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Anomalous origin of the right coronary artery from the pulmonary artery, a rare congenital cardiac defect, is typically not diagnosed during infancy. On the other hand, Turner syndrome is usually diagnosed early, and it is classically associated with bicuspid aortic valve and aortic coarctation. Individuals with Turner syndrome are also at increased risk for coronary artery anomalies. We present a case of anomalous right coronary artery from the pulmonary artery in a week-old neonate who also had Turner syndrome, patent ductus arteriosus, transverse aortic arch hypoplasia, and impaired ventricular function. Prostaglandin therapy through the ductus increased the patient's myocardial perfusion. Four months after corrective surgery, she was doing well. We discuss the reperfusion phenomenon in our patient's case, as well as other considerations in this combination of congenital defects., (© 2019 by the Texas Heart® Institute, Houston.)

Mechanical circulatory support for children under 6 years of age remains a challenge. This article describes the preclinical status and the results of recent animal testing with the Penn State Infant Left Ventricular Assist Device (VAD). The objectives have been to 1) demonstrate acceptably low thromboembolic risk to support Food and Drug Administration approval, 2) challenge the device by using minimal to no anticoagulation in order to identify any design or manufacturing weaknesses, and 3) improve our understanding of device thrombogenicity in the ovine animal model, using multicomponent measurements of the coagulation system and renal ischemia quantification, in order to better correlate animal results with human results.The Infant VAD was implanted as a left VAD (LVAD) in 18-29 kg lambs. Twelve LVAD and five surgical sham animals were electively terminated after approximately 30 or 60 days. Anticoagulation was by unfractionated heparin targeting thromboelastography R times of 2x normal (n = 6) or 1x normal (n = 6) resulting in negligible heparin activity as measured by anti-Xa assay (<0.1 IU/ml). Platelet inhibitors were not used.There were no clinically evident strokes or evidence of end organ dysfunction in any of the 12 electively terminated LVAD studies. The degree of renal ischemic lesions in device animals was not significantly different than that found in five surgical sham studies, demonstrating minimal device thromboembolism.In summary, these results in a challenging animal test protocol support the conclusion that the Penn State Infant VAD has a low thromboembolic risk and may allow lower levels of anticoagulation.

Purpose: To report on a 39-year-old gentleman with a background of Type 2 diabetes mellitus who was diagnosed with acute promyelocytic leukemia (APL), which was treated by all-trans retinoic acid (ATRA), and subsequently developed bilateral neovascularization of the disk (NVD)., Methods: Ophthalmic examination and investigation including fundus photography and fluorescein angiography., Results: Three months after commencement of ATRA therapy, the patient was found to have florid bilateral NVD with adjacent preretinal and intraretinal hemorrhages. Fundus fluorescein angiography was undertaken and NVD was confirmed in both eyes, which was significantly greater than expected for the extent of disease secondary to diabetic retinopathy. As a result of the fluorescein angiography findings, we believe ATRA-mediated upregulation of vascular endothelial growth factor may be the etiology of the NVD. Literature review shows some in vitro studies, which describe ATRA-induced upregulation of vascular endothelial growth factor in ocular tissues. The patient was managed successfully by cessation of ATRA and a single intravitreal injection of bevacizumab in each eye., Conclusion: Acute promyelocytic leukemia treated with ATRA may result in upregulation of vascular endothelial growth factor in retinal tissues. Subsequent development of NVD may occur; however, this resolves well by cessation of ATRA and intravitreal injection of bevacizumab. We recommend that all patients undergoing treatment with ATRA for acute promyelocytic leukemia be monitored by an ophthalmologist.

The objective of this study was to compare the effects of nonpulsatile and ECG-synchronized pulsatile extracorporeal life support on coronary and carotid blood flow velocities using transthoracic echocardiography and vascular ultrasound, respectively. Nine adult swine were randomly separated into nonpulsatile (NP, n = 5) and pulsatile (P, N = 4) groups and placed on ECLS for 24 h using an i-cor ECLS system. Noninvasive transthoracic images of the left and right coronary artery and the left carotid artery were acquired at the pre-ECLS (baseline), 30 min, 3, 6, 9, 12, and 24 h on-ECLS stages. The mean diastolic velocity of the left and right coronary arteries in the NP group significantly decreased after 24 h on ECLS compared to the baseline and 30 min ECLS stages (P < 0.05). There was no statistical difference in the mean diastolic velocity of the coronary arteries in the P group at 30 min, 3-, 6-, 9-, 12-, and 24-h ECLS compared to baseline. The P group showed a smaller decrease in the mean diastolic velocity of coronary arteries between the 30-min ECLS and 3-, 6-, 9-, 13-, 24-h ECLS stages compared to the NP group. The diastolic velocity of the left carotid artery in the NP group significantly decreased during 24-h ECLS compared to the P group (P < 0.05). An ECG-synchronized pulsatile ECLS system appeared to maintain coronary and carotid artery diastolic velocities better than conventional nonpulsatile ECLS. Further investigation of the perfusion modes during ECLS is warranted., (© 2018 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Background: In patients with trisomy 18, congenital heart surgery is controversial due to anticipated poor patient outcome. Data are lacking regarding clinical outcomes and family opinions about care received., Methods: A retrospective chart review of patients with trisomy 18 and congenital heart disease from 2005 to 2017 was performed. Patients were grouped into those receiving cardiac intervention (surgery or cardiac catheterization) versus medical management. A telephone survey was used to assess completeness of family counseling provided prior to treatment selection and parental opinions on the care received., Results: Seventeen infants were assessed. In the medical management group (n = 7), there were five deaths at a median age of 1.5 months (range: 1.2-4.1 months) and two survivors aged 29 and 44 months at latest follow-up. In the intervention group (n = 10), cardiac surgery was performed in nine patients at a median age of 4.3 months (0.2-23.4 months) and weight of 3.2 kg (1.5-12.2 kg); catheter intervention was performed in one patient at one week of age. At latest follow-up, seven intervention patients are alive at a median age of 50 months (5-91 months). Survey respondents (n = 12) unanimously stated that their child's quality of life was improved by their specific treatment strategy, that the experience of the parents was enhanced, and that they would choose the same treatment course again., Conclusions: Surgical repair may be associated with favorable early outcomes and may be judiciously offered in selected circumstances. In this limited experience, parental perceptions were positive regarding the quality of care and overall experience independent of the chosen treatment strategy or eventual outcome.

