Antithrombotic therapy for atrial fibrillation in hereditary hemorrhagic telangiectasia.

Antithrombotic therapy reduces stroke risk in patients with atrial fibrillation but at the cost of increased bleeding risk. Patients with hereditary hemorrhagic telangiectasia (HHT) are at increased bleeding risk due to fragile mucocutaneous telangiectasias and visceral arteriovenous malformations. These patients are simultaneously at elevated thrombotic risk due to the vascular abnormalities of HHT. Managing atrial fibrillation in patients with HHT represents an understudied and challenging clinical scenario. We present a retrospective cohort study investigating antithrombotic therapy in patients with HHT and atrial fibrillation. We found that antithrombotic therapy was poorly tolerated, leading to premature dose-reduction or discontinuation of therapy in a majority of patients and in a majority of treatment episodes. Five patients undergoing left atrial appendage procedures did well despite difficulties completing the prescribed course of post-procedure antithrombotic therapy. Left atrial appendage occlusion or simultaneous administration of systemic anti-angiogenic therapy may represent alternatives but require additional study in patients with HHT.

Carbon dioxide physiological forcing dominates projected Eastern Amazonian drying.

Future projections of east Amazonian precipitation indicate drying, but they are uncertain and poorly understood. In this study we analyse the Amazonian precipitation response to individual atmospheric forcings using a number of global climate models. Black carbon is found to drive reduced precipitation over the Amazon due to temperature-driven circulation changes, but the magnitude is uncertain. CO2 drives reductions in precipitation concentrated in the east, mainly due to a robustly negative, but highly variable in magnitude, fast response. We find that the physiological effect of CO2 on plant stomata is the dominant driver of the fast response due to reduced latent heating, and also contributes to the large model spread. Using a simple model we show that CO2 physiological effects dominate future multi-model mean precipitation projections over the Amazon. However, in individual models temperature-driven changes can be large, but due to little agreement, they largely cancel out in the model-mean.

Understanding Rapid Adjustments to Diverse Forcing Agents.

Rapid adjustments are responses to forcing agents that cause a perturbation to the top of atmosphere energy budget but are uncoupled to changes in surface warming. Different mechanisms are responsible for these adjustments for a variety of climate drivers. These remain to be quantified in detail. It is shown that rapid adjustments reduce the effective radiative forcing (ERF) of black carbon by half of the instantaneous forcing, but for CO2 forcing, rapid adjustments increase ERF. Competing tropospheric adjustments for CO2 forcing are individually significant but sum to zero, such that the ERF equals the stratospherically adjusted radiative forcing, but this is not true for other forcing agents. Additional experiments of increase in the solar constant and increase in CH4 are used to show that a key factor of the rapid adjustment for an individual climate driver is changes in temperature in the upper troposphere and lower stratosphere.

Quantifying the Importance of Rapid Adjustments for Global Precipitation Changes.

Different climate drivers influence precipitation in different ways. Here we use radiative kernels to understand the influence of rapid adjustment processes on precipitation in climate models. Rapid adjustments are generally triggered by the initial heating or cooling of the atmosphere from an external climate driver. For precipitation changes, rapid adjustments due to changes in temperature, water vapor, and clouds are most important. In this study we have investigated five climate drivers (CO2, CH4, solar irradiance, black carbon, and sulfate aerosols). The fast precipitation responses to a doubling of CO2 and a 10-fold increase in black carbon are found to be similar, despite very different instantaneous changes in the radiative cooling, individual rapid adjustments, and sensible heating. The model diversity in rapid adjustments is smaller for the experiment involving an increase in the solar irradiance compared to the other climate driver perturbations, and this is also seen in the precipitation changes.

Verification Testing to Confirm VO2max in Altitude-Residing, Endurance-Trained Runners.

We sought to explore the utility of the verification trial to confirm individual attainment of 'true' VO2max in altitude-residing, endurance-trained runners during treadmill exercise. 24 elite endurance-trained men and women runners (age=21.5±3.3 yr, ht=174.8±9.3 cm, body mass=60.5±6.7 kg, PR 800 m 127.5±13.1 s) completed a graded exercise test (GXT) trial (VO2max=60.0±5.8 mL·kg(-1)·min(-1)), and returned 20 min after incremental exercise to complete a verification trial (VO2max=59.6±5.7 mL·kg(-1)·min(-1)) of constant load, supramaximal exercise. The incidence of 'true' VO2max confirmation using the verification trial was 24/24 (100%) with all participants revealing differences in VO2max≤3% (the technical error of our equipment) between the GXT and verification trials. These findings support use of the verification trial to confirm VO2max attainment in altitude-residing, endurance-trained runners.

