What you need to know: The recommendations apply to patients under 60 years old with patent foramen ovale (PFO) who have had a cryptogenic ischaemic stroke, when extensive workup for other ...aetiologies of stroke is negative; For patients who are open to all options, we make a weak recommendation for PFO closure plus antiplatelet therapy rather than anticoagulant therapy; For patients in whom anticoagulation is contraindicated or declined, we make a strong recommendation for PFO closure plus antiplatelet therapy versus antiplatelet therapy alone; For patients in whom closure is contraindicated or declined, we make a weak recommendation for anticoagulant therapy rather than antiplatelet therapy; Further research may alter the recommendations that involve anticoagulant therapy. Options for the secondary prevention of stroke in patients younger than 60 years who have had a cryptogenic ischaemic stroke thought to be secondary to patent foramen ovale (PFO) include PFO closure (with antiplatelet therapy), antiplatelet therapy alone, or anticoagulants. International guidance and practice differ on which option is preferable. The BMJ Rapid Recommendations panel used a linked systematic review1 triggered by three large randomised trials published in September 2017 that suggested PFO closure might reduce the risk of ischaemic stroke more than alternatives.234 The panel felt that the studies, when considered in the context of the full body of evidence, might change current clinical practice.5 The linked systematic review finds that PFO closure prevents recurrent stroke relative to antiplatelet therapy, but possibly not relative to anticoagulants, and is associated with procedural complications and persistent atrial fibrillation.1 The review also presents evidence regarding the role of anticoagulants or antiplatelet therapy when PFO closure is not acceptable or is contraindicated.
Effective peer interaction is fundamental to social development, cognitive development, and academic success. Young children's early exposure to and development of social competence begins in the ...home and is further developed upon entry into early childhood programmes. In the United States, where early childhood programmes serve increasingly diverse families, discrepancies between families and teachers in relation to the social competencies valued may exist. This study compares parent and teacher perspectives of children's social competence (i.e. social skills and problem behaviours) and whether similarities and differences in perspectives are associated with children's classification as an emergent bilingual or monolingual native English speaker. Findings indicate statistically significant differences in parent and teacher ratings on the empathy, externalizing, and hyperactivity subscales for bilingual children and on the empathy, self-control, internalizing, externalizing, and hyperactivity subscales for monolingual English-speaking children. Recommendations for future research are discussed.
Some of these challenges may include orienting attention-responding when called by name, for example (Renner, Klinger, & Klinger 2006; Patten & Watson 2011); focusing on only one stimulus in the ...environment and deciding what visual information to attend to and what to disregard-as in the case of children with ASD who do not orient toward, or look at, an item presented to them if there are too many other items available (Ogilvie 2011); shifting attention away from an incentive item, such as shifting attention from a toy train to a block (Naber et al. 2007); and joint attention, as when a child looks at his mother and points to a red ball out of his reach, prompting the mother to see the ball and hand it to the child (Rocha, Schreibman, & Stahmer 2007). Because meals and snack time occur naturally across settings, and because adults can use these times as opportunities to reinforce desired positive behaviors, Jon's IEP team selects these occasions to have adults work with him on initiating requests.
Two diametrically opposed beliefs are held concerning the meaning of the least restrictive environment (LRE) when determining the class placements of students with disabilities. One group adheres to ...the placement philosophy that the LRE is always the general education setting. The other group believes that the LRE is where the students’ needs may best be met. The controversy concerning placement has resulted in a number of court cases that can provide guidance to individualized education program (IEP) teams when discussion of the LRE occurs. A checklist for use in IEP meetings is offered.
In this longitudinal study, stress attributed by parents to their family member with intellectual disability was investigated over a period of seven years in relation to specific foci of parental ...worry, and also in relation to stress attributed to the youngest sibling without a disability. The stress parents attributed to their family member with a disability was about double that attributed to the youngest sibling without a disability. However, multiple regression analysis revealed that the stress attributed to the sibling without a disability actually accounted for most of the variance in explaining the stress attributed to the family member with a disability. It is concluded that the stress attributed to any specific child may be an indicator of more general family stress. It was also found that, while the strength of parental worry decreased from time 1 to 2, the pattern of worries did not change over time, and nor did the specific foci of worry differentiate low-stressed from high-stressed parents. It is suggested that the latter result may be due to the inadequacy of the specific foci to cover all sources of parental stress over the duration of the study.