Previous research suggests that the complex symbolic, technological, and socioeconomic behaviors that typify Homo sapiens had roots in the middle Pleistocene <200,000 years ago, but data bearing on human behavioral origins are limited. We present a series of excavated Middle Stone Age sites from the Olorgesailie basin, southern Kenya, dating from ≥295,000 to ~320,000 years ago by argon-40/argon-39 and uranium-series methods. Hominins at these sites made prepared cores and points, exploited iron-rich rocks to obtain red pigment, and procured stone tool materials from ≥25- to 50-kilometer distances. Associated fauna suggests a broad resource strategy that included large and small prey. These practices imply notable changes in how individuals and groups related to the landscape and to one another and provide documentation relevant to human social and cognitive evolution., (Copyright © 2018 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Development of the African Middle Stone Age (MSA) before 300,000 years ago raises the question of how environmental change influenced the evolution of behaviors characteristic of early Homo sapiens We used temporally well-constrained sedimentological and paleoenvironmental data to investigate environmental dynamics before and after the appearance of the early MSA in the Olorgesailie basin, Kenya. In contrast to the Acheulean archeological record in the same basin, MSA sites are associated with a markedly different faunal community, more pronounced erosion-deposition cycles, tectonic activity, and enhanced wet-dry variability. Aspects of Acheulean technology in this region imply that, as early as 615,000 years ago, greater stone material selectivity and wider resource procurement coincided with an increased pace of land-lake fluctuation, potentially anticipating the adaptability of MSA hominins., (Copyright © 2018 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Chronic pulmonary insufficiency following transannular patch repair of tetralogy of Fallot may mandate restoration of a competent pulmonary valve. Pulmonary valve leaflets that are preserved at initial surgery may grow and develop normal morphology and subsequent valve repair may be possible. We reviewed our experience with native pulmonary valve restitution following transannular patch repair (2001-15). The cohort included 9 patients with a median age of 18.7 (range 10.6-31.3) years. Operative technique involved reapproximation of the anterior commissure of the pulmonary valve. Median length of stay was 3 days, and there were no deaths. At median follow-up of 2.0 (0.4-13.5) years, pulmonary insufficiency was graded as ≤mild (n = 4), mild-moderate or moderate (n = 4) and moderate-severe (n = 1); pulmonary stenosis was ≤mild (n = 8) and moderate (n = 1), with median peak gradient of 21 (16-64) mmHg. No patient required reintervention. At reoperation to treat pulmonary insufficiency in repaired TOF, if residual leaflets are found with favourable anatomy, restitution of the native valve should be considered. This valve-preserving technique avoids the certain failure of a bioprosthesis and is associated with favourable early outcomes. The viability of this option may influence surgeons to leave the pulmonary leaflets in situ at the time of initial repair., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Astronauts aboard the International Space Station (ISS) have exhibited hyperopic shifts, posterior eye globe flattening, dilated optic nerve sheaths, and even optic disk swelling from spaceflight. Elevated intracranial pressure (ICP) consequent to cephalad fluid shifts is commonly hypothesized as contributing to these ocular changes. Head-down tilt (HDT) is frequently utilized as an Earth-based analog to study similar fluid shifts. Sealed environments like the ISS also exhibit elevated CO 2 , a potent arteriolar vasodilator that could further affect cerebral blood volume (CBV) and cerebral blood flow, intracranial compliance, and ICP. A collaborative pilot study between the National Space Biomedical Research Institute and the German Aerospace Center tested the hypotheses that 1 ) HDT and elevated CO 2 physiologically interact and 2 ) cerebrovascular pulsatility is related to HDT and/or elevated CO 2 In a double-blind crossover study ( n = 6), we measured CBV pulsatility via near-infrared spectroscopy, alongside noninvasive ICP and intraocular pressure (IOP) during 28-h -12° HDT at both nominal (0.04%) and elevated (0.5%) ambient CO 2 In our cohort, CBV pulsatility increased significantly over time at cardiac frequencies (0.031 ± 0.009 μM/h increase in total hemoglobin concentration pulsatility amplitude) and Mayer wave frequencies (0.019 ± 0.005 μM/h increase). The HDT-CO 2 interaction on pulsatility was not robust but rather driven by one individual. Significant differences between atmospheres were not detected in ICP or IOP. Further work is needed to determine whether individual differences in pulsatility responses to CO 2 relate to visual changes in space. NEW & NOTEWORTHY Cerebral blood volume (CBV) pulsatility-as measured by near-infrared spectroscopy-increases over time during -12° head-down tilt at both cardiac and Mayer wave frequencies. CBV pulsatility appeared to increase more under elevated (0.5%) CO 2 at Mayer wave frequencies in some individuals. If similar dynamic pulsatility increases occur in astronauts, there is the potential to initiate vascular and possibly other remodeling processes that lead to symptoms associated with sustained increases in intracranial pressure.

Introduction: Flights to high altitude can lead to exposure and unique pathology not seen in normal commercial aviation., Methods: This paper assesses the potential for point-of-care ultrasound to aid in management and disposition of injured crewmembers from a high altitude incident. This was accomplished through a systematic literature review regarding current diagnostic and therapeutic uses of ultrasound for injuries expected in high altitude free fall and parachuting., Results: While current research supports its utility in diagnostics, therapeutic procedures, and triage decisions, little research has been done regarding its utility in high altitude specific pathology, but its potential has been demonstrated., Discussion: An algorithm was created for use in high altitude missions, in the event of an emergency descent and traumatic landing for an unconscious and hypotensive pilot, to rule out most life threatening causes. Each endpoint includes disposition, allowing concise decision-making.Galdamez LA, Clark JB, Antonsen EL. Point-of-care ultrasound utility and potential for high altitude crew recovery missions. Aerosp Med Hum Perform. 2017; 88(2):128-136.

