Pediatric Cardiology Fellowship Standards for Training in Exercise Medicine and Curriculum Outline.

Over the past 2 decades, fundamentals of exercise medicine, including clinical exercise testing, assessment and promotion of physical activity, exercise prescription, and supervised exercise training/rehabilitation programming have demonstrated considerable clinical value in the management of children and adolescents with congenital and acquired heart disease. Although the principles of exercise medicine have become an integral component in pediatric cardiology, there are no standardized training recommendations for exercise physiology during pediatric cardiology fellowship at this time. Thus, the Pediatric Cardiology Exercise Medicine Curriculum Committee (PCEMCC) was formed to establish core and advanced exercise physiology training recommendations for pediatric cardiology trainees. The PCEMCC includes a diverse group of pediatric cardiologists, exercise physiologists, and fellowship program directors. The expert consensus training recommendations are by no means a mandate and are summarized herein, including suggestions for achieving the minimum knowledge and training needed for general pediatric cardiology practice.

Diastasis recti is associated with incisional hernia after midline abdominal surgery.

PURPOSE: Incisional hernia occurs in up to 20% of patients after abdominal surgery and is most common after vertical midline incisions. Diastasis recti may contribute to incisional hernia but has not been explored as a risk factor or included in hernia risk models. We examined the association between diastasis recti and incisional hernia after midline incisions. METHODS: In this single-center study, all patients undergoing elective gastrointestinal surgery with a midline open incision or extraction site in a prospective surgical quality collaborative database between 2016 and 2020 were included. Eligible patients had axial imaging within 6 months prior to surgery and no less than 6 months after surgery to determine the presence of diastasis recti and incisional hernia, respectively. Radiographic hernia-free survival was assessed with log-rank tests and multivariable Cox regression, comparing patients with and without diastasis width > 25 mm. RESULTS: Of 156 patients, forty-four (28.2%) developed radiographic hernia > 1 cm. 36 of 85 patients (42.4%) with DR width > 25 mm developed IH, compared to 9 of 71 (12.7%) without DR (p < 0.001). Hernia-free survival differed by DR width on bivariate and multivariable Cox regression, adjusted hazard ratio: 3.87, 95% confidence interval: 1.84-8.14. CONCLUSION: Diastasis recti is a significant risk factor for incisional hernia after midline abdominal surgery. When present, surgeons can include these data when discussing surgical risks and should consider a lower risk, off-midline approach when feasible. Incorporating diastasis into larger studies may improve comprehensive models of incisional hernia risk.

Investigation of saliva, tongue swabs and buccal swabs as alternative specimen types to nasopharyngeal swabs for SARS-CoV-2 testing.

Throughout the ongoing SARS-CoV-2 pandemic, the recommended sample type for initial diagnostic testing for SARS-CoV-2 infection has been a nasopharyngeal swab. Shortages in swabs and difficulties in obtaining nasopharyngeal swabs in certain patient groups has prompted research into alternative specimen types for the diagnosis of COVID-19. The aim of this study was to assess how 'simply collected' saliva along with tongue swabs and buccal swabs preformed as an alternative specimen type for SARS-CoV-2 detection. It was observed that saliva samples allowed for the detection of 85.3% of positive patients, tongue swabs allowed for the detection of 67.6% of positive patients and buccal swabs allowed for detection of 20.8% of positive patients, when compared to nasopharyngeal swabs. From this data, it could be concluded that using simple saliva collection can provide a less invasive and reliable alternative method for the detection of SARS-CoV2 particularly in those patients where invasive sampling is difficult and where regular repeat testing is required.

A Study of GP Workload and Satisfaction.

Aims In this novel study in the Irish setting, we quantified the number items managed per General Practitioner (GP) consult, how each item is managed, and impact on a GP's job satisfaction. Methods Participating GPs at two surgeries completed a questionnaire - integrated into the practice management software - after each consultation that satisfied the inclusion criteria during a four-week period. Results Due to feasibility constraints, 500 of 857 (58.3%) completed questionnaires were randomly selected for our sample. GPs manage an average of 1.76 items per consultation. Older patients presented with more items. Greater number of presenting items led to less being managed on the day 71% (n=5) for 5 items vs. 95.2% (n= 246) for 1 item, longer consultation duration (mean = 14.63 minutes (4-45) and decreased GP satisfaction, mean 8/10 (2-10). Conclusion Increasing the number of items in a GP consultation has a statistically significant effect on duration of consultation, how each item is managed, and even GP satisfaction.

Life cycle assessment of pasture-based suckler steer weanling-to-beef production systems: Effect of breed and slaughter age.

