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Background:While progress has been made to decrease mortality in children under age five, there continues to be a need for improvement in the treatment of children with congenital heart disease. Many of these patients require surgical correction and live in areas without the expertise of surgical teams. Research has shown that appropriate training is critical to ensure the best clinical outcomes. The Ethiopian government has identified the need for increased training of health care professionals as a method to improve hospital outcomes. Methods:Twenty-five cardiac critical nurses participated in a remote didactic education curriculum over the course of multiple months. We used a pre- and post-test model to evaluate knowledge acquisition and retention after the curriculum. Nurses completed post-tests at 1-, 3-, 6-, and 12-month intervals to monitor knowledge retention over time. Results:We found a significant increase in nursing knowledge that was retained over the course of 12 months. Nursing knowledge on pre- and post-tests was impacted by experience level. However, after completion of the curriculum experience was not a significant factor. Conclusion:Virtual curriculum delivered via remote didactic education is an inexpensive and effective way to increase nursing knowledge in cardiac critical care. It encourages bidirectional learning and allows the sharing of expertise from individuals who may otherwise be limited by travel or finances. Our approach is generalizable and further research needs to be done to evaluate the effectiveness of this type of curriculum in other environments.

Objective: To assess implicit bias by administrating the Modified Finnegan Score (MFS) for quantifying neonatal opioid withdrawal and to evaluate risk of decreased opioid treatment of Black versus White infants. Study Design: Study participants were nurses recruited from a large tertiary care center who received three clinical vignettes portraying withdrawing infants and were randomized to receive an accompanying photo of either a Black or White infant. MFS results were compared for identical vignettes based on race of infant photo. Results: Out of 275 nurses, 70 completed the survey. In vignette 2, nurses aged ≤35 years scored Black infants lower than White infants (MFS=8.3 ± 2 vs. 9.5 ± 1.2, p=0.012). Nurses with <5 years of experience and ≤10 years of experience also scored Black infants lower for the same vignette (8.2 ± 2.3 vs. 9.6 ± 1.2, p=0.032 and 8.3 ± 2 vs. 9.5 ± 1.2, p=0.0083). Conclusion: Implicit bias may contribute to the difference in opioid treatment.

Routine gastric aspirate (RGA) monitoring is a common yet controversial practice intended for early identification of gastrointestinal pathology in infants receiving gavage feeds. Our objectives were to evaluate the association of ceasing RGA monitoring on the incidence of necrotizing enterocolitis (NEC) as well as nutritional outcomes in a large population of very low birth weight (VLBW) and very preterm neonates. Retrospective record review of neonates born =32 weeks and/or VLBW from 2 cohorts: (1) during pre-feed RGA monitoring (September 2015 to June 2018) and (2) after cessation of RGA (“non-RGA”) monitoring (July 2018 to December 2020). We compared incidence of NEC, time-to-full enteral feeds, central line duration, and duration of parenteral nutrition (PN) in bivariate and multivariable models accounting for changes in feeding protocols over time. We identified 617 subjects, 53% in the RGA monitoring cohort (n = 327) and 47% in non-RGA cohort (n = 290). The non-RGA cohort had feeds initiated earlier (P< 0.0001), achieved full enteral feeds more rapidly (P< 0.0001), received a shorter duration of PN (P= 0.0003), and had shorter central access duration (P< 0.0001) without increasing NEC risk. In fact, the non-RGA cohort had a lower incidence of NEC (P= 0.0345) compared to the RGA cohort. Even after adjusting for changes in feeding protocols over time in a multivariable model, the RGA cohort had significantly higher odds of NEC. Pre-feed RGA monitoring in the absence of concerning clinical exam findings is not indicated for neonates receiving gavage feeds as it does not improve NEC incidence but instead may delay important nutritional outcomes such as feed initiation and central line removal.

