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The population of adults with single-ventricle congenital heart disease (CHD) is growing. This study explores their lived experiences through an adult developmental psychology framework.
Methods:
Individuals aged 18 and older with single-ventricle CHD participated in Experience Group sessions and 1:1 interviews. Sessions were transcribed and analysed thematically. Themes were categorized by developmental domains and age group.
Results:
Of the 29 participants, 18 (62%) were female, 10 (35%) were emerging (18–29 years), 13 (45%) were established (30–45 years), and 6 (21%) were midlife adults (46–60 years). Emerging adults expressed reluctance to initiate romantic relationships and fear of burdening partners, while established adults reported strong relationships with partners deeply involved in caregiving. Emerging adults struggled with finding fulfilling work that meets their health needs, whereas established and midlife adults faced unemployment or early retirement due to health limits. Family dynamics shifted, with established and midlife adults educating their children to become caregivers. Physical limitations and low self-rated health were consistent across life stages, and midlife adults did not worry about traditional chronic conditions. Mental health concerns, including anxiety and depression, persisted across all life stages, but resiliency and positive affect were also evident.
Conclusion:
Adults with single-ventricle CHD experience developmental milestones differently, indicating the need for early anticipatory guidance in these domains to achieve optimal outcomes in adulthood.
To measure SARS-CoV-2 anti-nucleocapsid (anti-N) antibody seropositivity among healthcare personnel (HCP) without a history of COVID-19 and to identify HCP characteristics associated with seropositivity.
Design:
Prospective cohort study from September 22, 2020, to March 3, 2022.
Setting:
A tertiary care academic medical center.
Participants:
727 HCP without prior positive SARS-CoV-2 PCR testing were enrolled; 559 HCP successfully completed follow-up.
Methods:
At enrollment and follow-up 1–6 months later, HCP underwent SARS-CoV-2 anti-N testing and were surveyed on demographics, employment information, vaccination status, and COVID-19 symptoms and exposures.
Results:
Of 727 HCP enrolled, 27 (3.7%) had a positive SARS-CoV-2 anti-N test at enrollment. Seropositive HCPs were more likely to have a household exposure to COVID-19 in the past 30 days (OR 7.92, 95% CI 2.44–25.73), to have had an illness thought to be COVID-19 (4.31, 1.94–9.57), or to work with COVID-19 patients more than half the time (2.09, 0.94–4.77). Among 559 HCP who followed-up, 52 (9.3%) had a positive SARS-CoV-2 anti-N antibody test result. Seropositivity at follow-up was associated with community/household exposures to COVID-19 within the past 30 days (9.50, 5.02–17.96; 2.90, 1.31–6.44), having an illness thought to be COVID-19 (8.24, 4.44–15.29), and working with COVID-19 patients more than half the time (1.50, 0.80–2.78).
Conclusions:
Among HCP without prior positive SARS-CoV-2 testing, SARS-CoV-2 anti-N seropositivity was comparable to that of the general population and was associated with COVID-19 symptomatology and both occupational and non-occupational exposures to COVID-19.
At low levels of hydration, exchangeable D+ in montmorillonite interacts with lattice OH groups and quantitatively converts AlMgOH groups to AlMgOD. Hydroxyl groups coordinated to two Al ions undergo a slower exchange, the extent of which is restricted by octahedral Fe3+ ions. The OH stretching vibration of AlMgOH groups in montmorillonite is assigned an unusually high frequency (3687 cm−1) compared with that of the same group in phengites (3602 cm−1).
Infrared and Mössbauer spectroscopy show that the extent of the reduction of nontronite is dependent on the chemical composition of the nontronite and on the nature of the reducing agent. Hydrazine reversibly reduces about 10% of the iron in all of the nontronites studied irrespective of composition and it is suggested that the resulting ferrous iron occurs only in distorted octahedral sites. Similar conclusions are reached for the dithionite reduction of the nontronites containing little tetrahedral iron, but for those with more than one in eight silicons replaced by iron, changes brought about by dithionite treatment are irreversible due to dissolution of appreciable quantities of iron. Results from both spectroscopic techniques suggest that iron in tetrahedral sites is preferentially dissolved and that up to 80% of the structural iron can be reduced.