The parameters of environmental simulation models are often inferred by minimizing differences between simulated output and observed data. Heuristic global search algorithms are a popular choice for ...performing minimization but many algorithms yield lackluster results when computational budgets are restricted, as is often required in practice. One way for improving performance is to limit the search domain by reducing upper and lower parameter bounds. While such range reduction is typically done prior to optimization, this study examined strategies for contracting parameter bounds during optimization. Numerical experiments evaluated a set of novel “telescoping” strategies that work in conjunction with a given optimizer to scale parameter bounds in accordance with the remaining computational budget. Various telescoping functions were considered, including a linear scaling of the bounds, and four nonlinear scaling functions that more aggressively reduce parameter bounds either early or late in the optimization. Several heuristic optimizers were integrated with the selected telescoping strategies and applied to numerous optimization test functions as well as calibration problems involving four environmental simulation models. The test suite ranged from simple 2-parameter surfaces to complex 100-parameter landscapes, facilitating robust comparisons of the selected optimizers across a variety of restrictive computational budgets. All telescoping strategies generally improved the performance of the selected optimizers, relative to baseline experiments that used no bounds reduction. Performance improvements varied but were as high as 38% for a real-coded genetic algorithm (RGA), 21% for shuffled complex evolution (SCE), 16% for simulated annealing (SA), 8% for particle swarm optimization (PSO), and 7% for dynamically dimensioned search (DDS). Inter-algorithm comparisons suggest that the SCE and DDS algorithms delivered the best overall performance. SCE appears well-suited for solving low-dimensional problems using a moderate computational budget, while DDS appears better suited for solving high-dimensional problems using a restricted computational budget.
•We introduce a set of dynamic range reduction strategies for heuristic optimization.•The strategies are general and can be linked with any arbitrary optimizer.•The strategies were applied to a suite of environmental model calibration problems.•Performance improvements varied but were as high as 38% for a genetic algorithm.•Inter-algorithm comparisons suggest the SCE and DDS algorithms worked best.
Parent and teacher perspectives of young children’s social competence were compared by analyzing parent and teacher ratings of 30 dual language learners and 30 monolingual native English-speaking ...children. Parents and teachers rated children on the Social Skills Improvement System (SSIS) rating scales. Participants were 60 parents and 9 teachers of 3-to-5 year-old children who attended a Head Start preschool center. For each child, one parent and one teacher completed an SSIS rating scale, resulting in two rating scales for each child. The purpose of this study was to examine whether (a) parent and teacher ratings were significantly different on SSIS measures of social competence for young children and (b) whether parent and teacher ratings were significantly different for children based on children’s language designation. In particular, this study examined both social skills and problem behaviors when looking for differences in parent and teacher ratings. Results indicated that parent and teacher ratings were significantly different for four of the subscales based on participant category, meaning that the SSIS ratings differed based on whether parents or teachers were completing the rating scales. For the social skills subscale, empathy, results indicated that teachers were likely to give children higher ratings than parents. On the externalizing, internalizing, and hyperactivity/inattention subscales, which are all Problem Behaviors subscales, parent ratings for children were higher than teacher ratings, and these differences were statistically significant. Parent and teacher ratings on two subscales also differed for children based on their language designation. Results from analysis of the communication subscale, which is a social skills subscale, indicated that parents and teachers rated dual language learners higher than monolingual native English-speaking children. From the Problem Behaviors scale, parent and teacher ratings for bullying were higher for monolingual native English-speaking children than for dual language learners. Findings from this study also indicate that dual language learners received higher ratings on communication scales and lower ratings on bullying scales than their native English-speaking peers. Further research should more closely examine the relationship between these two constructs. The role of language in the development of social competence is still not well understood, however it is important to understand the developmental trajectory of dual language learners in order to provide the most appropriate educational experiences opportunities for children and their families and improve outcomes.
The primary mission of community health centers (CHCs) is to provide primary and preventive healthcare for the underserved and vulnerable populations, including the uninsured, underinsured, and ...Medicaid beneficiaries. Economic and regulatory challenges have placed these safety net providers in a precarious position, forcing some to respond using cooperative strategies. This article focuses on seven CHC-led networks, delineating their integrative efforts in the core areas of managed care, clinical, administrative, information, and finance. Interviews with key representatives from each network highlight the networks' accomplishments and the critical success factors and outcomes of their integrative efforts. Several underlying themes emerged from this study that are consistent with findings of previous studies conducted in other organizational settings. Specifically participants in CHC-led networks cite the following factors as contributors to success: reciprocity, communication, trust, and long-standing relationships among key individuals. This is the first study to provide a rich depiction of CHC network activities.
The primary mission of community health centers (CHCs) is to provide primary and preventive healthcare for the underserved and vulnerable populations, including the uninsured, underinsured, and ...Medicaid beneficiaries. Seven CHC-led networks are discussed with focus on their integrative efforts in the core areas of managed care, clinical, administrative, information, and finance. Interviews with key representatives from each network highlight the networks' accomplishments and the critical success factors and outcomes of their integrative efforts. Several underlying themes emerged from this study that are consistent with findings of previous studies conducted in other organizational settings. Specifically participants in CHC-led networks cite the following factors as contributors to success: reciprocity, communication, trust, and long-standing relationships among key individuals. This is the first study to provide a rich depiction of CHC network activities.
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