The impact of tuition fees amount on mental health over time in British students.

BACKGROUND: Previous studies have shown a relationship between debt and mental health problems in students. This study aimed to examine the effect of differences in tuition fees amount on changes in mental health over time. METHODS: A prospective cohort study followed 390 first-year British students who differed on their tuition fees level at 4 time points across their first 2 years at university. Participants completed measures of global mental health, depression, anxiety, stress, alcohol-related problems at up to four time points in their first two years at university. Mixed-factorial ANOVAs were used to assess the impact of tuition fees amount on changes in scores over time. RESULTS: There was no difference based on fees at Time 1 for anxiety, stress, depression and global mental health. At Time 2, those charged £0-2.9k or £3-4k improved while those charged £8-9k stayed the same. However, this trend reversed by Times 3 and 4. CONCLUSIONS: Undergraduates mental health is partially affected by the level of tuition fees; however, the recent increase in tuition fees does not appear to have had a lasting impact at present.

Consistent FFP2-masking as part of reducing viral respiratory infections on medical wards for allogeneic hematopoietic stem cell transplantation.

Patients undergoing allogenic hematopoietic stem cell transplantation (allo-HSCT) are highly susceptible to infections. The consequent use of masks on wards for allo-HSCT has been controversial in the past decades and was not common before the COVID-19 pandemic. We retrospectively compared incidence and outcomes of viral respiratory infections during allo-HSCT on our specialized ward between 01/2018 and 09/2020 to the era of FFP2 masking between 10/2020 and 10/2022 covering similar seasons of the year. Each group consisted of 150 matched patients. The usage of FFP2 masks reduced the incidence of viral respiratory infections from 22.1 to 2.1% (p < 0.005). This reduced the time on ward from a median of 26 days to 23.5 days (p = 0.002). It also resulted in less use of CT-scans (p = 0.003) and bronchoalveolar lavage procedures (p = 0.057). Median time to proof of infection was 21 days after admission in both groups. No difference was detected in progression free survival, hospital survival or non-relapse mortality (p = 0.78). Our retrospective results indicate that FFP2 masks worn by patients and hospital staff may help to significantly reduce the incidence of viral respiratory infections, including COVID-19, shorten the in-hospital time, and reduce costs without affecting survival.

Facilitators and barriers to using telemedicine for gender-affirming care in gender-diverse youth: A qualitative study.

INTRODUCTION: Access to gender-affirming care (GAC) is limited for gender-diverse (GD) youth, with the potential for further limitations given the current political climate. GAC has been shown to improve the mental health of GD youth and telemedicine (TM) could increase access to GAC. With limited data on the acceptability and feasibility of TM for GAC among GD youth, we sought to further explore their perspectives on the use of TM in their care. METHODS: We used a semi-structured interview guide, with prompts developed to explore participants' knowledge of TM, identify factors that influenced use, and advantages or disadvantages of use. RESULTS: Thirty GD participants aged 13-21 years old participated in TM. While TM was not the preferred option for medical visits, it was recognized as a practical option for providing GAC. Various actual and perceived disadvantages noted by youth included, technical issues interrupting the visit, not receiving care equivalent to that of an in-person visit, having to see themselves on the screen, family members interrupting visits, and meeting new staff while connecting to a TM visit. The advantages, however, were an increased autonomy and convenience of TM, especially when used for specific aspects of GAC. DISCUSSION: The use of TM in GAC could be optimized by limiting camera use, eliminating/reducing staff involvement, being sensitive to privacy issues, and alternating TM with in-person visits. Clinicians should be cognizant of patient preferences and concerns and be flexible with visit types.

Home environment: association with hyperactivity/impulsivity in children with ADHD and their non-ADHD siblings.

