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The mission of this declaration is to urge all relevant entities within the international cardiac surgery, industry, and government sectors to commit to develop and implement an effective strategy to address the scourge of rheumatic heart disease in the developing world through increased access to lifesaving cardiac surgery.

Objectives: To evaluate the major risk factors for adverse short and long term outcomes in patients with active native valve infective endocarditis needing cardiac surgery and to validate the EuroSCORE II in our cohort of patients. Methods: We retrospectively studied 149 patients who underwent native valve surgery for infective endocarditis in June 2000 - May 2011 at our referral centre. Ninety-six patients met the inclusion criteria for the study: 29 aortic valve replacements (AVR), 27 mitral valve replacements (MVR), 28 aortic/mitral (double) valve replacements (DVR) and 12 mitral valve repairs (MV Repair). Results: Mechanical valves were implanted in 68 patients (70.8%), bioprosthetic valves in 16 (16.7%) and mitral annuloplasty rings in 12 (12.5%). The Cox proportional hazard model showed that the most important risk factors for early 30-day mortality were: critical preoperative state, emergency surgery, EuroSCORE II >12%, low cardiac output state (LCOS), HIV positive status, preoperative embolic episodes, vegetation size >1cm and postoperative ventilation >24 hours. The EuroSCORE II underestimated early mortality for the entire cohort. The discriminatory ability was evaluated with the receiver operating characteristic (ROC) curve with an area under the curve of 0.796. The discriminatory ability in the subgroup analysis showed that the AUROC curve was poorer for MVR (0.696), 0.837 for DVR and better for AVR group (0.92). Conclusions: The EuroSCORE II underestimated mortality in the highest risk groups and overestimated mortality in the lowest risk groups. The discriminatory ability and model fit were evaluated to be good and a EuroSCORE II >12% predicted a signifi cantly higher early and medium term mortality.

Background. Heart transplantation in South Africa faces numerous challenges related to organ scarcity and unequal access to advanced heart therapy. There is an urgent need to analyse the current transplant referral pathway to optimise equitable access to transplantation. Objectives. To provide an audit of heart transplant referrals to Groote Schuur Hospital, Cape Town, over a 23-year period, focusing on patient demographics, indications for referral, waiting-list dynamics, and transplant referral outcomes. Methods. The study utilised a retrospective patient folder review for the period 1 January 1997 - 31 December 2019 and audited the trends in heart transplant referrals and associated outcomes of the referral at a tertiary academic hospital. Results. A total of 625 recipients were referred for heart transplantation, with the majority being male (n=412; 65.9%), while gender was undocumented for 69 cases (11.0%). The mean age was 38.1 (14.6) years, and 153 (24.5%) were listed for transplant, while 215 (34.4%) were deemed ineligible for listing. Contraindications for listing included social (n=106; 49.3%), medical (n=83; 38.6%) and psychological (n=26; 12.0%) factors, while 134 patients (21.4%) were considered too well. Poor social circumstances (n=38; 39.6%), poor insight (n=28; 29.2%) and poor compliance (n=21; 21.9%) were the most common non-medical reasons for not listing recipients, while obesity (n=30; 31.3%) and smoking (n=23; 24.0%) were notable medical contraindications. Forty-nine patients (7.8%) died during work-up, while 130 (85.0%) of the listed patients received a heart transplant. Of the 429 donor referrals, 139 (32.4%) were accepted for organ procurement. Reasons for declining donors included unsuitability for transplantation (30.3%), lack of capacity (1.8%), and recipient-donor mismatch (66.9%). Conclusion. Three-quarters of the referred patients were deemed unsuitable for heart transplantation for medical and/or social reasons. The ratio of referral to listing has decreased over time. However, once listed, the likelihood of receiving a transplant was high.

The majority of patients requiring heart valve replacement in low- to middle-income countries (LMICs) need it for rheumatic heart disease (RHD). While the young age of such patients largely prescribes replacement with mechanical prostheses, reliable anticoagulation management is often unattainable under the prevailing socioeconomic circumstances. Cases of patients with clotted valves presenting for emergency surgery as a consequence of poor adherence to anticoagulation control are frequent. The operative mortality rates of reoperations for thrombosed mechanical valves are several times higher than those for tissue valves, and long-term results are also disappointing. Under-anticoagulation prevails in these regions that has clearly been linked to poor international normalised ratio (INR) monitoring. In industrialised countries, safe anticoagulation is defined as >60%–70% of the time in the therapeutic range (TTR). In LMICs, the TTR has been found to be in the range of twenty to forty percent. In this study, we analysed >20,000 INR test results of 552 consecutive patients receiving a mechanical valve for RHD. Only 27% of these test results were in the therapeutic range, with the vast majority (61%) being sub-therapeutic. Interestingly, the post-operative frequency of INR tests of one every 3–4 weeks in year 1 had dropped to less than 1 per year by year 7. LMICs need to use clinical judgement and assess the probability of insufficient INR monitoring prior to uncritically applying Western guidelines predominantly based on chronological age. The process of identification of high-risk subgroups in terms of non-adherence to anticoagulation control should take into account both the adherence history of >50% of patients with RHD who were in chronic atrial fibrillation prior to surgery as well as geographic and socioeconomic circumstances.

