Transitioning children using home invasive mechanical ventilation from hospital to home: Discharge criteria, disparities, and ethical considerations.

Children using home invasive mechanical ventilation (HIMV), a valuable therapeutic option for chronic respiratory failure, constitute a growing population. Transitioning children using HIMV from hospital to home care is a complex process that requires a multidisciplinary approach involving healthcare professionals, caregivers, and community resources. Medical stability, caregiver competence, and home environment suitability are essential factors in determining discharge readiness. Caregiver education and training play a pivotal role in ensuring safe and effective home care. Simulation training and staged education progression are effective strategies for equipping caregivers with necessary skills. Resource limitations, inadequate home nursing support, and disparities in available community resources are common obstacles to successful HIMV discharge. International perspectives shed light on diverse healthcare systems and challenges faced by caregivers worldwide. While standardizing guidelines for HIMV discharge may be complex, collaboration among healthcare providers and the development of evidence-based regional guidelines can improve outcomes for children using HIMV and their caregivers. This review seeks to synthesize literature, provide expert guidance based on experience, and highlight components to safely discharge children using HIMV. It further assesses disparities and divergences within regional and international healthcare systems while addressing relevant ethical considerations.

Using remote sensing data within an optimal spatiotemporal model for invasive plant management: the case of Ailanthus altissima in the Alta Murgia National Park.

We tackle the problem of coupling a spatiotemporal model for simulating the spread and control of an invasive alien species with data coming from image processing and expert knowledge. In this study, we implement a spatially explicit optimal control model based on a reaction-diffusion equation which includes an Holling II type functional response term for modeling the density control rate. The model takes into account the budget constraint related to the control program and searches for the optimal effort allocation for the minimization of the invasive alien species density. Remote sensing and expert knowledge have been assimilated in the model to estimate the initial species distribution and its habitat suitability, empirically extracted by a land cover map of the study area. The approach has been applied to the plant species Ailanthus altissima (Mill.) Swingle within the Alta Murgia National Park. This area is one of the Natura 2000 sites under the study of the ongoing National Biodiversity Future Center (NBFC) funded by the Italian National Recovery and Resilience Plan (NRRP), and pilot site of the finished H2020 project ECOPOTENTIAL, which aimed at the integration of modeling tools and Earth Observations for a sustainable management of protected areas. Both the initial density map and the land cover map have been generated by using very high resolution satellite images and validated by means of ground truth data provided by the EU Life Alta Murgia Project (LIFE12 BIO/IT/000213), a project aimed at the eradication of A. altissima in the Alta Murgia National Park.

Insurance coverage and respiratory morbidities in bronchopulmonary dysplasia.

INTRODUCTION: Preterm infants and young children with bronchopulmonary dysplasia (BPD) are at increased risk for acute care utilization and chronic respiratory symptoms during early life. Identifying risk factors for respiratory morbidities in the outpatient setting could decrease the burden of care. We hypothesized that public insurance coverage was associated with higher acute care usage and respiratory symptoms in preterm infants and children with BPD after initial neonatal intensive care unit (NICU) discharge. METHODS: Subjects were recruited from BPD clinics at 10 tertiary care centers in the United States between 2018 and 2021. Demographics and clinical characteristics were obtained through chart review. Surveys for clinical outcomes were administered to caregivers. RESULTS: Of the 470 subjects included in this study, 249 (53.0%) received employer-based insurance coverage and 221 (47.0%) received Medicaid as sole coverage at least once between 0 and 3 years of age. The Medicaid group was twice as likely to have sick visits (adjusted odd ratio [OR]: 2.06; p = 0.009) and emergency department visits (aOR: 2.09; p = 0.028), and three times more likely to be admitted for respiratory reasons (aOR: 3.04; p = 0.001) than those in the employer-based group. Additionally, those in the Medicaid group were more likely to have nighttime respiratory symptoms (aOR: 2.62; p = 0.004). CONCLUSIONS: Children with BPD who received Medicaid coverage were more likely to utilize acute care and have nighttime respiratory symptoms during the first 3 years of life. More comprehensive studies are needed to determine whether the use of Medicaid represents a barrier to accessing care, lower socioeconomic status, and/or a proxy for detrimental environmental exposures.

