The effect of NHFOV on hemodynamics in mild and moderately preterm neonates: a randomized clinical trial.

The aim of this study is to study cardio-respiratory effects of nasal high-frequency oscillatory ventilation (NHFOV) vs. NCPAP as an initial mode of ventilation in moderate-late-preterm infants. A randomized controlled trial was conducted in NICU of Alexandria University Maternity Hospital (AUMH). One-hundred late-moderate-preterm infants were randomly assigned to either NHFOV-group (n = 50) or NCPAP-group (n = 50). For both groups, functional echocardiography was performed in the first 24 h to detect hemodynamic changes and respiratory outcome was monitored throughout the hospital stay. The main outcomes were hemodynamic measurements and myocardial function using functional echocardiography of those infants along with the respiratory outcome and complications. Kaplan-Meier survival plot was used representing time course of NCPAP and NHFOV failure. Left ventricular output values were not significantly different in both groups with median 202 ml/kg /min and IQR (176-275) in NCPAP-group and 226 ml/kg/min with IQR (181-286) in NHFOV group. Nevertheless, ejection fraction and fractional shortening were significantly higher in NHFOV-group with P 0.001. The time to weaning, the time to reach 30%-FIO2, the need for invasive ventilation, oxygen support duration, and maximal-FIO2 were significantly more in NCAPAP group.     Conclusion: NHFOV is an effective and promising tool of non-invasive-ventilation which can be used as a primary modality of respiratory support in preterm infants with variable forms of respiratory distress syndrome without causing detrimental effect on hemodynamics or significant respiratory complications.     Trial registration: NCT05706428 (registered on January 21, 2023). What is Known: • NHFOV might be beneficial as a secondary mode of ventilation and might have an impact on hemodynamics. What is New: • NHFOV can be used as an initial mode of ventilation with CDP beyond the reported pressure limits of CPAP without causing neither CO2 retention nor adverse hemodynamic consequences.

Intraventricular hemorrhage prediction in premature neonates in the era of hemodynamics monitoring: a prospective cohort study.

Unstable hemodynamics and prematurity are the main players in intraventricular hemorrhage (IVH) development. Our objective was to study 8 the use of superior vena cava flow (SVCF), left ventricular output (LVO), and right ventricular output (RVO), and anterior cerebral artery (ACA) Doppler measures in prediction of IVH in the first week of life in preterm infant ≤ 32 weeks and birth weight ≤ 1500 g. This prospective cohort study was conducted in 55NICU of Alexandria University maternity hospital. Of 147 enrolled patients, 132 infants born ≤ 32 weeks GA and birth weight ≤ 1500 g were eligible for- the study. One hundred twenty-seven infants completed the study. Infants were scanned for ACA-RI using transfontanellar ultrasound, and SVCF, LVO, and RVO using functional echocardiography in the first 24 h after birth. Patients had another two scans on DOL3 and 7 to detect IVH development. Low SVCF and high ACA-RI significantly increased the risk of IVH using logistic regression models with OR, 3.16; 95%CI, 1.19-8.39; P = 0.02 and OR, 1.64; 95%Cl, 1.10-2.44; P = 0.02, respectively. Low SVCF and high ACA-RI significantly increased risk of catastrophic IVH P = 0.025 and 0.023, respectively. Combined use of low SVCF < 55 ml/kg/min and ACA-RI > 0.75 is predictor of IVH with sensitivity 40.8% and 82.1% specificity. CONCLUSIONS: There are strong relations between both low SVCF and high ACA-RI, and IVH development in premature neonates ≤ 32 weeks and birth weight ≤ 1500 g, with more significance towards catastrophic IVH. Admission RSS and LVO are the strongest factors affecting SVCF. Maternal anemia, patent ductus arteriosus size (mm/kg), and capillary refill time were significantly associated with high ACA-RI. These findings help in more understanding of pathophysiological factors affecting central perfusion that might affect the longer term neurodeveopmental outcome. TRIAL REGISTRATION: This work was registered in clinical trial.gv no NCT05050032. WHAT IS KNOWN: •Whether SVCF and RI-ACA can predict IVH in preterm neonates is still debatable. WHAT IS NEW: •Low SVC flow and high ACA-RI significantly increased risk of IVH, confirming the role of hypoperfusion-reperfusion cycle in IVH development. The most striking result that combined metrics using the cut-off value of < 41 ml/kg/min for SVCF and > 0.85 for ACA-RI "in the first day of life" can correctly reject the presence of IVH in 98% of patients "during the first week of life."