A mass-casualty natural disaster such as an earthquake is a rare, surprising event that is usually characterized by chaos and a lack of information, resulting in an overload of casualties in hospitals. Thus, it is very important to refer minor and moderately-injured casualties, that are the majority of casualties and whose injuries are usually not life threatening, to ad hoc care facilities such as Emergency Treatment Sites (ETSs). These facilities support the efficient use of health resources and reduce the burden on permanent healthcare facilities. In our study, a hybrid simulation model, based on a combination of discrete events and an agent-based simulation, provides a solution to the uncertainty of positioning temporary treatment sites. The simulation methodology used compares between "rigid" and "flexible" operating concepts of ETSs (main vs. main+minor ETSs) and found the "flexible" concept to be more efficient in terms of the average walking distance and number of casualties treated in the disaster area.

IntroductionPreformed antibodies against αGal in the human and the presence of αGal antigens on the tissue constituting the commercial bioprosthetic heart valves (BHVs, mainly bovine or porcine pericardium), lead to opsonization of the implanted BHV, leading to deterioration and calcification. Murine subcutaneous implantation of BHVs leaflets has been widely used for testing the efficacy of anti-calcification treatments. Unfortunately, commercial BHVs leaflets implanted into a murine model will not be able to elicit an αGal immune response because such antigen is expressed in the recipient and therefore immunologically tolerated.MethodsThis study evaluates the calcium deposition on commercial BHV using a new humanized murine αGal knockout (KO) animal model. Furtherly, the anti-calcification efficacy of a polyphenol-based treatment was deeply investigated. By using CRISPR/Cas9 approach an αGal KO mouse was created and adopted for the evaluation of the calcific propensity of original and polyphenols treated BHV by subcutaneous implantation. The calcium quantification was carried out by plasma analysis; the immune response evaluation was performed by histology and immunological assays. Anti-αGal antibodies level in KO mice increases at least double after 2 months of implantation of original commercial BHV compared to WT mice, conversely, the polyphenols-based treatment seems to effectively mask the antigen to the KO mice’s immune system.ResultsCommercial leaflets explanted after 1 month from KO mice showed a four-time increased calcium deposition than what was observed on that explanted from WT. Polyphenol treatment prevents calcium deposition by over 99% in both KO and WT animals. The implantation of commercial BHV leaflets significantly stimulates the KO mouse immune system resulting in massive production of anti-Gal antibodies and the exacerbation of the αGal-related calcific effect if compared with the WT mouse. DiscussionThe polyphenol-based treatment applied in this investigation showed an unexpected ability to inhibit the recognition of BHV xenoantigens by circulating antibodies almost completely preventing calcific depositions compared to the untreated counterpart.

Mycobacteriophages Deby, LaterM, LilPharaoh, Paola, SgtBeansprout, and Sulley were isolated from soil using Mycobacterium smegmatis mc2155. Genomic analysis indicated that they belong to subclusters K1 and K5. Their genomic architectures are typical of cluster K mycobacteriophages, with most variability occurring on the right end of the genome sequence.

Socioeconomic factors such as poor health and poor nutrition in low- and middle-income countries (LMICs) may favour inflammatory reactions, thus contributing to the recurrence of rheumatic fever (RF) and thereby modifying trends in rheumatic heart disease (RHD). Apart from epidemiological studies, studies of HIV infections in RHD patients are limited. This systematic review synthesises data on the prevalence and impact of HIV infections or AIDS on RHD from PubMed, Scopus, Web of Science databases up to April 2021. The outcomes were managed using PRISMA guidelines. Of a total of 15 studies found, 10 were eligible for meta-analyses. Meta-analysis found that 17% (95 % CI 8–33, I2 = 91%) of adults in cardiovascular disease (CVD) cohorts in Southern Africa are HIV positive. The proportion of RHD diagnosed among people living with HIV was 4% (95% CI 2–8, I2 = 79%) for adults but lower [2% (95% CI 1–4, I2 = 87%)] among perinatally infected children. Despite limited reporting, HIV-infected patients with RHD are prone to other infections that may enhance cardiac complications due to poor immunological control. PROSPERO registration number: CRD42021237046.

Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. Summary: Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programmes that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of 'assisting only'. In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, it's 'Seal of Approval' for the sustainability of endorsed programmes in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programmes could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries. [ABSTRACT FROM AUTHOR]

One of the main reasons for acquiring a Bachelor's Degree is the perception of higher education as a means of improving graduates' financial status. In light of the increased accessibility of higher education, a growing number of students hope to use their studies as a financial springboard. In the current study we sought to examine this perception and to check whether and to what degree baccalaureate degrees indeed improve graduates' financial situation. In cooperation with Israel's Central Bureau of Statistics we gathered data on 6,091 graduates who completed their studies at the Ariel University Center during 2000-2008. Data analysis included exploring graduates' rate of employment and monthly salary from the day they began their academic studies until eight years later. We divided and distinguished between graduates by discipline and gender. The findings show that graduates earn almost three times the national average salary (and five times the median salary) and indicate employment rates of nearly 100%. Analysis of findings by discipline indicates that the most profitable fields are computer sciences and mathematics, engineering, and architecture. Salaries in the natural and social sciences and in the humanities are significantly lower both compared to the former fields and to the national average salary, at least for this eight year span. Analysis of the data by sex showed that the rate of employment among men is 12% higher than among women and that there is a disparity in employment within each discipline as well. Research conclusions show that academic degrees per se are not a guarantee of financial or occupational security. Employees with degrees in the social sciences and the humanities may find that their pay is no higher than those with no degree. One of the implications of this issue, already evident at this stage is that students are attempting to attain higher degrees in the hope of improving their financial status. The equation of a higher education with a higher income seems to involve other components as well, such as graduates' field of study, seniority on the job, and field of occupation.

The use of bioprostheses for heart valve therapy has gradually evolved over several decades and both surgical and transcatheter devices are now highly successful. The rapid expansion of the transcatheter concept has clearly placed a significant onus on the need for improved production methods, particularly the pre-treatment of bovine pericardium. Two of the difficulties associated with the biocompatibility of bioprosthetic valves are the possibilities of immune responses and calcification, which have led to either catastrophic failure or slow dystrophic changes. These have been addressed by evolutionary trends in cross-linking and decellularization techniques and, over the last two decades, the improvements have resulted in somewhat greater durability. However, as the need to consider the use of bioprosthetic valves in younger patients has become an important clinical and sociological issue, the requirement for even greater longevity and safety is now paramount. This is especially true with respect to potential therapies for young people who are afflicted by rheumatic heart disease, mostly in low- to middle-income countries, for whom no clinically acceptable and cost-effective treatments currently exist. To extend longevity to this new level, it has been necessary to evaluate the mechanisms of pericardium biocompatibility, with special emphasis on the interplay between cross-linking, decellularization and anti-immunogenicity processes. These mechanisms are reviewed in this paper. On the basis of a better understanding of these mechanisms, a few alternative treatment protocols have been developed in the last few years. The most promising protocol here is based on a carefully designed combination of phases of tissue-protective decellularization with a finely-titrated cross-linking sequence. Such refined protocols offer considerable potential in the progress toward superior longevity of pericardial heart valves and introduce a scientific dimension beyond the largely disappointing ‘anti-calcification’ treatments of past decades.

Healthcare systems are complex adaptive systems, requiring a change in leadership style, from the traditional model to collaborative, values-driven leadership (VDL). Family physicians are well positioned to facilitate integration and coordination between levels of care, across specialties and within teams, in partnership with local and district management team members. This short report describes a leadership innovation experience in a rural South African district, where a VDL course was introduced in a district health context to build on a strong tradition of relationship-centred outreach and support aimed at creating a learning health system. The authors reflect on the contribution of family physicians to strengthen team-based capacity building, care coordination and a learning culture aimed at quality improvement from the perspectives of the regional and district hospital environments. A values-based leadership style will enable family physicians to strengthen team-relationships and create organisational environments, which support shared learning and quality improvement approaches. Ultimately this approach should lead to improved health systems.

Though technology has played an increasingly significant role in all types of classrooms, the actual use of technologies has not caught up with the increased availability of hardware and software. Building community in an assistive course, can make full use of advanced technologies and create a student-centred learning environment to meet each individual student's styles and needs.