ObjectiveTo develop predictive models of Ureaplasmaspp lower airway tract infection in preterm infants.MethodsA dataset was assembled from five cohorts of infants born <33 weeks gestational age (GA) enrolled over 17 years (1999–2016) with culture and/or PCR-confirmed tracheal aspirate Ureaplasmastatus in the first week of life (n=415). Seventeen demographic, obstetric and neonatal factors were analysed including admission white blood cell (WBC) counts. Best subset regression was used to develop three risk scores for lower airway Ureaplasmainfection: (1) including admission laboratory values, (2) excluding admission laboratory values and (3) using only data known prenatally.ResultsGA and rupture of membranes >72 hours were significant predictors in all 3 models. When all variables including admission laboratory values were included in the regression, WBC count was also predictive in the resulting model. When laboratory values were excluded, delivery route was found to be an additional predictive factor. The area under the curve for the receiver operating characteristic indicated high predictive ability of each model to identify infants with lower airway Ureaplasmainfection (range 0.73–0.77).ConclusionWe developed predictive models based on clinical and limited laboratory information available in the perinatal period that can distinguish between low risk (<10%) and high risk (>40%) of lower airway Ureaplasmainfection. These may be useful in the design of phase III trials of therapeutic interventions to prevent Ureaplasma-mediated lung disease in preterm infants and in clinical management of at-risk infants.

ABSTRACTThis article reviews knowledge related to violent extremism risk assessment, discusses challenges in its use and identifies new developments. Several violent extremism risk assessment tools have been developed over the past decade. The application of such tools in national security, forensic and community practice as well as court proceedings has been documented. The benefits, constraints and interpretation of violent extremism risk assessments are considered. The advantages of a less complex approach to supplement the current time intensive in-depth risk assessment have been identified. Benefits include the early identification and screening of relevant populations including those in the pre-crime space. The way court appointed experts benefit from the included risk indicators and structured professional judgment methodology is also clarified. The paper identifies how risk assessment approaches can be used to inform individualised intervention programs, assess rehabilitation program efficacy as well as identify the risk and threat status of an individual. The new short analytical approach referred to as the Violent Extremism Screening Analysis (VESA) is introduced, developed by the article authors and based on their insights and experience in violent extremism risk assessment. A recommendation is the need to pilot the newly developed short screening approach to clarify applicability and relevance.

ABSTRACTIntroductionKetamine is gaining renewed interest among healthcare providers in the emergency department (ED) setting due to its novel clinical applications.Areas coveredThis article provides a comprehensive discussion of ketamine’s pharmacological properties, safety profile, and an overview of current evidence for ketamine in the management of ED patients with acute agitation, pain, depression/suicide ideation.Expert opinionKetamine is an effective adjunct to opioids, providing greater pain relief than morphine alone. Ketamine (0.1–0.3 mg/kg IV) alone can provide analgesia similar to that of morphine in patients with acute visceral and musculoskeletal pain, as well as for chronic painful conditions (cancer, vaso-occlusive pain crisis associated with sickle cell disease, and in patients with high opioid tolerance and/or opioid dependency). Available literature shows that ketamine (1–2 mg/kg IV or 4–5 mg/kg IM) is a safe, rapid (<5 minutes) and effective tranquilization agent for ED patients with acute agitation. Finally, there is growing evidence that suggests ketamine may have potential utility in the management of patients with self-harm ideation or acute depressive episodes. Intravenous infusion of ketamine (0.5 mg/kg over 40 mins) has been shown to produce an antidepressant effect and decrease in suicidal ideation within 4 hours with effects lasting up to one week.

ABSTRACTIn a well-known article, Marc Sageman (2014, The stagnation in terrorism research. Terrorism and Political Violence, 26(4)) foregrounds what he calls the ‘unbridgeable gaps’ between national security agencies and academics on the question of accessing and analysing the empirical data upon which innovative terrorism research depends. Yet while the divide between academic research and national security policy and practice can be pronounced, it is also mediated by the existence of common territory. This includes ideas about what constitutes ‘the public good’, despite bringing varied institutional, personal and philosophical approaches to how that good is understood and enacted. At their best, where these collaborations are embraced and nurtured, they can become unparalleled opportunities for expanded learning, constructive provocation and informed debate, bringing different forms of expertise to bear on understanding and reducing the risks and impacts of terrorism. At their worst, they can be minefields of compromised independence, ethical and reputational wounds, censorship, exploitation, and hollow research and policy agendas. We take up these issues through an edited collaborative dialogue between an academic and a national security practitioner, drawing on both the scholarly literature and our own experience as collaborators to explore the benefits, conflicts and risks of academic-national security collaboration.