Method of Assessing Skin Cancerization and KeratosesTM (MASCK™): development and photographic validation in multiple anatomical sites of a novel assessment tool intended for clinical evaluation of patients with extensive skin field cancerization.

BACKGROUND: A range of 'field-directed' treatments is available for the management of extensive skin field cancerization (ESFC), but to date, the only validated objective quantitative tools are limited to assessment of actinic keratoses (AKs) affecting the head. AIMS: To develop a versatile quantitative instrument for objective clinical assessment of ESFC and perform initial internal validation across multiple anatomical zones. METHODS: The study comprised instrument development, pilot testing and instrument refinement and two rounds of reliability and inter-rater validation testing. The study was noninterventional and used a convenience sample of de-identified patient photographs selected based on preset criteria. An expert panel developed the instrument and scoring system via a modified Delphi voting process. A sample of 16 healthcare professionals from multiple specialties undertook the pilot testing, and a panel of seven dermatologists were involved in validation testing. Validation was determined by assessment of overall inter-rater agreement using Gwet chance-corrected agreement coefficients (ACs). RESULTS: The instrument produced, called the Method for Assessing Skin Cancer and Keratoses™ (MASCK™), comprises the Skin Field Cancerization Index (SFCIndex), derived from area of skin involvement and AKs (number and thickness), a global assessment score and a cancer-in-zone score, and uses Likert scales for quantitative scoring. The SFCIndex is a composite score comprising the number and thickness of AKs multiplied by area of skin involvement. ACs for the SFCIndex components, the overall SFCIndex score and the global assessment score were > 0.80 (rated 'almost perfect') while the AC for the cancer-in-zone metric was lower (0.33, rated 'fair'). Internal consistency was demonstrated via positive correlation between the overall SFCIndex score and the global assessment score. CONCLUSIONS: Our study found near-perfect agreement in inter-rater reliability when using MASCK to assess the severity of ESFC in multiple anatomical sites. Further validation of this novel instrument is planned to specifically assess its reliability, utility and feasibility in clinical practice.

Compression stockings in addition to low-molecular-weight heparin to prevent venous thromboembolism in surgical inpatients requiring pharmacoprophylaxis: the GAPS non-inferiority RCT.

BACKGROUND: Patients admitted to hospital for surgery are at an increased risk of venous thromboembolism. Pharmaco-thromboprophylaxis and mechanical prophylaxis (usually graduated compression stockings or intermittent pneumatic compression) have been shown to reduce the incidence of venous thromboembolism. The evidence base supporting the National Institute for Health and Care Excellence's recommendation for the use of graduated compression stockings for venous thromboembolism prevention in the UK has recently been challenged. It is unclear if the risks and costs associated with graduated compression stockings are justified for deep-vein thrombosis prevention in moderate- and high-risk elective surgical inpatients receiving low-dose low-molecular-weight heparin pharmaco-thromboprophylaxis. OBJECTIVES: The primary objective was to compare the venous thromboembolism rate in elective surgical inpatients at moderate or high risk of venous thromboembolism who were receiving either graduated compression stockings and low-dose low-molecular-weight heparin (standard care) or low-dose low-molecular-weight heparin alone (intervention). DESIGN: This was a pragmatic, multicentre, prospective, non-inferiority, randomised controlled trial. SETTING: This took place in secondary care NHS hospitals in the UK. PARTICIPANTS: Patients aged ≥ 18 years who were assessed to be at moderate or high risk of venous thromboembolism according to the NHS England venous thromboembolism risk assessment tool (or the trust equivalent based on this form) and who were not contraindicated to low-molecular-weight heparin or graduated compression stockings were deemed eligible to take part. INTERVENTIONS: Participants were randomised 1 : 1 to either low-molecular-weight heparin or low-molecular-weight heparin and graduated compression stockings. MAIN OUTCOME MEASURES: The primary outcome measure was venous thromboembolism up to 90 days after surgery. A combined end point of duplex ultrasound-proven new lower-limb deep-vein thrombosis (symptomatic or asymptomatic) plus imaging-confirmed symptomatic pulmonary embolism. Secondary outcomes included quality of life, compliance with graduated compression stockings and low-molecular-weight heparin during admission, and all-cause mortality. RESULTS: A total of 1905 participants were randomised and 1858 were included in the intention-to-treat analysis. A primary outcome event occurred in 16 out of 937 (1.7%) patients in the low-molecular-weight heparin-alone arm compared with 13 out of 921 (1.4%) patients in the low-molecular-weight heparin plus graduated compression stockings arm. The risk difference between low-molecular-weight heparin and low-molecular-weight heparin plus graduated compression stockings was 0.30% (95% confidence interval -0.65% to 1.26%). As the 95% confidence interval did not cross the non-inferiority margin of 3.5% (p < 0.001 for non-inferiority), the results indicate that non-inferiority of low-molecular-weight heparin alone was shown. LIMITATIONS: In total, 13% of patients did not receive a duplex ultrasound scan that could have detected further asymptomatic deep-vein thrombosis. However, missing scans were balanced between both trial arms. The subpopulation of those aged ≥ 65 years assessed as being at a moderate risk of venous thromboembolism was under-represented in the study; however, this reflects that this group is under-represented in the general population. CONCLUSIONS: For elective surgical patients at moderate or high risk of venous thromboembolism, administration of pharmaco-thromboprophylaxis alone is non-inferior to a combination of pharmaco-thromboprophylaxis and graduated compression stockings. These findings indicate that graduated compression stockings may be unnecessary for most elective surgical patients. FUTURE WORK: Further studies are required to evaluate whether or not adjuvant graduated compression stockings have a role in patients receiving extended thromboprophylaxis, beyond the period of hospital admission, following elective surgery or in patients undergoing emergency surgical procedures. TRIAL REGISTRATION: Current Controlled Trials ISRCTN13911492. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 69. See the NIHR Journals Library website for further project information.

