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Background: Ketogenic diet is an effective therapy for patients with medically refractory epilepsy. It is generally well tolerated, with the most common side effects being gastrointestinal. Hepatic toxicity has been described as an uncommon side effect of ketogenic diet, usually with long-term use. However, there are limited data to implicate ketogenic diet in acute liver toxicity. Methods and results: We analyzed all patients who underwent elective inpatient ketogenic diet initiation at our institution from June 2019 to June 2022. Of the 25 patients reviewed, we found 6 patients who showed acute, asymptomatic changes in liver function tests during initiation, in both hepatocellular and cholestatic patterns. Two patients stopped the ketogenic diet acutely and 3 patients continued ketogenic diet with changes in medications and/or addition of choline—all patients had improvement and normalization of liver function tests in the short term. One patient had acute normalization of chronically elevated liver function tests on ketogenic diet initiation. Conclusion: Ketogenic diet can cause acute changes in liver function tests during initiation of ketogenic diet, with both hepatocellular and cholestatic patterns, with and without the concurrent use of hepatotoxic medications. In most patients, ketogenic diet can be continued successfully by making changes to medications or addition of choline. [ABSTRACT FROM AUTHOR]

Objectives: Sickle cell disease (SCD) is an inherited disorder that causes lifelong complications, substantially impacting the physical and emotional well‐being of patients and their caregivers. Studies investigating the effects of SCD on quality of life (QOL) are often limited to individual countries, lack SCD‐specific QOL questionnaires, and exclude the caregiver experience. The SHAPE survey aimed to broaden the understanding of the global burden of SCD on patients and their caregivers and to capture the viewpoint of healthcare providers (HCPs). Methods: A total of 919 patients, 207 caregivers, and 219 HCPs from 10, 9, and 8 countries, respectively, answered a series of closed‐ended questions about their experiences with SCD. Results: The symptoms most frequently reported by patients were fatigue/tiredness (84%) and pain/vaso‐occlusive crises (71%). Patients' fatigue/tiredness had one of the greatest impacts on both patients' and caregivers' QOL. On average, patients and caregivers reported missing 7.5 days and 5.0 days per month, respectively, of school or work. HCPs reported a need for effective tools to treat fatigue/tiredness and a desire for more support to educate patients on long‐term SCD‐related health risks. Conclusions: The multifaceted challenges identified using the SHAPE survey highlight the global need to improve both patient and caregiver QOL. [ABSTRACT FROM AUTHOR]

A 65-year-old, health-conscious man reports that he eats organic food and exercises regularly. He often asks his family physician for blood tests to assess for "silent abnormalities." He applies sunscreen whenever he goes outdoors, and at his wellness visit, he asks for a vitamin D test after reading that sunscreen blocks its production in the skin. He takes 1,000 IU of vitamin D3 as part of a daily multivitamin. His 25-hydroxyvitamin D level is 11 ng per mL (27 nmol per L). Although his primary care physician informed him that levels greater than 8 ng per mL (20 nmol per L) are considered adequate for 97.5% of the population, the patient decided to increase his daily vitamin D dose to 5,000 IU and insisted on more frequent checks, every 4 months, until the levels exceed 20 ng per mL (50 nmol per L). [ABSTRACT FROM AUTHOR]

ObjectiveTo compare the efficacy and safety of recombinant anti-D (R-anti-D) with conventional polyclonal anti-D (Poly anti-D) in preventing maternal-fetal rhesus D (RhD) alloimmunization and to investigate the immunogenicity of R-anti-D.MethodsThis was a randomized, open-label, multi-center clinical trial conducted in RhD-negative pregnant women who did not receive antenatal anti-D who delivered RhD-positive babies and showed negative indirect Coombs tests (ICTs) at baseline. The women were randomized in a 2:1 ratio to R-anti-D or Poly anti-D groups and were administered 300 mcg (IM) of the corresponding drug within 72 hours of delivery. ICT was performed 72 hours, 90 days, and 180 days after anti-D injection. Serum samples were collected to check for the development of antibodies against R-anti-D at days 90 and 180, using bridging enzyme-linked immunosorbent assay. The proportion of subjects who had positive ICT results at days 90 and 180 were compared between the groups using Fisher's exact test.ResultsA total of 144 women were randomized to the R-anti-D group and 71 to the Poly anti-D group. Three women in the R-anti-D and none in the Poly anti-D group had a positive ICT result at day 90. No woman in either group had positive ICT result at day 180. Both drugs were well tolerated with only 4 reports of adverse events in each group—all were mild, non-serious, and resolved without sequelae. No subject developed antibodies against R-anti-D.ConclusionThe studied R-anti-D is comparable in efficacy to conventional Poly anti-D and is safe and non-immunogenic.Trial RegistrationClinical Trials Registry of India Identifier: Trial RegistrationClinical Trials Registry of India Identifier: CTRI/2017/03/008101

