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Dysphagia is common in infants born with critical CHD. Thickened liquids are often used to treat dysphagia, but associated risks limit widespread use among feeding specialists. This survey aims to assess dysphagia treatment patterns and thickened liquid use across paediatric cardiac surgical centres.
Methods:
A 24-question, cross-sectional survey. Convenience and snowball sampling methods were used to engage 52 paediatric cardiac surgical centres affiliated with the Cardiac Newborn Neuroprotective Network. Descriptive statistics were used to analyse and compare responses.
Results:
Twenty-six individual respondents represented 21 unique paediatric cardiac surgical centres. Most responses were from experienced, speech–language pathologists (78%) at medium size centres (88%). Ninety-three percent of responding centres used thickened liquids to treat dysphagia and 81% only after formal instrumental assessment of swallowing. Thickened oral feeding was used for single-ventricle patients by 85% versus 69% for two-ventricle patients. Barriers to recommending thickened oral feedings included the cost of thickening agents, parental non-adherence, and gastrointestinal concerns.
Conclusions:
This is the first survey to report multi-institutional dysphagia treatment practice variation at United States congenital cardiac surgical centres. Thickened oral feedings are frequently used across centres in high-risk critical CHD patients but treatment benefit remains unclear. This survey highlights a broad scientific community poised to direct dysphagia research in critical CHD to address practice variation, short- and long-term impact of thickened oral feeding on feeding outcomes, and barriers to use and access of thickening agents.
The fossil record of dinosaurs in Scotland mostly comprises isolated highly fragmentary bones from the Great Estuarine Group in the Inner Hebrides (Bajocian–Bathonian). Here we report the first definite dinosaur body fossil ever found in Scotland (historically), having been discovered in 1973, but not collected until 45 years later. It is the first and most complete partial dinosaur skeleton currently known from Scotland. NMS G.2023.19.1 was recovered from a challenging foreshore location in the Isle of Skye, and transported to harbour in a semi-rigid inflatable boat towed by a motor boat. After manual preparation, micro-CT scanning was carried out, but this did not aid in identification. Among many unidentifiable elements, a neural arch, two ribs and part of the ilium are described herein, and their features indicate that this was a cerapodan or ornithopod dinosaur. Histological thin sections of one of the ribs support this identification, indicating an individual at least eight years of age, growing slowly at the time of death. If ornithopodan, as our data suggest, it could represent the world's oldest body fossil of this clade.
Palmer amaranth (Amaranthus palmeri S. Watson, AMAPA) is one of the most troublesome weeds in North America due to its rapid growth rate, substantial seed production, competitiveness and the evolution of herbicide-resistant populations. Though frequently encountered in the South, Midwest, and Mid-Atlantic regions of the United States, A. palmeri was recently identified in soybean [Glycine max (L.) Merr.] fields in Genesee, Orange, and Steuben counties, NY, where glyphosate was the primary herbicide for in-crop weed control. This research, conducted in 2023, aimed to (1) describe the dose response of three putative resistant NY A. palmeri populations to glyphosate, (2) determine their mechanisms of resistance, and (3) assess their sensitivity to other postemergence herbicides commonly used in NY crop production systems. Based on the effective dose necessary to reduce aboveground biomass by 50% (ED50), the NY populations were 42 to 67 times more resistant to glyphosate compared with a glyphosate-susceptible population. Additionally, the NY populations had elevated EPSPS gene copy numbers ranging from 25 to 135 located within extrachromosomal circular DNA (eccDNA). Label rate applications of Weed Science Society of America (WSSA) Group 2 herbicides killed up to 42% of the NY populations of A. palmeri. Some variability was observed among populations in response to WSSA Group 5 and 27 herbicides. All populations were effectively controlled by labeled rates of herbicides belonging to WSSA Groups 4, 10, 14, and 22. Additional research is warranted to confirm whether NY populations have evolved multiple resistance to herbicides within other WSSA groups and to develop effective A. palmeri management strategies suitable for NY crop production.