WHY DID WE CONDUCT THIS RESEARCH?: People undergoing operations are at risk of developing blood clots in their legs, which is known as a deep-vein thrombosis. Blood clots occur for several reasons, such as not being able to move around after an operation, changes in the blood or damage to the veins in which blood travels. To decrease the risk of getting deep-vein thrombosis, patients having operations are given tight elastic socks to wear called graduated compression stockings. They are also given blood thinning medicine to prevent clotting. There is little evidence that wearing elastic socks in hospital will reduce the risk of blood clots if blood thinners are also given. Many patients say that the socks can hurt or cause bruising and can be difficult to put on. The graduated compression as an adjunct to thromboprophylaxis in surgery (GAPS) trial investigated whether or not patients having an operation would benefit from wearing elastic socks as well as getting blood thinners, or if blood thinners on their own prevented blood clots. WHAT DID WE DO?: A total of 1905 patients who were having operations at seven hospitals in England agreed to take part. They were randomly assigned to different treatments by a computer program. Half of the patients were given elastic socks plus blood thinners, and the other half were given the blood thinners alone. WHAT DID WE FIND?: There was no significant difference in the number of people who had a blood clot in either study group. This could mean that blood thinners are as good at stopping blood clots as blood thinners and elastic socks for patients having operations. WHAT COULD BE CARRIED OUT NEXT?: The NHS spends around £63M per year across England on elastic stockings. This research indicates that patients might not get extra benefit from wearing them if they have taken blood thinners.

Assessment of threat and negativity bias in virtual reality.

Negativity bias, i.e., tendency to respond strongly to negative stimuli, can be captured via behavioural and psychophysiological responses to potential threat. A virtual environment (VE) was created at room-scale wherein participants traversed a grid of ice blocks placed 200 m above the ground. Threat was manipulated by increasing the probability of encountering ice blocks that disintegrated and led to a virtual fall. Participants interacted with the ice blocks via sensors placed on their feet. Thirty-four people were recruited for the study, who were divided into High (HN) and Low (LN) Neuroticism groups. Movement data were recorded alongside skin conductance level and facial electromyography from the corrugator supercilii and zygomaticus major. Risk-averse behaviours, such as standing on 'safe' blocks and testing blocks prior to movement, increased when threat was highest. HN individuals exhibited more risk-averse behaviour than the LN group, especially in the presence of high threat. In addition, activation of the corrugator muscle was higher for HN individuals in the period following a movement to an ice block. These findings are discussed with respect to the use of room-scale VE as a protocol for emotion induction and measuring trait differences in negativity bias within VR.

Infrastructure assessment post-disaster: Remotely sensing bridge structural damage by unmanned aerial vehicle in low-light conditions.

