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The delivery of paediatric cardiac care across the world occurs in settings with significant variability in available resources. Irrespective of the resources locally available, we must always strive to improve the quality of care we provide to our patients and simultaneously deliver such care in the most efficient and cost-effective manner. The development of cardiac networks is used widely to achieve these aims.
Methods:
This paper reports three talks presented during the 56th meeting of the Association for European Paediatric and Congenital Cardiology held in Dublin in April 2023.
Results:
The three talks describe how centres of congenital cardiac excellence can be developed in low-income countries, middle-income countries, and well-resourced environments, and also reports how centres across different countries can come together to collaborate and deliver high-quality care. It is a fact that barriers to creating effective networks may arise from competition that may exist among programmes in unregulated and especially privatised health care environments. Nevertheless, reflecting on the creation of networks has important implications because collaboration between different centres can facilitate the maintenance of sustainable programmes of paediatric and congenital cardiac care.
Conclusion:
This article examines the delivery of paediatric and congenital cardiac care in resource limited environments, well-resourced environments, and within collaborative networks, with the hope that the lessons learned from these examples can be helpful to other institutions across the world. It is important to emphasise that irrespective of the differences in resources across different continents, the critical principles underlying provision of excellent care in different environments remain the same.
In June of 2024, Becton Dickinson experienced a blood culture bottle shortage for their BACTEC system, forcing health systems to reduce usage or risk exhausting their supply. Virginia Commonwealth University Health System (VCUHS) in Richmond, VA decided that it was necessary to implement austerity measures to preserve the blood culture bottle supply.
Setting:
VCUHS includes a main campus in Richmond, VA as well as two affiliate hospitals in South Hill, VA (Community Memorial Hospital (CMH)) and Tappahannock Hospital in Tappahannock, VA. It also includes a free-standing Emergency Department in New Kent, VA.
Patients:
Blood cultures from both pediatric and adult patients were included in this study.
Interventions:
VCUHS intervened to decrease blood culture utilization across the entire health system. Interventions included communication of blood culture guidance as well as an electronic health record order designed to guide providers and discourage wasteful ordering.
Results:
Post-implementation analyses showed that interventions reduced overall usage by 35.6% (P < .0001) and by greater than 40% in the Emergency Departments. The impact of these changes in utilization on positivity were analyzed, and it was found that the overall positivity rate increased post-intervention from 8.8% to 12.1% (P = .0115) and in the ED specifically from 10.2% to 19.5% (P < .0001).
Conclusions:
These findings strongly suggest that some basic stewardship interventions can significantly change blood culture practice in a manner that minimizes the impact on patient care.
We present new Australia Telescope Compact Array (ATCA) radio observations towards N 49, one of the brightest extragalactic supernova remnants (SNRs) located in the Large Magellanic Cloud (LMC). Our new and archival ATCA radio observations were analysed along with Chandra X-ray data. These observations show a prominent ‘bullet’ shaped feature beyond the southwestern boundary of the SNR. Both X-ray morphology and radio polarisation analysis support a physical connection of this feature to the SNR. The ‘bullet’ feature’s apparent velocity is estimated at $\sim$1 300 km s$^{-1}$, based on its distance ($\sim$10 pc) from the remnant’s geometric centre and estimated age ($\sim$7 600 yr). we estimated the radio spectral index, $\alpha= -0.55 \pm 0.03$ which is typical of middle-age SNRs. Polarisation maps created for N 49 show low to moderate levels of mean fractional polarisation estimated at 7$\pm$1% and 10$\pm$1% for 5.5 and 9 GHz, respectively. These values are noticeably larger than found in previous studies. Moreover, the mean value for the Faraday rotation of SNR N 49 from combining CABB data is 212$\pm$65 rad m$^{-2}$ and the maximum value of RM is 591$\pm$103 rad m$^{-2}$.