OBJECTIVES/GOALS: The Clinical Implementation stage in the translational pipeline is hampered by the tension between formal evidence and clinician perceptions. For instance, when guidelines are translated into electronic clinical decision support alerts, they are often ignored. Using advances in LLMs we present a framework to quantify these discrepancies. METHODS/STUDY POPULATION: We hypothesize that ignoring guideline-based alerts may be driven by discordances between clinical guidelines’ deterministic realities and clinician’ perception of clinical reality. Until now this has been very difficult to measure using quantitative methods. We argue that advances in Large Language Models (LLM) provide an avenue for exploring this quantitatively. Here we present the method and preliminary results comparing the responses of BioBERTT from a carefully designed set of questions when the LLM is fine-tuned using either formal guidelines or transcripts of clinicians discussing guidelines and clinical care in the parallel domain. The formal “distance” between the LLM responses is evaluated using quantitative metrics like the Hamming Distance. RESULTS/ANTICIPATED RESULTS: We present a description of the architecture used to prove or disprove our hypothesis. We will present results obtained when training the architecture with data that could be used to test the limits of our hypothesis, by fine-tuning BioBERT with diverse synthetic clinical views, either in agreement or disagreement with the formal guidelines. Results comparing sepsis guideline text with transcripts of interviews with Emergency Department clinicians discussing care practices for sepsis in the ED transcripts will also be considered. Our current emphasis is on securing a wider range of transcripts of clinicians interviewed from different clinical specialties and different clinical settings. While here we focus on clinical guidelines, the framework supports any intervention in the Clinical Implementation stage. DISCUSSION/SIGNIFICANCE: Leveraging recent advances in LLMs, we develop a framework that can quantitatively measure the differences between guidelines and clinician perception of best practices. We demonstrated the functionality of this approach using synthetic data and initiated the collection of clinician transcripts to test the framework in real clinical situations.
Libraries in the United States promote social justice by preserving and providing the public with free, equitable access to information. Libraries can provide this free access only because of exceptions and limitations in the U.S. Copyright Act such as the first sale doctrine, the fair use right, and the safe harbors for providers of online services. As a result of these exceptions and limitations, Americans at every social-economic level of our society enjoy access to the knowledge contained in millions of copyrighted works, and they use that knowledge to improve their daily lives and to enhance their participation in and contributions to civil society. This chapter explores the importance of these exceptions and limitations, particularly in the modern remote information society, to the pursuit of the precepts of equitable access, inclusion, and empowerment in the fulfillment of libraries’ social justice mission.
Circadian clocks in all tissues confer temporal organization to the physiology and behavior of organisms. Rhythms of the cardiovascular system have been scrutinized because of the morning peak of adverse cardiovascular events and because night and rotating shift work have been associated with heart disease and biomarkers of elevated cardiometabolic risk. Animal models support the important role that the clock plays in the heart. External disruptions such as jetlag and internal disruptions such as loss of clock function contribute to poor heart health. In this chapter, we review key findings from animal models of circadian disruption and from experiments in humans designed to isolate the effects of the circadian clock on cardiovascular physiology.
Neurodevelopmental challenges are the most prevalent comorbidity associated with a diagnosis of critical CHD, and there is a high incidence of gross and fine motor delays noted in early infancy. The frequency of motor delays in hospitalised infants with critical CHD requires close monitoring from developmental therapies (physical therapists, occupational therapists, and speech-language pathologists) to optimise motor development. Currently, minimal literature defines developmental therapists’ role in caring for infants with critical CHD in intensive or acute care hospital units.
Purpose:
This article describes typical infant motor skill development, how the hospital environment and events surrounding early cardiac surgical interventions impact those skills, and how developmental therapists support motor skill acquisition in infants with critical CHD. Recommendations for healthcare professionals and those who provide medical or developmental support in promotion of optimal motor skill development in hospitalised infants with critical CHD are discussed.
Conclusions:
Infants with critical CHD requiring neonatal surgical intervention experience interrupted motor skill interactions and developmental trajectories. As part of the interdisciplinary team working in intensive and acute care settings, developmental therapists assess, guide motor intervention, promote optimal motor skill acquisition, and support the infant’s overall development.
Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, “Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease,” includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.