The initial experiment explores the viability of using a low-cost unmanned aerial vehicle equipped with thermal imaging and lowlight camera to assess structural damage to steel girders. Damage assessments following natural disasters are daunting and arduous tasks that are resources intensive and dangerous. Unmanned aerial vehicles with remote sensing (UAV-RS) technology have been used in recent largescale disaster events such as Hurricanes Katerina, Harvey, Irma, and Maria as well as others. Current assessment methods of structures include inspectors physically conducting detailed and rapid surveys of damage with or without the assistance of special equipment, use of helicopters, satellite imagery, and new innovative methods using UAV-RS technology. The initial experiment utilized the Steel Bridge Research, Inspection, Training, and Engineering and Training Center (S-BRITE) facility at Purdue University and a small building in Lafayette, Indiana. Two steel girders located at S-BRITE were used in the experiment with damages that render them structurally deficient. The small building was used for semiautonomous inspection during hours of darkness. Most scientific studies have focused on using UAV-RS during hours of daylight. In this article, the authors explore the use of UAV-RS during low-light conditions (ie, early evening nautical twilight and night) for detecting global damage to steel girders. The authors' goal is to present evidence for further study in the use of UAV-RS during low-light conditions for inspecting structures to include primary load bearing members. The authors conclude that while the UAV-RS can detect global damage in low visibility conditions, further experiments in varying low-light conditions including 3D imaging and semiautonomous inspection are necessary for structural damage assessments.

Automated formation of black lipid membranes within a microfluidic device via confocal fluorescence feedback-controlled hydrostatic pressure manipulations.

Black lipid membranes (BLMs) provide a biomimetic model system for studying cellular membrane processes, and are important tools in drug screening and biosensing applications. BLMs offer advantages over liposomes and solid-supported lipid bilayers in applications where access to both leaflets of the bilayer is critical. Reliable and repeatable formation of BLMs presents a major challenge, especially in systems that require interrogation of the membrane via optical microscopy. BLMs for optical interrogation are often formed by the manual painting method, which is tedious and has a high failure rate because it involves manual manipulation of nanoscale liquid films for membrane self-assembly. Here, we describe a fully automated technique for the formation of BLMs within the imaging plane of an inverted fluorescence microscope. The technique utilizes hydrostatic pressure manipulations within a simple microfluidic device, which are feedback controlled via confocal fluorescence monitoring of the BLM formation process. An algorithm for monitoring and precision control of BLM formation is devised and optimized to yield an 80% success rate for the formation of BLMs, with formation times on the order of 78 min. Membranes formed via the automated procedure are confirmed to be fluid and biomimetic via spontaneous insertion of α-hemolysin pores with characteristic conductance of ca. 1 nS. Graphical Abstract ᅟ.

Is increasing urbanicity associated with changes in breastfeeding duration in rural India? An analysis of cross-sectional household data from the Andhra Pradesh children and parents study.

OBJECTIVE: To investigate whether village-level urbanicity and lower level socioeconomic factors are associated with breastfeeding practices in transitioning rural communities in India. SETTING: 29 villages in Ranga Reddy district, southern India between 2011 and 2014. PARTICIPANTS: 7848 children under 6 years identified via a cross-sectional household survey conducted as part of the Andhra Pradesh Children and Parents Study. OUTCOME MEASURES: Two key indicators of optimal breastfeeding: termination of exclusive breastfeeding before 6 months and discontinuation of breastfeeding by 24 months. Village urbanicity was classified as low, medium or high according to satellite assessed night-light intensity. RESULTS: Breastfeeding initiation was almost universal, and approximately two in three children were exclusively breastfed to 6 months and a similar proportion breastfed to 24 months. Using multilevel logistic regression, increasing urbanicity was associated with breastfeeding discontinuation before 24 months (medium urbanicity OR 1.45, 95% CI 0.71 to 2.96; high urbanicity OR 2.96, 95% CI 1.45 to 6.05) but not with early (<6 months) termination of exclusive breastfeeding. Increased maternal education was independently associated with both measures of suboptimal breastfeeding, and higher household socioeconomic position was associated with early termination of exclusive breastfeeding. CONCLUSION: In this transitional Indian rural community, early stage urbanicity was associated with a shorter duration of breastfeeding. Closer surveillance of changes in breastfeeding practices alongside appropriate intervention strategies are recommended for emerging economies.