Demand for beef produced from pasture-based diets is rising as it is perceived to be healthier, animal friendly and good for the environment. Animals reared on a solely grass forage diet, however, have a lower growth rate than cereal-fed animals and consequently are slaughtered at an older age. This study focused on the former by conducting life cycle assessments of beef production systems offering only fresh or conserved grass, and comparing them to a conventional pasture-based beef production system offering concentrate feeding during housing. The four suckler weanling-to-beef production systems simulated were: (i) Steers produced to slaughter entirely on a grass forage diet at 20 months (GO-20); (ii) Steers produced to slaughter entirely on a grass forage diet at 24 months (GO-24); (iii) Steers produced to slaughter on a grass forage diet with concentrate supplementation during housing (GC-24), and (iv) Steers produced to slaughter entirely on a grass forage diet at 28 months (GO-28). Two breed types were evaluated: early-maturing and late-maturing (LM). The environmental impacts assessed were global warming potential (GWP), non-renewable energy (NRE), acidification potential (AP), eutrophication potential (marine (MEP) and freshwater) were expressed per animal, per kg live weight gain (LWG), kg carcass weight gain, and kg meat weight gain (MWG). The GO-20 production system had the lowest environmental impact across all categories and functional units for both breeds. Extending age at slaughter increased environmental impact across all categories per animal. The LWG response of EM steers to concentrate feed supplementation in GC-24 was greater than the increase in total environmental impact resulting in GC-24 having a lower environmental impact across categories per kg product than GO-24. Concentrate feed supplementation had a similar effect on LM steers with the exception of NRE and AP. The increase in daily LWG in the third grazing season in comparison to the second grazing and housing resulted in GO-28 having lower GWP, NRE, AP, and MEP per kg product than GO-24. Early-maturing steers had lower environmental impact than LM when expressed per kg LWG. However the opposite occurred when impacts were expressed per kg MWG, despite LM steers producing the least LWG. The LM steers compensated for poor LWG performance by having superior carcass traits, which caused the breed to have the lowest environmental impact per kg MWG. The results reaffirms the importance of functional unit and suggests reducing the environmental impact of LWG does not always translate into improvements in the environmental performance of meat.

Upskilling the surgical workforce for vascular access provision during the COVID-19 pandemic - The Salisbury experience.

A vascular access device is defined as a catheter inserted into veins allowing fluids and medicines to be delivered intravenously1. The need for such devices in acutely unwell patients has remained steady throughout the COVID-19 pandemic. We describe here our experience of up-skilling the resident plastic surgery and maxillofacial surgical registrars to provide a vascular access service to reduce the workload on our intensive care colleagues. We hope that our practice and an 'all hands on deck' approach to the utilisation of baseline skills within the existing workforce will inform other departments to help ease the burden on critical care departments as we progress through the next stages of the COVID-19 pandemic.

Prophylactic closed-incision negative-pressure wound therapy is associated with decreased surgical site infection in high-risk colorectal surgery laparotomy wounds.

AIM: Surgical site infection in colorectal surgery is associated with significant healthcare costs, which may be reduced by using a closed-incision negative-pressure therapy device. The aim of this study was to assess the impact of closed-incision negative-pressure therapy on the incidence of surgical site infection. METHOD: In this retrospective cohort study we evaluated all patients who had undergone high-risk open colorectal surgery at a single tertiary care centre from 2012 to 2016. We compared the incidence of surgical site infection between those receiving standard postoperative wound care between 2012 and 2014 and those receiving closed-incision negative-pressure therapy via a customizable device (Prevena Incision Management System, KCI, an Acelity company, San Antonio, Texas, USA) between 2014 and 2016. A validated surgical site infection risk score was used to create a 1:1 matched cohort subset. RESULTS: Negative pressure therapy was used in 77 patients and compared with 238 controls. Negative pressure patients were more likely to have a stoma (92% vs 48%, P < 0.01) and to be smokers (33% vs 15%, P < 0.01). Surgical site infection was higher in control patients (15%, n = 35/238) compared with negative pressure patients (7%, n = 5/77) (P = 0.05). On regression analysis, negative pressure therapy was associated with decreased surgical site infection (OR 0.27; 95% CI 0.09-0.78). These differences persisted in the matched analysis. CONCLUSION: Negative pressure therapy was associated with decreased surgical site infection. Negative pressure therapy offers significant potential for quality improvement.

The effects of Hurricane Sandy on trauma center admissions.

