Many factors affect patient outcome after congenital heart surgery, including the complexity of the heart disease, pre-operative status, patient specific factors (prematurity, nutritional status and/or presence of comorbid conditions or genetic syndromes), and post-operative residual lesions. The Residual Lesion Score is a novel tool for assessing whether specific residual cardiac lesions after surgery have a measurable impact on outcome. The goal is to understand which residual lesions can be tolerated and which should be addressed prior to leaving the operating room. The Residual Lesion Score study is a large multicentre prospective study designed to evaluate the association of Residual Lesion Score to outcomes in infants undergoing surgery for CHD. This Pediatric Heart Network and National Heart, Lung, and Blood Institute-funded study prospectively enrolled 1,149 infants undergoing 5 different congenital cardiac surgical repairs at 17 surgical centres. Given the contribution of echocardiographic measurements in assigning the Residual Lesion Score, the Residual Lesion Score study made use of a centralised core lab in addition to site review of all data. The data collection plan was designed with the added goal of collecting image quality information in a way that would permit us to improve our understanding of the reproducibility, variability, and feasibility of the echocardiographic measurements being made. There were significant challenges along the way, including the coordination, de-identification, storage, and interpretation of very large quantities of imaging data. This necessitated the development of new infrastructure and technology, as well as use of novel statistical methods. The study was successfully completed, but the size and complexity of the population being studied and the data being extracted required more technologic and human resources than expected which impacted the length and cost of conducting the study. This paper outlines the process of designing and executing this complex protocol, some of the barriers to implementation and lessons to be considered in the design of future studies.

Background: Advances in multiple sclerosis (MS) disease modifying therapy (DMT) have increased laboratory monitoring requirements. Our goal was to survey existing practices and perceptions of risk in laboratory monitoring throughout Canada and assess whether opportunities to improve patient care and safety exist. Methods: A web-based survey assessing prescriber demographics, current infrastructure, and concerns for lab monitoring was sent to the Canadian Network of MS Clinics (CNMSC) listserv, inviting MS clinicians across the country to participate. Results: Respondents included 32/65 CNMSC-affiliated neurologists (49%), 6 registered nurses (RN), 2 nurse practitioners (NP), and 2 non-neurologist physicians from 8/10 provinces. For some questions, analysis was limited to 34 DMT-prescribing clinicians only. Despite broad implementation of electronic medical records (25/34, 74%), many prescribers (15/34, 44%) still receive laboratory results in paper form. In terms of lab monitoring infrastructure, we noted regional variability in the employment of nursing to monitor patient compliance with required laboratory monitoring. There is also a gap in laboratory surveillance, as less than 5% of respondents reported regularly reviewing results on weekends. Providers’ length of practice and volume of MS patients were not associated with different perception of DMT laboratory monitoring risk. Conclusions: This nation-wide survey showed variability in infrastructure used in laboratory monitoring and regional variation in nursing involvement. Providers’ level of concern for laboratory monitoring for DMTs did not vary by years of experience or volume of MS patients followed, suggesting that improved systems, rather than education, could ameliorate perceptions of risk.

The requirement for aromatic amino acids during the rapid catch-up in weight phase of recovery from severe childhood undernutrition (SCU) is not clearly established. As a first step, the present study aimed to estimate the tyrosine requirement of children with SCU during the catch-up growth phase of nutritional rehabilitation using a diet enriched in energy and proteins. Tyrosine requirement was calculated from the rate of excretion of 13CO2 (F 13CO2) during [13C]phenylalanine infusion in thirteen children with SCU, five females and eight males, at about 19 d after admission when the subjects were considered to have entered their rapid catch-up growth phase and were consuming 627·3 kJ and about 3·5 g protein/kg per d. Measurements of F 13CO2 during [13C]phenylalanine infusion were made on two separate days with a 1 d interval. Three measurements at tyrosine intakes of 48, 71 and 95 mg/kg per d were performed on experimental day 1 and measurements at tyrosine intakes of 148, 195 and 241 mg/kg per d were performed on experimental day 2. An estimate of the mean requirement was derived by breakpoint analysis with a two-phase linear regression cross-over model. The breakpoint, which represents an estimate of the mean tyrosine requirement, is a value of 99 mg/kg per d when the children were growing at about 15 g/kg per d. The result indicates that the mean requirement for tyrosine during the catch-up growth phase of SCU is about 99 mg/kg per d under similar conditions to the present study.

