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Background The lifetime journey of patients with single‐ventricle congenital heart disease is characterized by long‐term challenges that are incompletely understood and still unfolding. Health care redesign requires a thorough understanding of this journey to create and implement solutions that improve outcomes. This study maps the lifetime journey of individuals with single‐ventricle congenital heart disease and their families, identifies the most meaningful outcomes to them, and defines significant challenges in the journey. Methods and Results This qualitative research study involved experience group sessions and 1:1 interviews of patients, parents, siblings, partners, and stakeholders. Journey maps were created. The most meaningful outcomes to patients and parents and significant gaps in care were identified across the life journey. A total of 142 participants from 79 families and 28 stakeholders were included. Lifelong and life‐stage specific journey maps were created. The most meaningful outcomes to patients and parents were identified and categorized using a “capability (doing the things in life you want to), comfort (experience of physical/emotional pain/distress), and calm (experiencing health care with the least impact on daily life)” framework. Gaps in care were identified and classified into areas of ineffective communication, lack of seamless transitions, lack of comprehensive support, structural deficiencies, and insufficient education. Conclusions There are significant gaps in care during the lifelong journey of individuals with single‐ventricle congenital heart disease and their families. A thorough understanding of this journey is a critical first step in developing initiatives to redesign care around their needs and priorities. This approach can be used for people with other forms of congenital heart disease and other chronic conditions. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04613934.

Background: Adults with congenital heart disease (ACHD) face psychological challenges. Furthermore, ACHD patients experience an under-recognition of mental health disorders (MHD). Understanding the impact of MHDs on ACHD hospitalizations may better inform and help re-design the ACHD care model. Methods: A retrospective review of the Texas Inpatient Discharge Dataset (TIDD) was performed. Data was queried across a ten-year period, from the beginning of 2009 to the end of 2018. ACHD discharges as well as twelve different MHD were identified utilizing ICD-9/10 diagnostic codes. Demographic characteristics and outcomes were recorded. CHD were classified using the American College of Cardiology (ACC)/American Heart Association (AHA) lesion severity score system (LSS). Results: A total of 10,515 eligible discharges were identified, of which 1643(15.6%) had at least one MHD. Demographic differences were found for those with a mental health, anxiety, or depression diagnosis when compared to those without. ACHD patients with MHD had a longer length of stay (LOS) compared to those without (5 [3-8] vs. 4 [2-7] days, p

Background: There are more than 1.4 million adult congenital heart disease (ACHD) patients estimated in the United States. As this population continues to grow, as will their utilization of the healthcare system. Objectives: This study aims to analyze trends in discharges of ACHD patients in the state of Texas from 2009 through 2018. Methods: This is a retrospective review of the Texas Inpatient Discharge Public Use File from 2009 through 2018. Discharges from acute care hospitals of patients ≥18 years of age with an International Classification of Diseases 9 or 10 diagnosis code consistent with a CHD diagnosis which could be categorized by the American Heart Association/American College of Cardiology lesion severity score (LSS). Isolated atrial septal defect and congenital aortic valve insufficiency diagnoses were excluded from the analysis. Results: A total of 10,515 ACHD discharges were identified. Annual discharges increased from 930 to 1,315, a 41% increase during the study period (p-trend

Patients with chronic rhinosinusitis (CRS) report improved sleep quality after dupilumab, an anti IL4/13 therapy. Concurrent CRS and obstructive sleep apnea (OSA) cases are not rare, and CRS seemingly raises nasal resistance. Thus, we hypothesized that improved sleep quality by dupilumab therapy in CRS patients might be due to lowered nasal resistance and subsequent improvement of unrecognized comorbid OSA. Patients with concurrent CRS and OSA were recruited. Nasal resistance was measured invasively with transnasal pressure and flow data collected during normal respiration in the supine position. Results from the first five participants did not support our hypothesis. Subjective and objective measures for CRS and nasal resistance values were improved with dupilumab therapy in CRS patients with nasal polyps. However, apnea severity and sleep-related subjective parameters did not change. In the patients with CRS without nasal polyps, no significant changes in either CRS or OSA-related measures were observed.