Determining a suitable, adaptive region of interest (ROI) automatically for extracting information related to cardiac activity (signal-ROI/S-ROI), and another containing information on ambient light-fluctuation (background-ROI/B-ROI, as close as possible to the signal-ROI), and robust signal processing are important in webcam based heart-rate (HR) estimation - in real life situations. We describe a novel method of automatically determining both the ROIs. The forehead is the candidate for the S-ROI, due to its uniformity and minimum vulnerability for deformation. We first identify the skin-pixels within the face-region detected by the Viola-Jones (VJ) algorithm. The forehead-region, and a uniform sub-rectangle within it not containing hair - determined by using variance as a measure - yields the S-ROI. The B-ROI - consisting of 3 rectangles - each of the same size as that of S-ROI, at the two sides and the top of the VJ-rectangle - is used to generate a reference signal for an adaptive noise-cancellation scheme. The situation arising from (possibly simultaneous) facial expressions deforming the S-ROI, is addressed - by extracting the phase sequence associated with the analytic representation of the signal. Experiments conducted with 21 healthy subjects, using this novel array of techniques, have produced good correspondence with the ground truth obtained from a standard finger-pulse transducer - as reflected by the Bland-Altman plot.

Many Catholic high schools have transitioned to a president-principal administrative structure. This article discusses the strengths and weaknesses of the model, revealing pertinent issues that must be addressed while operationalizing the model. Recent research supports some aspects of the model, but it is no panacea. Clear job descriptions, role expectations, and administrative alignment can help the model succeed. (Contains 2 tables.)

Standard automated perimetry (SAP) is the gold standard for evaluating the presence of visual field defects (VFDs). Nevertheless, it has requirements such as prolonged attention, stable fixation, and a need for a motor response that limit application in various patient groups. Therefore, a novel approach using eye movements (EMs) – as a complementary technique to SAP – was developed and tested in clinical settings by our group. However, the original method uses a screen-based eye-tracker which still requires participants to keep their chin and head stable. Virtual reality (VR) has shown much promise in ophthalmic diagnostics – especially in terms of freedom of head movement and precise control over experimental settings, besides being portable. In this study, we set out to see if patients can be screened for VFDs based on their EM in a VR-based framework and if they are comparable to the screen-based eyetracker. Moreover, we wanted to know if this framework can provide an effective and enjoyable user experience (UX) compared to our previous approach and the conventional SAP. Therefore, we first modified our method and implemented it on a VR head-mounted device with built-in eye tracking. Subsequently, 15 controls naïve to SAP, 15 patients with a neuro-ophthalmological disorder, and 15 glaucoma patients performed three tasks in a counterbalanced manner: (1) a visual tracking task on the VR headset while their EM was recorded, (2) the preceding tracking task but on a conventional screen-based eye tracker, and (3) SAP. We then quantified the spatio-temporal properties (STP) of the EM of each group using a cross-correlogram analysis. Finally, we evaluated the human–computer interaction (HCI) aspects of the participants in the three methods using a user-experience questionnaire. We find that: (1) the VR framework can distinguish the participants according to their oculomotor characteristics; (2) the STP of the VR framework are similar to those from the screen-based eye tracker; and (3) participants from all the groups found the VR-screening test to be the most attractive. Thus, we conclude that the EM-based approach implemented in VR can be a user-friendly and portable companion to complement existing perimetric techniques in ophthalmic clinics.

