Medical education and training within congenital cardiology: current global status and future directions in a post COVID-19 world.

Despite enormous strides in our field with respect to patient care, there has been surprisingly limited dialogue on how to train and educate the next generation of congenital cardiologists. This paper reviews the current status of training and evolving developments in medical education pertinent to congenital cardiology. The adoption of competency-based medical education has been lauded as a robust framework for contemporary medical education over the last two decades. However, inconsistencies in frameworks across different jurisdictions remain, and bridging gaps between competency frameworks and clinical practice has proved challenging. Entrustable professional activities have been proposed as a solution, but integration of such activities into busy clinical cardiology practices will present its own challenges. Consequently, this pivot towards a more structured approach to medical education necessitates the widespread availability of appropriately trained medical educationalists, a development that will better inform curriculum development, instructional design, and assessment. Differentiation between superficial and deep learning, the vital role of rich formative feedback and coaching, should guide our trainees to become self-regulated learners, capable of critical reasoning yet retaining an awareness of uncertainty and ambiguity. Furthermore, disruptive innovations such as "technology enhanced learning" may be leveraged to improve education, especially for trainees from low- and middle-income countries. Each of these initiatives will require resources, widespread advocacy and raised awareness, and publication of supporting data, and so it is especially gratifying that Cardiology in the Young has fostered a progressive approach, agreeing to publish one or two articles in each journal issue in this domain.

High-order fractal states in graphene superlattices.

Graphene superlattices were shown to exhibit high-temperature quantum oscillations due to periodic emergence of delocalized Bloch states in high magnetic fields such that unit fractions of the flux quantum pierce a superlattice unit cell. Under these conditions, semiclassical electron trajectories become straight again, similar to the case of zero magnetic field. Here, we report magnetotransport measurements that reveal second-, third-, and fourth-order magnetic Bloch states at high electron densities and temperatures above 100 K. The recurrence of these states creates a fractal pattern intimately related to the origin of Hofstadter butterflies. The hierarchy of the fractal states is determined by the width of magnetic minibands, in qualitative agreement with our band-structure calculations.

Are e-learning Webinars the future of medical education? An exploratory study of a disruptive innovation in the COVID-19 era.

OBJECTIVE: This study investigated the impact of the Webinar on deep human learning of CHD. MATERIALS AND METHODS: This cross-sectional survey design study used an open and closed-ended questionnaire to assess the impact of the Webinar on deep learning of topical areas within the management of the post-operative tetralogy of Fallot patients. This was a quantitative research methodology using descriptive statistical analyses with a sequential explanatory design. RESULTS: One thousand-three-hundred and seventy-four participants from 100 countries on 6 continents joined the Webinar, 557 (40%) of whom completed the questionnaire. Over 70% of participants reported that they "agreed" or "strongly agreed" that the Webinar format promoted deep learning for each of the topics compared to other standard learning methods (textbook and journal learning). Two-thirds expressed a preference for attending a Webinar rather than an international conference. Over 80% of participants highlighted significant barriers to attending conferences including cost (79%), distance to travel (49%), time commitment (51%), and family commitments (35%). Strengths of the Webinar included expertise, concise high-quality presentations often discussing contentious issues, and the platform quality. The main weakness was a limited time for questions. Just over 53% expressed a concern for the carbon footprint involved in attending conferences and preferred to attend a Webinar. CONCLUSION: E-learning Webinars represent a disruptive innovation, which promotes deep learning, greater multidisciplinary participation, and greater attendee satisfaction with fewer barriers to participation. Although Webinars will never fully replace conferences, a hybrid approach may reduce the need for conferencing, reduce carbon footprint. and promote a "sustainable academia".

Role of non-contrast CT component of prostate-specific membrane antigen PET/CT scan in the detection of peripheral zone prostate cancer.