The effect of placental transfusion on hemodynamics in premature newborns: a randomized controlled trial.

Despite of growing evidence of the beneficial effects of placental transfusion techniques, there is no available sufficient data about their effects on vulnerable hemodynamics and myocardium of premature infants. The purpose of this work is to study ventricular functions and hemodynamics after applying different placental transfusion techniques, delayed cord clamping (DCC), cut cord milking (C-UCM), and intact cord milking (I-UCM). Sixty-four infants delivered whether by C-section or vaginal delivery were randomly assigned to undergo C-UCM (20-30 cm), I-UCM (3-4 strippings), and DCC (30-60 s). Functional echocardiography was done on day 1 and day 3 of life for 57 infants. Primary outcome variable was superior vena cava flow measurement in infants having placental transfusion in the first 24 h of life and between 64 and 72 h. Secondary outcomes were other echocardiographic and clinical hemodynamic parameters, and biventricular functions in those infants. Of a total 196 preterm infants ≤ 32 weeks delivered in the study period, from January 2021 to August 2021, 57 infants were eligible and survived till the second examination. They were randomly assigned to the three groups. Neonates randomly assigned to DCC had significantly higher superior vena cava flow and lower right ventricular systolic function in the first 24 h of life. This finding vanished at day 3. Neonates undergone different methods of placental transfusions had similar hemoglobin, admission temperature, and mean blood pressure in the first 24 h of life. CONCLUSION: Despite their potential benefits, placental transfusions have shown to alter the hemodynamics and adversely affect myocardial function of premature neonates. TRIAL REGISTRATION: This trial was registered in the clinical trial gov NCT04811872. WHAT IS KNOWN: • Placental transfusion techniques might have benefits regarding prematurity- related morbidities and mortality. WHAT IS NEW: • Placental transfusion might adversely affect the myocardium and alter hemodynamics in premature infants.

What We Know Now: An Economic Evaluation of Chickenpox Vaccination and Dose Timing Using an Agent-Based Model.

OBJECTIVES: The value of chickenpox vaccination is still debated in the literature and by jurisdictions worldwide. This uncertainty is reflected in the inconsistent uptake of the vaccine, where some countries offer routine childhood immunization programs, others have targeted programs, and in many the vaccine is only privately available. Even across the countries that have universal funding for the vaccine, there is a diversity of schedules and dosing intervals. Using an agent-based model of chickenpox and shingles, we conducted an economic evaluation of chickenpox vaccination in Alberta, Canada. METHODS: We compared the cost-effectiveness of 2 common chickenpox vaccination schedules, specifically a long dosing interval (first dose: 12 months; second dose: 4-6 years) and a short dosing interval (first dose: 12 months; second dose: 18 months). RESULTS: The economic evaluation demonstrated a shorter dosing interval may be marginally preferred, although it consistently led to higher costs from both the societal and healthcare perspectives. We found that chickenpox vaccination would be cost-saving and highly cost-effective from the societal and healthcare perspective, assuming there was no impact on shingles. CONCLUSION: Chickenpox vaccine was cost-effective when not considering shingles and remained so even if there was a minor increase in shingles following vaccination. However, if chickenpox vaccination did lead to a substantial increase in shingles, then chickenpox vaccination was not cost-effective from the healthcare perspective.

Polariton induced conical intersection and berry phase.

We investigate the Polariton induced conical intersection (PICI) created from coupling a diatomic molecule with the quantized photon mode inside an optical cavity, and the corresponding Berry Phase effects. We use the rigorous Pauli-Fierz Hamiltonian to describe the quantum light-matter interactions between a LiF molecule and the cavity, and use the exact quantum propagation to investigate the polariton quantum dynamics. The molecular rotations relative to the cavity polarization direction play a role as the tuning mode of the PICI, resulting in an effective CI even within a diatomic molecule. To clearly demonstrate the dynamical effects of the Berry phase, we construct two additional models that have the same Born-Oppenheimer surface, but the effects of the geometric phase are removed. We find that when the initial wavefunction is placed in the lower polaritonic surface, the Berry phase causes a π phase-shift in the wavefunction after the encirclement around the CI, indicated from the nuclear probability distribution. On the other hand, when the initial wavefunction is placed in the upper polaritonic surface, the geometric phase significantly influences the couplings between polaritonic states and therefore, the population dynamics between them. These BP effects are further demonstrated through the photo-fragment angular distribution. PICI created from the quantized radiation field has the promise to open up new possibilities to modulate photochemical reactivities.