Objective Alcohol-related liver disease (ALD) is the most common cause of liver-related ill health and liver-related deaths in the UK, and deaths from ALD have doubled in the last decade. The management of ALD requires treatment of both liver disease and alcohol use; this necessitates effective and constructive multidisciplinary working. To support this, we have developed quality standard recommendations for the management of ALD, based on evidence and consensus expert opinion, with the aim of improving patient care.Design A multidisciplinary group of experts from the British Association for the Study of the Liver and British Society of Gastroenterology ALD Special Interest Group developed the quality standards, with input from the British Liver Trust and patient representatives.Results The standards cover three broad themes: the recognition and diagnosis of people with ALD in primary care and the liver outpatient clinic; the management of acutely decompensated ALD including acute alcohol-related hepatitis and the posthospital care of people with advanced liver disease due to ALD. Draft quality standards were initially developed by smaller working groups and then an anonymous modified Delphi voting process was conducted by the entire group to assess the level of agreement with each statement. Statements were included when agreement was 85% or greater. Twenty-four quality standards were produced from this process which support best practice. From the final list of statements, a smaller number of auditable key performance indicators were selected to allow services to benchmark their practice and an audit tool provided.Conclusion It is hoped that services will review their practice against these recommendations and key performance indicators and institute service development where needed to improve the care of patients with ALD.

Abstract Background Despite considerable progress, it remains unclear why some patients admitted for COVID-19 develop adverse outcomes while others recover spontaneously. Clues may lie with the predisposition to hypoxemia or unexpected absence of dyspnea (‘silent hypoxemia’) in some patients who later develop respiratory failure. Using a recently-validated breath-holding technique, we sought to test the hypothesis that gas exchange and ventilatory control deficits observed at admission are associated with subsequent adverse COVID-19 outcomes (composite primary outcome: non-invasive ventilatory support, intensive care admission, or death). Methods Patients with COVID-19 (N = 50) performed breath-holds to obtain measurements reflecting the predisposition to oxygen desaturation (mean desaturation after 20-s) and reduced chemosensitivity to hypoxic-hypercapnia (including maximal breath-hold duration). Associations with the primary composite outcome were modeled adjusting for baseline oxygen saturation, obesity, sex, age, and prior cardiovascular disease. Healthy controls (N = 23) provided a normative comparison. Results The adverse composite outcome (observed in N = 11/50) was associated with breath-holding measures at admission (likelihood ratio test, p = 0.020); specifically, greater mean desaturation (12-fold greater odds of adverse composite outcome with 4% compared with 2% desaturation, p = 0.002) and greater maximal breath-holding duration (2.7-fold greater odds per 10-s increase, p = 0.036). COVID-19 patients who did not develop the adverse composite outcome had similar mean desaturation to healthy controls. Conclusions Breath-holding offers a novel method to identify patients with high risk of respiratory failure in COVID-19. Greater breath-hold induced desaturation (gas exchange deficit) and greater breath-holding tolerance (ventilatory control deficit) may be independent harbingers of progression to severe disease.

Study Objectives: Obstructive sleep apnea (OSA) is increasingly recognized as a complex and heterogenous disorder. As a result, a “one-size-fits-all” management approach should be avoided. Therefore, evaluation of pathophysiological endotyping in OSA patients is emphasized, with upper airway collapse during sleep as one of the main features. To assess the site(s) and pattern(s) of upper airway collapse, natural sleep endoscopy (NSE) is defined as the gold standard. As NSE is labor-intensive and time-consuming, it is not feasible in routine practice. Instead, drug-induced sleep endoscopy (DISE) is the most frequently used technique and can be considered as the clinical standard. Flow shape and snoring analysis are non-invasive measurement techniques, yet are still evolving. Although DISE is used as the clinical alternative to assess upper airway collapse, associations between DISE and NSE observations, and associated flow and snoring signals, have not been quantified satisfactorily. In the current project we aim to compare upper airway collapse identified in patients with OSA using endoscopic techniques as well as flow shape analysis and analysis of tracheal snoring sounds between natural and drug-induced sleep.Methods: This study is a blinded prospective comparative multicenter cohort study. The study population will consist of adult patients with a recent diagnosis of OSA. Eligible patients will undergo a polysomnography (PSG) with NSE overnight and a DISE within 3 months. During DISE the upper airway is assessed under sedation by an experienced ear, nose, throat (ENT) surgeon using a flexible fiberoptic endoscope in the operating theater. In contrast to DISE, NSE is performed during natural sleep using a pediatric bronchoscope. During research DISE and NSE, the standard set-up is expanded with additional PSG measurements, including gold standard flow and analysis of tracheal snoring sounds.Conclusions: This project will be one of the first studies to formally compare collapse patterns during natural and drug-induced sleep. Moreover, this will be, to the authors' best knowledge, the first comparative research in airflow shape and tracheal snoring sounds analysis between DISE and NSE. These novel and non-invasive diagnostic methods studying upper airway mechanics during sleep will be simultaneously validated against DISE and NSE.Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04729478.