Evidence is presented for the formation in these extensively reduced nontronites of a small amount of a mica-like phase resembling celadonite or glauconite, and, as dithionite is used for the pretreatment of soils, the implication of this observation is briefly discussed.
The use of deuterated hydrazine as a reducing agent has enabled the nontronite absorption band near 850 cm-1 to be assigned to a Si-O (apical) stretching vibration, which is inactive in the infrared for perfect hexagonal symmetry, but which is activated by distortions in the tetrahedral layer.
Mössbauer and i.r. spectra of a series of nontronites show that Fe3+ and Al3+ are distributed between tetrahedral and octahedral sites. The Mössbauer results have reaffirmed the occupation by Fe3+ of octahedral sites at which these ions are coordinated to pairs of OH groups in both cis and trans configurations. The distribution of Fe3+ between these two sites varies considerably but in all of the nontronites some Fe3+ occurs in the trans site in contrast to the all cis occupancy of the centro-symmetric structure proposed by Mering and Oberlin (1967). In one of the nontronites the distribution of Fe3+ between these two sites approaches that in the ideal non-centrosymmetric structure proposed for montmorillonite.
Paediatric cardiac electrophysiologists are essential in CHD inpatient care, but their involvement is typically limited to consultation with individual patients. In our integrated heart centre, an electrophysiologist reviews all cardiac inpatient telemetry over the preceding 24 hours and participates in daily multidisciplinary morning report. This study investigates the impact of the strategy of consistent, formalised electrophysiologist presence at multidisciplinary morning report.
Methods:
This is a single-centre, prospective, observational study of electrophysiologist participation in patient encounters during heart centre multidisciplinary morning report from 10/20/2021 to 10/31/2022. Multidisciplinary morning report includes discussion of all intensive care and non-intensive care cardiac patients. An encounter was defined as reporting on one patient for one day. Electrophysiologists were initially blinded to observations.
Results:
Two electrophysiologists were observed over 215 days encompassing 6413 patient encounters. Electrophysiologists made comments on 581(9.1%) encounters in 234 unique patients with diverse diagnoses, equating to a median of 3[interquartile range:1–4] encounters per day. These included identifications of arrhythmias and describing electrocardiographic findings. Recommendation to change management occurred in 282(48.5%) encounters, most commonly regarding medications (n = 142, 24.4%) or pacemaker management (n = 48, 8.3%). Of the 581 encounters, there were 61(10.5%) in which they corrected another physician’s interpretation of rhythm or electrocardiogram.
Conclusion:
Routine electrophysiologist involvement in multidisciplinary morning report provides significant, frequent, and timely input in patient management by identifying precise rhythm-related diagnoses and allowing nuanced, patient-specific medication and pacemaker management of all cardiac patients, not just those consulted. Electrophysiologist presence at multidisciplinary morning report is a vital resource and this practice should be considered at integrated paediatric cardiac centres.
Packed red blood cell transfusions occur frequently after congenital heart surgery to augment haemodynamics, with limited understanding of efficacy. The goal of this study was to analyse the hemodynamic response to packed red blood cell transfusions in a single cohort, as “proof-of-concept” utilising high-frequency data capture of real-time telemetry monitoring.
Methods:
Retrospective review of patients after the arterial switch operation receiving packed red blood cell transfusions from 15 July 2020 to 15 July 2021. Hemodynamic parameters were collected from a high-frequency data capture system (SickbayTM) continuously recording vital signs from bedside monitors and analysed in 5-minute intervals up to 6 hours before, 4 hours during, and 6 hours after packed red blood cell transfusions—up to 57,600 vital signs per packed red blood cell transfusions. Variables related to oxygen balance included blood gas co-oximetry, lactate levels, near-infrared spectroscopy, and ventilator settings. Analgesic, sedative, and vasoactive infusions were also collected.