Background: South African doctors work up to 60 h per week to ensure 24-h service delivery. Many doctors are physically and emotionally exhausted, neglecting families, self-care, patient empathy and innovative thinking about complex health issues. Exposure to clinical work hours demonstrated a dose effect with burnout, suggesting cause and effect, affecting up to 80% of doctors. To retain good doctors, their complex needs must be recognised and allowances made for flexible work options. Taking a risk: George Hospital, a large regional training hospital in a rural district, converted some full-time medical officer posts to part-time posts. This was in response to doctors’ requests for more flexible work options, often after returning from maternity leave or in response to burnout. Perceived risks revolved around institutional resource security and that part-time post vacancies would be difficult to fill. Reaping the benefits: Employing doctors in part-time posts has created stability and continuity in the health team. The hospital had generated a cohort of young professionals who care with empathy and have emotional resilience to train others and plough their skills back into the healthcare service. Conclusion: Reducing working hours and creating flexible options were concrete ways of promoting resilience and retaining competent doctors. We recommend that training and work of doctors be structured towards more favourable options to encourage retention, which may lead to better patient care.

Transport of beach sand to the foredune by wind is essential for dunes to grow. The aeolian sand transport rate is related to wind velocity, but wind-based models often overpredict this transport for narrow beaches (weeks).

Teachers in academia are usually not required to have teacher training but must often be evaluated by their students who expect them to have much better teaching qualifications than their high school teachers. However, teachers in elementary and high schools are required to go through several years of teacher training, resulting in a teaching certificate, which is usually mandatory in the secondary school system. This anomaly causes great tension in colleges and universities and often results in pressure to "improve" teaching evaluation in regard to academic level. In many countries, a doctorate degree in any field automatically allows its holder to teach in academic institutions because the students are expected to learn on their own while the professor is the expert responsible for helping with complicated questions. These discrepancies often hamper the advances of higher education. This paper presents the situation of teaching in higher education in selected countries, while presenting various paradigms for improving the state of teaching in higher education. The aim is to study the methodologies used to assess the quality of teaching in higher education systems, in general, and in Israel, specifically.

This article deals with paradoxical relationships between Israeli universities and colleges and their effect on the system of higher education. The article analyzes the history of the higher-education discourse, ranging from patronizing and domineering relations to collaboration based on the recognition that Israel's entire system of higher education is headed in the same direction. Dialogue between the different types of academic schools in Israel is examined in light of the historical-organizational evolution of both universities and colleges. Paradoxical relationships are examined in light of the goals of the various schools, distinctive features of their student populations, their curricula, and their organizational structure. The article illuminates one of the most dynamic and paradoxical dialogues in Israel in the past decade and suggests a potential scenario encompassing the impact of this dialogue on Israel's entire system of higher education. The authors believe that the case of Israel can contribute to at least two important discussions in the field of international and comparative education: (1) the influence of local and global forces on education policy; and (2) policy implementation and the connection between policy and practice. Discussion of the case of Israel and the paradigmatic transformation of higher education may shed light on implications for the field of higher education worldwide.

Patello-femoral pain syndrome (PFPS) is a common knee joint disability. The integration of hip soft tissue regimens are not always emphasized, although current literature implies that there is a significant relationship between the two and there is a lack of randomized clinical trials to substantiate this relationship in clinical practice. A randomized controlled assessor blinded trial was designed to explore different rehabilitation programs related to PFPS. The study was conducted at RAZIEL institute of physical therapy, Netania, Israel with a total of 30 consecutive patients (mean age 35y), diagnosed with PFPS. All patients were randomly allocated into 3 groups. Group I conventional knee rehabilitation program. Included quadriceps strengthening and Trans Electric Neuromuscular Stimulation (TENS). Group II hip oriented rehabilitation program. included stretching, Hip external rotators strengthening and TENS. Group III a combination of the two above programs. Pain and function were documented on initial of the program and again 3 weeks later, on the completion. Pain was assessed by a numeric visual analogue scale (VAS); function was assessed by Patello-femoral joint evaluation scale (PFJES) (0-100 points). At end of trial, all groups showed significant improvements in VAS and PFJES (p

The recommendations of international scientific societies for the treatment of hypertension in the geriatric population are different. Lack of outcome trials, non-standardised terminology as well as differing levels of evidence contribute to the inconsistencies in the guidelines. This review article compares six international guidelines (ESH-ESC 2007/2009, SHG 2009, DHL 2008, CHEP 2010, NICE 2011 and JNC7 2003) as well as the consensus document of the ACCF/AHA 2011 in terms of their recommendations of drug classes, target blood pressure values and the use of combination therapy. Generally, antihypertensive therapy appears to be clinically beneficial in geriatric patients. Target blood pressure values of