OBJECTIVE: The aim of this study was to look for feasibility of non-contrast CT (NCCT) in detecting peripheral zone prostate cancer (PCa). METHODS: A retrospective analysis included 50 biopsy-proven PCa patients between April 2019 and March 2022 who underwent staging whole body prostate-specific membrane antigen (PSMA)/CT prior to treatment. The control subjects were 50 randomly selected adult male patients who underwent PET/CT for non-prostate malignancy during the same time period. Two readers independently calculated the Hounsfield unit (HU) of normal peripheral zone, central zone, and corresponding PSMA avid focus in cases. RESULTS: No significant difference was seen in the mean HU value of normal peripheral zone between cases and controls. Significant difference in the mean HU was seen between the PSMA avid focus in cases (40.1 ± 6.2) and normal peripheral zone of cases (28.2 ± 7.0) and controls (27.7 ± 5.8). No significant difference was found between the mean HU values of high-grade PCa and non-high-grade PCa. Receiver operating characteristic (ROC) curve analysis revealed a mean HU cut-off of ≥35 for detecting PCa with a sensitivity and specificity of 86% and 90%, respectively, between cases and controls (AUC 0.88). CONCLUSION: Detection of clinically significant PCa is possible on routinely performed NCCT scans. Radiologists should routinely look for and convey these findings to facilitate further work-up and early detection of PCa. ADVANCES IN KNOWLEDGE: Our study adds to the knowledge that NCCT scans performed for unrelated indications can serve as a screening tool for clinically significant PCa.

Impact of Type of Enteral Feeds on Early Postoperative Outcomes After Congenital Heart Surgery in Neonates and Young Infants: A Single Center Experience in a Limited Resource Environment.

Background: Breast milk is known to prevent infections and is recommended for enteral feeding of infants after congenital heart surgery (CHS). During the Covid-19 pandemic, expressed breast milk (EBM) was not always available; hence, feeding after CHS was maintained with EBM or infant formula (IF) or both; we evaluated the impact of enteral feed type on early postoperative outcomes after CHS. Methods: In a prospective observational study, consecutive neonates and infants <4 months undergoing CHS were divided into EBM, IF, or EBM+IF groups; incidences of postoperative infections, ventilation duration, intensive care unit (ICU) stay, and mortality were studied. Results: Among 270 patients; 90 (33.3%) received EBM, 89 (32.9%) received IF, and 91 (33.7%) received EBM+IF. IF group had more neonates (78.7%[IF] vs 42.2%[EBM] and 52.7%[EBM+IF], P < 0.001) and greater surgical complexity. Postoperative infections were 9 (10.0%) in EBM; 23 (25.8%) in IF; and 14 (15.4%) in EBM+IF (P = .016). IF group (OR 2.58 [1.05-6.38], P = .040), absence of preoperative feeding (OR 6.97 [1.06-45.97], P = .040), and increase in cardiopulmonary bypass time (OR 1.005 [1.001-1.010], P = .027) were associated with postoperative infection. Ventilation duration in hours was 26 (18-47.5) in EBM; 47 (28-54.5) in IF; and 40 (17.5-67) in EBM+IF (P = .004). ICU stay in days was 4 (3-7) in EBM; 6 (5-9) in IF; and 5 (3-9) in EBM+IF (P = .001). Mortality did not differ (P = .556). Conclusion: IF group had a greater proportion of neonates with higher surgical complexity. Patients who received EBM after CHS had fewer postoperative infections and better postoperative outcomes compared to those receiving IF or EBM+IF.

Imaging update in spinal tuberculosis.

Tuberculosis is ancient disease known to mankind. Diagnosis and management of spinal tuberculosis has immensely improved in last few decades. Imaging, particularly MRI, plays important role in diagnosis of spinal tuberculosis and its complications. Four common imaging patterns of spinal tuberculosis include paradiscal type, central type, Anterior subligamentous type, and posterior type. Imaging also plays important role in differentiation of spinal tuberculosis from its mimics, particularly pyogenic spondylitis, and metastasis. Radiological interventions, such as CT guided vertebral biopsy, and percutaneous drainage of cold abscess, are commonly used in management of spinal tuberculosis. Monitoring of therapeutic response is often based on clinical evaluation and imaging. MRI is most common imaging modality used. Signs of healing include bony ankylosis, resolution of marrow edema, decrease in contrast enhancement, and fatty change with in bone marrow. PET CT is recently evaluated for response assessment with promising results. This review summarizes pathophysiology, clinical presentation, imaging features, radiological interventions, and response assessment in spinal tuberculosis.

Total Anomalous Pulmonary Venous Connection Repair: Single-Center Outcomes in a Lower-Middle Income Region.