Socio-demographic and environmental risk factors associated with multiple under-five child loss among mothers in Bangladesh.

BACKGROUND: Despite the substantial decline in child mortality globally over the last decade, reducing neonatal and under-five mortality in Bangladesh remains a challenge. Mothers who experienced multiple child losses could have substantial adverse personal and public health consequences. Hence, prevention of child loss would be extremely desirable during women's reproductive years. The main objective of this study was to determine the risk factors associated with multiple under-five child loss from the same mother in Bangladesh. METHODS: In this study, a total of 15,877 eligible women who had given birth at least once were identified from the 2014 Bangladesh Demographic and Health Survey. A variety of count regression models were considered for identifying socio-demographic and environmental factors associated with multiple child loss measured as the number of lifetime under-five child mortality (U5M) experienced per woman. RESULTS: Of the total sample, approximately one-fifth (18.9%, n = 3003) of mothers experienced at least one child's death during their reproductive period. The regression analysis results revealed that women in non-Muslim families, with smaller household sizes, with lower education, who were more advanced in their childbearing years, and from an unhygienic environment were at significantly higher risk of experiencing offspring mortality. This study also identified the J-shaped effect of age at first birth on the risk of U5M. CONCLUSIONS: This study documented that low education, poor socio-economic status, extremely young or old age at first birth, and an unhygienic environment significantly contributed to U5M per mother. Therefore, improving women's educational attainment and socio-economic status, prompting appropriate timing of pregnancy during reproductive life span, and increasing access to healthy sanitation are recommended as possible interventions for reducing under-five child mortality from a mother. Our findings point to the need for health policy decision-makers to target interventions for socio-economically vulnerable women in Bangladesh.

Assessing the contextual effect of community in the utilization of postnatal care services in Ghana.

BACKGROUND: Inequalities in the use of postnatal care services (PNC) in Ghana have been linked to poor maternal and neonatal health outcomes. This has ignited a genuine concern that PNC interventions with a focus on influencing solely individual-level risk factors do not achieve the desired results. This study aimed to examine the community-level effect on the utilization of postnatal care services. Specifically, the research explored clusters of non-utilization of PNC services as well as the effect of community-level factors on the utilization of PNC services, with the aim of informing equity-oriented policies and initiatives. METHODS: The 2014 Ghana Demographic and Health Survey GDHS dataset was used in this study. Two statistical methods were used to analyze the data; spatial scan statistics were used to identify hotspots of non-use of PNC services and second two-level mixed logistic regression modeling was used to determine community-level factors associated with PNC services usage. RESULTS: This study found non-use of PNC services to be especially concentrated among communities in the Northern region of Ghana. Also, the analyses revealed that community poverty level, as well as community secondary or higher education level, were significantly associated with the utilization of PNC services, independent of individual-level factors. In fact, this study identified that a woman dwelling in a community with a higher concentration of poor women is less likely to utilize of PNC services than those living in communities with a lower concentration of poor women (Adjusted odds ratio (AOR) = 0.60, 95%CI: 0.44-0.81). Finally, 24.0% of the heterogeneity in PNC services utilization was attributable to unobserved community variability. CONCLUSION: The findings of this study indicate that community-level factors have an influence on women's health-seeking behavior. Community-level factors should be taken into consideration for planning and resource allocation purposes to reduce maternal health inequities. Also, high-risk communities of non-use of obstetric services were identified in this study which highlights the need to formulate community-specific strategies that can substantially shift post-natal use in a direction leading to universal coverage.

Role of Near-Infrared Spectroscopy in Monitoring the Clinical Course of Asphyxiated Neonates Treated with Hypothermia.