Results:
Six patients, at 8.5[IQR:5-22] days old and weighing 3.1[IQR:2.8-3.2]kg, received transfusions following the arterial switch operation. There were 10 packed red blood cell transfusions administered with a median dose of 10[IQR:10-15]mL/kg over 169[IQR:110-190]min; at median post-operative hour 36[IQR:10-40]. Significant increases in systolic and mean arterial blood pressures by 5-12.5% at 3 hours after packed red blood cell transfusions were observed, while renal near-infrared spectroscopy increased by 6.2% post-transfusion. No significant changes in ventilation, vasoactive support, or laboratory values related to oxygen balance were observed.
Conclusions:
Packed red blood cell transfusions given after the arterial switch operation increased arterial blood pressure by 5-12.5% for 3 hours and renal near-infrared spectroscopy by 6.2%. High-frequency data capture systems can be leveraged to provide novel insights into the hemodynamic response to commonly used therapies such as packed red blood cell transfusions after paediatric cardiac surgery.
This study investigated sex differences in Fe status, and associations between Fe status and endurance and musculoskeletal outcomes, in military training. In total, 2277 British Army trainees (581 women) participated. Fe markers and endurance performance (2·4 km run) were measured at the start (week 1) and end (week 13) of training. Whole-body areal body mineral density (aBMD) and markers of bone metabolism were measured at week 1. Injuries during training were recorded. Training decreased Hb in men and women (mean change (–0·1 (95 % CI –0·2, –0·0) and –0·7 (95 % CI –0·9, –0·6) g/dl, both P < 0·001) but more so in women (P < 0·001). Ferritin decreased in men and women (–27 (95 % CI –28, –23) and –5 (95 % CI –8, –1) µg/l, both P ≤ 0·001) but more so in men (P < 0·001). Soluble transferrin receptor increased in men and women (2·9 (95 % CI 2·3, 3·6) and 3·8 (95 % CI 2·7, 4·9) nmol/l, both P < 0·001), with no difference between sexes (P = 0·872). Erythrocyte distribution width increased in men (0·3 (95 % CI 0·2, 0·4)%, P < 0·001) but not in women (0·1 (95 % CI –0·1, 0·2)%, P = 0·956). Mean corpuscular volume decreased in men (–1·5 (95 % CI –1·8, –1·1) fL, P < 0·001) but not in women (0·4 (95 % CI –0·4, 1·3) fL, P = 0·087). Lower ferritin was associated with slower 2·4 km run time (P = 0·018), sustaining a lower limb overuse injury (P = 0·048), lower aBMD (P = 0·021) and higher beta C-telopeptide cross-links of type 1 collagen and procollagen type 1 N-terminal propeptide (both P < 0·001) controlling for sex. Improving Fe stores before training may protect Hb in women and improve endurance and protect against injury.
To determine the prevalence of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) IgG nucleocapsid (N) antibodies among healthcare personnel (HCP) with no prior history of COVID-19 and to identify factors associated with seropositivity.
Design:
Prospective cohort study.
Setting:
An academic, tertiary-care hospital in St. Louis, Missouri.
Participants:
The study included 400 HCP aged ≥18 years who potentially worked with coronavirus disease 2019 (COVID-19) patients and had no known history of COVID-19; 309 of these HCP also completed a follow-up visit 70–160 days after enrollment. Enrollment visits took place between September and December 2020. Follow-up visits took place between December 2020 and April 2021.
Methods:
At each study visit, participants underwent SARS-CoV-2 IgG N-antibody testing using the Abbott SARS-CoV-2 IgG assay and completed a survey providing information about demographics, job characteristics, comorbidities, symptoms, and potential SARS-CoV-2 exposures.
Results:
Participants were predominately women (64%) and white (79%), with median age of 34.5 years (interquartile range [IQR], 30–45). Among the 400 HCP, 18 (4.5%) were seropositive for IgG N-antibodies at enrollment. Also, 34 (11.0%) of 309 were seropositive at follow-up. HCP who reported having a household contact with COVID-19 had greater likelihood of seropositivity at both enrollment and at follow-up.
Conclusions:
In this cohort of HCP during the first wave of the COVID-19 pandemic, ∼1 in 20 had serological evidence of prior, undocumented SARS-CoV-2 infection at enrollment. Having a household contact with COVID-19 was associated with seropositivity.