BACKGROUND: The management of total anomalous pulmonary venous connection (TAPVC) in neonates and infants is resource-intensive. We describe early and follow-up outcomes after surgical repair of isolated TAPVC at a single institution in a resource-limited setting. METHODS: The data of 316 consecutive patients with isolated TAPVC undergoing repair (January 2010-September 2020) were reviewed. The study setting was a tertiary hospital in southern India that provides subsidized or charitable care. Standard surgical technique was used for repair, circulatory arrest was avoided, and suture-less anastomosis was reserved for small or stenotic pulmonary veins. Surgical and postoperative strategies were directed toward minimizing intensive care unit (ICU) stay. RESULTS: 302 (95.6%) patients were infants and 128 patients (40.5%) were neonates; median weight was 3.3 kg (IQR 2.8-4.0 kg). Obstruction of the TAPVC was seen in 176 patients (56%) and pulmonary hypertension in 278 patients (88%). Seventeen (5.4%) underwent delayed sternal closure. The median postoperative ICU stay was 120 h (IQR 96-192 h), mechanical ventilation was 45 h (IQR 24-82 h), and hospital stay was 13 days (IQR 9-17 days). There were three in-hospital deaths (0.9%). Over a median follow-up period of 53.3 months (IQR 22.9-90.4), pulmonary vein restenosis was seen in 32 patients (10.1%) after a mean of 2.2 months (1-6 months). No perioperative risk factors for restenosis were identified. CONCLUSIONS: Using specific perioperative strategies, it is possible to correct TAPVC with excellent surgical outcomes in low-resource environments. Late pulmonary vein restenosis remains an important complication.

Control of electron-electron interaction in graphene by proximity screenings.

Electron-electron interactions play a critical role in many condensed matter phenomena, and it is tempting to find a way to control them by changing the interactions' strength. One possible approach is to place a studied system in proximity of a metal, which induces additional screening and hence suppresses electron interactions. Here, using devices with atomically-thin gate dielectrics and atomically-flat metallic gates, we measure the electron-electron scattering length in graphene and report qualitative deviations from the standard behavior. The changes induced by screening become important only at gate dielectric thicknesses of a few nm, much smaller than a typical separation between electrons. Our theoretical analysis agrees well with the scattering rates extracted from measurements of electron viscosity in monolayer graphene and of umklapp electron-electron scattering in graphene superlattices. The results provide a guidance for future attempts to achieve proximity screening of many-body phenomena in two-dimensional systems.

Dental caries experience in relation to body mass index and anthropometric measurements of rural children of Nellore district: A cross-sectional study.

CONTEXT: The relationship between body mass index (BMI) and dental caries consists of multiple contributing factors. There have been no studies documented in the literature in this part of rural India assessing the prevalence of dental caries in relation to BMI. Hence, an attempt was made to study dental caries in relation to BMI and anthropometric measurements. AIMS: The aims were to study dental caries experience in relation to BMI and anthropometric measurements of rural children in Nellore district. SETTINGS AND DESIGN: A descriptive cross-sectional study was carried out in Nellore city. SUBJECTS AND METHODS: A total of 1500 6- and 12-year-old children were examined. Dental caries was examined using the WHO dentition status criteria (1997) and 1-day diet chart was collected from each child followed by collection of anthropometric data. STATISTICAL ANALYSIS USED: Statistical analysis was performed using Chi-square test, Fisher's exact test, and Spearman's correlation test. RESULTS: In the present study, out of all the participants, 59.2% of low weight children, 41.3% of normal weight children, and 25.7% of overweight-obese children were having dental caries. Dental caries was more among low weight children compared to normal weight and overweight-obese children and was statistically significant. CONCLUSIONS: All the anthropometric measurements were positively correlated with dental caries except height for age and BMI for age. There was an inverse graded association between the height for age and BMI for age with dental caries in 6- and 12-year-old children.

Strong magnetophonon oscillations in extra-large graphene.

Van der Waals materials and their heterostructures offer a versatile platform for studying a variety of quantum transport phenomena due to their unique crystalline properties and the exceptional ability in tuning their electronic spectrum. However, most experiments are limited to devices that have lateral dimensions of only a few micrometres. Here, we perform magnetotransport measurements on graphene/hexagonal boron-nitride Hall bars and show that wider devices reveal additional quantum effects. In devices wider than ten micrometres we observe distinct magnetoresistance oscillations that are caused by resonant scattering of Landau-quantised Dirac electrons by acoustic phonons in graphene. The study allows us to accurately determine graphene's low energy phonon dispersion curves and shows that transverse acoustic modes cause most of phonon scattering. Our work highlights the crucial importance of device width when probing quantum effects and also demonstrates a precise, spectroscopic method for studying electron-phonon interactions in van der Waals heterostructures.

Giant oscillations in a triangular network of one-dimensional states in marginally twisted graphene.