Quantum fluctuations of the electromagnetic vacuum produce measurable physical effects such as Casimir forces and the Lamb shift. They also impose an observable limit-known as the quantum backaction limit-on the lowest temperatures that can be reached using conventional laser cooling techniques. As laser cooling experiments continue to bring massive mechanical systems to unprecedentedly low temperatures, this seemingly fundamental limit is increasingly important in the laboratory. Fortunately, vacuum fluctuations are not immutable and can be 'squeezed', reducing amplitude fluctuations at the expense of phase fluctuations. Here we propose and experimentally demonstrate that squeezed light can be used to cool the motion of a macroscopic mechanical object below the quantum backaction limit. We first cool a microwave cavity optomechanical system using a coherent state of light to within 15 per cent of this limit. We then cool the system to more than two decibels below the quantum backaction limit using a squeezed microwave field generated by a Josephson parametric amplifier. From heterodyne spectroscopy of the mechanical sidebands, we measure a minimum thermal occupancy of 0.19 ± 0.01 phonons. With our technique, even low-frequency mechanical oscillators can in principle be cooled arbitrarily close to the motional ground state, enabling the exploration of quantum physics in larger, more massive systems.

The StratEx program used a self-contained space suit and balloon system to loft pilot Alan Eustace to a record-breaking altitude and skydive from 135,897 feet (41,422 m). After releasing from the balloon and a stabilized freefall, the pilot safely landed using a parachute system based on a modified tandem parachute rig. A custom spacesuit provided life support using a similar system to NASA's (National Aeronautics and Space Administration; Washington, DC USA) Extravehicular Mobility Unit. It also provided tracking, communications, and connection to the parachute system. A recovery support team, including at least two medical personnel and two spacesuit technicians, was charged with reaching the pilot within five minutes of touchdown to extract him from the suit and provide treatment for any injuries. The team had to track the flight at all times, be prepared to respond in case of premature release, and to operate in any terrain. Crew recovery operations were planned and tailored to anticipate outcomes during this novel event in a systematic fashion, through scenario and risk analysis, in order to minimize the probability and impact of injury. This analysis, detailed here, helped the team configure recovery assets, refine navigation and tracking systems, develop procedures, and conduct training. An extensive period of testing and practice culminated in three manned flights leading to a successful mission and setting the record for exit altitude, distance of fall with stabilizing device, and vertical speed with a stabilizing device. During this mission, recovery teams reached the landing spot within one minute, extracted the pilot, and confirmed that he was not injured. This strategy is presented as an approach to prehospital planning and care for improved safety during crew recovery in novel, extreme events. Menon AS , Jourdan D , Nusbaum DM , Garbino A , Buckland DM , Norton S , Clark JB , Antonsen EL . Crew recovery and contingency planning for a manned stratospheric balloon flight - the StratEx program. Prehosp Disaster Med. 2016;31(5):524-531.

Nail gun injuries primarily occur in the extremities of adult males as a consequence of accidental occupational trauma. Such injury involving the thorax is much less common, and penetrating cardiac injury secondary to pneumatic nail gun discharge is rare. Although potentially lethal, most cases with cardiac trauma are survivable with expedient surgical intervention. Despite improvements in engineered safety mechanisms, the incidence of nail gun injuries has risen as use of the devices has increased. The widespread availability of these tools to nonprofessional consumers exposes a broader population to the potential hazards associated with these devices. We describe the presentation and successful management of the first reported case of penetrating cardiac nail gun injury in a young child.

Background: Noninvasive intracranial pressure (ICP) measurement would represent a major advance for patients with neurological problems. The Vittamed ICP meter is an ultrasound-based device reported to have high agreement with lumbar puncture cerebrospinal fluid (CSF) pressure measurement. However, previous studies included mostly patients with normal levels of ICP. The purpose of our study was to perform an independent clinical validation study of a transcranial Doppler-based noninvasive ICP meter in patients anticipated to have a wide range of ICP., Methods: In a prospective cross-sectional design, we simultaneously measured ICP with the Vittamed device and the invasive lumbar CSF pressure. The operator of each procedure was blinded to the result of the other method. Data were analyzed using Bland-Altman plots, Pearson correlation coefficients, and receiver operator characteristic curves., Results: Twenty-four independent paired measurements of Vittamed and lumbar CSF pressure were obtained; with mean absolute difference between paired measures of 4.5 mmHg (standard deviation 3.1). The 95% limits of agreement were -10.5 to +11.0. The systematic bias (mean of paired differences) was negligible at 0.25 mmHg. The sensitivity, specificity, and area under the curve for ICP >20 mmHg were 0.73, 0.77, and 0.71, respectively., Conclusions: The Vittamed ICP meter had fair agreement with lumbar CSF pressure measurement. The wide limits of agreement would preclude using this version of the device as a stand-alone method for ICP determination, but may be useful if combined with other ICP screening methods. Ongoing improvements to the Vittamed hardware and software may lead to improvements in accuracy and clinical utility of this device., (Copyright © 2015 Elsevier Inc. All rights reserved.)

We report the observation of efficient and low-noise frequency conversion between two microwave modes, mediated by the motion of a mechanical resonator subjected to radiation pressure. We achieve coherent conversion of more than 10^{12}  photons/s with a 95% efficiency and a 14 kHz bandwidth. With less than 10^{-1}  photons·s^{-1}·Hz^{-1} of added noise, this optomechanical frequency converter is suitable for quantum state transduction. We show the ability to operate this converter as a tunable beam splitter, with direct applications for photon routing and communication through complex quantum networks.