OBJECTIVE: Hypoxic-ischemic encephalopathy (HIE) affects millions of newborns annually, especially in low-resource settings. Real-time monitoring of hypoxic-ischemic brain damage is urgently needed for assessment of severity and management of neonates with birth asphyxia. Aim of the work is monitoring of near-infrared spectroscopy (NIRS)-measured cerebral regional oxygen saturation (cRSO2) and cerebral fractional tissue oxygen extraction (FTOE) in neonates after birth asphyxia in relation to their clinical course. STUDY DESIGN: Forty asphyxiated-term and near-term neonates with mild to severe HIE admitted at neonatal intensive care unit of Alexandria University Maternity Hospital from March to October 2019, received therapeutic hypothermia (TH) and had continuous NIRS monitoring of cRSO2 for 72 hours. Infants were categorized into HIE with seizing and nonseizing groups, and abnormal and normal magnetic resonance imaging (MRI) groups. RESULTS: Clinical seizures (CS) occurred in 15 (37.5%) of HIE neonates and 13.3% of them died (n = 2). In the current study, significantly higher cRSO2 and lower FTOE values were found in the seizing infants as compared with nonseizing group (p < 0.001). NIRS-measured day 2-cRSO2 and day 1-FTOE were associated with CS in newborns with HIE and day 1-cRSO2 and FTOE were associated with abnormal MRI at 1 month of age. cRSO2 values were found to correlate positively with initial Thompson score especially in days 1 and 2. Further, neonates with CS were more likely to have MRI abnormalities at follow-up. CONCLUSION: NIRS measures may highlight differences between asphyxiated neonates who develop CS or later MRI abnormalities and those who do not. KEY POINTS: · Day 1 FTOE is the early and sensitive predictor for both clinical seizures and abnormal MRI.. · Cerebral oxygenation metrics help in selecting patients in urgent need of an early MRI scan.. · Cerebral oxygenation metrics can be used hand in hand with clinical assessment using Thompson score at admission to select patient candidate for therapeutic hypothermia..

A Study of Red Cell Distribution Width in Neonatal Sepsis.

OBJECTIVES: The objective of this study was to evaluate a new nontraditional value of the red cell distribution width (RDW) in predicting the clinical outcome of neonatal sepsis. METHODS: In this retrospective study, data were collected from the medical files of 500 full-term neonates with a diagnosis of early onset or late onset sepsis. Baseline RDW and other traditional biomarkers, including C-reactive protein (CRP), total leucocytic count, and platelet count were analyzed in light of the clinical data. The primary outcome was 30-day mortality. RESULTS: Red cell distribution width was significantly higher in nonsurvivors compared with survivors (P < 0.0001). Red cell distribution width was significantly elevated in infants with septic shock compared with those having severe sepsis and those with sepsis (P < 0.0001). A strong positive correlation was found between RDW and CRP (r = 0.8; P <0.0001). Red cell distribution width had an area under the receiver operating characteristic curve of 0.75 for prediction of mortality, which was almost equal to that of CRP and platelet count. Furthermore, logistic regression analysis showed a positive association of RDW with mortality (odds ratio, 1.31; 95% confidence interval, 1.241-1.399). CONCLUSIONS: Red cell distribution width is a useful prognostic marker in neonatal sepsis. Larger prospective studies are required to confirm the value of this routinely available marker in this category of patients.

Socioeconomic inequalities in the use of caesarean section delivery in Ghana: a cross-sectional study using nationally representative data.

BACKGROUND: Inappropriate use of Caesarean Section (CS) delivery is partly to blame for Ghana's high maternal mortality rate. However, previous research offered mixed findings about factors associated with CS use. The goal of this study is to examine use of CS in Ghana and the socioeconomic factors associated with it. METHODS: Data from the nationally representative 2014 Ghana Demographic and Health Survey (GDHS) was used after permission from the Monitoring and Evaluation to Assess and Use Results (MEASURE) Demographic and Health Survey (DHS) program. Univariable and multivariable logistic regression models were fitted to examine the socioeconomic inequalities in CS use. The independent variables included maternal age, marital status, religion, ethnicity, education, place of residence, wealth quintile, and working status. Concentration index (CI) and rate-ratios were computed to ascertain the level of CS inequalities. RESULTS: Out of the 4294 women, 11.4% had CS delivery. However, the percentage of CS delivery ranged from 5% of women in the poorest quintile to 27.5% of women in the richest qunitle. Significant associations were detected between CS delivery and maternal age, parity, education, and wealth quintile . CONCLUSIONS: This study revealed that first, even though Ghana has achieved an aggregate CS rate consistent with WHO recommendations, it still suffers from inequities in the use of CS. Second, both underuse of CS among poorer women in Ghana and overuse among rich and educated women are public health concerns that need to be addressed. Third, the results show in spite of Ghana's free maternal care services policies, wealth status of women continues to be strongly and signtificantly associated with CS delivery, indicating that there are indirect health care costs and other reasons preventing poorer women from having access to CS which should be understood better and addressed with appropriate policies.