The current small study utilised prospective data collection of patterns of prenatal alcohol and tobacco exposure (PAE and PTE) to examine associations with structural brain outcomes in 6-year-olds and served as a pilot to determine the value of prospective data describing community-level patterns of PAE and PTE in a non-clinical sample of children. Participants from the Safe Passage Study in pregnancy were approached when their child was ∼6 years old and completed structural brain magnetic resonance imaging to examine with archived PAE and PTE data (n = 51 children–mother dyads). Linear regression was used to conduct whole-brain structural analyses, with false-discovery rate (FDR) correction, to examine: (a) main effects of PAE, PTE and their interaction; and (b) predictive potential of data that reflect patterns of PAE and PTE (e.g. quantity, frequency and timing (QFT)). Associations between PAE, PTE and their interaction with brain structural measures demonstrated unique profiles of cortical and subcortical alterations that were distinct between PAE only, PTE only and their interactive effects. Analyses examining associations between patterns of PAE and PTE (e.g. QFT) were able to significantly detect brain alterations (that survived FDR correction) in this small non-clinical sample of children. These findings support the hypothesis that considering QFT and co-exposures is important for identifying brain alterations following PAE and/or PTE in a small group of young children. Current results demonstrate that teratogenic outcomes on brain structure differ as a function PAE, PTE or their co-exposures, as well as the pattern (QFT) or exposure.
Early surgical intervention in infants with complex CHD results in significant disruptions to their respiratory, gastrointestinal, and nervous systems, which are all instrumental to the development of safe and efficient oral feeding skills. Standardised assessments or treatment protocols are not currently available for this unique population, requiring the clinician to rely on knowledge based on neonatal literature. Clinicians need to be skilled at evaluating and analysing these systems to develop an appropriate treatment plan to improve oral feeding skill and safety, while considering post-operative recovery in the infant with complex CHD. Supporting the family to re-establish their parental role during the hospitalisation and upon discharge is critical to reducing parental stress and oral feeding success.
Data from neurocognitive assessments may not be accurate in the context of factors impacting validity, such as disengagement, unmotivated responding, or intentional underperformance. Performance validity tests (PVTs) were developed to address these phenomena and assess underperformance on neurocognitive tests. However, PVTs can be burdensome, rely on cutoff scores that reduce information, do not examine potential variations in task engagement across a battery, and are typically not well-suited to acquisition of large cognitive datasets. Here we describe the development of novel performance validity measures that could address some of these limitations by leveraging psychometric concepts using data embedded within the Penn Computerized Neurocognitive Battery (PennCNB).
Methods:
We first developed these validity measures using simulations of invalid response patterns with parameters drawn from real data. Next, we examined their application in two large, independent samples: 1) children and adolescents from the Philadelphia Neurodevelopmental Cohort (n = 9498); and 2) adult servicemembers from the Marine Resiliency Study-II (n = 1444).
Results:
Our performance validity metrics detected patterns of invalid responding in simulated data, even at subtle levels. Furthermore, a combination of these metrics significantly predicted previously established validity rules for these tests in both developmental and adult datasets. Moreover, most clinical diagnostic groups did not show reduced validity estimates.
Conclusions:
These results provide proof-of-concept evidence for multivariate, data-driven performance validity metrics. These metrics offer a novel method for determining the performance validity for individual neurocognitive tests that is scalable, applicable across different tests, less burdensome, and dimensional. However, more research is needed into their application.