Introduction: The Stratex Project is a high altitude balloon flight that culminated in a freefall from 41,422 m (135,890 ft), breaking the record for the highest freefall to date. Crew recovery operations required an innovative approach due to the unique nature of the event as well as the equipment involved. The parachutist donned a custom space suit similar to a NASA Extravehicular Mobility Unit (EMU), with life support system mounted to the front and a parachute on the back. This space suit had a metal structure around the torso, which, in conjunction with the parachute and life support assembly, created a significant barrier to extraction from the suit in the event of a medical emergency. For this reason the Medical Support Team coordinated with the pressure suit assembly engineer team for integration, training in suit removal, definition of a priori contingency leadership on site, creation of color-coded extraction scenarios, and extraction drills with a suit mock-up that provided insight into limitations to immediate access. This paper discusses novel extraction processes and contrasts the required medical preparation for this type of equipment with the needs of the prior record-holding jump that used a different space suit with easier immediate access. Garbino A, Nusbaum DM, Buckland DM, Menon AS, Clark JB, Antonsen EL. Emergency medical considerations in a space-suited patient. Aerosp Med Hum Perform. 2016; 87(11):958-962.

Objective: Posttraumatic stress disorder (PTSD) has been linked with neuropsychological deficits in several areas, including attention, learning and memory, and cognitive inhibition. Although memory dysfunction is among the most commonly documented deficits associated with PTSD, our existing knowledge pertains only to retrospective memory. The current study investigated the relationship between PTSD symptom severity and event-based prospective memory (PM)., Method: Forty veterans completed a computerized event-based PM task, a self-report measure of PTSD, and measures of retrospective memory., Results: Hierarchical regression analysis results revealed that PTSD symptom severity accounted for 16% of the variance in PM performance, F(3, 36) = 3.47, p < .05, after controlling for age and retrospective memory. Additionally, each of the three PTSD symptom clusters was related, to varying degrees, with PM performance., Conclusions: Results suggest that elevated PTSD symptoms may be associated with more difficulties completing tasks requiring PM. Further examination of PM in PTSD is warranted, especially in regard to its impact on everyday functioning.

Introduction: Postflight postural ataxia reflects both the control strategies adopted for movement in microgravity and the direct effects of deconditioning. Computerized dynamic posturography (CDP) has been used during the first decade of the International Space Station (ISS) expeditions to quantify the initial postflight decrements and recovery of postural stability., Methods: The CDP data were obtained on 37 crewmembers as part of their pre- and postflight medical examinations. Sensory organization tests evaluated the ability to make effective use of (or suppress inappropriate) visual, vestibular, and somatosensory information for balance control. This report focuses on eyes closed conditions with either a fixed or sway-referenced base of support, with the head erect or during pitch-head tilts (± 20° at 0.33 Hz). Equilibrium scores were derived from peak-to-peak anterior-posterior sway. Motor-control tests were also used to evaluate a crewmember's ability to automatically recover from unexpected support-surface perturbations., Results: The standard Romberg condition was the least sensitive. Dynamic head tilts led to increased incidence of falls and revealed significantly longer recovery than head-erect conditions. Improvements in postflight postural performance during the later expeditions may be attributable to higher preflight baselines and/or advanced exercise capabilities aboard the ISS., Conclusions: The diagnostic assessment of postural instability is more pronounced during unstable-support conditions requiring active head movements. In addition to supporting return-to-duty decisions by flight surgeons, the CDP provides a standardized sensorimotor measure that can be used to evaluate the effectiveness of countermeasures designed to either minimize deconditioning on orbit or promote reconditioning upon return to Earth.

By coupling a macroscopic mechanical oscillator to two microwave cavities, we simultaneously prepare and monitor a nonclassical steady state of mechanical motion. In each cavity, correlated radiation pressure forces induced by two coherent drives engineer the coupling between the quadratures of light and motion. We, first, demonstrate the ability to perform a continuous quantum nondemolition measurement of a single mechanical quadrature at a rate that exceeds the mechanical decoherence rate, while avoiding measurement backaction by more than 13 dB. Second, we apply this measurement technique to independently verify the preparation of a squeezed state in the mechanical oscillator, resolving quadrature fluctuations 20% below the quantum noise.

Background: Increasing use of intrauterine devices (IUDs) is seen as a promising strategy to prevent unintended pregnancies, particularly among young women. In this study, we examined correlates of young women's interest in using an IUD, including sources of information about, knowledge of, and attitudes toward IUDs., Methods: We conducted a national Web survey of young adults (ages 18-29) in 2012. Using a subset of data from 382 sexually experienced young women who had never used an IUD, we employed multinominal logit regression models to examine differences in IUD interest., Findings: Twenty percent of women in the sample were interested in using an IUD in the future, 32% were not, and 48% were unsure. Women who thought IUDs were unattractive owing to the devices being inside their bodies, the need for provider insertion and removal, or the potential for pain during insertion were less likely to be interested in ever using an IUD. Those who found IUDs attractive owing to the ease of use, the ability to have sex without interruption or a barrier method, the option of a nonhormonal method, the potential length of use, the internal nature of the method, or the high level of effectiveness were more likely to be interested., Conclusions: These data suggest that young women's attitudes toward IUDs are strongly linked to their interest-or lack thereof-in using an IUD. Health care providers attuned to women's contraceptive preferences are well-poised to help their patients match with methods that best accommodate these preferences., (Copyright © 2015 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