Correction to: Response to: Costs and savings associated with a pharmacists prescribing for minor ailments program in Saskatchewan.

[This corrects the article DOI: 10.1186/s12962-018-0159-y.].

Two-State, Three-Mode Parametrization of the Force Field of a Retinal Chromophore Model.

In recent years, the potential energy surfaces of the penta-2,4-dieniminium cation have been investigated using several electronic structure methods. The resulting pool of geometrical, electronic, and energy data provides a suitable basis for the construction of a topographically correct analytical model of the molecule force field and, therefore, for a better understanding of this class of molecules, which includes the chromophore of visual pigments. In the present contribution, we report the construction of such a model for regions of the force field that drive the photochemical and thermal isomerization of the central double bound of the cation. While previous models included only two modes, it is here shown that the proposed three-mode model and corresponding set of parameters are able to reproduce the complex topographical and electronic structure features seen in electronically correlated data obtained at the XMCQDPT2//CASSCF/6-31G* level of theory.

The social determinants of health facility delivery in Ghana.

BACKGROUND: Many women still deliver outside a health facility in Ghana, often under unhygienic conditions and without skilled birth attendants. This study aims to examine the social determinants influencing the use of health facility delivery among reproductive-aged women in Ghana. METHODS: Nationally representative data from the 2014 Ghana Demographic and Health Survey was used to fit univariable and multivariable logistic regression models to estimate the influence of the social determinants on health facility delivery. Andresen's health care utilization model was used as the conceptual framework guiding this study.. RESULTS: Only 72% of deliveries take place at a health facility in Ghana. The results of the adjusted model indicate that place of residence, financial status, education, religion, parity and perceived need were significantly associated with health facility delivery. First, urban women had a higher likelihood of health facility delivery than rural women (Adjusted Odds ratio [AOR] =2.21; 95% Confidence interval [CI] = 1.53-3.19). Second, middle-class and rich women were 1.57 (95%CI = 1.18-2.08) times and 6.91 (95%CI = 4.12-11.59) times, respectively more likely to deliver at health facility compared to the poor. Third, women with either at least secondary education (AOR = 2.04; 95%CI = 1.57-2.64) or primary education (AOR = 1.39, 95%CI = 1.02-1.92) were more likely to deliver at health facility than women with no education. In terms of parity, first time mothers were 1.58 (95% CI = 1.18-2.12) times more likely to deliver at health facility than those who had given birth three or more times before. Finally, regarding perceived need, women who were aware of pregnancy complications were 1.32 (95%CI = 1.02-1.70) times more likely to use health facility delivery than those who were not informed about pregnancy complications. CONCLUSIONS: First, in spite of Ghana's free maternal health services policy, poorer women were much less likely to have a health facility delivery, which points to the need to understand the indirect costs and other financial barriers preventing women from delivering at a health facility. Second, many of the identified variables influence the demand and not just the supply for health care services, and highlight the importance of the social determinants of health and investments in interventions that extend beyond improving physical access.

Association between patient attachment to a regular doctor and self-perceived unmet health care needs in Canada: A population-based analysis of the 2013 to 2014 Canadian community health surveys.