OBJECTIVE: We wished to ascertain if there is an association between symptoms of attention-deficit/hyperactivity disorder (ADHD) and home environment in children with ADHD and non-ADHD siblings, controlling for other environmental measures. METHODS: 96 children with ADHD combined type (ADHD-CT) and their siblings participated in the study. Parent and teacher Conners' rating scales were completed and home environment was assessed using the middle childhood and early adolescent Home Observation for Measurement of the Environment (HOME). ADHD symptoms were assessed for correlation with HOME in children with ADHD-CT and non-ADHD siblings and multiple regression analysis was used to control for gender, socio-economic status, exposure to nicotine, exposure to alcohol in utero, birth weight, gestational age, pregnancy and perinatal risk factors. The presence of oppositional disorders was assessed for association with HOME score in those with ADHD-CT. The multiple regression analysis was repeated controlling for environmental factors and for oppositional disorders in those with ADHD-CT. Oppositional symptoms were assessed for correlation with HOME score in non-ADHD siblings. RESULTS: Teacher-rated hyperactive/impulsive scores correlated with HOME (r=-0.27, P < 0.01) in children with ADHD-CT. This association remained significant when other environmental factors and oppositional disorders were controlled for. Environmental factors and gender contributed to 30% of the variance of ADHD symptoms in ADHD-CT. Parent-rated hyperactive/impulsive scores also correlated with HOME (r=-0.28, P < 0.05) for non-ADHD siblings. An association between HOME and diagnosis of oppositional defiant disorder or conduct disorder was found for children with ADHD-CT and between HOME and oppositional symptoms in non-ADHD siblings. CONCLUSIONS: The home environment has a small but significant association with hyperactive/impulsive symptoms in children with ADHD-CT and non-ADHD siblings. This association remained when other environmental factors were taken into account. Oppositional symptoms are associated with home environment in ADHD-CT and in non-ADHD siblings.

Cardiac Sarcoidosis and a Likely Pathogenic TTN Variant in a Patient Presenting With Ventricular Tachycardia.

Rare variants in TTN are the most common monogenic cause of early-onset atrial fibrillation and dilated cardiomyopathy. Whereas cardiac sarcoidosis is very underdiagnosed, a common presentation can be ventricular arrhythmias. This report presents a patient with a likely pathogenic TTN variant and cardiac sarcoidosis. (Level of Difficulty: Intermediate.).

Recognition of infants at high risk for vertical HIV transmission at delivery in rural Western Cape Province, South Africa.

Background: Despite South Africa's substantial reduction in vertical HIV transmission (VHT), national paediatric HIV elimination is not yet attained. National and Western Cape Province (WC) HIV guidelines recommend enhanced postnatal prophylaxis for infants at high risk for VHT, identified in the WC 2015/2016 guidelines by any single high-risk criterion (maternal antiretroviral therapy (ART) <12 weeks, absent/ unsuppressed maternal HIV viral load (HIV-VL) <12 weeks before/including delivery, spontaneous preterm labour, prolonged rupture of membranes, chorioamnionitis). Accuracy of high-risk infant identification is unknown. Objectives: Primarily, to determine the proportion of infants at high risk for VHT, the accuracy of labour-ward risk classification, the criteria determining high-risk statuses and the criteria missed among unrecognised high-risk infants; secondarily, to determine maternal factors associated with high-risk infants. Methods: Infants born to women living with HIV at a rural regional hospital (May 2016 - April 2017) were retrospectively evaluated using data from the labour ward VHT register, standardised maternity case records, National Health Laboratory Service database and WC Provincial Health Data Centre. The study-derived risk status for each infant was determined using documented presence/absence of risk criteria and compared with labour ward assigned risk to determine accuracy. Proportions of high-risk and unrecognised high-risk infants with each high-risk criterion were determined. Maternal characteristics associated with having a high-risk infant were evaluated using multivariable logistic regression. Results: For liveborn infants, labour ward assigned risk classifications were 40% (n=75/188) high risk, 50% (n=94/188) low risk and 10% (n=19/188) unclassified. Study-derived risk was high risk for 69% (n=129/188) and low risk for 31% (n=59/188), yielding a high-risk classification sensitivity of 51% (95% confidence interval (CI) 42 - 60) and specificity of 69% (95% CI 56 - 80). Absent/unsuppressed HIVVL <12 weeks before delivery accounted for 83% (n=119/143) of study-derived high-risk exposures and 81% (n=60/74) of missed high-risk exposures. Fewer mothers of high-risk infants had >4 antenatal visits (38% v. 81%, p<0.01) and first antenatal visit <20 weeks' gestation (57% v. 77%, p=0.01). Only the number of antenatal visits remained associated with having a high-risk infant after adjusting for gestation at first visit and timing of HIV diagnosis and ART initiation: each additional antenatal visit conferred a 39% (95% CI 25 - 50) reduction in the odds of having a high-risk infant. Conclusion: Labour ward risk classification failed to recognise half of high-risk infants. Infant high-risk status as well as non-detection thereof were driven by suboptimal maternal HIV-VL monitoring. Reinforcing visit frequency later in pregnancy may improve antenatal HIV-VL monitoring, and point-of-care HIV-VL monitoring at delivery could improve recognition of virally unsuppressed mothers and their high-risk infants.

