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Polypharmacy is commonly encountered by providers caring for patients with medically complex and palliative care needs in many settings. The purpose of this quality improvement project was to measure the impact of an evidence-based educational deprescribing intervention on polypharmacy rate and provider confidence and knowledge in the nursing home. We invited providers working in 52 nursing homes to attend a 1-hour-long educational deprescribing session. Twenty-one nurse practitioners and 1 physician assistant across 11 states participated in the intervention. Provider confidence level related to deprescribing improved in all categories, with statistical significance demonstrated with both paired ttest and Wilcoxon signed rank test (P< .001). The polypharmacy rate 3 months after the intervention decreased more in centers where a provider had attended the training. Additional open-ended data about experiences with and barriers to deprescribing were collected and analyzed. The findings from this quality improvement project demonstrate that an educational intervention focused on providers practicing in the nursing home setting can improve deprescribing confidence and reduce polypharmacy rates. These findings may be used to implement similar deprescribing education programs for palliative care nurses and providers that prioritize goals of care for patients living with serious illness.

Background The primary objective of this study was to identify specific factors in pediatric cardiac surgical patients when tracheal extubation was performed on the operating table after completion of open-heart surgery (Group-1), postoperatively in the intensive care unit within 6 h (Group-II) or after 6 h (Group-III). The causes of failed extubation, the presence of chromosomal disorders in addition to arterial blood gas analysis parameters at the time of tracheal extubation, and the duration of intensive care unit stay were also evaluated in each group.Methods In addition to the three groups, Groups I and II were combined as a “fast-track” extubation group. The demographic data, Risk Adjustment for Congenital Heart Surgery (RACHS-1) score, the Society of Thoracic Surgeons - European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Category (STAT Mortality Category), cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, and vasoactive-inotropic score (VIS) at the time of tracheal extubation along with data related to secondary objectives were recorded for each patient.Results A significant association was found by bivariate analysis between clinical variables and for both operating table and fast-track extubation in terms of age, weight, RACHS-1 score, STAT category, CPB and ACC time, and VIS. A multivariate-adjusted analysis showed weight, lower STAT category, CPB time, and VIS were independent predictors for operating table and fast-track extubation.Conclusions Younger age, lower weight, higher RACHS-1, STAT category, and VIS, along with longer CPB and ACC, are associated with delay in the timing of tracheal extubation in pediatric cardiac surgical patients.

Anorectal malformations (ARMs) are a spectrum of congenital anomalies where there is abnormal development of the anus and rectum. With an incidence of 1:5000 live births and affecting both males and females, these anomalies vary in their appearance and presentation, lack features enabling antenatal detection and should be detected at birth by the examining midwife or within 72 hours through the newborn and infant physical examination (NIPE) screening programme. However, it is recognised that the diagnosis of ARMs can be missed or delayed leading to morbidity and mortality. In the UK, despite the existence of the NIPE screening programme and NICE guidelines, published literature shows that nearly a quarter of ARMs are not diagnosed at birth. This review takes a critical look at the frequency of missed/delayed diagnosis of ARMs at birth, the implications of delayed diagnosis, and the possible reasons for this related to education and training of healthcare professionals involved in newborn examination, focusing on the UK national screening programme for NIPE. We propose a strategy for enhancing detection of ARMs in a timely manner through the existing framework of the NIPE screening programme.

The article discusses Robin Carolan's experience as the composer for Robert Eggers's films, particularly focusing on his work on "The Northman" and "Nosferatu." Carolan used a mix of traditional Nordic instruments and modern techniques to create the films' soundtracks, staying true to the period settings. He collaborated closely with Eggers and other musicians to bring his musical ideas to life, aiming to evoke a sense of dread and terror in the films. Despite initial challenges, Carolan found the experience rewarding and valuable for his growth as a film composer. [Extracted from the article]

Postoperative rehabilitation following rotator cuff repair is essential for a positive patient outcome. Each patient should have a program tailored to their individual tear and repair characteristics. Their plan should be advanced according to their progress, with therapist and surgeon communication. The rehabilitation progresses through 4 stages. This begins with a period of immobilization, passive range of motion, and protecting the repair and ends with functional and sport-specific exercises. Rehabilitation advances in progress-based steps during 24 weeks. The rehabilitation process aims to balance healing of the tendon repair and the risk of postoperative stiffness.