CHD care is resource-intensive. Unwarranted variation in care may increase cost and result in poorer health outcomes. We hypothesise that process variation exists within the pre-operative evaluation and planning process for children undergoing repair of atrial septal defect or ventricular septal defect and that substantial variation occurs in a small number of care points.
Methods:
From interviews with staff of an integrated congenital heart centre, an initial process map was constructed. A retrospective chart review of patients with isolated surgical atrial septal defect and ventricular septal defect repair from 7/1/2018 through 11/1/2020 informed revisions of the process map. The map was assessed for points of consistency and variability.
Results:
Thirty-two surgical atrial septal defect/ventricular septal defect repair patients were identified. Ten (31%) were reviewed by interventional cardiology before surgical review. Of these, 6(60%) had a failed catheter-based closure and 4 (40%) were deemed inappropriate for catheter-based closure. Thirty (94%) were reviewed in case conference, all attended surgical clinic, and none were admitted prior to surgery. The process map from interviews alone identified surgery rescheduling as a point of major variability; however, chart review revealed this was not as prominent a source of variability as pre-operative interventional cardiology review.
Conclusions:
Significant variation in the pre-operative evaluation and planning process for surgical atrial septal defect/ventricular septal defect patients was identified. If such process variation is widespread through CHD care, it may contribute to variations in outcome and cost previously documented within CHD surgery. Future research will focus on determining whether the variation is warranted or unwarranted, associated health outcomes and cost variation attributed to these variations in care processes.
To perform a statewide characteristics and outcomes analysis of the Trisomy 18 (T18) population and explore the potential impact of associated congenital heart disease (CHD) and congenital heart surgery.
Study Design:
Retrospective review of the Texas Hospital Inpatient Discharge Public Use Data File between 2009 and 2019, analysing discharges of patients with T18 identified using ICD-9/10 codes. Discharges were linked to analyse patients. Demographic characteristics and available outcomes were evaluated. The population was divided into groups for comparison: patients with no documentation of CHD (T18NoCHD), patients with CHD without congenital heart surgery (T18CHD), and patients who underwent congenital heart surgery (T18CHS).
Results:
One thousand one hundred fifty-six eligible patients were identified: 443 (38%) T18NoCHD, 669 (58%) T18CHD, and 44 (4%) T18CHS. T18CHS had a lower proportion of Hispanic patients (n = 9 (20.45%)) compared to T18CHD (n = 315 (47.09%)), and T18NoCHD (n = 219 (49.44%)) (p < 0.001 for both). Patients with Medicare/Medicaid insurance had a 0.42 odds ratio (95%CI: 0.20–0.86, p = 0.020) of undergoing congenital heart surgery compared to private insurance. T18CHS had a higher median total days in-hospital (47.5 [IQR: 12.25–113.25] vs. 9 [IQR: 3–24] and 2 [IQR: 1–5], p < 0.001); and a higher median number of admissions (n = 2 [IQR: 1–4]) vs. 1 [IQR: 1–2] and 1 [IQR: 1–1], (p < 0.001 for both). However, the post-operative median number of admissions for T18CHS was 0 [IQR: 0–2]. After the first month of life, T18CHS had freedom from in-hospital mortality similar to T18NoCHD and superior to T18CHD.
Conclusions:
Short-term outcomes for T18CHS patients are encouraging, suggesting a freedom from in-hospital mortality that resembles the T18NoCHD. The highlighted socio-economic differences between the groups warrant further investigation. Development of a prospective registry for T18 patients should be a priority for better understanding of longer-term outcomes.
In conceptualizing animal welfare, it is useful to distinguish among three types of concepts. ‘Type 1” are single, measurable attributes. ‘Type 2’ are single attributes that cannot be measured directly but can be estimated by correctly combining various contributing attributes. ‘Type 3’ are concepts involving multiple attributes which are grouped together because they serve some common function, and whose relative importance cannot be established in an entirely objective way. Individuals who treat animal welfare as a type 1 concept may propose single, objective measures of welfare, such as longevity or levels of stress-related hormones; however, this approach rests on judgements, which are not purely objective, about the relative importance of different factors for an animal's quality of life. Studies of animal preferences and motivation are sometimes seen as an objective way to weight different attributes according to the animals’ own priorities, and thus allow animal welfare to be treated as a type 2 concept. However, numerous technical and fundamental difficulties limit our ability to do this. Animal welfare is best seen as a type 3 concept incorporating multiple attributes, with considerable consensus over certain general principles (eg that a high level of welfare implies freedom from suffering) but with value-related disagreement over how these principles should be applied. Because the various attributes cannot be combined in a purely objective way, science is limited in its ability to determine the ‘overall’ welfare of an animal and to compare welfare in disparate environments. Instead of attempting to ‘measure’ animal welfare, the role of science should be seen as identifying, rectifying and preventing welfare problems.