BACKGROUND: Hurricane Sandy was a particularly unusual storm with regard to both size and location of landfall. The storm landed in New Jersey, which is unusual for a tropical storm of such scale, and created hazardous conditions which caused injury to residents during the storm and in the months following. This study aims to describe differences in trauma center admissions and patterns of injury during this time period when compared to a period with no such storm. METHODS: Data were collected for this study from patients who were admitted to the trauma center at Morristown Medical Center during Hurricane Sandy or the ensuing cleanup efforts (patients admitted between 29 October 2012 and 27 December 2012) as well as a control group consisting of all patients admitted to the trauma center between 29 October 2013 and 27 December 2013. Patient information was collected to compare the admissions of the trauma center during the period of the storm and cleanup to the control period. RESULTS: A total of 419 cases were identified in the storm and cleanup period. 427 were identified for the control. Striking injuries were more common in the storm and cleanup group by 266.7% (p = 0.0107); cuts were more common by 650.8% (p = 0.0044). Medical records indicate that many of these injuries were caused by Hurricane Sandy. Self-inflicted injuries were more common by 301.3% (p = 0.0294). There were no significant differences in the total number of patients, mortality, or injury severity score between the two cohorts. CONCLUSION: The data we have collected show that the conditions caused by Hurricane Sandy and the following cleanup had a significant effect on injury patterns, with more patients having been injured by being struck by falling or thrown objects, cut while using tools, or causing self-inflicted injuries. These changes, particularly during the cleanup period, are indicative of environmental changes following the storm which increase these risks of injury.

Water footprinting of pasture-based farms; beef and sheep.

In the context of water use for agricultural production, water footprints (WFs) have become an important sustainability indicator. To understand better the water demand for beef and sheep meat produced on pasture-based systems, a WF of individual farms is required. The main objective of this study was to determine the primary contributors to freshwater consumption up to the farm gate expressed as a volumetric WF and associated impacts for the production of 1 kg of beef and 1 kg of sheep meat from a selection of pasture-based farms for 2 consecutive years, 2014 and 2015. The WF included green water, from the consumption of soil moisture due to evapotranspiration, and blue water, from the consumption of ground and surface waters. The impact of freshwater consumption on global water stress from the production of beef and sheep meat in Ireland was also computed. The average WF of the beef farms was 8391 l/kg carcass weight (CW) of which 8222 l/kg CW was green water and 169 l/kg CW was blue water; water for the production of pasture (including silage and grass) contributed 88% to the WF, concentrate production - 10% and on-farm water use - 1%. The average stress-weighted WF of beef was 91 l H2O eq/kg CW, implying that each kg of beef produced in Ireland contributed to freshwater scarcity equivalent to the consumption of 91 l of freshwater by an average world citizen. The average WF of the sheep farms was 7672 l/kg CW of which 7635 l/kg CW was green water and 37 l/kg CW was blue water; water for the production of pasture contributed 87% to the WF, concentrate production - 12% and on-farm water use - 1%. The average stress-weighted WF was 2 l H2O eq/kg CW for sheep. This study also evaluated the sustainability of recent intensification initiatives in Ireland and found that increases in productivity were supported through an increase in green water use and higher grass yields per hectare on both beef and sheep farms.

Assessment of patients' attitudes towards weight loss in an Irish general practice setting.

BACKGROUND: Ireland is on course to become the most obese country in Europe by 2025. A recently published action plan for obesity in Ireland identifies primary care as one of the best places to tackle this issue. AIM: This study aims to assess patients' attitudes towards weight loss management in general practice in Ireland. DESIGN AND SETTING: A descriptive study was conducted at one urban single-handed and one rural group practice in the south west of Ireland. METHOD: The study is a quantitative cross-sectional survey. RESULTS: The response rate was 18.72% in the rural and 22.8% in the urban practice. Thirty-three percent of patients underestimated their BMI. Sixty-four percent of overweight and 39% of obese patients said their general practitioner (GP) had never discussed their weight with them. Eighty-five percent of overweight and 68% of obese patients were never told their weight might be affecting their health. Only 19% of obese patients had been referred to a weight loss service. Eighty-seven percent of respondents felt their GP would be a good person to advise them. The main reasons patients felt that their weight was not addressed include patients themselves only wanting to discuss the issue they came with and they also felt that time pressure was stopping GPs. CONCLUSION: Overweight or obese patients are more likely to underestimate their BMI. GPs are not discussing weight management with patients who would benefit the most. There is a poor referral rate to weight loss services. Patients are happy to discuss their weight with their GP but are aware that time management is an issue in their consultations.

Variable phenotypes in Greig cephalopolysyndactyly sydrome (GCPS) and their relevance to plastic surgery.