Small changes in deltoid tension and moment arm due to glenosphere lateralization may be associated with an increase in acromion or scapular spine strain in reverse shoulder arthroplasty (RSA), which can lead to stress fracture. The coracoacromial ligament (CAL) may be protective and lower the strain seen on the acromion or scapular spine. This biomechanical study investigated the impact of glenosphere lateralization and CAL integrity on acromion and scapular spine strain after RSA.

Debilitating headache persists after acute aneurysmal subarachnoid hemorrhage (SAH). Despite high prevalence, little is known regarding optimal treatment strategies for SAH-related headache. Nonpharmacologic adjunctive therapies are emerging as tools to help treat pain and limit opioid exposure in the hospital. Virtual reality (VR) is an immersive audiovisual experience that has been shown to reduce pain perception in other patient populations. The role of VR in acute brain injury is unknown. Here we report a patient with SAH who suffered from persistent headache during her hospitalization despite escalation of analgesic pharmacotherapy. A trial of VR was used as an adjunct to medication over four days. The patient reported subjective improvement in pain and anxiety. VR may provide additional analgesia and anxiolysis over pharmacologic measures alone and warrants further study in patients with acute brain injury.

This cross-sectional study examined the factors associated with depression among people with chronic pain (PwCP) attending specialized pain clinics in Muscat, Oman. Two-hundred eighty-seven participants were recruited for the study, and univariate analyses were used to investigate the difference between individuals who scored above/below the cutoff points for depressive symptoms. A multiple regression analysis was used to detect the independent predictors. Twenty-six percent of participants scored above the cutoff point. Further analysis indicated that unstable family relationships pre-existing depressive symptoms (odds ratio [OR], 2.86; p= 0.044), a family history of depression (OR, 4.75; p= 0.019), severe pain (OR, 4.21; p< 0.006), having fibromyalgia (OR, 28.29; p= 0.005), and lumbago/truck (OR, 2.41; p= 0.039) were independent predictors of depressive symptoms. This study indicates that one in four patients with chronic pain also presents with depressive symptoms. However, the role of culture needs to be taken into consideration when interpreting these findings and when building on these data.

Complex elbow dislocations involve periarticular fractures in addition to capsuloligamentous disruption. These dislocations can result from a simple fall on an outstretched hand or from high-energy trauma, and the pattern of injury is affected by the direction of the force causing the injury. Fracture patterns in complex elbow dislocations vary based on whether the injury is posterolateral, anterior, posteromedial, or medial. The primary goals of care in treating complex elbow dislocations include restoring anatomical alignment of the ulnohumeral and radiocapitellar joints, providing stability, and facilitating early motion after definitive treatment. Depending on fracture pattern and joint stability, definitive treatment can be nonoperative with closed reduction and bracing or operative with capsuloligamentous repair, open reduction and internal fixation of fractures, arthroplasty, or application of an external fixator. Common complications include neurovascular injury, chronic instability, posttraumatic arthritis, compartment syndrome, stiffness, and heterotopic ossification. Understanding how best to treat each type of complex elbow dislocation is essential to optimizing long-term elbow mobility and function while avoiding potential complications.

Improvements in neonatal care and surgical advances, has led to an increased prevalence of children with small and large bowel anastomoses. Ulceration at the site of anastomosis is a rare, but well-recognised phenomenon, with no clearly understood pathogenesis. Paediatric case series have been reported but there remains no clear effective treatment strategy and there is limited experience with endoscopic techniques in their management. We report our tertiary centre experience of managing nine anastomotic ulcer patients, including endoscopic treatment with argon plasma coagulation and clips. Two patients with inflammatory bowel disease (IBD) responded to optimisation of medical therapy. In our non-IBD patients, those requiring a blood transfusion (n = 2) ultimately required surgery and those who did not require a blood transfusion responded to aminosalicylate treatment (n = 1) or endoscopic therapeutic techniques (n = 3). We conclude that endoscopic interventions can be an effective management strategy for anastomotic ulcers when a blood transfusion isn't required.