The purpose of this study was to assess an upper body exoskeleton during automotive assembly processes that involve elevated arm postures. Sixteen team members at Toyota Motor Manufacturing Canada were fitted with a Levitate Airframe, and each team member performed between one and three processes with and without the exoskeleton. A total of 16 assembly processes were studied. Electromyography (EMG) data were collected on the anterior deltoid, biceps brachii, upper trapezius, and erector spinae. Team members also completed a usability survey. The exoskeleton significantly reduced anterior deltoid mean active EMG amplitude (p = .01, Δ = −3.2 %MVC, d = 0.56 medium effect) and fatigue risk value (p < .01, Δ = −5.1 %MVC, d = 0.62 medium effect) across the assembly processes, with no significant changes for the other muscles tested. A subset of nine assembly processes with a greater amount of time spent in arm elevations at or above 90° (30 vs. 24%) and at or above 135° (18 vs. 9%) appeared to benefit more from exoskeleton usage. For these processes, the exoskeleton significantly reduced anterior deltoid mean active EMG amplitude (p < .01, Δ = −5.1 %MVC, d = 0.95 large effect) and fatigue risk value (p < .01, Δ = −7.4 %MVC, d = 0.96 large effect). Team members responded positively about comfort and fatigue benefits, although there were concerns about the exoskeleton hindering certain job duties. The results support quantitative testing to match exoskeleton usage with specific job tasks and surveying team members for perceived benefits/drawbacks.
Otitis externa accounts for 1.1–1.3 per cent of patient presentations in primary care and 25 per cent of urgent referrals to ENT. This study aimed to explore otitis externa clinical decision-making at the primary-secondary care interface, otitis externa prevalence and recent trends in antimicrobial resistance in otitis externa related bacterial isolates and ototopical prescribing.
Method
This is a mixed-methods study drawing on data from primary and secondary care and open National Health Service sources.
Results
A total of 101 general practitioner survey respondents reported frequently prescribing oral antibiotics for otitis externa. General practitioner consultations for otitis externa increased 25 per cent over 15 years. General practitioner ototopical preparations cost the National Health Service £7 410 440 in 2006 and £11 325 241 in 2016. A total of 162 consecutive hospital otitis externa-related bacterial isolates yielded 128 pseudomonas species, with 18 that were resistant to gentamicin and 7 that were resistant to ciprofloxacin. Ten guidelines reviewed showed systematic inconsistencies.
Conclusion
General practitioners reported regularly prescribing oral antibiotics for otitis externa. Antimicrobial drug resistance is common in otitis externa. The available guidance is suboptimal.
Following the national lockdown in the UK in March 2020 in response to the COVID-19 pandemic, we instigated regular online tutorials for fourth year medical students undertaking their psychiatry placement.
Objectives
The aims of these tutorials were threefold: to ensure that students covered a range of key psychiatry topics, to enable them to have the opportunity for interactive tutorials with experienced psychiatrists and, not least, to create a sense of continuity and connection with their tutors and peers across the mental health block.
Methods
Each student was allocated to a tutorial group comprising 10 – 15 medical students and a psychiatrist facilitator. These groups met weekly for 7 consecutive weeks at an agreed time for 60 – 90 minutes via an online platform and all covered the same allocated topic each week. We evaluated these groups via an online survey sent to the students following the programme.
Results
The students rated the tutorials on average as 4.5/5 on whether they met the defined learning outcomes. On average the students did not consider that the virtual format made a significant difference to their learning, but this disguised a wide range of views that were expressed via a comment box.
Conclusions
The evaluation of this project supports the use of virtual tutorials as a valuable learning tool but educators need to be aware that student views’ on these can be varied and so, long-term, a blend of virtual and face to face learning is most likely to meet the needs of all students.
The delivery of medical education has changed alongside the effects of COVID-19. As a result, the undergraduate psychiatry training for medical students at Guy’s King’s and St Thomas’ School of Medicine had to adapt rapidly. This poster portrays the journey in which the teaching sessions were developed and delivered throughout the first academic term of 2020-2021.
Objectives
To deliver an interactive online teaching day that can provide students with the knowledge and understanding of common psychiatric disorders in the interface of other medical conditions.
Methods
A clinical skills teaching day was developed to deliver the sessions via the online video calling platform Zoom. Published articles regarding online medical education as well as guidelines from the Royal College of Psychiatry were used as a resource to develop the structure. Feedback of the teaching day was collected via an anonymous survey.
Results
78 responses were collected in total from 4 teaching days. Overall satisfaction was high with a score of 86.5/100 in overall satisfaction. Themes for positive feedback included utilising actors in simulation (38% 30/78) and high interactivity within the teaching (31% 24/78). There were a number of students who found the whole day session online tiring (13% 10/78) and others felt the variation of scenarios were too limited (12% 9/78).