In the social debate about animal welfare we can identify three different views about how animals should be raised and how their welfare should be judged: (1) the view that animals should be raised under conditions that promote good biological functioning in the sense of health, growth and reproduction, (2) the view that animals should be raised in ways that minimise suffering and promote contentment, and (3) the view that animals should be allowed to lead relatively natural lives. When attempting to assess animal welfare, different scientists select different criteria, reflecting one or more of these value-dependent views. Even when ostensibly covering all three views, scientists may differ in what they treat as inherently important versus only instrumentally important, and their selection of variables may be further influenced by a desire to use measures that are scientifically respected and can be scored objectively. Value assumptions may also enter animal welfare assessment at the farm and group level (1) when empirical data provide insufficient guidance on important issues, (2) when we need to weigh conflicting interests of different animals, and (3) when we need to weigh conflicting evidence from different variables. Although value assumptions cannot be eliminated from animal welfare assessment, they can be made more explicit as the first step in creating animal welfare assessment tools. Different value assumptions could lead to different welfare assessment tools, each claiming validity within a given set of assumptions.
Scientific research on ‘animal welfare’ began because of ethical concerns over the quality of life of animals, and the public looks to animal welfare research for guidance regarding these concerns. The conception of animal welfare used by scientists must relate closely to these ethical concerns if the orientation of the research and the interpretation of the findings is to address them successfully.
At least three overlapping ethical concerns are commonly expressed regarding the quality of life of animals: (1) that animals should lead natural lives through the development and use of their natural adaptations and capabilities, (2) that animals should feel well by being free from prolonged and intense fear, pain, and other negative states, and by experiencing normal pleasures, and (3) that animals should function well, in the sense of satisfactory health, growth and normal functioning of physiological and behavioural systems. Various scientists have proposed restricted conceptions of animal welfare that relate to only one or other of these three concerns. Some such conceptions are based on value positions about what is truly important for the quality of life of animals or about the nature of human responsibility for animals in their care. Others are operational claims: (1) that animal welfare research must focus on the functioning of animals because subjective experiences fall outside the realm of scientific enquiry, or (2) that studying the functioning of animals is sufficient because subjective experiences and functioning are closely correlated. We argue that none of these positions provides fully satisfactory guidance for animal welfare research.
We suggest instead that ethical concerns about the quality of life of animals can be better captured by recognizing three classes of problems that may arise when the adaptations possessed by an animal do not fully correspond to the challenges posed by its current environment. (I) If animals possess adaptations that no longer serve a significant function in the new environment, then unpleasant subjective experiences may arise, yet these may not be accompanied by significant disruption to biological functioning. Thus, a bucket-fed calf may experience a strong, frustrated desire to suck, even though it obtains adequate milk. (2) If the environment poses challenges for which the animal has no corresponding adaptation, then functional problems may arise, yet these may not be accompanied by significant effects on subjective feelings. Thus, a pig breathing polluted air may develop lung damage without appearing to notice or mind the problem. (3) Where animals have adaptations corresponding to the kinds of environmental challenges they face, problems may still arise if the adaptations prove inadequate. For example, an animal's thermoregulatory adaptations may be insufficient in a very cold environment such that the animal both feels poorly and functions poorly. We propose that all three types of problems are causes of ethical concern over the quality of life of animals and that they together define the subject matter of animal welfare science.
