Presurgical evaluation and surgery in the pediatric age group are unique in challenges related to caring for the very young, range of etiologies, choice of appropriate investigations, and surgical ...procedures. Accepted standards that define the criteria for levels of presurgical evaluation and epilepsy surgery care do not exist. Through a modified Delphi process involving 61 centers with experience in pediatric epilepsy surgery across 20 countries, including low–middle‐ to high‐income countries, we established consensus for two levels of care. Levels were based on age, etiology, complexity of presurgical evaluation, and surgical procedure. Competencies were assigned to the levels of care relating to personnel, technology, and facilities. Criteria were established when consensus was reached (≥75% agreement). Level 1 care consists of children age 9 years and older, with discrete lesions including hippocampal sclerosis, undergoing lobectomy or lesionectomy, preferably on the cerebral convexity and not close to eloquent cortex, by a team including a pediatric epileptologist, pediatric neurosurgeon, and pediatric neuroradiologist with access to video‐electroencephalography and 1.5‐T magnetic resonance imaging (MRI). Level 2 care, also encompassing Level 1 care, occurs across the age span and range of etiologies (including tuberous sclerosis complex, Sturge‐Weber syndrome, hypothalamic hamartoma) associated with MRI lesions that may be ill‐defined, multilobar, hemispheric, or multifocal, and includes children with normal MRI or foci in/abutting eloquent cortex. Available Level 2 technologies includes 3‐T MRI, other advanced magnetic resonance technology including functional MRI and diffusion tensor imaging (tractography), positron emission tomography and/or single photon emission computed tomography, source localization with electroencephalography or magnetoencephalography, and the ability to perform intra‐ or extraoperative invasive monitoring and functional mapping, by a large multidisciplinary team with pediatric expertise in epilepsy, neurophysiology, neuroradiology, epilepsy neurosurgery, neuropsychology, anesthesia, neurocritical care, psychiatry, and nursing. Levels of care will improve safety and outcomes for pediatric epilepsy surgery and provide standards for personnel and technology to achieve these levels.
Parenting plan Assessments, also known as child custody evaluations, are forensic psychological investigations into the needs of children, the parenting capacities of their caregivers, and the ...resulting fit between the children's needs and caregiver capacities. Typically, they result in recommendations that are, in the opinion of the assessor, formulated to meet the best interests of children regarding a parenting plan, child sharing, parental responsibilities and ancillary services that are likely to support the children's optimal functioning as well as the functioning of the now reconfigured family. Such assessments are part of a pathway to untangling conflicts between the parents regarding the most appropriate parenting plan for the reconfigured family. Paradoxically, the assessment process can exacerbate the conflict, entrench parental polarization, and create lingering feelings of helplessness, frustration, and disempowerment in the parents. This article provides a rationale for the use of a hybrid process that incorporates alternative dispute resolution as an integrated part of the parenting plan assessment and provides an illustrative model of such a hybrid process.
Integrative Oncology in Cancer Care Continuum Gundeti, Manohar S.; Arnold, Julia T.
Journal of Ayurveda and integrative medicine,
January-February 2024, 2024 Jan-Feb, 2024-01-00, 20240101, 2024-01-01, Letnik:
15, Številka:
1
Journal Article
Atmospheric measurements show that emissions of hydrofluorocarbons (HFCs) and hydrochlorofluorocarbons are now the primary drivers of the positive growth in synthetic greenhouse gas (SGHG) radiative ...forcing. We infer recent SGHG emissions and examine the impact of future emissions scenarios, with a particular focus on proposals to reduce HFC use under the Montreal Protocol. If these proposals are implemented, overall SGHG radiative forcing could peak at around 355 mW m−2 in 2020, before declining by approximately 26% by 2050, despite continued growth of fully fluorinated greenhouse gas emissions. Compared to “no HFC policy” projections, this amounts to a reduction in radiative forcing of between 50 and 240 mW m−2 by 2050 or a cumulative emissions saving equivalent to 0.5 to 2.8 years of CO2 emissions at current levels. However, more complete reporting of global HFC emissions is required, as less than half of global emissions are currently accounted for.
Key Points
Measurements of all the major synthetic greenhouse gases have been compiled
These measurements have been used to infer recent global emissions trends
Based on these trends, future emissions scenarios have been investigated
Post-procedural aortic regurgitation (AR) has been described in a large number of patients receiving transcatheter aortic valve implantation (TAVI).
The aim of this study was to examine the ...intraoperative 2-dimensional (2D) and 3-dimensional (3D) echocardiographic features of the aortic valve associated with significant post-procedural paravalvular AR.
A total of 135 patients (81±7 years) with severe symptomatic aortic stenosis, who underwent TAVI, were imaged with comprehensive 2D and 3D transoesophageal echocardiography before the procedure and peri-procedure. Various baseline and peri-procedural echocardiographic characteristics were tested to predict paravalvular AR post-TAVI: calcifications at the aortic valve commissures and leaflets, 'aortic annulus eccentricity index', 'area cover index', overlap between aortic prosthesis and anterior mitral leaflet. Post-procedural paravalvular AR≥2 was considered significant.