Between 2015 and 2019, 3,475 deaths occurred, and nearly $400 billion dollars of damage was incurred due to flooding and tropical cyclones in the United States. Despite several initiatives at the federal level, a unified national strategy for flood risk management does not exist in the United States. The approach also varies widely from state to state. Since all communities in a watershed are tied together through river systems, water resource management must take place on a regional basis. This paper outlines the current structure of flood risk management in the U.S., examines present needs, and suggests an organizational restructuring to provide for a more strategic approach to infrastructure security. Chief among the recommendations is to consolidate overlapping federal agencies, create a clear hierarchy of flood risk management at all levels of government, mandate participation in national programs, and require that states take an active role in flood risk planning and infrastructure management.

Autophagy is an evolutionary conserved cellular degradation system that underlies the positive effects of exercise. Currently, few human data exist investigating the autophagic response to exercise including the response to high-intensity interval training (HIIT), response in divergent tissues, and if sex differences exist. The purpose of this study was to investigate the autophagy response in skeletal muscle and peripheral blood mononuclear cells (PBMCs) following an acute bout of HIIT and moderate-intensity continuous training (MICT) with treadmill running in males and females. Using a crossover design, ten recreationally-active males (n = 5; 25.2 ± 1.1 yrs) and females (n = 5; 21.6 ± 3.6 yrs) performed a bout of MICT (60 min at 55% of max velocity [Vmax]]) and HIIT (12 bouts of 1 min at 100% Vmax and 1 min at 3 miles per hour) in a fasted state separated by ≥ 72 h. Muscle biopsy samples from the vastus lateralis and PBMCs were collected pre- and 3 h post-exercise and analyzed for differences in protein expression of LC3I, LC3II, and p62 via western blot analysis. Expression of LC3II:LC3I was significantly different from pre-exercise 3 h post-exercise in MICT in skeletal muscle (64.3 ± 47.3%; p = 0.024). A significant time effect was found for p62 3 h post-exercise compared to pre-exercise (135.23 ± 84.6%; p = 0.043) in skeletal muscle. No differences in markers of autophagy were observed in PBMCs. When sexes were analyzed separately there was a condition x time x sex interaction in LC3II (p = 0.007) and LC3II:LC3I (p = 0.043) in PBMCs. Post hoc analyses revealed a difference in LC3II pre vs. 3 h post exercise in males, but not females, in both HIIT (144.2 ± 89.7%; p = 0.024) and MICT (61.8 ± 36.1%; p = 0.043). Our findings show that HIIT results in changes in markers of autophagy and that the exercise-induced autophagy response varies in tissues and between sexes.

Stimulant drugs are most commonly used to treat ADHD. Here, the authors demonstrate that in adolescents with ADHD who also have genetic variation in genes impacting metabotropic glutamate signaling, the non-stimulant mGluR activator fasoracetam is well tolerated and may be beneficial in alleviating symptoms of this disease.

Power line communication (PLC) has made remarkable strides to become a key enabler of smart grid and its applications. Existing PLC systems are based on orthogonal frequency division multiplexing (OFDM), which has a high peak-to-average power ratio (PAPR). This paper presents vector OFDM (VOFDM) with advanced signal processing at the receiver to improve the energy efficiency of the PLC system. Results show that, due to its low PAPR properties, VOFDM is less sensitive to impulsive noise and provides a reduction of 5.8 dB in transmit power requirement relative to conventional OFDM. Furthermore, unlike the existing impulsive noise cancellation methods, the adopted signal processing technique also improves the SNR at the receiver by 2.1 dB, which further reduces the power requirement of the PLC transceiver. Together, these can simplify design, reduce cost, and improve energy efficiency of future PLC transceivers.

A key requirement of an adaptive sensor array involves the ability to deterministically adjust the directional response of the array to reduce noise and reverberations, null interferences, and enhance the gain and recognition of the desired signal. This paper presents a low-carbon adaptive broadband beamforming algorithm called the regulated-element Frost beamformer. It enhances the desired signal based on the noise conditions of the individual omnidirectional sensors deployed in a complex dynamic environment that is prone to steering errors. The investigation of this algorithm was carried out in an interference-dominant, noisy automobile environment characterized by diffuse noise conditions. An embedded system measurement of real-time signals was carried out using omnidirectional acoustic sensors mounted in a model convertible F-Type car driven at speed limits of 20 to 50 mph. The simulation results indicate an array gain enhancement of 2 dB higher than the conventional Frost beamformer and it requires less sensors and filter taps for real-time reconfigurable implementations. The experimental results reveal that the average array gain of the regulated-element beamformer is 2.9 dB higher than the conventional Frost beamformer response. The minimum floor array gain of the regulated-element beamformer is 5 dB, representing 70% noise reduction than the conventional adaptive beamformers.