It is economically essential, but challenging, for dairy farmers to manage bovine fertility. Vets can help farmers to improve fertility, and this is cost-effective bringing benefits for production, animal health and welfare, and the environment. However, the extent to which vets are involved in fertility varies considerably between farms, for reasons that are unclear. This study investigated the motivators and barriers that vets perceive when trying to increase their involvement with fertility management on UK dairy farms. Interviews were conducted with 20 vets and four themes identified. The first, “clinical baggage,” highlighted vets' disillusionment due to past experiences of low uptake of their advice by farmers. Consequently, some vets made assumptions about farmer needs and behaviours, and exhibited ageist stereotyping. These issues, along with concerns and fatigue associated with repeatedly offering the same advice which was not acted upon, negatively influenced vets' engagement with farmers. The second theme “stuck in the comfort zone” revealed a loss of enthusiasm by some senior vets, whilst others lacked confidence to engage due to perceived gaps in their knowledge. Vets also reported farmers not perceiving their problems and lack of farm data or facilities, as barriers. The “vet-farmer relationship” theme highlighted building trust and developing strong relationships which were key drivers for vets to proactively engage and to “go the extra mile” for their clients. The final theme “money matters” explored vets' motivations to improve their clients' profitability and included the future sustainability of their own businesses. Our themes provide useful insight into the challenges vets face and provide key areas that can be targeted in future interventions to improve veterinary involvement in fertility management. For example, post-graduate training and support for vets needs to consider factors such as reflection, mentorship, stereotyping, relationships, communication, and leadership skills. This type of postgraduate support is currently limited for vets and requires investment from stakeholders if improvements in production, animal health and welfare, and the environment are to be achieved. Our findings are informative for facilitating veterinary involvement in any disease context, and are relevant for stakeholders including governments, educators, charities, farmer representatives, environmentalists, and veterinary leaders.

This article examines a wide range of parish school indicators that can be used to predict long-term viability. The study reported in this article explored the relationship between demographic variables, financial variables, and parish grade school closures in the Archdiocese of Saint Louis. Specifically, this study investigated whether statistically significant and substantively meaningful differences exist between open and closed schools on selected demographic and financial variables. Discriminant function analysis was utilized to create a model for predicting parish school viability. The final portion of this study describes the translation of this discriminant function analysis into a diagnostic tool that could be used as an early warning system to assess school viability on an ongoing basis. (Contains 10 tables and 5 figures.)

As Catholic high schools continue to experience success in interscholastic athletic leagues, state associations have repeatedly contemplated ways to thwart the perceived Catholic school advantage. In a number of states, the athletic associations have responded to the success of private schools in interscholastic competition by applying a multiplier to the private school's enrollment. The multiplier artificially inflates private school enrollment so that when schools are divided into separate classifications based on enrollment, private schools are grouped with public schools that have larger enrollments and presumably better teams. The underlying assumption is that private schools have an unfair advantage that requires such an adjustment. This article will take a case-study methodological approach, examining those states that have considered enacting a multiplier. The case study approach will inform a critical analysis regarding the multiplier and the rationale for its use.

died of kidney stones after an illness of fourteen days. According to Hermippus he climbed into a bronze bath, requested wine, and 'tossed it back.' He soaked his legs and, [...]

Introduction In the Greater Mekong Subregion, adults are at highest risk for malaria. The most relevant disease vectors bite during daytime and outdoors which makes forest work a high-risk activity for malaria. The absence of effective vector control strategies and limited periods of exposure during forest visits suggest that chemoprophylaxis could be an appropriate strategy to protect forest goers against malaria.Methods and analysis The protocol describes an open-label randomised controlled trial of artemether-lumefantrine (AL) versus multivitamin as prophylaxis against malaria among forest goers aged 16–65 years in rural northeast Cambodia. The primary objective is to compare the efficacy of the artemisinin combination therapy AL versus a multivitamin preparation as defined by the 28-day PCR parasite positivity rate and incidence of confirmed clinical malaria of any species. The sample size is 2200 patient-episodes of duration 1 month in each arm. The duration of follow-up and prophylaxis for each participant is 1, 2 or 3 consecutive 28-day periods, followed by a further 28 days of post-exposure prophylaxis, depending on whether they continue to visit the forest. Analysis will be done both by intention to treat and per protocol.Ethics and dissemination All participants will provide written, informed consent. Ethical approval was obtained from the Oxford Tropical Research Ethics Committee and the Cambodia National Ethics Committee for Health Research. Results will be disseminated by peer-reviewed open access publication together with open data.Trial registration number NCT04041973; Pre-result.