Conclusions
As lockdown has forced students to have less patient contact, they have suffered from the lack of learning opportunities. This teaching day showed the importance of organising high fidelity scenarios in order to try and fill the void that has been created due to COVID-19.
Assessing risk is an important core skill yet there is not a consensus as to how to teach it. Clinically, there has been a move away from using risk prediction tools in favour of clinical judgement.We describe an iterative process to develop high quality, online teaching around risk assessment for medical undergraduates.
Objectives
To teach the clinical skill of risk assessment to enable medical students to evaluate and manage risk when encountering patients with mental health issues.
Methods
A half day tutorial was designed and refined in an iterative process using feedback from participants on this session and other concurrent teaching occurring in the department. Sessions were also reviewed by external medical educators to ensure quality and learning objectives were met.
Results
The average rating from 62 students was 4.4/5. Students commented that the session was well organised and delivered. Following feedback, the use of actors was prioritised to simulate evolving clinical situations. Students placed a high value on this: “simulated patients were amazing! They were really interesting and I was able to practice the skills I learnt over placement”. Logistical changes e.g. more breaks, followed appreciation of the exhausting nature of the session and maintained student engagement. There was increased emphasis on promoting group interaction through functions like a ‘break-out room’.
Conclusions
This session may give educators confidence that they can take risks when teaching the skill of risk assessment. Students were receptive and meaningfully engaged with concepts such as clinical judgement and bio-psycho-social formulations as opposed to ‘tick box’ assessments.
In 2018, the Neurodevelopmental and Psychosocial Interventions Working Group of the Cardiac Neurodevelopmental Outcome Collaborative convened through support from an R13 grant from the National Heart, Lung, and Blood Institute to survey the state of neurodevelopmental and psychosocial intervention research in CHD and to propose a slate of critical questions and investigations required to improve outcomes for this growing population of survivors and their families. Prior research, although limited, suggests that individualised developmental care interventions delivered early in life are beneficial for improving a range of outcomes including feeding, motor and cognitive development, and physiological regulation. Interventions to address self-regulatory, cognitive, and social-emotional challenges have shown promise in other medical populations, yet their applicability and effectiveness for use in individuals with CHD have not been examined. To move this field of research forward, we must strive to better understand the impact of neurodevelopmental and psychosocial intervention within the CHD population including adapting existing interventions for individuals with CHD. We must examine the ways in which dedicated cardiac neurodevelopmental follow-up programmes bolster resilience and support children and families through the myriad transitions inherent to the experience of living with CHD. And, we must ensure that interventions are person-/family-centred, inclusive of individuals from diverse cultural backgrounds as well as those with genetic/medical comorbidities, and proactive in their efforts to include individuals who are at highest risk but who may be traditionally less likely to participate in intervention trials.
Assessment of risks of illnesses has been an important part of medicine for decades. We now have hundreds of ‘risk calculators’ for illnesses, including brain disorders, and these calculators are continually improving as more diverse measures are collected on larger samples.
Methods
We first replicated an existing psychosis risk calculator and then used our own sample to develop a similar calculator for use in recruiting ‘psychosis risk’ enriched community samples. We assessed 632 participants age 8–21 (52% female; 48% Black) from a community sample with longitudinal data on neurocognitive, clinical, medical, and environmental variables. We used this information to predict psychosis spectrum (PS) status in the future. We selected variables based on lasso, random forest, and statistical inference relief; and predicted future PS using ridge regression, random forest, and support vector machines.
Results
Cross-validated prediction diagnostics were obtained by building and testing models in randomly selected sub-samples of the data, resulting in a distribution of the diagnostics; we report the mean. The strongest predictors of later PS status were the Children's Global Assessment Scale; delusions of predicting the future or having one's thoughts/actions controlled; and the percent married in one's neighborhood. Random forest followed by ridge regression was most accurate, with a cross-validated area under the curve (AUC) of 0.67. Adjustment of the model including only six variables reached an AUC of 0.70.
Conclusions
Results support the potential application of risk calculators for screening and identification of at-risk community youth in prospective investigations of developmental trajectories of the PS.
Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.