Development Goals in this domain. Funding Information: National Natural Science Foundation of China, Shanghai Outstanding Medical Academic Leader program, and Collaborative Innovation Program of Shanghai Municipal Health Commission. Declaration of Interests: We declare no competing interests. Ethics Approval Statement: The GBD study uses deidentified data and a waiver of informed consent was approved by the University of Washington Institutional Review Board.

Anesthesiologists are the primary service consulted when patients present to the emergency department with post-dural puncture headaches (PDPH). Sometimes these PDPHs occur as a result of lumbar punctures or intrathecal contrast injections, which are performed by other specialty services such as neurology and interventional radiology. These procedures are performed using relatively large diameter needles, thus increasing the risk of PDPH. Other times, PDPHs are the result of unintended dural puncture, i.e., a wet tap, when an anesthesiologist is placing an epidural. It is important for the consultant anesthesiologist to correctly identify whether the patient truly has a PDPH and decide whether to proceed with conservative management or place an epidural blood patch. This chapter discusses risk factors for wet taps. It then moves to indications and contraindications to epidural blood patch and steps for placing a blood patch.

Anesthesiologists are frequently called to intubate patients in an urgent or emergent setting outside of the operating room, especially at code blues when a patient has gone into cardiac or respiratory arrest. This chapter outlines how to assess a patient’s status in an efficient manner, including assessing vital signs and ABCs (airway, breathing, and circulation status). Outside of the operating room, the anesthesiologist must rely on supplies provided in an emergency crash cart or in a department-provided code bag. Using the MOMSAID mnemonic (Machine, Oxygen, Monitor, Suction, Airway, IV, Drugs), this chapter highlights how to pick and choose supplies and ensure appropriate setup for a safe intubation.

Anesthesiologists are frequently tasked with assisting with vascular access both in and outside of the operating room. Ultrasound-guided vascular access has become an invaluable skill, especially with the advent of more portable, readily available ultrasounds. This chapter reviews several different techniques for using an ultrasound to obtain peripheral IV access. No technique is foolproof and should be modified based on the patient, provider preferences, and provider dexterity with ultrasound.

This chapter discusses how to manage unanticipated aspiration that occurs during induction of anesthesia. While there are certain risk factors that should prompt an anesthesiologist to anticipate vomiting, this can occur independent of those risk factors. This chapter focuses on the prevention of aspiration after emesis occurs and management of the airway and lungs after aspiration has already taken place.

Laryngeal mask airways (LMAs) are a common airway device often used for short surgeries. It is also an essential part of the American Society of Anesthesiology’s Difficult Airway Algorithm. In a patient who cannot be mask ventilated and cannot be intubated, the next step is placement of a laryngeal mask airway. This chapter reviews absolute and relative contraindications to LMA placement and reviews some of the most common types of LMAs on the market. It also discusses techniques for placing LMAs and common ways to troubleshoot suboptimally functioning LMAs.

This chapter discusses on how to intubate a patient without neuromuscular blockade. While this is more commonly done in pediatric patients after achieving a deep plane of anesthesia, it is less commonly done in adult patients due to concern for laryngospasm and suboptimal views for intubation. The most common techniques involve use of a potent but short-acting narcotic such as alfentanil or remifentanil. Steps for performing intubation without paralytic are outlined below.

The radial artery is the most commonly used site for arterial lines, but sometimes the upper extremities are unavailable due to positioning or trauma. Rather than move to the femoral artery which would mean puncturing a much larger vessel, the provider may consider placing a dorsalis pedis arterial line in the foot instead. Dorsalis pedis arterial lines may be challenging to place. While the vessel is relatively superficial and often easy to palpate, it may be so superficial and at such an angle that it is hard to thread a guidewire or catheter. Dorsalis pedis arterial lines are an important procedure to learn. This chapter reviews how to identify, access, and cannulate the dorsal pedal artery using anatomic landmarks and palpation.

There are multiple factors to weigh when deciding whether to perform a fiberoptic intubation, and if so, whether this is to be done asleep or awake. When the provider determines that the safest and most appropriate airway management is an asleep fiberoptic intubation, the provider must then decide whether to try to maintain ventilation while intubating or to allow apnea. Maintaining ventilation affords the provider additional time because there is continued active oxygenation and exchange of carbon dioxide, which may be especially beneficial in a more tenuous patient who may not tolerate apnea for long. This chapter provides detailed instructions for performing asleep fiberoptic intubations in several variations: maintaining or not maintaining ventilation, using an intubating oral airway, using a laryngeal mask airway, and/or using an Aintree catheter.