The impact of the DoH Commissioning for Quality and Innovation incentive on the success of venous thromboembolism risk assessment in hospitalised patients. A single institution experience in a quality outcome improvement over a 4-year cycle.

OBJECTIVES: To i) demonstrate compliance with the Commissioning for Quality and Innovation for venous thromboembolism risk assessment ii) to undertake root cause analysis of Hospital Acquired Thrombosis and to investigate its impact on quality of care. DESIGN: Prospective monitoring of all admissions. SETTING: Imperial College Healthcare Hospitals, London. PARTICIPANTS: All Hospital Provider Spells as defined on the NHS Data Model and Dictionary. MAIN OUTCOME MEASURES: i) Percentage of patients undergoing Venous Thromboembolism Risk Assessment (VTE-RA) at and 24-hours after admission ii) root cause analysis of Hospital Acquired Thrombosis up to 90 days following discharge. RESULTS: Over a 48-month cycle 83% were overall VTE-RA assessed with 36% in the first 12 months but with significant improvement to ≥95% between April 2013 and April 2015, achieving compliance target since April 2012 involving a massive 633, 850 Spells over the 4 year period. We undertook root cause analysis of all VTE episodes from April 2013 to March 2014, to ascertain Hospital Acquired Thrombosis (HAT), we analysed 433, 174 inpatient days and found a HAT rate of 1 per 1000 with 23% and 24% for DVTs and PEs potentially avoidable respectively. We further analysed VTE risk stratification (n = 1000) and found 37.0% at high risk, 44.4% at medium risk and 18.6 % at low risk, indicating the need of thromboprophylaxis in 81.4% (high and medium) of whom 33.6% were excluded. CONCLUSIONS: We achieved 95% RA compliance which has favourably impacted on our daily practice and improved the quality of the clinical care.

Comparison of methods for quantitating Salmonella enterica Typhimurium and Heidelberg strain attachment to reusable plastic shipping container coupons and preliminary assessment of sanitizer efficacy.

Salmonella serovars, one of the leading contributors to foodborne illness and are especially problematic for foods that are not cooked before consumption, such as fresh produce. The shipping containers that are used to transport and store fresh produce may play a role in cross contamination and subsequent illnesses. However, methods for quantitatively attached cells are somewhat variable. The overall goal of this study was to compare conventional plating with molecular methods for quantitating attached representative strains for Salmonella Typhimurium and Heidelberg on reusable plastic containers (RPC) coupons, respectively. We attached Salmonella enterica serovar Typhimurium ATCC 14028 and serovar Heidelberg SL486 (parent and an antibiotic resistant marker strain) to plastic coupons (2.54 cm(2)) derived from previously used shipping containers by growing for 72 h in tryptic soy broth. The impact of the concentration of sanitizer on log reductions between unsanitized and sanitized coupons was evaluated by exposing attached S. Typhimurium cells to 200 ppm and 200,000 ppm sodium hypochlorite (NaClO). Differences in sanitizer effectiveness between serovars were also evaluated with attached S. Typhimurium compared to attached S. Heidelberg populations after being exposed to 200 ppm peracetic acid (PAA). Treatment with NaClO caused an average of 2.73 ± 0.23 log CFU of S. Typhimurium per coupon removed with treatment at 200 ppm while 3.36 ± 0.54 log CFU were removed at 200,000 ppm. Treatment with PAA caused an average of 2.62 ± 0.15 log CFU removed for S. Typhimurium and 1.41 ± 0.17 log CFU for S. Heidelberg (parent) and 1.61 ± 0.08 log CFU (marker). Lastly, scanning electron microscopy (SEM) was used to visualize cell attachment and coupon surface topography. SEM images showed that remaining attached cell populations were visible even after sanitizer application. Conventional plating and qPCR yielded similar levels of enumerated bacterial populations indicating a high concordance between the two methods. Therefore, qPCR could be used for the rapid quantification of Salmonella attached on RPC.

Metagenomic assessment of the microbial diversity in ground pork products from markets in the North Central Region of South Korea.