Rinsing only with water or washing with soap and water are common methods of skin decontamination for skin contaminated during a chemical hazard release. The null hypothesis was that a 15-minute water irrigation (decontamination method 1) would not be superior to decontamination using a microfiber towel, followed by a wet wipe (Signature Select Softly Flushable Tissue Better Living Brands LLC, Pleasanton, CA), followed by using another microfiber towel (decontamination method 2).
Methods
A simulated contaminant (Magic Fluorescent Glow Paint for Face and Body, iLC Shenzhen Fulimei Technology Co. LTD, Shenzhen, the People’s Republic of China) was applied to the dorsal skin of each subject’s forearms. Then, photographs of these subject’s skin were taken before and after decontamination of the simulated contaminant by using either decontamination method 1 or 2. Each of the subjects underwent both decontamination methods in separate trials, with each subject using one forearm for decontamination method 1 and their other forearm for decontamination method 2. Discrete points of contamination were quantified on the photographs that were taken with the skin illuminated by ambient visible light or ultraviolet light (395nm, Roceei ultraviolet flashlight, China).
Results
Under visible light, no residual contamination was seen by inspecting photographs taken after decontaminating with either method. Under ultraviolet light, less visible contamination was seen by inspecting photographs taken after decontaminating with method 1 than after decontaminating with method 2.
Conclusion
In this study, skin decontamination with water irrigation was superior to skin decontamination without water irrigation.
Identify risk factors for central line-associated bloodstream infections (CLABSI) in pediatric intensive care settings in an era with high focus on prevention measures.
Design:
Matched, case–control study.
Setting:
Quaternary children’s hospital.
Patients:
Cases had a CLABSI during an intensive care unit (ICU) stay between January 1, 2015 and December 31, 2020. Controls were matched 4:1 by ICU and admission date and did not develop a CLABSI.
Methods:
Multivariable, mixed-effects logistic regression.
Results:
129 cases were matched to 516 controls. Central venous catheter (CVC) maintenance bundle compliance was >70%. Independent CLABSI risk factors included administration of continuous non-opioid sedative (adjusted odds ratio (aOR) 2.96, 95% CI [1.16, 7.52], P = 0.023), number of days with one or more CVC in place (aOR 1.42 per 10 days [1.16, 1.74], P = 0.001), and the combination of a chronic CVC with administration of parenteral nutrition (aOR 4.82 [1.38, 16.9], P = 0.014). Variables independently associated with lower odds of CLABSI included CVC location in an upper extremity (aOR 0.16 [0.05, 0.55], P = 0.004); non-tunneled CVC (aOR 0.17 [0.04, 0.63], P = 0.008); presence of an endotracheal tube (aOR 0.21 [0.08, 0.6], P = 0.004), Foley catheter (aOR 0.3 [0.13, 0.68], P = 0.004); transport to radiology (aOR 0.31 [0.1, 0.94], P = 0.039); continuous neuromuscular blockade (aOR 0.29 [0.1, 0.86], P = 0.025); and administration of histamine H2 blocking medications (aOR 0.17 [0.06, 0.48], P = 0.001).
Conclusions:
Pediatric intensive care patients with chronic CVCs receiving parenteral nutrition, those on non-opioid sedative infusions, and those with more central line days are at increased risk for CLABSI despite current prevention measures.
Pediatric patients with frontal lobe epilepsy (FLE) have higher rates of attention deficit hyperactivity disorder (ADHD), as well as executive functioning (EF) and fine motor (FM) challenges. Relations between these constructs have been established in youth with ADHD and are supported by FM and EF skill involvement in frontal-subcortical systems. Still, they are not well understood in pediatric FLE. We hypothesized that poorer FM performance would be related to greater executive dysfunction and ADHD symptomatology in this group.
Participants and Methods:
47 children and adolescents with FLE (AgeM=12.47, SD=5.18; IQM=84.07; SD=17.56; Age of Seizure OnsetM=6.85, SD=4.64; right-handed: n=34; left-handed: n=10; Unclear: n=3) were enrolled in the Pediatric Epilepsy Research Consortium dataset as part of their phase I epilepsy surgical evaluation. Participants were selected if they had unifocal FLE and completed the Lafayette Grooved Pegboard (GP). Seizure lateralization (left-sided: n=19; right-sided: n=26; bilateral: n=2) and localization were established via data (e.g., EEG, MRI) presented at a multidisciplinary team case conference. Patients completed neuropsychological measures of FM, attention, and EF. Parents also completed questionnaires inquiring about their child’s everyday EF and ADHD symptomatology. Correlational analyses were conducted to examine FM, EF, and ADHD relations.