The primary objective of this study was to evaluate a novel electrocardiogram (ECG)-synchronized pulsatile extracorporeal life support (ECLS) system for adult partial mechanical circulatory support for adequate quality of pulsatility and enhanced hemodynamic energy generation in an in vivo animal model. The secondary aim was to assess end-organ protection during nonpulsatile versus synchronized pulsatile flow mode. Ten adult swine were randomly divided into a nonpulsatile group (NP, n = 5) and pulsatile group (P, n = 5), and placed on ECLS for 24 h using an i-cor system consisting of an i-cor diagonal pump, an iLA membrane ventilator, an 18 Fr femoral arterial cannula and a 23/25 Fr femoral venous cannula. Trials were conducted at a flow rate of 2.5 L/min using nonpulsatile or pulsatile mode (with assist ratio 1:1). Real-time pressure and flow data were recorded using a custom-based data acquisition system. To the best of our knowledge, the oxygenator and circuit pressure drops were the lowest for any available system in both groups. The ECG-synchronized i-cor ECLS system was able to trigger pulsatile flow in the porcine model. After 24-h ECLS, energy equivalent pressure, surplus hemodynamic energy, and total hemodynamic energy at preoxygenator and prearterial cannula sites were significantly higher in the P group than those in the NP group (P < 0.05). Urine output was higher in P versus NP (3379 ± 443 mL vs. NP, 2598 ± 1012 mL), and the P group seemed to require less inotropic support, but both did not reach statistical significances (P > 0.05). The novel i-cor system performed well in the nonpulsatile and ECG-synchronized pulsatile mode in an adult animal ECLS model. The iLA membrane oxygenator had an extremely lower transmembrane pressure gradient and excellent gas exchange capability. Our findings suggest that ECG-triggered pulsatile ECLS provides superior end-organ protection with improved renal function and systemic vascular tone., (Copyright © 2015 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Space applications have evolved to play a significant role in disaster relief by providing services including remote sensing imagery for mitigation and disaster damage assessments; satellite communication to provide access to medical services; positioning, navigation, and timing services; and data sharing. Common issues identified in past disaster response and relief efforts include lack of communication, delayed ordering of actions (eg, evacuations), and low levels of preparedness by authorities during and after disasters. We briefly summarize the Space for Health (S4H) Team Project, which was prepared during the Space Studies Program 2014 within the International Space University. The S4H Project aimed to improve the way space assets and experiences are used in support of public health during disaster relief efforts. We recommend an integrated solution based on nano-satellites or a balloon communication system, mobile self-contained relief units, portable medical scanning devices, and micro-unmanned vehicles that could revolutionize disaster relief and disrupt different markets. The recommended new system of coordination and communication using space assets to support public health during disaster relief efforts is feasible. Nevertheless, further actions should be taken by governments and organizations in collaboration with the private sector to design, test, and implement this system.

Background: Bovine pericardial valves are often used for pulmonary valve replacement (PVR) in patients with previously repaired congenital heart disease. Attention has recently focused on the safety of the Mitroflow (Sorin Group USA, Arvada, CO) bovine pericardial valve after a national alert describing several cases of sudden valve failure in young patients. In response, we reviewed our experience using the Mitroflow bioprosthesis for PVR., Methods: Medical records were reviewed for all patients who underwent PVR using a Mitroflow valve at our center (2008-2013)., Results: The cohort included 84 patients with a median age of 18.3 years (range, 0.8-62.1 years) and weight of 48.4 kg (range, 5.7-167.8 kg). Indications for surgical intervention included native outflow tract insufficiency (59 patients), valved conduit failure (20 patients), and isolated prosthetic valve failure (5 patients). Median length of stay was 3 days (range, 2-13 days). There were no hospital deaths. Median follow-up was 2.4 years (range, 0.2-5.6 years). Pulmonary valve insufficiency and peak gradient increased with time. At latest follow-up, freedom from insufficiency greater than or equal to a moderate degree was 83%, and freedom from a peak gradient greater than or equal to 50 mm Hg was 92%. Reintervention was required in 4 patients. One patient experienced endocarditis and underwent surgical PVR (0.6 years after initial intervention). Three patients underwent transcatheter treatment for valve stenosis including PVR (at 4.2 and 4.4 years in 2 patients) and balloon valvuloplasty (at 5.2 years in the third patient). Kaplan-Meier freedom from reintervention at 5 years was 81%., Conclusions: Early outcomes using the Mitroflow bovine pericardial valve for PVR in children and adults with repaired congenital heart disease appear acceptable and similar to reported outcomes for other tissue valve options. Valve failure from premature structural deterioration was not observed., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Apolipoprotein E (apoE) may play a critical role in modulating the response to neurological injury after cardiopulmonary bypass (CPB) in children. Plasma samples were collected from 38 pediatric patients. Half of the patients received nonpulsatile flow and the other half underwent pulsatile flow during CPB. Plasma samples were collected at three time points: at baseline prior to incision (T1), 1 h after CPB (T2), and 24 h after CPB (T3). The study included 38 pediatric patients undergoing heart surgery (mean age 2.5 ± 2.1 years). Baseline apoE levels were low (<30 μg/mL) in 21 patients (55%). ApoE levels were significantly decreased at 1 h after CPB compared with baseline (22 ± 14 vs. 34 ± 18 μg/mL, P = 0.001). At 24 h after CPB, apoE levels were significantly increased compared with baseline (47 ± 25 vs. 34 ± 18 μg/mL, P = 0.002). Pulsatile mode was associated with lower apoE levels at 24 h after CPB compared with nonpulsatile mode (38 ± 14 vs. 57 ± 29 μg/mL, P = 0.018). ApoE levels correlated negatively with pump time (r = -0.525, P = 0.021) and cross-clamp time (r = -0.464, P = 0.045) at 24 h following CPB for the nonpulsatile group but not for the pulsatile group. In this cohort of young children with congenital heart disease, baseline apoE levels were low in the majority of patients prior to surgery. ApoE levels decreased further at 1 h after CPB, and then significantly increased by 24 h. The mode of perfusion and the duration of pump time and clamp time influence the apoE levels after CPB. An improved understanding of these mechanisms may translate into the development of new techniques to improve the clinical outcomes after pediatric CPB., (Copyright © 2015 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Arrhythmias are a frequent complication during extracorporeal life support (ECLS). A new ECLS system can provide pulsatile flow synchronized to the patient's intrinsic cardiac cycle based upon the R wave of the electrocardiogram (ECG). It is unclear how the occurrence of arrhythmias may alter the hemodynamic performance of the system. This in vitro study evaluated the effect of simulated arrhythmias on hemodynamics during R wave-triggered pulsatile ECLS. The ECLS circuit with an i-cor diagonal pump and iLA membrane ventilator was primed with whole blood at room temperature. Flow and pressure data were collected at 2.5 and 4 L/min for each condition using a customized data acquisition system. Pulsatile ECLS flow was R wave synchronized to an ECG simulator using 1:1, 1:2, and 1:3 assist ratios. Conditions tested included sinus rhythm at 45 and 90 bpm, supraventricular tachycardia (SVT), ventricular tachycardia (VT), and irregular rhythms such as ventricular fibrillation. Pulsatile mode was successfully triggered by ECG signals of normal sinus rhythm, SVT, VT, atrial fibrillation, atrial flutter, and ventricular bigeminy with assist ratios 1:1, 1:2, and 1:3. Regular rhythm at 90 bpm generated the best surplus hemodynamic energy (SHE). For SVT and VT, an assist ratio of 1:2 resulted in maximum pulsatile flow waveforms with optimal SHE at 2.5 L/min flow rate. At 4 L/min, SHE declined and the pressure drop increased independent of arrhythmia condition. Irregular rhythms still produced adequate pulsatile wave forms at lower pulsatile frequency. This study demonstrated the feasibility of generating pulsatile ECLS flow with the novel ECG-synchronized i-cor system during various simulated rhythms. The optimal rate for pulsatile flow was 90 bpm. During irregular rhythms, the lower pulsatile frequency was the more reliable synchronization mode for generating pulsatile flow., (Copyright © 2015 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