This article outlines the significant legal decisions regarding collective bargaining in Catholic schools, identifies the governance structures employed in Catholic schools and the methods of translating these governance structures into documents required by civil law, and concludes with the citation of two recent court decisions that demonstrate the method of incorporation and the day-to-day governance practices utilized in Catholic schools that are of great importance to educational leaders.

Context: A new indigenous recombinant human chorionic gonadotropin (r-hCG) has been developed in India with a comparable pharmacological profile to that of Ovitrelle® (Merck Serono). Aims: This study aims to compare the efficacy and safety of the new r-hCG with that of Ovitrelle for induction of ovulation in women undergoing intrauterine insemination (IUI). Settings and Design: Randomized (2:1), multicenter, open-label, equivalence clinical trial conducted in India. Subjects and Methods: A total of 217 women, aged 20–37 years, undergoing IUI were administered the new r-hCG (test) 250 mcg or Ovitrelle 250 mcg (comparator) after ovarian stimulation with gonadotropins. The ovulation rate was compared as the primary outcome. In addition, pregnancy rates, incidence of adverse events (AEs), and development of immunogenicity were assessed. Statistical Analysis Used: The ovulation and pregnancy rates were compared using Chi-squared test with statistical significance at P < 0.05. Results: With 144 women in the test group and 73 in the comparator group, the ovulation rate (85.4% vs. 78.1%; P = 0.17) and pregnancy rate (serum β hCG test) (11.8% vs. 12.3%; P = 0.91) were similar in both groups. A total of 15 AEs were reported (11 in the test r-hCG group and 4 in the comparator group) in 11 women; none of these were serious, and all were judged to be unrelated to the study drug. No subject developed immunogenic reaction to the test drug. Conclusions: The new preparation of r-hCG was equivalent to the conventional preparation of r-HCG in the induction of ovulation in patients undergoing IUI.

Context: Therapeutic proteins can cause immune responses, which may have clinical implications. Aims: The aim of the study was to assess the immunogenicity of recombinant human follicle-stimulating hormone (r-hFSH), when used for controlled ovarian stimulation (COS). Settings and Design: Prospective, multicenter study conducted at reproductive medicine clinics in India and Vietnam. Materials and Methods: A total of 285 women, aged 20–40 years, undergoing 354 COS cycles for either intrauterine insemination (IUI) orin vitro fertilization (IVF) were studied. The primary outcome measure was the incidence of development of anti-drug antibodies (ADA) and their neutralization potential. Other outcome measures were follicle development, dose and duration of r-hFSH, positive serum pregnancy test, clinical pregnancy, cycle cancellation, and adverse events (AEs). Statistical Analysis Used: A sample size of 250 was planned. Descriptive statistics are presented. Results: Four patients tested positive for ADA after r-hFSH administration at different time points; all of them tested negative, subsequently. None were found to have neutralization potential. The mean dose and duration of r-hFSH were 816 IU and 8.1 days in IUI and 2183 IU and 9.5 days in IVF, respectively. The serum and clinical pregnancy rates were 12.4% and 11.6% in IUI and 32.7% and 29.9% in IVF cycles, respectively. Seven AEs were reported, including two cases of ovarian hyperstimulation syndrome; two AEs were judged to be serious. Conclusions: The tested r-hFSH has very low immunogenic potential and did not lead to the development of neutralizing antibodies. The overall efficacy and safety of the drug were in-line with existing literature data, and no specific clinical impact of immunogenicity could be identified.