BACKGROUND: Although Canada operates a universal health care insurance system, equitable access to required health care services when needed still poses a challenge for some. The aim of this study was to examine the relationship between patient attachment to a family physician and self-perceived unmet health care needs (UHN) in Canada, after adjusting for predisposing, enabling, and need factors of the behavioral model of health services use. METHODS: This cross-sectional study used data from the Canadian Community Health Surveys, cycle 2013 to 2014. A sample of 58 462 individuals aged 12 years and over was analyzed. Logistic regression models were used to examine the relationship between patient attachment and self-perceived UHN. RESULTS: An estimated 10.41% of the Canadian population 12 years and older reported having UHN in the previous year. Among people with self-perceived UHN, there was significantly greater likelihood of unattachment to a family physician-no regular doctor or having a regular site of care, being younger, being female, being divorced, separated or widowed, having higher education, having lower income, having poorer perceived physical or mental health, having a weak sense of community belonging, having at least one chronic condition, and having greater activity limitations. CONCLUSION: Ongoing public discourses on improving primary health care performance and reducing the burden of UHN in Canada should prioritize efforts that promote and facilitate the use of a regular family physician.

Facilitators and Barriers toward Food Security of Afghan Refugees Residing in Karachi, Pakistan.

The present study comparatively assesses how Afghan refugees in Pakistan understand both the factors and barriers affecting their food security status before and after refuge. Through qualitative in-depth interviews with 25 Afghan refugee families, we assess how quality of life, together with perceptions of a balanced meal, food environments both pre- and post-migration and push and pull factors of migration, impact food security and food choices for refugee families. Furthermore, our results reveal that regardless of the length of protracted status for Afghan refugees, food insecurity remains as a consistent condition for refugee families.

The origin of absorptive features in the two-dimensional electronic spectra of rhodopsin.

In rhodopsin, the absorption of a photon causes the isomerization of the 11-cis isomer of the retinal chromophore to its all-trans isomer. This isomerization is known to occur through a conical intersection (CI) and the internal conversion through the CI is known to be vibrationally coherent. Recently measured two-dimensional electronic spectra (2DES) showed dramatic absorptive spectral features at early waiting times associated with the transition through the CI. The common two-state two-mode model Hamiltonian was unable to elucidate the origin of these features. To rationalize the source of these features, we employ a three-state three-mode model Hamiltonian where the hydrogen out-of plane (HOOP) mode and a higher-lying electronic state are included. The 2DES of the retinal chromophore in rhodopsin are calculated and compared with the experiment. Our analysis shows that the source of the observed features in the measured 2DES is the excited state absorption to a higher-lying electronic state and not the HOOP mode.

Sleep duration and sleep disturbances in association with falls among the middle-aged and older adults in China: a population-based nationwide study.

BACKGROUND: Falls pose major health problems to the middle-aged and older adults and may potentially lead to various levels of injuries. Sleep duration and disturbances have been shown to be associated with falls in literature; however, studies of the joint and distinct effects of those sleep problems are still sparse. To fill this gap, we aimed to determine the association between sleep duration, sleep disturbances and falls among middle-aged and older adults in China controlling for psychosocial, lifestyle, socio-demographical factors and comorbidity. METHODS: Data were derived from the China Health and Retirement Longitudinal Study (CHARLS) based on multi-stage sampling designs, with respondents aged 50 and older. Associations were evaluated by using multiple logistic regression adjusting for confounders and complex survey design. To further determine if the association of sleep duration/disturbance and falls depends on age groups, the study data were divided into two samples (age 50-64 vs. age 65+) and comparison was made between the two age groups. RESULTS: Of the 12,759 respondents, 2172 (17%) had falls within the last 2 years. Our findings indicated that the participants who had nighttime sleep duration ≤5 were more likely to report falls than those who had nighttime sleep duration ≥6 h; whereas no association between nighttime sleep duration > 8 h and falls. Participants having sleep disturbances 1-2 days, or 3-4 days, and 5-7 days per week were also more likely to report falls than those who had no sleep disturbance. The nap sleep duration was not significantly associated with falls. Although the combined sample found both sleep duration and sleep disturbance to be strongly associated with falls after adjusting for various confounders, sleep disturbance was not significantly related to falls among participants aged 65 + . CONCLUSIONS: Our study suggested that there is an independent association between falls and short sleep duration and disturbed sleep among middle-aged and older adults in China. Findings underscore the need for evidence-based prevention and interventions targeting sleep duration and disturbance among this study population.