Results:
Dominant hand (DH) manual dexterity (GP) was related to parent-reported EF (Behavior Rating Inventory of Executive Function, Second Edition [BRIEF-2]-Global Executive Composite [GEC]: r(15) =-.70, p<.01, d=1.96). While not statistically significant, medium to large effect sizes were found for GP DH and parent-reported inattention (Behavior Assessment System for Children, Third Edition [BASC-3]-Attention Problems: r(12)=-.39, p=.17, d=.85) and hyperactivity/impulsivity (BASC-3-Hyperactivity: r(11)= -.44, p=.13, d=.98), as well as performance-based attention (Conners Continuous Performance Test, Third Edition -Omission Errors: r(12)=-.35, p=.22, d=.41), working memory (Wechsler Intelligence Scale for Children - Fifth Edition [WISC-V]-Digit Span [DS]: r(19)=.38, p=.09, d=.82) and cognitive flexibility (Delis-Kaplan Executive Function System (D-KEFS) Verbal Fluency Category Switching: r(13)=.46, p=.08, d=1.04); this suggests that these relations may exist but that our study was underpowered to detect them. Non-dominant hand (NDH) manual dexterity was related to performance-based working memory (WISC-V-DS: r(19)=.50, p<.01, d=1.12) and cognitive flexibility (D-KEFS-Trails Making Test Number-Letter Switching: r(17)=.64, p<.01, d=1.67). Again, while underpowered, medium to large effect sizes were found for GP NDH and parent-reported EF (BRIEF-2 GEC: r(15) =-.45, p=.07, d=1.01) and performance-based phonemic fluency (D-KEFS-Letter Fluency: r(13)=.31, p=.20, d=.65).
Conclusions:
Our findings suggest that FM, EF, and ADHD are related in youth with FLE; however, these relations appear to vary by skill and hand. We posit that our findings are due in part to the frontal-cerebellar networks given their anatomic proximity between frontal motor areas and the dorsolateral prefrontal cortex - as well as their shared functional involvement in these networks. Future studies should evaluate the predictive validity of initial FM skills for later executive dysfunction and ADHD symptomatology in FLE. If such relations emerge, contributions of early FM interventions on EF development should be examined. Further replication of these findings with a larger sample is warranted.
The Eighth World Congress of Pediatric Cardiology and Cardiac Surgery (WCPCCS) will be held in Washington DC, USA, from Saturday, 26 August, 2023 to Friday, 1 September, 2023, inclusive. The Eighth World Congress of Pediatric Cardiology and Cardiac Surgery will be the largest and most comprehensive scientific meeting dedicated to paediatric and congenital cardiac care ever held. At the time of the writing of this manuscript, The Eighth World Congress of Pediatric Cardiology and Cardiac Surgery has 5,037 registered attendees (and rising) from 117 countries, a truly diverse and international faculty of over 925 individuals from 89 countries, over 2,000 individual abstracts and poster presenters from 101 countries, and a Best Abstract Competition featuring 153 oral abstracts from 34 countries. For information about the Eighth World Congress of Pediatric Cardiology and Cardiac Surgery, please visit the following website: [www.WCPCCS2023.org]. The purpose of this manuscript is to review the activities related to global health and advocacy that will occur at the Eighth World Congress of Pediatric Cardiology and Cardiac Surgery.