The objective of this study is to investigate the impact of every component of extracorporeal life support (ECLS) circuit on hemodynamic energy transmission in terms of energy equivalent pressure (EEP), total hemodynamic energy (THE), and surplus hemodynamic energy (SHE) under nonpulsatile and pulsatile modes in a novel ECLS system. The ECLS circuit consisted of i-cor diagonal pump and console (Xenios AG, Heilbronn, Germany), an iLA membrane ventilator (Xenios AG), an 18 Fr femoral arterial cannula, a 23/25 Fr femoral venous cannula, and 3/8-in ID arterial and venous tubing. The circuit was primed with lactated Ringer's solution and human whole blood (hematocrit 33%). All trials were conducted under room temperature at the flow rates of 1-4 L/min (1 L/min increments). The pulsatile flow settings were set at pulsatile frequency of 75 beats per minute and differential speed values of 1000-4000 rpm (1000 rpm increments). Flow and pressure data were collected using a custom-based data acquisition system. EEP was significantly higher than mean arterial pressure in all experimental conditions under pulsatile flow (P < 0.01). THE was also increased under pulsatile flow compared with the nonpulsatile flow (P < 0.01). Under pulsatile flow conditions, SHE was significantly higher and increased differential rpm resulted in significantly higher SHE (P < 0.01). There was no SHE generated under nonpulsatile flow. Energy loss depending on the circuit components was almost similar in both perfusion modes at all different flow rates. The pressure drops across the oxygenator were 3.8-24.9 mm Hg, and the pressure drops across the arterial cannula were 19.3-172.6 mm Hg at the flow rates of 1-4 L/min. Depending on the pulsatility setting, i-cor ECLS system generates physiological quality pulsatile flow without increasing the mean circuit pressure. The iLA membrane ventilator is a low-resistance oxygenator, and allows more hemodynamic energy to be delivered to the patient under pulsatile mode. The 18 Fr femoral arterial cannula has acceptable pressure drops under nonpulsatile and pulsatile modes. Further in vivo studies are warranted to confirm these results., (Copyright © 2015 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

The U.S. Supreme Court decisions in U.S. v. Windsor (570 U.S. 307) and Hollingsworth v. Perry (570 U.S. 399) created a focal point for public discussion of marriage equality for same-sex couples. This article reports the results of an exploratory study of the reactions of individuals currently or previously in same-sex couple relationships and a heterosexual sibling who is currently or previously married (N = 371) to the Supreme Court decisions. Thematic content analysis was used to explore participants' responses to an open-ended question on a survey. Reactions of individuals from same-sex couples revealed the following themes: (1) longitudinal perspectives on the advancement of rights for same-sex couples; (2) emotional responses celebrating the decisions or expressing relief; (3) affirmation of their relationship or rights; (4) practical consequences of the extension of rights; and (5) minority stress related to anticipation of future prejudice or discrimination. Themes in the heterosexual siblings' responses were (1) ally support; (2) flat support without emotion or elaboration; (3) indifference to or ignorance about the decisions; and (4) disapproval of the decisions. These themes are compared and discussed in light of prior research on reactions to marriage restriction debates and marriage (in)equality and family relationships.

Introduction: Red Bull Stratos was a commercial program that brought a test parachutist, protected by a full-pressure suit, in a stratospheric balloon with pressurized capsule to over 127,582 ft (38,969 m), from which he free fell and subsequently parachuted to the ground. Given that the major risks to the parachutist included ebullism, negative Gz (toe-to-head) acceleration exposure from an uncontrolled flat spin, and trauma, a comprehensive plan was developed to recover the parachutist under nominal conditions and to respond to any medical contingencies that might have arisen. In this report, the project medical team describes the experience of providing emergency medical support and crew recovery for the manned balloon flights of the program., Methods: The phases of flight, associated risks, and available resources were systematically evaluated., Results: Six distinct phases of flight from an Emergency Medical Services (EMS) standpoint were identified. A Medical Support Plan was developed to address the risks associated with each phase, encompassing personnel, equipment, procedures, and communications., Discussion: Despite geographical, communications, and resource limitations, the medical team was able to implement the Medical Support Plan, enabling multiple successful manned balloon flights to 71,615 ft (21,828 m), 97,221 ft (29,610 m), and 127,582 ft (38,969 m). The experience allowed refinement of the EMS and crew recovery procedures for each successive flight and could be applied to other high altitude or commercial space ventures.