Neck and back pain are among the most common symptom-related complaints for visits to the emergency department (ED). They contribute to high levels of lost work days, disability, and health care use. The goal of ED assessment of patients with neck and back pain is to evaluate for potentially dangerous causes that could result in significant morbidity and mortality. This article discusses the efficient and effective evaluation, management, and treatment of patients with neck and back pain in the ED. Emphasis is placed on vertebral osteomyelitis, epidural abscess, acute transverse myelitis, epidural compression syndrome, spinal malignancy, and spinal stenosis.

ObjectiveTo test whether azithromycin eradicates Ureaplasmafrom the respiratory tract in preterm infants.DesignProspective, phase IIb randomised, double-blind, placebo-controlled trial.SettingSeven level III–IV US, academic, neonatal intensive care units (NICUs).PatientsInfants 240–286weeks’ gestation (stratified 240–266; 270–286weeks) randomly assigned within 4 days following birth from July 2013 to August 2016.InterventionsIntravenous azithromycin 20 mg/kg or an equal volume of D5W (placebo) every 24 hours for 3 days.Main outcome measuresThe primary efficacy outcome was Ureaplasma-free survival. Secondary outcomes were all-cause mortality, Ureaplasmaclearance, physiological bronchopulmonary dysplasia (BPD) at 36 weeks’ postmenstrual age, comorbidities of prematurity and duration of respiratory support.ResultsOne hundred and twenty-one randomised participants (azithromycin: n=60; placebo: n=61) were included in the intent-to-treat analysis (mean gestational age 26.2±1.4 weeks). Forty-four of 121 participants (36%) were Ureaplasmapositive (azithromycin: n=19; placebo: n=25). Ureaplasma-free survival was 55/60 (92% (95% CI 82% to 97%)) for azithromycin compared with 37/61 (61% (95% CI 48% to 73%)) for placebo. Mortality was similar comparing the two treatment groups (5/60 (8%) vs 6/61 (10%)). Azithromycin effectively eradicated Ureaplasmain all azithromycin-assigned colonised infants, but 21/25 (84%) Ureaplasma-colonised participants receiving placebo were culture positive at one or more follow-up timepoints. Most of the neonatal mortality and morbidity was concentrated in 21 infants with lower respiratory tract Ureaplasmacolonisation. In a subgroup analysis, physiological BPD-free survival was 5/10 (50%) (95% CI 19% to 81%) among azithromycin-assigned infants with lower respiratory tract Ureaplasmacolonisation versus 2/11 (18%) (95% CI 2% to 52%) in placebo-treated infants.ConclusionA 3-day azithromycin regimen effectively eradicated respiratory tract Ureaplasmacolonisation in this study.Trial registration numberNCT01778634.

Car Seat Tolerance Screening (CSTS) and Critical Congenital Heart Disease (CCHD) screens were both implemented to identify infants with cardiorespiratory distress. We hypothesized that the CCHD screen would be poorly sensitive to predict a failed CSTS for many reasons.

Background:Prenatal toluene exposure can cause neurodevelopmental disabilities similar to fetal alcohol syndrome. Both share neuroanatomic pathologies similar to children with mutations in L1 cell adhesion molecule (L1). L1 mediates neurite outgrowth (NOG) via signaling through ERK1/2, which require trafficking of L1 through lipid rafts. Our objective is to determine if toluene inhibits L1-mediated NOG and toluene inhibits L1 signaling at concentrations achieved during occupational exposure.Methods:Concentrations of toluene reflective of blood concentrations achieved in solvent abusers and occupational settings are used. Cerebellar granule neurons (CGN) harvested from postnatal day 6 rat pups are plated on coverslips coated with poly-L-lysine (PLL) alone or PLL followed by laminin. L1 is added to the media of CGN plated on PLL alone. Toluene is added 2?h after plating. Cells are fixed at 24?h and neurite length is measured. ERK1/2 activation by L1 in CGN is analyzed by immunoblot.Results:Toluene significantly reduced mean neurite length of CGN exposed to L1 but not laminin. Toluene significantly reduced L1-mediated ERK1/2 phosphorylation.Conclusion:Results suggest that toluene inhibits L1-lipid raft interactions at occupationally relevant concentrations and may lead to a fetal solvent spectrum disorder similar to fetal alcohol spectrum disorder.