At very small twist angles of ∼0.1°, bilayer graphene exhibits a strain-accompanied lattice reconstruction that results in submicron-size triangular domains with the standard, Bernal stacking. If the interlayer bias is applied to open an energy gap inside the domain regions making them insulating, such marginally twisted bilayer graphene is expected to remain conductive due to a triangular network of chiral one-dimensional states hosted by domain boundaries. Here we study electron transport through this helical network and report giant Aharonov-Bohm oscillations that reach in amplitude up to 50% of resistivity and persist to temperatures above 100 K. At liquid helium temperatures, the network exhibits another kind of oscillations that appear as a function of carrier density and are accompanied by a sign-changing Hall effect. The latter are attributed to consecutive population of the narrow minibands formed by the network of one-dimensional states inside the gap.

Measuring Hall viscosity of graphene's electron fluid.

An electrical conductor subjected to a magnetic field exhibits the Hall effect in the presence of current flow. Here, we report a qualitative deviation from the standard behavior in electron systems with high viscosity. We found that the viscous electron fluid in graphene responds to nonquantizing magnetic fields by producing an electric field opposite to that generated by the ordinary Hall effect. The viscous contribution is substantial and identified by studying local voltages that arise in the vicinity of current-injecting contacts. We analyzed the anomaly over a wide range of temperatures and carrier densities and extracted the Hall viscosity, a dissipationless transport coefficient that was long identified theoretically but remained elusive in experiments.

Platelet parameters in children with chromosome 22q11 deletion and conotruncal heart defects.

BACKGROUND AND OBJECTIVES: The 22q11 deletion syndrome is associated with a wide spectrum of phenotypic features, hence clinical diagnosis is difficult. Individuals with this syndrome are found to have a risk of developing transfusion associated graft-versus-host reaction, if they are given nonirradiated blood. Our aim was to elucidate whether chromosome 22q11 deletion in children with syndromic conotruncal heart defects is associated with platelet abnormality. MATERIALS AND METHODS: The genetic analysis was performed by standard cytogenetic and Fluorescence in situ hybridization technique. The platelet parameters in 39 patients with chromosome 22q11 deletion were compared with 154 cases without deletion. RESULTS: In deletion versus no deletion group, the mean of mean platelet volume (MPV) was 10.5 ± 2.5 vs 7.6 ± 1.5 fL, platelet count was 225 ± 80.7 and 339 ± 127.3 × 10 9 /L and frequency of high MPV was 49% vs 7% (P < .0001). The MPV was associated with a sensitivity of 90.9% and a specificity of 79.6% at a cutoff value of 8.32 fL, (area under the ROC curve 91%). A nonsignificant negative correlation was found between MPV and platelet count (r = -0.152; P = .361) in children with deletion. CONCLUSION: A cutoff value of 8.32 fL for MPV can be an indicator of high risk of chromosome 22q11 deletion in individuals with syndromic conotruncal defects. Individuals with chromosome 22q11 deletion should be given irradiated blood especially during cardiac surgery. Further investigation should clarify the etiology behind variation in frequency of high MPV in different conotruncal lesions.

High-temperature quantum oscillations caused by recurring Bloch states in graphene superlattices.

Cyclotron motion of charge carriers in metals and semiconductors leads to Landau quantization and magneto-oscillatory behavior in their properties. Cryogenic temperatures are usually required to observe these oscillations. We show that graphene superlattices support a different type of quantum oscillation that does not rely on Landau quantization. The oscillations are extremely robust and persist well above room temperature in magnetic fields of only a few tesla. We attribute this phenomenon to repetitive changes in the electronic structure of superlattices such that charge carriers experience effectively no magnetic field at simple fractions of the flux quantum per superlattice unit cell. Our work hints at unexplored physics in Hofstadter butterfly systems at high temperatures.

Negative local resistance caused by viscous electron backflow in graphene.

Graphene hosts a unique electron system in which electron-phonon scattering is extremely weak but electron-electron collisions are sufficiently frequent to provide local equilibrium above the temperature of liquid nitrogen. Under these conditions, electrons can behave as a viscous liquid and exhibit hydrodynamic phenomena similar to classical liquids. Here we report strong evidence for this transport regime. We found that doped graphene exhibits an anomalous (negative) voltage drop near current-injection contacts, which is attributed to the formation of submicrometer-size whirlpools in the electron flow. The viscosity of graphene's electron liquid is found to be ~0.1 square meters per second, an order of magnitude higher than that of honey, in agreement with many-body theory. Our work demonstrates the possibility of studying electron hydrodynamics using high-quality graphene.

Supramolecular Multiporphyrin Architecture. Coordination Polymers and Open Networks in Crystals of Tetrakis(4-cyanophenyl)- and Tetrakis(4-nitrophenyl)metalloporphyrin.