Comparison of ex vivo optical coherence tomography with conventional frozen-section histology for visualizing basal cell carcinoma during Mohs micrographic surgery.

BACKGROUND: Mohs micrographic surgery offers high cure rates of nonmelanoma skin cancers with optimal sparing of normal tissue. However, it is generally more time-consuming and labour-intensive than traditional surgery. Optical coherence tomography (OCT) is an emergent technology that has the potential to diagnose basal cell carcinoma (BCC) in vivo. OBJECTIVE: To compare the efficiency and accuracy of ex vivo OCT with frozen-section histology for identifying BCC in Mohs surgery. METHODS: Thirty-eight patients were enrolled. After the stages were taken, images were captured with an OCT microscope and subsequently processed for standard frozen sections. RESULTS: In total, 75 sections were scanned and the mean time to produce one OCT image was 7 min. In four of 26 positive haematoxylin-eosin sections and 23 of 49 negative sections, there was a good correlation with OCT images. The sensitivity and specificity were 19% and 56%, respectively. CONCLUSIONS: It is possible to identify BCC with ex vivo OCT and this is more rapidly obtained than with haematoxylin-eosin frozen sections. However, tumour visualization in OCT was disappointing. Practical benefit may be obtained by optimizing this technology and combining it with other new diagnostic tools.

Microbial processes in the Athabasca Oil Sands and their potential applications in microbial enhanced oil recovery.

The Athabasca Oil Sands are located within the Western Canadian Sedimentary Basin, which covers over 140,200 km(2) of land in Alberta, Canada. The oil sands provide a unique environment for bacteria as a result of the stressors of low water availability and high hydrocarbon concentrations. Understanding the mechanisms bacteria use to tolerate these stresses may aid in our understanding of how hydrocarbon degradation has occurred over geological time, and how these processes and related tolerance mechanisms may be used in biotechnology applications such as microbial enhanced oil recovery (MEOR). The majority of research has focused on microbiology processes in oil reservoirs and oilfields; as such there is a paucity of information specific to oil sands. By studying microbial processes in oil sands there is the potential to use microbes in MEOR applications. This article reviews the microbiology of the Athabasca Oil Sands and the mechanisms bacteria use to tolerate low water and high hydrocarbon availability in oil reservoirs and oilfields, and potential applications in MEOR.

Dental examiners consistency in applying the ICDAS criteria for a caries prevention community trial.

AIM: To examine dental examiners' one-year consistency in utilizing the International Caries Detection and Assessment System (ICDAS) criteria after baseline training and calibration. METHODS: A total of three examiners received baseline training/calibration by a "gold standard" examiner, and one year later re-calibration was conducted. For the baseline training/calibration, subjects aged 8-16 years, and for the re-calibration subjects aged five to six years were recruited for the study. The ICDAS criteria were used to classify visual caries lesion severity (0-6 scale), lesion activity (active/inactive), and presence of filling material (0-9 scale) of all available tooth surfaces of permanent and primary teeth. The examination used a clinical light, mirror and air syringe. Kappa (weighted: Wkappa, unweighted: Kappa) statistics were used to determine inter-and intra-examiner reliability at baseline and re-calibration. RESULTS: For lesion severity and filling criteria, the baseline calibration on 35 subjects indicated an inter-rater Wkappa ranging from 0.69-0.92 and intra-rater Wkappa ranging from 0.81-0.92. Re-calibration on 22 subjects indicated an inter-rater Wkappa of 0.77-0.98 and intra-rater Wkappa ranged from 0.93-1.00. The Wkappa for filling was consistently in the excellent range, while lesion severity was in the good to excellent range. Activity kappa was in the poor to good range. All examiners improved with time. CONCLUSIONS: The baseline training/calibration in ICDAS was crucial to maintain the stability of the examiners reliability over a one year period. The ICDAS can be an effective assessment tool for community-based clinical trials.