Role of plasma asymmetric dimethyl-L-arginine levels in detection of pulmonary hypertension in children with CHD.

OBJECTIVES: The objectives of this study were to evaluate the plasma levels of asymmetric dimethyl-L-arginine in children with pulmonary hypertension due to CHD before and after treatment with sildenafil and to evaluate its diagnostic and prognostic value as a biomarker in such children. METHODS: A total of 60 children with CHD and 30 healthy control children matched for age and sex were recruited. Children with CHD were divided into two equal groups: the normal pulmonary pressure group (n=30) and the pulmonary hypertension group (n=30). Children with pulmonary hypertension were treated with sildenafil and were followed up for 6 months. Clinical data, haemodynamic parameters, echocardiographic examination, and asymmetric dimethyl-L-arginine levels were evaluated before and after treatment. RESULTS: Asymmetric dimethyl-L-arginine levels were significantly higher in patients with pulmonary hypertension than in those with CHD-only or the control group, and this increase was positively correlated with increased severity of pulmonary hypertension. Asymmetric dimethyl-L-arginine levels, mean pulmonary artery pressure, and pulmonary vascular resistance were significantly decreased after treatment with sildenafil. Moreover, asymmetric dimethyl-L-arginine level was significantly lower in patients who responded to sildenafil treatment compared with those who did not. At a cut-off point of more than 0.85 nmol/ml, asymmetric dimethyl-L-arginine has a sensitivity of 83% and a specificity of 80% to diagnose pulmonary hypertension-CHD. Asymmetric dimethyl-L-arginine has a sensitivity of 100% and a specificity of 94% to predict poor prognosis in pulmonary hypertension-CHD children at a cut-off point of 1.3 nmol/ml. CONCLUSION: Asymmetric dimethyl-L-arginine level has a good diagnostic and prognostic value as a biomarker in children with pulmonary hypertension-CHD and can be used for following up patients with pulmonary hypertension and predicting response to treatment.

Provincial health expenditure and cardiovascular disease mortality, a panel data study of Canadian provinces.

OBJECTIVE: Health expenditures on cardiovascular disease (CVD) account for a large proportion of health care expenditures of all the diseases in Canada, and hence there is a need to examine the responsiveness of CVD outcomes to health expenditures. The objective of this study was to examine the relationship between health care expenditures and CVD mortality, as a health care outcome at the provincial level in Canada. METHODS: A 10-year (2000-2009) panel dataset was constructed from multiple data sources for the purposes of this study. The dataset composed of age standardized CVD mortalities, health care expenditures, and covariates for the 10 Canadian provinces. We employed a fixed effects model based on the results of the Hausman test, with CVD mortalities as the dependent variable and health care expenditure and other covariates, as explanatory variables. RESULTS: Health care expenditures were significantly (0.05) and negatively associated with CVD mortality, with a 1% increase in health care expenditures associated with a decrease of 6.31 per 1 000 000 people in CVD mortality. CONCLUSION: In the Canadian context, increases in spending on health care were associated with improvements in CVD outcomes for the time period under investigation.

Determinants of self-perceived health for Canadians aged 40 and older and policy implications.

BACKGROUND: Perceived health status indicates people's overall perception of their health, including both physical and psychological dimensions. The aim of this study was to examine the determinants of self-perceived health for Canadians aged 40 and older using data from the Canadian Community Health Survey (2010). METHODS: Multiple logistic regression models were employed to identify factors associated with self-perceived health in two age groups: Adults aged 65+ and Adults aged 40-64. RESULTS: We found that higher income was significantly associated with better health status while chronic conditions and stress were associated with worse health status. In the 40-64 and 65+ age groups, individuals in the highest income bracket were 4.65 and 1.94 times, respectively, more likely to report better health than individuals in the lowest income bracket. The difference in the level of income associated health inequities between the two age groups point to the need for understanding the reasons behind lower inequities among seniors and how much the social protections provided by the Canadian government to seniors contribute to lowering inequities. CONCLUSIONS: Though Canada has a national public health insurance system providing coverage to all Canadians, health inequities associated with income persist providing further evidence of the importance of the social determinants of health. Examining the extent of these inequities and what factors influence them helps direct policy attention. In addition to documenting inequities, this paper discusses policy options for reducing the identified inequities.