Neuraxial blockade is a common anesthetic for labor and delivery and orthopedic surgeries. Single shot spinals are a type of neuraxial blockade involving a single administration of intrathecal local anesthetic possibly paired with adjuncts. This chapter reviews techniques for placing a single shot spinal, including positioning, dosing, complications, and assessment.

An unstable cervical spine poses several challenges to the anesthesiologist. It restricts the neck range of motion, thereby limiting the ease with which an optimal view of the larynx can be obtained. This chapter reviews essential questions that must be addressed when presented with an unstable cervical spine. In answering these questions, the anesthesiologist can gather essential information and make an informed decision on how to proceed safely with intubation. Ultimately the goal is to secure the airway without causing harm to the patient.

Part of the art of anesthesia is performing timely emergence and extubation. There are multiple ways to safely and efficiently perform an anesthetic. This chapter is simply one option for performing emergence without the use of nitrous oxide, in particular.

Anesthesiologists are often asked to assist with peripheral IV placement in patients who are at difficult vascular access. In such situations, there are typically no visible peripheral veins, so anesthesiologists must rely on knowledge of vascular anatomy to look for potential IV sites. This chapter discusses common locations and reviews such anatomy.

Seven years after its addition to the US Recommended Uniform Screening Panel, newborn screening for critical congenital heart disease (CCHD) using pulse oximetry became mandatory in the United States. Although CCHD newborn screening reduces morbidity and mortality, there remain important opportunities to improve. An expert panel convened for a 1-day meeting in September 2018, including subject matter experts and representatives from stakeholder organizations. Presentations on CCHD outcomes, variations in approach to screening, and data and quality improvement helped identify improvement opportunities. The expert panel concluded that sufficient evidence exists to recommend modifying the current American Academy of Pediatrics algorithm by (1) requiring an oxygen saturation of at least 95% in both (formerly either) the upper and lower extremities to pass and (2) requiring only 1 repeat screen instead of 2 for cases that neither pass nor fail initially. The panel underscored the importance of improving public health reporting by further specifying the targets of screening and criteria for reporting outcomes (false-negative and false-positive cases). The panel also highlighted the need to ensure sufficient public health funding for CCHD newborn screening and opportunities for education and global implementation. Newborn screening for CCHD using pulse oximetry has led to significant improvements in child health outcomes. However, further important work is required to understand and improve the effectiveness and efficiency of screening.

Congenital heart disease (CHD) is the most common congenital malformation. Diagnosis of critical congenital heart disease (CCHD), the most severe type of congenital heart disease, in a newborn may be difficult. The addition of CCHD screening, using pulse oximetry, to clinical assessment significantly improves the rate of detection. We conducted a pilot study in Morocco on screening neonates for critical congenital heart disease. This study was conducted in the maternity ward of Mohammed VI University Hospital of Marrakesh, Morocco, and included asymptomatic newborns delivered between March 2019 and January 2020. The screening of CCHD was performed by pulse oximetry measuring the pre- and post-ductal saturation. Screening was performed on 8013/10,451 (76.7%) asymptomatic newborns. According to the algorithm, 7998 cases passed the screening test (99.82%), including one inconclusive test that was repeated an hour later and was normal. Fifteen newborns failed the screening test (0.18%): five CCHD, five false positives, and five CHD but non-critical. One false negative case was diagnosed at 2 months of age. Our results encourage us to strengthen screening for CCHD by adding pulse oximetry to the routine newborn screening panel.

The model of regional economic development in the Lipetsk region based on the allocation of industry and agriculture production in Special Economic Zones has shown its effectiveness for the development of the whole region. However, this model was helpless to introduce any significant breakthrough changes in the structure of the economy. Currently there has been an attempt to apply the same allocation model to tourism segment objects. It is shown that tourist entities unlike industrial and agricultural have different development imperatives. The main condition for the successful formation and functioning of tourist objects on a territory is their interconnected interaction within a tourist cluster. A tourist cluster can not be created at the only site. Tourist objects of a tourist cluster must be distributed according to tourist destinations and integrated through a well-developed infrastructure in a single functional system. When applying the special economic zone model to a territory it is necessary to make adaptations in accordance to the specifics of the allocated objects. The conclusion is that the application of the same management model for different economy segments needs adjustment. It is also important to distinguish a “Cluster” which is a geographic concentration of interconnected companies and a “Special Economic Zone” which is a territory with economic preferences.