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Background Critical care ultrasound (CCUS) is essential in modern practice, with CCUS including cardiac and noncardiac ultrasound. The most effective CCUS training is unknown, with a diverse skill set and knowledge needed for competence. The objective of this project was to evaluate the effect of a surgical intensivist-led training program on CCUS competence in critical care fellows.Methods This was a single institution retrospective review from 2016 to 2018 at the R Adams Cowley Shock Trauma Center. Our yearlong surgical intensivist (SI)-led CCUS training program for critical care fellows includes a daylong CCUS training class, CCUS lectures, a CCUS rotation, and bedside CCUS instruction during rotations. Fellows take a knowledge test and skills test before (pretest) and after (posttest) this program. Critical care ultrasound skill was graded on a scale from 1-5, with 4 (minimal help) or 5 (no help) considered competent. Emergency medicine, surgery, and medicine-trained critical care fellows were included.Results Forty-two critical care fellows were included. Mean posttest scores increased significantly for 21/22 (96%) of skills tested and for 14/30 (47%) of knowledge questions compared to pretest scores. The mean composite skill score increased from 3.25 to 4.82 from pretest to posttest (P< .001). The mean composite knowledge score increased from 60% to 80% from pretest to posttest (P< .001).Conclusion SI-led training improves CCUS competence and knowledge despite the breadth of CCUS.

ABSTRACTAggregates are the fundamental ingredient for making concrete. The incremental demand for aggregates in concrete is affecting the environment due to excessive exploitation of natural rocks. In an effort to conserve the natural resources and minimise the adverse impacts of industrial by-products in the environment, it is essential to explore the suitable alternate materials for construction. Under such circumstances, an attempt was made with coconut shell aggregate (CSA) as a substitute for conventional coarse aggregate (CA) in self-compacting concrete (SCC). In this investigation, binary and ternary blended SCC were developed using the mineral admixtures such as rice husk ash (RHA) and silica fume (SF). Two series of SCC were designed with the total powder content of 450 and 550 kg/m3, respectively, for investigation. The effects of CSA in SCC on fresh and hardened properties were studied and compared with the results obtained without CSA. The results revealed that use of 75% CSA in SCC reduced the density below the threshold level of structural lightweight concrete (1850 kg/m3) in dry state. The CSA-based lightweight self-compacting concrete (LWSCC) possesses good fluidity, deformability, passing ability and filling ability in its fresh state. The compressive strength and elastic modulus of LWSCC were determined and found that the results are decreased after the substitution of more than 75% of CSA. Further, the paper intended to predict an appropriate correlation between compressive strength and elastic modulus of CSA-based LWSCC.

Over the past 20 years, the prevalence of obesity has risen dramatically worldwide, with an increase in occurrence among women in their reproductive age. Obesity during pregnancy is associated with significantly increased maternal and fetal morbidity and mortality. In addition to the short-term adverse health outcomes, both mother and the child are prone to develop cardiovascular, metabolic and neurological disorders. Although associations between obesity during pregnancy and adverse maternalfetal health outcomes are clear, the complex molecular mechanisms underlying maternal obesity remain largely unknown. This review describes multimeric self-assembling protein complexes, namely inflammasomes, as potential molecular targets in the pathophysiology of maternal obesity. Inflammasomes are implicated in both normal physiological and in pathophysiological processes that occur in response to an inflammatory milieu throughout gestation. This review highlights the current knowledge of inflammasome expression and its activity in pregnancies affected by maternal obesity. Key discussions in defining pharmacological inhibition of upstream as well as downstream targets of the inflammasome signaling cascade; and the inflammasome platform, as a potential therapeutic strategy in attenuating the pathophysiology underpinning inflammatory component in maternal obesity are presented herein.