As adult cats can often be difficult to re-home, they may spend long periods in rescue shelters where barren housing and inconsistent handling can reduce their welfare. In this study, 165 adult cats in an animal shelter in Vancouver, Canada, were assigned to four treatments. The Basic Single treatment reflected typical conditions in that particular shelter, with cats handled in an inconsistent manner by various staff and housed singly in relatively barren cages. Three alternative treatments involved more consistent, positive handling by only the experimenter and research assistants, plus three housing conditions: Enriched Single (individual cages with opportunities to perch and hide), Basic Communal (group housing with opportunity for each cat to have personal space), and Enriched Communal (group housing enriched to encourage play and cat – cat interaction). The Basic Single treatment had the lowest percentage adopted in 21 days (45% versus 69-76% for other treatment, and higher stress scores than other treatments. The three alternative treatments did not differ significantly on any measure. Cats euthanised for poor health showed higher stress levels when alive than other cats. In a questionnaire, most adopters cited certain behavioural/emotional traits (‘friendly’, ‘playful’, ‘happy’) as reasons for selecting cats; these were generally associated with lower stress scores. The results suggest that consistent handling combined with a range of improved housing options can improve the chances of adoption for adult cats, perhaps by reducing fear-related behaviours that make cats less attractive to adopters.
In hedonic theories of motivation, ‘motivational affective states’ (MASs) are typically seen as adaptations which motivate certain types of behaviour, especially in situations where a flexible or learned response is more adaptive than a rigid or reflexive one. MASs can be negative (eg unpleasant feelings of hunger or pain) or positive (eg pleasant feelings associated with eating and playing). Hedonic theories often portray negative and positive MASs as opposite ends of a one-dimensional scale.
We suggest that natural selection has favoured negative and positive affect as separate processes to solve two different types of motivational problems. We propose that negative MASs (eg thirst, fear) evolved in response to ‘need situations’ where the fitness benefit of an action has increased, often because the action is needed to cope with a threat to survival or reproductive success. We propose that these negative MASs develop in response to a change in the body (eg dehydration) or the environment (eg the approach of a predator) which creates the need for action, and that negative MASs can become intense and prolonged if the threat to fitness is high and persistent. We propose that positive MASs evolved in ‘opportunity situations ‘ where an action (eg playing, exploring) has become advantageous because the fitness cost of performing it has declined. We propose that these positive MASs occur during, or as a result of, the performance of types of behaviour which are beneficial for fitness at a variety of times, not only when they are required to meet immediate needs; and that the pleasure inherent in the behaviour motivates the animal to perform it when the cost of so doing is sufficiently low. Some behaviour (eg eating) can be motivated by both positive and negative affect. Other behaviour, such as playing or fleeing from a predator, may be motivated largely by positive or negative affect alone. Our hypothesis needs to be tested, but we suggest that it corresponds well to common human experience.
The hypothesis provides a basis for predicting whether an aspect of animal management is likely to cause strong and prolonged negative affect (‘suffering’), or to prevent animals from experiencing certain types of pleasure. This distinction is important for bringing animal welfare assessment into line with ethical concerns.
Six drug regulatory reviewers and 11 pharmaceutical industry scientists were interviewed to explore their perspectives on the obstacles and opportunities for greater implementation of the Three Rs (replacement, reduction, refinement) in drug research and development. Participants generally supported the current level of animal use in the pharmaceutical industry and viewed in vitro methods as supporting, but not replacing, the use of animals. Obstacles to greater use of the Three Rs cited by participants included the lack of non-animal alternatives; requirements for statistical validity; reluctance by industry and regulators to depart from established patterns of animal use; the priority of commercial objectives ahead of the Three Rs; and concern that less animal testing could jeopardise human safety. Opportunities identified for the Three Rs included the development of better animal models including genetically modified (GM) animals; pursuit of more basic knowledge, notably drug action on gene expression; re-use of animals; greater use of pilot studies; using sufficient numbers of animals per test to avoid repeating inconclusive studies; regular review of animal data in regulatory requirements; and following the regulatory option of combining segments of reproductive toxicology studies into one study. In some areas, greater implementation of the Three Rs seemed well aligned with industry priorities, for example, phenotypic characterisation of GM animals and validation of alternative methods. In other areas, wider use of the Three Rs may require building consensus on areas of disagreement including the usefulness of death as an endpoint; the suitability of re-using animals; and whether GM animals and the use of pilot studies contribute to reduction.