Successful TAVI was achieved in all patients. The incidence of paravalvular AR≥2 immediately after the procedure was 21% (28 patients). Commissural calcifications and, particularly, the calcification of the commissure between the right coronary and non-coronary cusps was significantly more frequent in presence of paravalvular AR; the area cover index pre-TAVI was significantly lower among patients with AR (11.1±11.8% vs 20.8±12.5%, p=0.0004). Multivariate analysis revealed that calcification of the commissure between the right coronary and non-coronary cusps (OR=2.66, 95% CI 1.39 to 5.12, p=0.001), and the area cover index pre-TAVI (OR=0.95, 95% CI 0.91 to 0.99, p=0.006) were the only independent predictors of significant paravalvular AR after TAVI.
Intraoperative 2D and 3D transoesophageal echocardiography identified calcification of the commissure between the right coronary and non-coronary cusps and the area cover index as independent predictors of significant paravalvular AR following TAVI.
Aims
To identify changes in multidirectional strain and strain rate (SR) in patients with aortic stenosis (AS).
Methods and results
A total of 420 patients (age 66.1 ± 14.5 years, 60.7% men) with ...aortic sclerosis, mild, moderate, and severe AS with preserved left ventricular (LV) ejection fraction (EF), ≥50% were included. Multidirectional strain and SR imaging were performed by two-dimensional speckle tracking. Patients were more likely to be older (P < 0.001) and at a worse New York Heart Association functional class (P < 0.001) with increasing AS severity. There was a progressive stepwise impairment in longitudinal, circumferential, and radial strain and SR with increasing AS severity (all P < 0.001). The myocardial dysfunction appeared to start in the subendocardium with mild AS, to mid-wall dysfunction with moderate AS, and eventually transmural dysfunction with severe AS. Aortic valve area, as a measure of AS severity, was an independent determinant of multidirectional strain and SR on multiple linear regressions.
Conclusions
Patients with AS have evidence of subclinical myocardial dysfunction early in the disease process despite normal LVEF. The myocardial dysfunction appeared to start in the subendocardium and progressed to transmural dysfunction with increasing AS severity. Symptomatic moderate and severe AS patients had more impaired multidirectional myocardial functions compared with asymptomatic patients.
Clinicopathologic data from a population-based endometrial cancer cohort, unselected for age or family history, were analyzed to determine the optimal scheme for identification of patients with ...germline mismatch repair (MMR) gene mutations.
Endometrial cancers from 702 patients recruited into the Australian National Endometrial Cancer Study (ANECS) were tested for MMR protein expression using immunohistochemistry (IHC) and for MLH1 gene promoter methylation in MLH1-deficient cases. MMR mutation testing was performed on germline DNA of patients with MMR-protein deficient tumors. Prediction of germline mutation status was compared for combinations of tumor characteristics, age at diagnosis, and various clinical criteria (Amsterdam, Bethesda, Society of Gynecologic Oncology, ANECS).
Tumor MMR-protein deficiency was detected in 170 (24%) of 702 cases. Germline testing of 158 MMR-deficient cases identified 22 truncating mutations (3% of all cases) and four unclassified variants. Tumor MLH1 methylation was detected in 99 (89%) of 111 cases demonstrating MLH1/PMS2 IHC loss; all were germline MLH1 mutation negative. A combination of MMR IHC plus MLH1 methylation testing in women younger than 60 years of age at diagnosis provided the highest positive predictive value for the identification of mutation carriers at 46% versus ≤ 41% for any other criteria considered.
Population-level identification of patients with MMR mutation-positive endometrial cancer is optimized by stepwise testing for tumor MMR IHC loss in patients younger than 60 years, tumor MLH1 methylation in individuals with MLH1 IHC loss, and germline mutations in patients exhibiting loss of MSH6, MSH2, or PMS2 or loss of MLH1/PMS2 with absence of MLH1 methylation.
In this synthesis, we assess present research and anticipate future development needs in modeling water quality in watersheds. We first discuss areas of potential improvement in the representation of ...freshwater systems pertaining to water quality, including representation of environmental interfaces, in‐stream water quality and process interactions, soil health and land management, and (peri‐)urban areas. In addition, we provide insights into the contemporary challenges in the practices of watershed water quality modeling, including quality control of monitoring data, model parameterization and calibration, uncertainty management, scale mismatches, and provisioning of modeling tools. Finally, we make three recommendations to provide a path forward for improving watershed water quality modeling science, infrastructure, and practices. These include building stronger collaborations between experimentalists and modelers, bridging gaps between modelers and stakeholders, and cultivating and applying procedural knowledge to better govern and support water quality modeling processes within organizations.
Key Points
We assess four potential improvements in water quality modeling: environmental interfaces, in‐stream processes, soil health, and urban areas
Challenges include data quality control, model calibration, uncertainty management, scale mismatches, and model tool provision
Modelers need to strengthen connections with experimentalists and stakeholders and cultivate procedural knowledge for modeling processes
PDF