The purpose of this study was to characterize the microbial community in ground pork using molecular approaches. Forty six ground pork products were purchased from local stores in the north central area of South Korea. Aerobic plate counts varied 4.23 ± 5.14 × 10(5) CFU/g with the range between 5.00 × 10(3) and 1.85 × 10(6) CFU/g for ground pork samples. Four ground meat samples were further processed for metagenomic analysis. Pseudomonas species was the most relative abundant with a wide range occurring (1.72 to 77.7%) as part of the microbial genera in ground pork. Bacteria such as Carnobacterium, Yersinia, Photobacterium were also identified in ground pork. Despite the prominence of certain genera across all samples there was still extensive microbial diversity among ground pork products that originated from different slaughter houses and were processed in different markets. Such diversity indicates that designing interventions to extend shelf life may be hampered by the extensive variability in the microbial consortia associated with pork products. However, this diversity may be useful for developing microbial traceability signatures unique to a slaughter house or a particular market.

Organ donation as an outcome of traumatic cardiopulmonary arrest: A cost evaluation.

BACKGROUND: Survival after traumatic cardiopulmonary arrest (TCPA) is rare and requires significant resource expenditure. Organ donation as an outcome of TCPA resuscitation has not yet been included in a cost analysis. The aims of this study were to identify variables associated with survival and organ donation after TCPA, and to estimate the cost of achieving these outcomes. We hypothesized that the inclusion of organ donation as a potential outcome would make TCPA resuscitation more cost-effective. METHODS: Adult patients who required resuscitation for TCPA at a level I trauma center were retrospectively reviewed over 36 months. Data were obtained from medical records, hospital accounting records, and the local organ procurement agency. Outcomes included survival to discharge, neurologic function, and organ donor eligibility. An individual-level state-transition cost-effectiveness model was used to evaluate the cost of TCPA resuscitation with and without organ donation included as an outcome. Incremental cost-effectiveness ratio was calculated to determine additional cost per life saved when organ donation is included. RESULTS: Over the study period, 8,932 subjects were evaluated. Traumatic cardiopulmonary arrest occurred in 237 patients (3%). The mortality rate was 97%. Variables associated with survival included emergency department disposition to the operating room (p < 0.01) and reactive pupils (p < 0.001). Of seven survivors, four were discharged neurologically intact. Of the patients with TCPA, 5% were eligible for organ donation with a procurement rate of 2%. Organ donor eligibility was associated with arrest after arrival to the emergency department (p < 0.01) and transfusion of fresh frozen plasma (p = 0.01). The cost of TCPA resuscitation per survivor was $1.8 million; cost per survivor or life saved by donation was $538,000. The incremental cost-effectiveness ratio was $76,816 per additional life saved including donation as an outcome. CONCLUSION: The decision to pursue resuscitation should continue to be based on the presence of signs of life, especially pupil reactivity and duration of arrest. If the primary objective is survival, organ procurement will be maximized without conflict of interest. Early fresh frozen plasma transfusion may increase successful organ donation. The financial burden of TCPA resuscitation can be mitigated by expanding end points to include organ donation. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III; cost analysis, level V.

Prospective series of two hours supine rest after 4fr sheath-based diagnostic cerebral angiography: Outcomes, productivity and cost.

There is no standard of care for catheter size or post-procedure supine time in cerebral angiography. Catheter sizes range from 4-Fr to 6-Fr with supine times ranging from two to over six hours. The objective of our study was to establish the efficacy, safety, and cost savings of two-hour supine time after 4-Fr elective cerebral angiography. A prospective, single arm study was performed on 107 patients undergoing elective cerebral angiography. All cerebral angiograms were performed with a 4-Fr sheath-based system without closure devices. Ten minutes of manual compression was applied to the femoral access site, with further compression held as clinically indicated. Patients were then monitored in a nursing unit for two hours supine and subsequently mobilized. Nursing discretion was allowed for earlier mobilization. Patients were called the next day to assess delayed hematoma and bleeding. Estimates of cost savings and productivity increases are provided. All patients ambulated in two hours or less. There were no strokes or vessel dissections. Five patients (4.7%) experienced a palpable hematoma, three patients (2.8%) experienced bleeding immediately following the procedure requiring further compression, and one patient (0.9%) experienced minor groin oozing at home. No patient required transfusion, thrombin injection, or endovascular/surgical management of a groin complication. A two-hour post-procedure supine time resulted in cost savings of $952 per angiogram and a total of $101,864. 4-Fr sheath based cerebral angiography with two-hour post-procedure supine time is safe and effective, and allows for a considerable increase in patient satisfaction, cost savings and productivity.