Environmental Impact Assessment (EIA) is an issue of concern to governments, organized civil society groups, as well as business actors in the Mekong region. EIA and related forms of environmental assessments are being carried out throughout the region with varying levels of quality, legal frameworks, monitoring and compliance. Through a political economy approach, we seek to understand the interests and incentives among key stakeholders in each of the five Mekong region countries and propose ways that EIA processes can potentially be improved, with reference to hydropower and other infrastructure and development projects. The analysis is based on a collaborative research process carried out under the auspices of the Mekong Partnership for the Environment, a USAID-funded program implemented by Pact that aims to advance regional cooperation on environmental governance. We find that at present, EIA implementation is limited by numerous political economy constraints, some general across the Mekong region, others specific to one or more country contexts. Certain of these constraints can be addressed through a regional cooperative approach, while others will require longer-term changes in social and political dynamics to encourage uptake and impact and avoid possible blockage from entrenched interest groups.

Abstract Background The apicomplexan parasite Cryptosporidium represents a threat to water quality and public health. An important zoonotic species involved in human cryptosporidiosis from contaminated water is Cryptosporidium parvum (C. parvum), the main reservoirs of which are known to be farm livestock particularly neonatal calves, although adult cattle, sheep, lambs and wildlife are also known to contribute to catchment loading of C. parvum. This study aimed to establish Cryptosporidium prevalence, species and genotype in livestock, deer and water in a catchment with a history of Cryptosporidium contamination in the public water supply. Methods A novel method of processing adult ruminant faecal sample was used to concentrate oocysts, followed by a nested species specific multiplex (nssm) PCR, targeting the 18S rRNA gene, to speciate Cryptosporidium. A multilocus fragment typing (MLFT) tool was used, in addition to GP60 sequencing, to genotype C. parvum positive samples. Results A very high prevalence of Cryptosporidium was detected, with speciation identifying a predominance of C. parvum in livestock, deer and water samples. Four GP60 subtypes were detected within C. parvum with the majority IIaA15G2R1 which was detected in all host species and on all farms. Multilocus fragment typing further differentiated these into 6 highly related multilocus genotypes. Conclusion The high prevalence of Cryptosporidium detected was possibly due to a combination of the newly developed sample processing technique used and a reflection of the high rates of the parasite present in this catchment. The predominance of C. parvum in livestock and deer sampled in this study suggested that they represented a significant risk to water quality and public health. Genotyping results suggested that the parasite is being transmitted locally within the study area, possibly via free-roaming sheep and deer. Further studies are needed to verify particular host associations with subtypes/MLGs. Land and livestock management solutions to reduce Cryptosporidium on farm and in the catchment are planned with the aim to improve animal health and production as well as water quality and public health.

Between Vietnam’s independence and its reunification in 1975, the country’s socialist land tenure system was underpinned by the principle of “land to the tiller”. During this period, government redistributed land to farmers that was previously owned by landlords. The government’s “egalitarian” approach to land access was central to the mass support that it needed during the Indochinese war. Even when the 1993 Land Law transitioned agricultural land from collectivized to household holdings with 20-year land use certificates, the “land to the tiller” principle remained largely sacrosanct in state policy. Planned amendments to the current Land Law (issued in 2013), however, propose a fundamental shift from “land to the tiller” to the concentration of land by larger farming concerns, including private sector investors. This is explained as being necessary for the modernization of agricultural production. The government’s policy narrative concerning this change emphasizes the need to overcome the low productivity that arises from land fragmentation, the prevalence of unskilled labor and resource shortages among smallholders. This is contrasted with the readily available resources and capacity of the private sector, together with opportunities for improved market access and high-tech production systems, if holdings were consolidated by companies. This major proposed transition in land governance has catalyzed heated debate over the potential risks and benefits. Many perceive it as a shift from a “pro-poor” to “pro-rich” policy, or from “land to the tiller” to the establishment of a “new landlord”—with all the historical connotations that this badge invokes. Indeed, the growing level of public concern over land concentration raises potential implications for state legitimacy. This paper examines key narratives on the government-supported land concentration policy, to understand how the risks, benefits and legitimacy of the policy change are understood by different stakeholders. The paper considers how the transition could change land access and governance in Vietnam, based on early experience with the approach.

As science and society better understand the challenges of global climate change, colleges and universities must prepare students to be environmentally just actors. To prepare tomorrow’s leaders, today’s educators must foster a culture of environmental justice on college campuses through independent efforts and collaborations between faculty and staff. This article examines the potential for student and academic affairs to collaborate to enhance students’ learning about environmental justice through liberal arts education. The author also provides examples of pro-environmental work done in student and academic affairs and introduces opportunities for collaboration between staff and faculty.