Context: Little research has examined the relationship between women's preferences of contraceptive features and their interest in IUD use. Given high levels of contraceptive discontinuation and dissatisfaction, a better understanding of contraceptive preferences may support women in finding their optimal method and meeting their family planning goals., Methods: Data from 382 heterosexual women aged 18-29 were collected via a 2012 Internet survey. Chi-square tests and multivariate, multinomial logistic regression models were used to examine relationships between contraceptive features preferred by women and their interest in IUD use., Results: Forty-eight percent of women reported being unsure whether they would ever use an IUD; 20% were interested in using one, and 32% were not. In multivariate analyses, characteristics of a contraceptive method found positively associated with IUD interest were the method's not interfering with sexual pleasure (relative risk ratio, 3.4), being 99% effective without user action (2.5) and being effective for up to five years without any user action (3.8). Women who preferred a method that they could see or that would allow them to resume fertility immediately after discontinuation were less likely than those who did not to be interested in using rather than not using an IUD (0.4-0.5)., Conclusions: The findings of this exploratory analysis indicate that women value a multitude of contraceptive features, which may have implications for their interest in using an IUD. Future research should consider the ways that women's contraceptive preferences can be incorporated into contraceptive counseling., (Copyright © 2014 by the Guttmacher Institute.)

Biodegradable polymers are clinically used in numerous biomedical applications, and classically show a loss of mechanical properties within weeks of implantation. This work demonstrates a new class of semi-degradable polymers that show an increase in mechanical properties through degradation via a controlled shift in a thermal transition. Semi-degradable polymer networks, poly(β-amino ester)-co-methyl methacrylate, were formed from a low glass transition temperature crosslinker, poly(β-amino ester), and high glass transition temperature monomer, methyl methacrylate, which degraded in a manner dependent upon the crosslinker chemical structure. In vitro and in vivo degradation revealed changes in mechanical behavior due to the degradation of the crosslinker from the polymer network. This novel polymer system demonstrates a strategy to temporally control the mechanical behavior of polymers and to enhance the initial performance of smart biomedical devices., (Copyright © 2014 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Aims: To assess the willingness to utilise follow-up eye care services among participants of community vision screenings in rural villages surrounding Chennai., Methods: Vision screening participants aged ≥40 years were selected by systematic sampling and were invited to respond to a pretested verbal survey with close-ended questions before undergoing screening., Results: Two hundred and ninety-two people responded. Among the respondents, 50.3% reported experiencing an eye problem, and 53% of these individuals had never had an eye examination. Acceptance rate for eye surgery, medications, and eyeglasses among the respondents was 59.2%, 52.7% and 90.8%, respectively. These acceptances were not associated with sex, age, or employment; medication acceptance was inversely associated with literacy. Surgery acceptance and medication acceptance were associated with area of residence. Presence of another chronic disease was a predictor for surgery acceptance among respondents experiencing eye problems., Conclusions: Maintaining consistent quality of services delivered is crucial for increasing uptake of existing eye care services. Educational interventions may increase eye care service usage by targeting all demographic subgroups of rural populations equally. Additional interventions should be offered to patients without previous exposure to the healthcare system., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

A left atrial appendage aneurysm is a rare cause of atrial arrhythmia in a young adult. Resection of the aneurysm is uniformly recommended in order to prevent thromboembolism and stroke. In patients without evidence of clot within the aneurysm, operative resection via a limited thoracotomy provides a safe and effective alternative to median sternotomy with cardiopulmonary bypass., (© The Author(s) 2014.)

Introduction: The Red Bull Stratos Project consisted of incremental high altitude parachute jumps [maximum altitude 127,852 ft (38,969 m)] from a pressurized capsule suspended from a stratospheric helium-filled balloon. A physiological monitoring system was worn by the parachutist to provide operational medical and acceleration data and to record a unique set of data in a supersonic environment., Methods: Various physiological parameters, including heart rate (HR), respiratory rate (RR), skin temperature, and triaxial acceleration, were collected during the ascent, high altitude float, free fall, and parachute opening and descent stages of multiple low- and high altitude jumps. Physiologic data were synchronized with global positioning system (GPS) and audiovisual data for a comprehensive understanding of the environmental stressors experienced., Results: HR reached maximum during capsule egress and remained elevated throughout free fall and landing. RR reached its maximum during free fall. Temperature data were unreliable and did not provide useful results. The highest accelerations parameters were recorded during parachute opening and during landing. During each high altitude jump, immediately after capsule egress, the parachutist experienced a few seconds of microgravity during which some instability occurred. Control was regained as the parachutist entered denser atmosphere., Discussion: The high altitude environment resulted in extremely high vertical speeds due to little air resistance in comparison to lower altitude jumps with similar equipment. The risk for tumbling was highest at initial step-off. Physiological responses included elevated HR and RR throughout critical phases of free fall. The monitoring unit performed well despite the austere environment and extreme human performance activities.

Background: Ultrasound (U/S) and MRI measurements of the optic nerve sheath diameter (ONSD) have been proposed as intracranial pressure measurement surrogates, but these methods have not been fully evaluated or standardized. The purpose of this study was to develop an ex-vivo model for evaluating ONSD measurement techniques by comparing U/S and MRI measurements to physical measurements., Methods: The left eye of post mortem juvenile pigs (N = 3) was excised and the subdural space of the optic nerve cannulated. Caliper measurements and U/S imaging measurements of the ONSD were acquired at baseline and following 1 cc saline infusion into the sheath. The samples were then embedded in 0.5% agarose and imaged in a 7 Tesla (7T) MRI. The ONSD was subsequently measured with digital calipers at locations and directions matching the U/S and direct measurements., Results: Both MRI and sonographic measurements were in agreement with direct measurements. U/S data, especially axial images, exhibited a positive bias and more variance (bias: 1.318, 95% limit of agreement: 8.609) compared to MRI (bias: 0.3156, 95% limit of agreement: 2.773). In addition, U/S images were much more dependent on probe placement, distance between probe and target, and imaging plane., Conclusions: This model appears to be a valid test-bed for continued scrutiny of ONSD measurement techniques. In this model, 7T MRI was accurate and potentially useful for in-vivo measurements where direct measurements are not available. Current limitations with ultrasound imaging for ONSD measurement associated with image acquisition technique and equipment necessitate further standardization to improve its clinical utility.