A review and meta-analysis of computerized cognitive behaviour therapy for the treatment of pain in children and adolescents.

BACKGROUND: Chronic pain is relatively common in children and adolescents. Cognitive behaviour therapy (CBT) has been shown to be effective for treating pain in this age group. This paper aims to review the literature on the use of computerized cognitive behavioural therapy (cCBT) with children and adolescents with pain. METHODS: Three databases, Pubmed (including Medline), Embase and PsychInfo, were searched and papers were identified using specific inclusion criteria. RESULTS: Four studies met the inclusion criteria, all of which indicated beneficial results of using cCBT, with those who completed cCBT being more likely to experience at least a 50% post-treatment reduction in symptoms than those in a control group. A meta-analysis suggested a medium effect size of -0.41 for reduced pain intensity post treatment for cCBT compared with the control groups. A mean odds ratio of 6.03 was found for achieving a clinically significant reduction in pain in the cCBT group compared with the control groups. CONCLUSION: This review tentatively suggests potential for using cCBT for pain in children and adolescents. However, there is only a small body of research exploring this relationship at present, and so further research is needed before any solid conclusions can be drawn.

"Always Events® " just another quality improvement tool or is it?

INTRODUCTION: Always Events® are defined as "those aspects of the care experience that should always occur when patients, their family members or other care partners, and service users interact with health care professionals and the health care system". It is a quality improvement methodology that starts by asking our patients the simple question "what matters to you?" and then through coproduction, works out a way to achieve this. METHODS AND RESULTS: This article tells our story and highlights the value of undertaking an Always Event® within the Radiology department at Warrington and Halton Hospitals. It will demonstrate how this approach combines research, an evaluation of findings and implementation of those findings within a very short timeframe. Embedded within the article are comments from our staff, volunteers and patients which reflect upon their experiences, our limitations, the outcomes we achieved and the impact it has had upon our patients and staff. CONCLUSION AND IMPLICATIONS FOR PRACTICE: It was important to our patients that they would be informed of how long they would wait for their examination once they booked in at x-ray reception. By undertaking an Always Event® this process is now embedded in our departments everyday activities with over 90% of our patients now being informed of their waiting time. This continued collaboration has really emphasised the value of listening to our patients, and the benefits this can lead to. It has also encouraged a positive research culture within our department (optimisation studies, working with industry, quality projects), helping to progress our profession and resulting in a quality service for our patients.

Migration tracking reveals geographic variation in the vulnerability of a Nearctic-Neotropical migrant bird.

We compared the vulnerability of a Nearctic-Neotropical migrant (Swainson's Thrush, Catharus ustulatus) for three geographically-defined breeding populations in California by linking breeding and wintering regions, estimating migration distances, and quantifying relative forest loss. Using data from light-level geolocator and GPS tags, we found that breeding birds from the relatively robust coastal population in the San Francisco Bay area wintered predominantly in western Mexico (n = 18), whereas the far rarer breeding birds from two inland populations that occur near one another in the Sierra Nevada and southern Cascades mountain ranges migrated to farther wintering destinations, with birds from the Lassen region (n = 5) predominantly going to Central America and birds from the Tahoe region (n = 7) predominantly to South America. Landscape-level relative forest loss was greater in the breeding and wintering regions of the two Cascade-Sierra populations than those of coastal birds. Longer migration distances and greater exposure to recent forest loss suggest greater current vulnerability of Cascade-Sierra birds. Our results demonstrate that for some species, quantifying migration distances and destinations across relatively small distances among breeding populations (in this case, 140-250 km apart) can identify dramatically different vulnerabilities that need to be considered in conservation planning.

Author Correction: Combined ground and aerial measurements resolve vent-specific gas fluxes from a multi-vent volcanic system.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Correction: A chemical inhibitor of PPM1D that selectively kills cells overexpressing PPM1D.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.