Both intra-uterine and early childhood development contribute to the risk of developing CVD in adult life. We therefore evaluated the maternal, placental, fetal, birth, infant and childhood determinants of cardiovascular risk in a cohort of Afro-Jamaican children. The Vulnerable Windows Cohort is a longitudinal survey of 569 mothers and their offspring recruited from the first trimester. The offspring's anthropometry was measured at birth, at 6 weeks, every 3 months to 1 year and then every 6 months. At mean age 11·5 years, fasting blood was sampled for glucose, insulin and lipids. Analyses were confined to 296 women and their offspring who had complete data. Waist circumference (WC) was related to maternal weight and BMI, placental weight and to the size of the offspring in utero, at birth and the rate of growth in childhood (P < 0·05). Total cholesterol, TAG and glucose concentrations were unrelated to maternal, placental, fetal, neonatal and childhood measurements. Fasting insulin and homeostasis model assessment of insulin resistance were related to maternal weight and BMI (P < 0·05), but not after adjusting for WC. HDL-cholesterol was inversely related to placental and birth weight, and inversely related to weight and BMI throughout childhood (P < 0·001), but not after adjusting for WC. Systolic blood pressure was directly related to maternal weight, child's height, weight and BMI (P < 0·05), but not after adjustment for WC. Systolic blood pressure and fasting glucose concentration were inversely related to birth weight in boys but directly associated in girls. We concluded that maternal anthropometry during pregnancy, fetal size, and childhood growth rate contribute to cardiovascular risk factors in childhood.

Ancient Egyptians are thought to have been the only people in the Old World who were practising mummification in the Bronze Age (c. 2200-700 BC). But now a remarkable series of finds from a remote Scottish island indicates that Ancient Britons were performing similar, if less elaborate, practices of bodily preservation. Evidence of mummification is usually limited to a narrow range of arid or frozen environments which are conducive to soft tissue preservation. Mike Parker Pearson and his team show that a combination of microstructural, contextual and AMS 14C analysis of bone allows the identification of mummification in more temperate and wetter climates where soft tissues and fabrics do not normally survive. Skeletons from Cladh Hallan on South Uist, Western Isles, Scotland were buried several hundred years after death, and the skeletons provide evidence of post mortem manipulation of body parts. Perhaps these practices were widespread in mainland Britain during the Bronze Age.

A water purification and sterilization device was tested for its functional capabilities. Challenge water consisting of potable water augmented with bacteria, endotoxin, virus, suspended solids, and dissociable ions (sodium chloride, lead or arsenic salts) was passed through the device. The product water quality attributes were analyzed. The device demonstrated reduction in bacteria of >7 logs, endotoxin was reduced by >4 logs, virus was reduced by >4 logs, and dissociable ions were reduced by >3 logs. The product water of the device met the limits for a range of chemical entities specified by the United States Pharmacopeia and Association for the Advancement of Medical Instrumentation. The product water met the quality attributes of Sterile Water for Injection, USP, Sterile Purified Water, USP, and the Water for Dialysis. The device provides a logistical advantage in reducing the weight of transport of packaged water by 83% and the cube by 67%. It operates manually by gravity and is disposable after a single use. The device provides an effective alternative to the transport and use of packaged sterile water in remote locations by production of sterile water at the pointof-need using available water. It also is capable of producing safe drinking water following the production of clinical waters. This device has been cleared by the US Food and Drug Administration for production of three liters Sterile Purified Water, USP from Environmental Protection Agency (EPA) grade drinking water.

This paper examines the advantages that arise from an individual differences approach to children's coping and vulnerabilities. It suggests that the basic motivational and attentional systems involved in temperament constitute relatively primitive coping mechanisms. With development, these primitive coping skills are aided by representational and other cortical functions, allowing the coping process to begin before a stressful event and thereby increasing the child's capacity to plan an effective coping option and to enhance self-control. Such an emphasis on motivational and attentional differences allows us to take advantage of children's diverse personalities as “experiments of nature” and to better understand the temperamental patterns that contribute to adaptive and maladaptive outcomes.