Abstract:Medical pluralism flourished in the 18thcentury in the Dutch colony of Suriname. White physicians and surgeons, trained in European medicine, existed along with Indigenous priest/healers and herbalists, slave priest/diviners, and healers of African origin, their diverse practices played out on the plantation itself. While decrying the “superstition” of slave healers, physicians began to take note of their plant remedies, such as the local bark used to reduce fever discovered by the celebrated diviner Quassie. Some slave healers were trained in European surgical practices. The Suriname government acted against the slave “poisoners,” who were feared by slaves as well, but they did not act against other non-European healers. Résumé:Au 18esiècle, le pluralisme médical a prospéré dans la colonie hollandaise du Suriname. Alors que les médecins et chirurgiens blancs formés en Europe y côtoyaient les prêtres/guérisseurs et herboristes Autochtones, les prêtres/devins esclaves, et les guérisseurs d’origine africaine, leurs diverses pratiques ont influencé la colonie. Tout en décriant les « superstitions » des esclaves-guérisseurs, les médecins ont commencé à s’intéresser à leurs remèdes à base de plantes médicinales, tel que l’écorce d’un arbre local utilisé pour réduire la fièvre, découvert par le célèbre devin Quassie. Certains esclaves-guérisseurs ont aussi été formés aux techniques chirurgicales européennes. Bien qu’il ait réprimé les esclaves « empoisonneurs », craints par les esclaves eux-mêmes, le gouvernement colonial du Suriname n’a toutefois pas agi contre les autres guérisseurs autochtones et noirs.

Oropharyngeal aspiration (OPA) is a common cause of morbidity in premature neonates. We sought to identify significant risk factors and determine the timing of feeding maturation in preterm infants with OPA.

Oropharyngeal aspiration (OPA) is a common cause of morbidity in premature neonates. We sought to identify significant risk factors and determine the timing of feeding maturation in preterm infants with OPA. We performed a retrospective medical record review of 148 former preterm neonates referred for modified barium swallow study (MBSS) during a 3-year period. We looked at the MBSS results and potential clinical and demographic risk factors and performed bivariate and multivariable logistic regression analyses to evaluate predictors of failure. We evaluated the timing of resolution of OPA based on MBSS results. Of the 148 infants comprising our study cohort, 47 (32%) passed their initial MBSS and 101 (68%) were found to aspirate thin liquids. Infants who aspirate had younger corrected gestational age (CGA) and postnatal age at the time of testing. Increasing CGA led to lower odds of failing. Infants passed a MBSS at a median CGA of 53 weeks and those who failed an initial MBSS eventually passed after a median of ~3.4 months from the first study. Infants with bronchopulmonary dysplasia had lower odds of failing their MBSS (odds ratio 0.16), but those taking inhaled corticosteroids and diuretics had higher odds of failing, and infants who were multiples also had higher odds of failing. We determined the median CGA for passing MBSS and identified risk factors for OPA in this population. This information can help guide providers when counseling families on timing of feeding maturity and anticipation of appropriate timing for follow-up MBSS testing.

Ethanol and nicotine are commonly coabused drugs, and the incidence of codependence is greater than would be expected on the basis of the summed probability of dependence on each drug alone. Previous findings from our laboratory and others suggest that interactive mechanisms at the level of discriminative stimulus (SD) effects may contribute to this coabuse phenomenon. Specifically, ethanol overshadows the nicotine SDwhereas nicotine potentiates the stimulus salience of ethanol when the two drugs are conditioned as a drug mixture. The goal of the current study was to begin to delineate the pharmacological bases of these ethanol–nicotine interactions. Three groups of C57BL6J mice were trained to discriminate 0.8 mgkg nicotine0.5 gkg ethanol (0.8N0.5E), 0.8N1.0E, or 0.8N2.0E. An NMDA receptor antagonist (MK-801) and three nACh receptor ligands were tested for their ability to generalize from or antagonize, respectively, the drug mixtures. MK-801 fully generalized from the 0.8N1.0E and 0.8N2.0E mixtures and partially generalized from 0.8N0.5E. In contrast, nACh receptor ligands had minimal influence in blocking the perception of 0.8N1.0E and 0.8N2.0E mixtures, and only mecamylamine partially blocked 0.8N0.5E. Reduced and enhanced contributions of nACh and NMDA receptors, respectively, in the discrimination of ethanol–nicotine mixtures may contribute to the overshadowing and potentiation phenomena observed previously.