Hemodynamic response to intravenous adenosine and its effect on fractional flow reserve assessment: results of the Adenosine for the Functional Evaluation of Coronary Stenosis Severity (AFFECTS) study.

BACKGROUND: We studied the hemodynamic response to intravenous adenosine on calculation of fractional flow reserve (FFR). Intravenous adenosine is widely used to achieve conditions of stable hyperemia for measurement of FFR. However, intravenous adenosine affects both systemic and coronary vascular beds differentially. METHODS AND RESULTS: A total of 283 patients (310 coronary stenoses) underwent coronary angiography with FFR using intravenous adenosine 140 mcg/kg per minute via a central femoral vein. Offline analysis was performed to calculate aortic (Pa), distal intracoronary (Pd), and reservoir (Pr) pressure at baseline, peak, and stable hyperemia. Seven different hemodynamic patterns were observed according to Pa and Pd change at peak and stable hyperemia. The average time from baseline to stable hyperemia was 68.2±38.5 seconds, when both ΔPa and ΔPd were decreased (ΔPa, -10.2±10.5 mm Hg; ΔPd, -18.2±10.8 mm Hg; P<0.001 for both). The fall in Pa closely correlated with the reduction in peripheral Pr (ΔPr, -12.9±15.7 mm Hg; P<0.001; r=0.9; P<0.001). ΔPa and ΔPd were closely related under conditions of peak (r=0.75; P<0.001) and stable hyperemia (r=0.83; P<0.001). On average, 56% (10.2 mm Hg) of the reduction in Pd was because of fall in Pa. FFR lesion classification changed in 9% using an FFR threshold of ≤0.80 and 5.2% with FFR threshold <0.75 when comparing Pd/Pa at peak and stable hyperemia. CONCLUSIONS: Intravenous adenosine results in variable changes in systemic blood pressure, which can lead to alterations in FFR lesion classification. Attention is required to ensure FFR is measured under conditions of stable hyperemia, although the FFR value at this point may be numerically higher.

Improvement in coronary haemodynamics after percutaneous coronary intervention: assessment using instantaneous wave-free ratio.

OBJECTIVE: To determine whether the instantaneous wave-free ratio (iFR) can detect improvement in stenosis significance after percutaneous coronary intervention (PCI) and compare this with fractional flow reserve (FFR) and whole cycle Pd/Pa. DESIGN: A prospective observational study was undertaken in elective patients scheduled for PCI with FFR ≤ 0.80. Intracoronary pressures were measured at rest and during adenosine-mediated vasodilatation, before and after PCI. iFR, Pd/Pa and FFR values were calculated using the validated fully automated algorithms. SETTING: Coronary catheter laboratories in two UK centres and one in the USA. PATIENTS: 120 coronary stenoses in 112 patients were assessed. The mean age was 63 ± 10 years, while 84% were male; 39% smokers; 33% with diabetes. Mean diameter stenosis was 68 ± 16% by quantitative coronary angiography. RESULTS: Pre-PCI, mean FFR was 0.66 ± 0.14, mean iFR was 0.75 ± 0.21 and mean Pd/Pa 0.83 ± 0.16. PCI increased all indices significantly (FFR 0.89 ± 0.07, p<0.001; iFR 0.94 ± 0.05, p<0.001; Pd/Pa 0.96 ± 0.04, p<0.001). The change in iFR after intervention (0.20 ± 0.21) was similar to ΔFFR 0.22 ± 0.15 (p=0.25). ΔFFR and ΔiFR were significantly larger than resting ΔPd/Pa (0.13 ± 0.16, both p<0.001). Similar incremental changes occurred in patients with a higher prevalence of risk factors for microcirculatory disease such as diabetes and hypertension. CONCLUSIONS: iFR and FFR detect the changes in coronary haemodynamics elicited by PCI. FFR and iFR have a significantly larger dynamic range than resting Pd/Pa. iFR might be used to objectively document improvement in coronary haemodynamics following PCI in a similar manner to FFR.

Should compliance with the Surgical Care Improvement Project (SCIP) process measures determine Medicare and Medicaid reimbursement rates?