The ‘deinstitutionalisation’ (DI) movement, also known as ‘care reforms’, is spreading rapidly across the globe, gaining momentum with the growing understanding among both practitioners and policy makers of the harmful effects of institutionalisation on the development and well-being of children as well as the strengthening of the child rights discourse. This has led to a growing international trend towards the development of, and a strong belief in, family-based care options for children deprived of parental care, away from large-scale institutions. This trend is reflected in and supported by international frameworks guiding the care of children, including the United Nations Convention on the Rights of the Child and in particular the United National Guidelines for the Alternative Care of Children, which was hailed in 2009. These instruments recognise that a caring and protective family is central to a child’s development, that governments should fulfil children’s right to quality care in families of origin and in alternative care and that institutionalisation of a child should be discouraged.DI processes are, however, not simple and straightforward as there are many challenges and complexities in their cross-cultural implementation. Even though unequivocally agreed by all stakeholders that the ‘best interest of the child’ should be at the heart of such care reform processes, its actual practice can often contradict such understandings as it gets submerged in numerous other considerations, constraints and challenges. This article analyses some of the dominant DI trends prevailing at present, in particular the primacy of family-based care and the misconceptions associated with the suitability of residential care, illustrated by the experience of SOS Children’s Villages in the DI process and its outcomes in Rwanda. The analysis is premised on the framework of the UN guidelines for the alternative care of children and strives to understand whether DI as it is practiced in Rwanda is aligned with the principles of ‘necessity’, ‘suitability’ and the ‘best interest of the child’ as stipulated in the Guidelines. The attempt is to draw lessons for South Asia from the success as well as the challenges faced in Rwanda, as many governments in South Asia progressively join the DI movement.It is critical for all child-focused international non-governmental organization/ non-governmental organizations (INGOs/NGOs) in Asia to understand the UNGL, learn from different experiences about the challenges of DI and prepare to engage with policy makers. One of the most important lessons from the Rwanda experience is that the ‘quality’ of care should take precedence over the ‘form’ of care, and that quality is not always guaranteed in family-based care. The shift in the positionality of the government of Rwanda and their willingness to rethink their approach to DI particularly in terms of recognising quality residential care is commendable. This needs to be taken as a precedence by other governments across the world including in South Asia—especially by those who are truly interested in ensuring the best interest of children who have lost the care of their parents.

Liquid substance intrusion into concrete is one of the issues that gradually damage its physical and structural integrity. The permeability properties of lightweight self-consolidating concrete containing coconut shell aggregate was investigated in this study. A partial replacement of crushed rock (granite) with coconut shell from 0 to 100% in step of 25% was considered for the mixtures. Rice husk ash (RHA) and Silica fume (SF) were considered for developing binary and ternary blended self-consolidating concrete with total powder content of 450 kg/m3and 550 kg/m3. The testing of concrete involved the saturated water absorption, sorptivity and chloride ingress, which were used to examine the permeability properties of the concrete developed. The laboratory investigations showed encouraging results with better performance up to 75% replacement of crushed granite with coconut shell aggregate.

Tea leaf cultivation is a major part of livelihood in hill station like Nilgiris. The conventional method of tea leaf plucking is done manually with a knife. Harvesting machines have also been designed that could quickly. This gives better result in manpower who has better experience and knowledge about terrains. The paper has proposed a semi-automatic working model that has an arm that can move around and pluck the leaves. A complete pre-processing phase has been done using keyframe extraction, rice counting, optical flow with noise model by the author in an earlier paper. This process is improved by using active contour with optical flow algorithm that minimises the region on which the tea leaf detection algorithm is applied. The second phase of the paper also suggests how deep learning approach can also be used for improving the performance of the proposed work. The proposed work is novel because it has capabilities of considering motion with keyframe capabilities and the noise model using deep learning. The proposed work has experimented with parameters like precision, recall, FAR, FRR to evaluate the nature of misclassifications.