The American Academy of Pediatrics (AAP) recommends that all preterm neonates undergo a period of observation in a car safety seat before discharge, known as the Infant Car Seat Challenge (ICSC), to monitor for respiratory immaturity and the risk of adverse cardiopulmonary events in the upright position. However, no universal guidelines exist to define appropriate cutoffs for failure of the ICSC. We sought to evaluate regional neonatal intensive care unit (NICU) implementation of the ICSC and to evaluate variation in failure criteria.

This article discusses the relationship between historical research and the globalization of the 21st century. The author comments on the evolution of history research post-World War II to focus on themes related to the working class, women, ethnicity, and race, as well as to non-Western topics. She also describes the emphasis that was subsequently placed on global history, referred to as a decentralized perspective. Several examples of this transition in her historical research projects are outlined, including such topics as authors Hasan al-Wazzan (Leo Africanus) and Ibn Khaldun.

This article discusses the origins of creole languages in 18th century Suriname, then a Dutch colony. The author examines the use of creole languages by the slave, free black, and ethnically-mixed populations, with a particular focus on the town of Paramaribo. She also comments on the provenance of her sources, many of which were documents derived from missions and plantations. The use of creole by the Dutch settlers as a method of converting the native populations to Christianity is considered.

“Two negroes hanged,” John Gabriel Stedman wrote in his Suriname journal for March 9, 1776, and then two days later, among his purchases of “soap, wine, tobacco, [and] rum” and his dinners with an elderly widow, he records, “A negro's foot cut off.” Stedman expanded on these events in the later Narrativeof his years as a Dutch–Scottish soldier fighting against the Suriname Maroons: And now, this being the period of the [court] sessions, another Negro's leg was cut off for sculking from a task to which he was unable, while two more were condemned to be hang'd for running away altogether. The heroic behavior of one of these men deserves particularly to be quotted, he beg'd only to be heard for a few moments, which, being granted, he proceeded thus––“I was born in Africa, where defending my prince during an engagement, I was made a captive, and sold for a slave by my own countrimen. One of your countrimen, who is now to be my judge, became then my purchaser, in whose service I was treated so cruelly by his overseer that I deserted and joined the rebels in the woods . . .”To which his former master, who as he observed was now one of his judges, made the following laconick reply, “Rascal, that is not what we want to know. But the torture this moment shall make you confess crimes as black as yourself, as well as those of your hateful accomplices.” To which the Negroe, who now swel'd in every vain with rage [replied, holding up his hands], “Massera, the verry tigers have trembled for these hands . . . and dare you think to threaten me with your wretched instrument? No, I despise the greatest tortures you can now invent, as much as I do the pitiful wrech who is going to inflict them.” Saying which, he threw himself down on the rack, where amidst the most excruciating tortures he remained with a smile and without they were able to make him utter a syllable. Nor did he ever speak again till he ended his unhappy days at the gallows.

Using her experience as historical consultant for Le Retour de Martin Guerre, the author weighs the advantages and disadvantages of describing the past in the language of film and the language of professional prose. She concludes that both forms of communication should be used: historians should amplify their role as consultants or filmmakers through discussion and written debate.

Background:

No relevant conflicts of interest to declare.

DNA ring closure methods have been applied to TATA box DNA and its complex with the TATA box-binding protein (TBP). The J factors for cyclization (effective concentrations of one DNA end about the other) have been measured using cyclization kinetics, with and without bound TBP, for 18 DNA constructs containing the adenovirus major late promoter TATA box (TATAAAAG) separated by a variable helical phasing adapter from sequence-induced A-tract DNA bends. Six phasing lengths were used at three overall DNA lengths each. Cyclization kinetics were also measured in the absence of protein for the same set of molecules bearing a mutant TATA box (TACAAAAG). The results suggest that the TATA box DNA itself is strongly bent and anisotropically flexible, in a direction opposite to the bend induced by TBP, and that the mutant TACA box is much less bent/flexible. The bending and flexibility of the free DNA may govern the energetics of recognition of different DNA sequences by TBP, and the intrinsic bend may act to repress transcription complex assembly in the absence of TBP. The cyclization kinetics of TBP-DNA complexes in solution predict a geometry generally consistent with crystal structures, which show dramatic bending and unwinding. The novel observation of TBP-induced topoisomers suggests that this minicircle approach is able to distinguish TBP-induced unwinding from writhe (these cancel out in larger DNA), and this in turn suggests that changes in supercoiling in small topological domains can control TBP binding. Copyright 1999 Academic Press