Acknowledging the need for urgent change, we wanted to take the opportunity to bring a common voice to the global community and issue the Washington DC WCPCCS Call to Action on Addressing the Global Burden of Pediatric and Congenital Heart Diseases. A copy of this Washington DC WCPCCS Call to Action is provided in the Appendix of this manuscript. This Washington DC WCPCCS Call to Action is an initiative aimed at increasing awareness of the global burden, promoting the development of sustainable care systems, and improving access to high quality and equitable healthcare for children with heart disease as well as adults with congenital heart disease worldwide.
The transition from residency to paediatric cardiology fellowship is challenging due to the new knowledge and technical skills required. Online learning can be an effective didactic modality that can be widely accessed by trainees. We sought to evaluate the effectiveness of a paediatric cardiology Fellowship Online Preparatory Course prior to the start of fellowship.
Methods:
The Online Preparatory Course contained 18 online learning modules covering basic concepts in anatomy, auscultation, echocardiography, catheterisation, cardiovascular intensive care, electrophysiology, pulmonary hypertension, heart failure, and cardiac surgery. Each online learning module included an instructional video with pre-and post-video tests. Participants completed pre- and post-Online Preparatory Course knowledge-based exams and surveys. Pre- and post-Online Preparatory Course survey and knowledge-based examination results were compared via Wilcoxon sign and paired t-tests.
Results:
151 incoming paediatric cardiology fellows from programmes across the USA participated in the 3 months prior to starting fellowship training between 2017 and 2019. There was significant improvement between pre- and post-video test scores for all 18 online learning modules. There was also significant improvement between pre- and post-Online Preparatory Course exam scores (PRE 43.6 ± 11% versus POST 60.3 ± 10%, p < 0.001). Comparing pre- and post-Online Preparatory Course surveys, there was a statistically significant improvement in the participants’ comfort level in 35 of 36 (97%) assessment areas. Nearly all participants (98%) agreed or strongly agreed that the Online Preparatory Course was a valuable learning experience and helped alleviate some anxieties (77% agreed or strongly agreed) related to starting fellowship.
Conclusion:
An Online Preparatory Course prior to starting fellowship can provide a foundation of knowledge, decrease anxiety, and serve as an effective educational springboard for paediatric cardiology fellows.
Disruptive behavior disorders (DBD) are heterogeneous at the clinical and the biological level. Therefore, the aims were to dissect the heterogeneous neurodevelopmental deviations of the affective brain circuitry and provide an integration of these differences across modalities.
Methods
We combined two novel approaches. First, normative modeling to map deviations from the typical age-related pattern at the level of the individual of (i) activity during emotion matching and (ii) of anatomical images derived from DBD cases (n = 77) and controls (n = 52) aged 8–18 years from the EU-funded Aggressotype and MATRICS consortia. Second, linked independent component analysis to integrate subject-specific deviations from both modalities.
Results
While cases exhibited on average a higher activity than would be expected for their age during face processing in regions such as the amygdala when compared to controls these positive deviations were widespread at the individual level. A multimodal integration of all functional and anatomical deviations explained 23% of the variance in the clinical DBD phenotype. Most notably, the top marker, encompassing the default mode network (DMN) and subcortical regions such as the amygdala and the striatum, was related to aggression across the whole sample.
Conclusions
Overall increased age-related deviations in the amygdala in DBD suggest a maturational delay, which has to be further validated in future studies. Further, the integration of individual deviation patterns from multiple imaging modalities allowed to dissect some of the heterogeneity of DBD and identified the DMN, the striatum and the amygdala as neural signatures that were associated with aggression.
The Fontan Outcomes Network was created to improve outcomes for children and adults with single ventricle CHD living with Fontan circulation. The network mission is to optimise longevity and quality of life by improving physical health, neurodevelopmental outcomes, resilience, and emotional health for these individuals and their families. This manuscript describes the systematic design of this new learning health network, including the initial steps in development of a national, lifespan registry, and pilot testing of data collection forms at 10 congenital heart centres.
Brain imaging studies have shown altered amygdala activity during emotion processing in children and adolescents with oppositional defiant disorder (ODD) and conduct disorder (CD) compared to typically developing children and adolescents (TD). Here we aimed to assess whether aggression-related subtypes (reactive and proactive aggression) and callous-unemotional (CU) traits predicted variation in amygdala activity and skin conductance (SC) response during emotion processing.