Introduction:This article provides an overview of occupational therapy practice in India by discussing the inception and development of the profession, the educational system, the credentialing process, remuneration, types of research produced in India, and the challenges that Indian occupational therapists face because there is no central council.Methods:Data for this conceptual review came from official government documents, the World Federation of Occupational Therapists, the Data for this conceptual review came from official government documents, the World Federation of Occupational Therapists, the Indian Journal of Occupational Therapy,and the All India Occupational Therapists' Association.Results:There are approximately 5,000 occupational therapists in India. Most are employed in the private sector in hospitals, special schools, rehabilitation clinics, home health systems, subacute clinics, and nongovernmental and nonprofit organizations. India has more than 21 million disabled individuals and an increasing need for health care and rehabilitation services. In addition, India has more than 21 undergraduate and 6 graduate occupational therapy educational programs that are accredited by the World Federation of Occupational Therapists.Conclusion:To increase the efficacy of occupational therapy, practitioners must build and promote culturally relevant services that promote values of justice, peace, equality, cultural relevance, meaning, and advocacy. To increase the efficacy of occupational therapy, practitioners must build and promote culturally relevant services that promote values of justice, peace, equality, cultural relevance, meaning, and advocacy. [[Annals of International Occupational Therapy.2019; 2(3):141–148.]

Placental development is particularly altered in trisomy of chromosome 21 (T21)-affected pregnancies. We previously described in T21-affected placentae an abnormal paracrine crosstalk between the villus mesenchymal core and villus trophoblasts. T21-affected placentae are known to be characterized by their hypovascularity. However, the causes of this anomaly remain not fully elucidated. Therefore, the hypothesis of an abnormal paracrine crosstalk between fetal mesenchymal core and placental endothelial cells (PLECs) was evocated. Villus mesenchymal cells from control (CMCs) and T21 placentae (T21MCs) were isolated and grown in culture to allow their characterization and collection of conditioned media for functional analyses (CMC-CM and T21MC-CM, respectively). Interestingly, PLEC proliferation and branching ability were less stimulated by T21MC-CM than by CMC-CM. Protein array analysis identified secreted proangiogenic growth factors in CMC-CM, which were reduced in T21MC-CM. Combined mass spectrometry and biochemical analysis identified spondin-2 as a factor decreased in T21MC-CM compared with CMC-CM. We found that exogenous spondin-2 stimulated PLEC proliferation and established that T21MC-CM supplemented with spondin-2 recovered conditioned media ability to induce PLEC proliferation and angiogenesis. Hence, this study demonstrates a crosstalk between villus mesenchymal and fetal endothelial cells, in which spondin-2 secreted from mesenchymal cells plays a central role in placental vascular functions. Furthermore, our results also suggest that a reduction in spondin-2 secretion may contribute to the pathogenesis of T21 placental hypovascularity.

AbstractObjective:Radiological emergency preparedness and response are increasingly acknowledged as vital components of both emergency readiness and public health. Previous studies have shown that medical providers feel unprepared to respond to radiation incidents. The existing level of knowledge, attitudes, and awareness held by emergency medicine residents and physicians in Oman, remain unexplored. This study aims to evaluate the knowledge, attitude, and awareness level of emergency residents and physicians in Oman regarding the management of radiation emergencies.Methods:An electronic survey was distributed to 44 emergency residents and 57 emergency physicians.Results:The response rate was 62.7% (N = 69/110). Notably, 62% reported no prior engagement in radiation emergency training. The majority of participants had neither employed nor received training in operating radiation detection devices. A significant gap in knowledge emerged, with the median self-reported knowledge score of 50/100. The majority of participants (59%) expressed a need for educational programs and materials.Conclusion:Our findings underscore the imperative for enhanced training in radiological incident preparedness for emergency medicine residents and physicians in Oman. The study reveals a clear necessity to bridge the existing gaps in knowledge and attitudes to bolster the readiness of health-care professionals to respond effectively to radiation emergencies.