In the brain, the components of the fibrinolytic system, tissue plasminogen activator (tPA) and its endogenous inhibitor plasminogen activator inhibitor-1 (PAI-1), regulate various neurophysiological and pathological responses. Fibrinolytic balance depends on PAI-1 and tPA concentrations. The objective of this study is to compare the effects of pulsatile and nonpulsatile perfusion on fibrinolytic balance in children undergoing pediatric cardiopulmonary bypass (CPB). Plasma PAI-1 antigen and tPA antigen were measured in 40 children (n = 20 pulsatile and n = 20 nonpulsatile group). Plasma samples (1.5 mL) were collected (i) prior to incision, (ii) 1 h after CPB, and (iii) 24 h after CPB. PAI-1 and tPA levels were measured at each time point. PAI-1 and tPA levels were significantly increased at 1 h after CPB, followed by a decrease at 24 h. Nonpulsatile but not pulsatile CPB lowered PAI-1 : tPA ratio significantly at 24 h (median PAI-1 : tPA ratio 4.63 ± 0.83:1.98 ± 0.48, P = 0.03, for the nonpulsatile group and 4.50 ± 0.92:3.56 ± 1.28, P = 0.2, for the pulsatile group). These results suggest that pulsatile flow maintains endogenous fibrinolytic balance after pediatric cardiopulmonary bypass. Further studies are needed to define the clinical significance of these differences., (© 2013 Wiley Periodicals, Inc. and International Center for Artificial Organs and Transplantation.)

Background: Nontraumatic, nonhydrocephalic increases in intracranial pressure (ICP) are often difficult to diagnose and may underlie spaceflight-related visual changes. This study looked at the utility of a porcine animal model of increasing cephalic venous pressure to mimic acute changes in ICP and optic nerve sheath diameter (ONSD) from cephalic venous fluid shifts observed during spaceflight., Methods: Anesthetized juvenile piglets were assigned to groups of either naïve (N = 10) or elevated superior vena cava pressure (SVCP; N = 20). To elevate SVCP, a 6F custom latex balloon catheter was inserted and inflated to achieve SVCP of 20 and 40 mmHg for 1 h at each pressure. In both groups, serial measurements of ICP, internal jugular pressure (IJP), and external jugular pressure (EJP) were made hourly for 3 h, and ONSD of the right eye was measured hourly by ultrasound (US)., Results: There was a significant linear correlation between IJP and ICP (slope: 0.9614 +/- 0.0038, r = 0.9683). With increasing SVCP, resulting ONSD was also well correlated with the ICP (slope: 0.0958 +/- 0.0061, r = 0.7841). The receiver operating characteristic curve for ONSD in diagnosing elevated ICP had an area under the curve of 0.9632 with a sensitivity and specificity of 92% and 91%, respectively, for a cutoff of 5.45 mm., Conclusions: Increases in SVCP result in ICP changes that are well correlated with alteration in ONSD. These changes are consistent with observed ONSD changes monitored during spaceflight.

Introduction: Red Bull Stratos was a commercial program that brought a test parachutist protected by a full pressure suit to 127,852 ft (38,964 m), via a stratospheric balloon with a pressurized capsule, from which he free fell and subsequently parachuted to the ground. In light of the uniqueness of the operation and the medical threats faced, medical protocols specific to distinctive injury patterns were developed. One unique threat was that of a flat spin during free fall with resultant exposure to -Gz (toe-to-head) acceleration. In preparation for stratospheric free fall, the medical team conducted a review of the literature on the spectrum of human and animal injury patterns attributable to -Gz exposures. Based on the findings, an emergency medical field response protocol was developed for the rapid assessment, diagnosis, and treatment of individuals suspected of -Gz injury., Methods: A systematic review was conducted on available literature on human and animal studies involving significant -Gz exposure, with subsequent development of an applicable field treatment protocol., Results: The literature review identified pathophysiologic processes and mitigation strategies that were used to develop a prevention and treatment protocol, outlining appropriate interventions using current best medical practices. A medical field treatment protocol was successfully established for the high-altitude balloon program., Discussion: Available literature provided insight into best medical practices for the prevention and treatment of significant -Gz exposures during high-altitude parachute activity. Using the protocol developed for the field medical response, injuries from sustained -Gz exposure can be effectively managed in similar high-altitude and space operations.

Background: Patients approaching death often have a decreasing oral intake, which can be distressing for relatives. Little is known about the relatives' experiences with and perceptions of oral intake at the end of life., Aim: This study aims to contribute to a more thorough understanding of relatives' concerns regarding decreased oral intake of the patient at the end of life., Design: Qualitative interview study: semi-structured interviews were transcribed verbatim and analysed using qualitative content analysis., Setting/participants: Twenty-three bereaved relatives of patients who had been referred to a New Zealand palliative care service were interviewed., Results: All relatives experienced significant changes in patients' oral intake at the end of life. Oral intake towards the end of life was considered important and is perceived as meaningful by relatives in different ways, such as nutritional value, enjoyment, social time, daily routine and a way of caring. Relatives responded differently to decreasing oral intake; some accepted it as inherent to the dying process, others continued efforts to support the patient's oral intake. Some relatives perceived decreasing oral intake as the patient's choice, and some viewed maintaining oral intake as part of the battle against the disease. Relatives recalled limited communication with health-care professionals concerning oral intake at the end of life., Conclusions: This study revealed the complexity of meaning relatives' experiences with dying patients' decreasing oral intake. Their perceptions and concerns were related to their awareness of the imminent death. These findings can guide staff involved in care delivery to better support relatives.

Occult coronary artery obstruction can be a late source of morbidity and mortality following the arterial switch operation for transposition of the great arteries. We describe a case of undiagnosed left coronary ostial obstruction in a teenager which may have contributed to perioperative ventricular dysfunction and subsequent mortality following a reoperation many years after arterial switch., (© 2013 Wiley Periodicals, Inc.)