The Surgical Care Improvement Project (SCIP) is a project that focuses on improving surgical care by reducing surgical morbidity and mortality by 25 per cent by 2010. Starting in 2011, SCIP compliance affects Medicare and Medicaid reimbursement rates. Although SCIP reinforces better practices in surgical care, does compliance with SCIP measures actually result in a decrease in surgical morbidity and mortality? This study examined compliance with the SCIP surgical site infection (SSI) module (prophylactic antibiotic received within 1 hour before surgical incision) during 2009 to 2010 (n = 703) to determine whether patients compliant with SCIP data had a correlation with SSI rates as reported by National Surgery Quality Improvement Program (NSQIP) data for the same time period. We found no statistically significant association in patients that have failed SCIP INF1 in the years 2009 to 2010 (n = 43) and the rates of SSI (n = 0) for the same time period. These data suggest that SCIP compliance should not be used to determine Medicare and Medicaid reimbursement rates because there is no correlation between failure of SCIP INF1 and SSI. Instead, further effort should be placed on developing tools designed to acknowledge outcome measures that result in decreased morbidity/mortality and change practices accordingly such as NSQIP.

Assessment of NER solutions against the first and second CALBC Silver Standard Corpus.

BACKGROUND: Competitions in text mining have been used to measure the performance of automatic text processing solutions against a manually annotated gold standard corpus (GSC). The preparation of the GSC is time-consuming and costly and the final corpus consists at the most of a few thousand documents annotated with a limited set of semantic groups. To overcome these shortcomings, the CALBC project partners (PPs) have produced a large-scale annotated biomedical corpus with four different semantic groups through the harmonisation of annotations from automatic text mining solutions, the first version of the Silver Standard Corpus (SSC-I). The four semantic groups are chemical entities and drugs (CHED), genes and proteins (PRGE), diseases and disorders (DISO) and species (SPE). This corpus has been used for the First CALBC Challenge asking the participants to annotate the corpus with their text processing solutions. RESULTS: All four PPs from the CALBC project and in addition, 12 challenge participants (CPs) contributed annotated data sets for an evaluation against the SSC-I. CPs could ignore the training data and deliver the annotations from their genuine annotation system, or could train a machine-learning approach on the provided pre-annotated data. In general, the performances of the annotation solutions were lower for entities from the categories CHED and PRGE in comparison to the identification of entities categorized as DISO and SPE. The best performance over all semantic groups were achieved from two annotation solutions that have been trained on the SSC-I.The data sets from participants were used to generate the harmonised Silver Standard Corpus II (SSC-II), if the participant did not make use of the annotated data set from the SSC-I for training purposes. The performances of the participants' solutions were again measured against the SSC-II. The performances of the annotation solutions showed again better results for DISO and SPE in comparison to CHED and PRGE. CONCLUSIONS: The SSC-I delivers a large set of annotations (1,121,705) for a large number of documents (100,000 Medline abstracts). The annotations cover four different semantic groups and are sufficiently homogeneous to be reproduced with a trained classifier leading to an average F-measure of 85%. Benchmarking the annotation solutions against the SSC-II leads to better performance for the CPs' annotation solutions in comparison to the SSC-I.

Including the urban heat island in spatial heat health risk assessment strategies: a case study for Birmingham, UK.

BACKGROUND: Heatwaves present a significant health risk and the hazard is likely to escalate with the increased future temperatures presently predicted by climate change models. The impact of heatwaves is often felt strongest in towns and cities where populations are concentrated and where the climate is often unintentionally modified to produce an urban heat island effect; where urban areas can be significantly warmer than surrounding rural areas. The purpose of this interdisciplinary study is to integrate remotely sensed urban heat island data alongside commercial social segmentation data via a spatial risk assessment methodology in order to highlight potential heat health risk areas and build the foundations for a climate change risk assessment. This paper uses the city of Birmingham, UK as a case study area. RESULTS: When looking at vulnerable sections of the population, the analysis identifies a concentration of "very high" risk areas within the city centre, and a number of pockets of "high risk" areas scattered throughout the conurbation. Further analysis looks at household level data which yields a complicated picture with a considerable range of vulnerabilities at a neighbourhood scale. CONCLUSIONS: The results illustrate that a concentration of "very high" risk people live within the urban heat island, and this should be taken into account by urban planners and city centre environmental managers when considering climate change adaptation strategies or heatwave alert schemes. The methodology has been designed to be transparent and to make use of powerful and readily available datasets so that it can be easily replicated in other urban areas.