Methods
We included 177 participants (n = 108 cases with disruptive behaviour and/or ODD/CD and n = 69 TD), aged 8–18 years, across nine sites in Europe, as part of the EU Aggressotype and MATRICS projects. All participants performed an emotional face-matching functional magnetic resonance imaging task.
Results
Differences between cases and TD in affective processing, as well as specificity of activation patterns for aggression subtypes and CU traits, were assessed. Simultaneous SC recordings were acquired in a subsample (n = 63). Cases compared to TDs showed higher amygdala activity in response to negative faces (fearful and angry) v. shapes. Subtyping cases according to aggression-related subtypes did not significantly influence on amygdala activity; while stratification based on CU traits was more sensitive and revealed decreased amygdala activity in the high CU group. SC responses were significantly lower in cases and negatively correlated with CU traits, reactive and proactive aggression.
Conclusions
Our results showed differences in amygdala activity and SC responses to emotional faces between cases with ODD/CD and TD, while CU traits moderate both central (amygdala) and peripheral (SC) responses. Our insights regarding subtypes and trait-specific aggression could be used for improved diagnostics and personalized treatment.
Implementation of genome-scale sequencing in clinical care has significant challenges: the technology is highly dimensional with many kinds of potential results, results interpretation and delivery require expertise and coordination across multiple medical specialties, clinical utility may be uncertain, and there may be broader familial or societal implications beyond the individual participant. Transdisciplinary consortia and collaborative team science are well poised to address these challenges. However, understanding the complex web of organizational, institutional, physical, environmental, technologic, and other political and societal factors that influence the effectiveness of consortia is understudied. We describe our experience working in the Clinical Sequencing Evidence-Generating Research (CSER) consortium, a multi-institutional translational genomics consortium.
Methods:
A key aspect of the CSER consortium was the juxtaposition of site-specific measures with the need to identify consensus measures related to clinical utility and to create a core set of harmonized measures. During this harmonization process, we sought to minimize participant burden, accommodate project-specific choices, and use validated measures that allow data sharing.
Results:
Identifying platforms to ensure swift communication between teams and management of materials and data were essential to our harmonization efforts. Funding agencies can help consortia by clarifying key study design elements across projects during the proposal preparation phase and by providing a framework for data sharing data across participating projects.
Conclusions:
In summary, time and resources must be devoted to developing and implementing collaborative practices as preparatory work at the beginning of project timelines to improve the effectiveness of research consortia.
WEEDSIM is a bioeconomic decision aid for management of annual weeds in corn and soybean. It was field-tested for 4 yr in Minnesota. The decision aid has two categories of management recommendations: soil-applied plus postemergence (PRE+), based on estimated weed seedbank composition and density; and postemergence (POST), based upon observed weed seedling composition and density. Weed densities, weed control, herbicide use, environmental impact of herbicide use, weed management costs, crop yields, and economic returns that resulted from PRE+ and POST recommendations were compared to those associated with herbicide management systems (HERB) that were standard for the region. After 4 yr of applying WEEDSIM recommendations to the same plots, there were no increases in annual weed densities (seedbanks, seedlings, established plants, or seed production) or decreases in weed control or crop (soybean, rotation corn, and continuous corn) yields, compared to HERB. WEEDSIM recommendations resulted in average annual herbicide applications of 1.1 kg ai ha−1 for PRE+ and 1.0 kg ai ha−1 for POST, compared to 3.5 kg ai ha−1 for HERB. Environmental impact indices associated with PRE+, POST, and HERB were 0.75, 0.71, and 0.54, with the lowest value indicating greater environmental risk than the two higher values. Similarly, average weed management costs were $24, $33, and $77 ha−1 for PRE+, POST, and HERB, respectively. Based on crop prices of $94 Mg−1 for corn and $220 Mg-1 for soybean, the average gross margins over weed control costs were higher for PRE+ ($509 ha−1) and POST ($522 ha−1) than for HERB ($455 ha−1). In general, WEEDSIM appeared to make management recommendations that adequately controlled weeds, maintained crop yields, reduced herbicide use, decreased environmental risk, lowered weed management costs, and increased gross margins over weed control costs compared to the use of herbicides standard for the region.