Crystalline solids based on the tetrakis(4-cyanophenyl) and tetrakis(4-nitrophenyl) derivatives of zinc(II)-porphyrin or copper(II)-porphyrin as building blocks have been prepared and structurally analyzed by X-ray diffraction in order to elucidate the characteristic modes of self-assembly of these functionalized moieties and evaluate the utility of such materials in a controlled design of crystalline microporous solids. In suitable crystallization environments, the cyanophenyl derivative was found to form two-dimensional coordination polymers through direct ligation of two of the -C&tbd1;N functions on each molecule to the metal centers of two neighboring porphyrins (1-3). Uniquely structured layered interporphyrin chains and networks with large cavities were observed in most of the other materials (4-9). The layered organization in the latter is dominated to a large extent by molecular shape and aromaticity of the porphyrin frameworks, while its open nature is sustained by hydrogen-bonding assisted dipolar interactions between the cyanophenyl or nitrophenyl fragments of adjacent metallomacrocyclic units. This gives rise to partly selective cocrystallization of the porphyrin material with suitably sized guest components. The discussion relates also to successful applications of other synthons for engineering polymeric and networked structures of porphyrin-based molecular solids.

Retinal nerve fiber layer measurements in indian eyes using the scanning laser polarimeter, GDx.

PURPOSE: To obtain retinal nerve fiber layer (RNFL) measurements in normal Indian subjects of different age groups; and to determine the differences between the right and the left eye of a subject and variations between male and female gender using the scanning laser polarimeter GDx. MATERIALS AND METHODS: Prospective cross-sectional study of 180 eyes of 94 subjects. The RNFL values were obtained with the nerve fiber analyser GDx using default quadrant positions supplied by the manufacturer. Fourteen parameters were studied. Of these 6 were average-based parameters (average thickness, superior maximum, inferior maximum, ellipse average, superior average, inferior average), 4 ratio-based parameters (symmetry, superior ratio, inferior ratio, superior/nasal), 4 "other" parameters (maximum modulation, number, ellipse modulation, superior integral). The main outcome measures were effect of age on RNFL values, comparison of males and females and the right and the left eye of a subject. RESULTS: There was a negative linear correlation with age. Three ratio-based parameters showed a statistically significant negative correlation with age. "Number" increased with age. Superior maximum, superior average, superior integral, symmetry and superior ratio were higher for the left eye. 'Number' was higher for the right eye. Superior ratio and maximum modulation were more in females than males, no difference was noted with other parameters. CONCLUSION: There was a gradual decrease of RNFL values with increasing age - the superior quadrant values were higher for the left eye than the right eye, suggesting asymmetry. No significant differences were detected between males and females.

Congenital insensitivity to pain (hereditary sensory and autonomic neuropathy) HSAN: a report of two cases.

Pain is one of the protective phenomenon possessed by the body. Pain arouses and demands our immediate attention. There are instances in which there is a congenital insensitivity to pain. Two cases of congenital insensitivity to pain are reported.

Relationship between stimulated salivary factors, dental caries status and nutritional condition among institutionalized elderly people.

BACKGROUND: Nutrition is one of the important components of health, functional independence and quality of life in elderly population. In this age group, malnutrition is common and the risk of malnutrition increases with the advancing age. Nutritional status acts as a modifying factor in the development of many oral diseases. AIM: To assess the relationship of salivary factors, dental caries and nutritional status among institutionalized elderly people. MATERIALS AND METHODS: A cross-sectional descriptive study was conducted in three old age homes in Nellore city. All the institutionalized elderly aged 50 years and above were included for the study. Pearson co-relation was done to know the relationship of malnutrition, salivary parameters and dental caries experience. RESULTS: A total of 81 subjects with a mean age of 70.12 ± 7.32 yrs participated in the study. 43% of subjects were at risk of malnourishment and 14% were malnourished. Analysis of salivary parameters in relation to nutritional status of subjects revealed that salivary flow rate decreased among malnourished subjects (0.50 ± 0.100) when compared to well-nourished subjects (0.93 ± 0.260). DMFT scores increased in subjects who were malnourished (12.45 ± 5.574) compared to well-nourished subjects (6.34 ± 5.765). Co-relation of nutritional status with salivary parameters and caries experience revealed a positive co-relation between nutritional status and salivary flow rate, where as a negative co-relation was observed between caries experience. CONCLUSION: Prevalence of malnourishment was 14% among the institutionalized elderly. All of them had lower salivary flow rate, buffering capacity and pH with increased caries experience.