Previous efforts to model crop yield loss from multiple weed species constructed competitive indices based on yield loss from individual weed species. Our model uses a multispecies modification of Cousens’ rectangular hyperbolic yield function to estimate a nonlinear competitive index for weed-crop interference. Results from 13 Minnesota and Wisconsin data sets provide measures of the relative competitiveness of mixed green and yellow foxtails, common lambsquarters, redroot pigweed, velvetleaf, and several other weed species. Competition coefficient estimates are stable over years, but not locations.
Field studies were conducted in 1993–1994 and 1994–1995 to evaluate the effects of preherbicide mowing and herbicide rate on tropical soda apple (TSA) control. Mature TSA plants were mowed one, two, or three times to a 7.5-cm stubble with a 60-d interval between mowings. Triclopyr was applied at 0, 0.6, and 1.1 kg ai/ha at 375 L/ha at 207 kPa 60 d after each mowing treatment. Mowing TSA plants twice before an application of 0.6 kg ai/ha triclopyr resulted in 100% control. Tropical soda apple control (2-yr average) for the triclopyr treatment increased between one (28% control) and two (82% control) preherbicide mowings, with no additional control benefits from three mowings (84% control). In a second study, TSA control increased from 10% 60 d after a single mowing to 92% after three consecutive mowings at 60-d intervals with no herbicide. Total nonstructural carbohydrates in TSA crowns decreased from 19.1% for unclipped plants to 4.3% 60 d after three preherbicide mowings.
Two broad aims drive weed science research: improved management and improved
understanding of weed biology and ecology. In recent years, agricultural
weed research addressing these two aims has effectively split into separate
subdisciplines despite repeated calls for greater integration. Although some
excellent work is being done, agricultural weed research has developed a
very high level of repetitiveness, a preponderance of purely descriptive
studies, and has failed to clearly articulate novel hypotheses linked to
established bodies of ecological and evolutionary theory. In contrast,
invasive plant research attracts a diverse cadre of nonweed scientists using
invasions to explore broader and more integrated biological questions
grounded in theory. We propose that although studies focused on weed
management remain vitally important, agricultural weed research would
benefit from deeper theoretical justification, a broader vision, and
increased collaboration across diverse disciplines. To initiate change in
this direction, we call for more emphasis on interdisciplinary training for
weed scientists, and for focused workshops and working groups to develop
specific areas of research and promote interactions among weed scientists
and with the wider scientific community.
There are many concerns about the effects of repeated use of glyphosate in glyphosate-resistant (GR) crops, including two that are seemingly contradictory. These are (1) weed escapes and (2) loss of weed diversity. Weeds that escape glyphosate treatment represent species that likely will become troublesome and difficult to control in the future, and identifying these future problems may allow more effective management. In contrast, complete weed control directly reduces the weed component of agroecosystem biodiversity and may lower other components indirectly (e.g., weed-dependent granivores). During 2001 and 2002 effects of glyphosate and conventional weed control treatments on weed community composition and GR soybean yields were studied. Field studies were conducted along a north–south transect of sites spanning a distance of 1600 km from Minnesota to Louisiana. Low-intensity use (single application yr−1) of glyphosate allowed more escapes and maintained higher weed diversity than high-intensity use (two applications yr−1) of glyphosate, and it was equivalent to or even higher than diversity in non-GR systems. Although the same weeds escaped from low- and high-intensity glyphosate treatments, frequency of escapes was higher with less intensive use. These results suggest that limited use of glyphosate would not have profound effects on weed diversity. In addition, crop yield did not differ between GR and non-GR treatments at high latitudes, but below 40° N latitude, with a longer cropping season, yields with low-intensity glyphosate use decreased by about 2% per degree latitude because of competition from escaped weeds.