BACKGROUND: Greig cephalopolysyndactyly syndrome (GCPS) is an uncommon entity characterised by polysyndactyly and craniofacial features. The syndrome is not defined by classic signs. Instead there is a high variability in phenotypes observed. This is due to the large number of different mutations in the glioma-associated oncogene 3 (GLI3) that can give rise to the syndrome. We present a case series of five un-related individuals with GCPS treated in our hand surgery unit with different phenotype presentations of GCPS. CONCLUSION: An awareness of the diversity in phenotypes is important for diagnosis and early referral for genetic confirmation and counselling.

Essential roles of Crk and CrkL in fibroblast structure and motility.

Cytosolic proteins containing SH2 and SH3 domains, such as Crk and Crk-like (CrkL), are broadly expressed adapters that interact with a variety of proteins to fulfill key roles in signal transduction pathways triggered by activation of receptor and non-receptor tyrosine kinases. Crk and CrkL are similar to each other in structure and biochemical function, although they provide both distinct, as well as overlapping, biological roles during development. We developed a systematic approach to investigate Crk family functions at the cellular level by generating a conditional knock-out system for ablation of Crk and CrkL in cultured fibroblasts. The loss of both Crk and CrkL from fibroblasts resulted in reduced cell surface area and adoption of a rounded, refractile cellular phenotype. These morphological alterations were accompanied by a decrease in focal adhesion sites, reduced actin stress fibers and a collapse of microtubule structures. In addition, cells exhibited decreases in spontaneous motility and wound-healing behavior. Reduced p130Cas phosphorylation and actin levels closely followed the loss of Crk and CrkL, and stabilization of polymerized actin by jasplakinolide suppressed the morphological conversion. Ablation of Crk or CrkL alone conferred a much more modest phenotype suggesting that Crk and CrkL have overlapping functions that are critical for maintaining cell structure. The morphological alterations could be partially rescued by reintroduction of CrkII, and, to a lesser extent, CrkL. Taken together, our results suggest that Crk and CrkL have critical roles in cell structure and motility by maintaining cytoskeletal integrity.

Hydrogen sulfide gas emissions during disturbance and removal of stored spent mushroom compost.

Spent mushroom compost (SMC) is a by-product of the mushroom industry that is used as an agricultural fertilizer. In Europe, SMC storage and use are governed by EU Nitrates Directive 91/676/EEC to protect waterways against pollution by nitrates. A health and safety risk was identified during the removal of stored SMC for land application, as the stored SMC released high levels of toxic H2S gas into the atmosphere when disturbed. In this study, emissions of H2S were monitored at two outdoor and two indoor locations where stored SMC was being removed for land application. A repeating peak-trough pattern of H2S emissions was detected at all sites, with peaks corresponding to periods of active disturbance of SMC. The highest H2S concentrations (10 s average) detected at the SMC face were, respectively, 680 and 2083 ppm at outdoor sites 1 and 2, and 687 and 89 ppm at indoor sites 3 and 4. Higher concentrations of H2S were released from older SMC compared to newer material. Indoor-stored SMC had lower moisture content (53% to 65%) compared to outdoor-stored material (66% to 72%), while the temperature of indoor-stored SMC was higher (33 degrees C to 51 degrees C) compared to outdoor-stored material (24 degrees C to 36 degreees C). The current short-term exposure limit (STEL) of 10 ppm was exceeded at all sites except site 4, which was smaller than the other sites, indicating a significant health and safety risk associated with working in the vicinity of stored SMC when it is being actively disturbed. Results suggest that SMC stored under cover in small heaps (600 m3) emits less H2S during disturbance and removal compared to SMC stored outdoors in large heaps (> 1500 m3). This should be taken into consideration in the design, construction, and management of SMC storage facilities. Health and safety protocols should be in place at SMC storage facilities to cover the risks of exposure to toxic H2S gas during disturbance of stored SMC.

Hydrogen sulfide gas emissions in the human-occupied zone during disturbance and removal of stored spent mushroom compost.

Hydrogen sulfide (H2S) gas levels were monitored in the human-occupied zone at four spent mushroom compost (SMC) storage sites during removal of SMC for application on agricultural land. During SMC removal operations, H2S gas monitors were mounted on the outside of the tractor positioned at the SMC periphery, and worn by individual tractor drivers. The highest H2S concentrations (10 s average) detected outside the tractor, at the SMC periphery, and for the tractor driver were, respectively, 454, 249, and 100 ppm for the outdoor sites and 214, 75, and 51 ppm for the indoor sites. The highest short-term exposure values (STEV over a 15 min period) outside the tractor at the SMC periphery, and for the tractor driver were 147, 55, and 86 ppm for the outdoor sites and 19, 9, and 10 ppm for the indoor sites. The values exceeded the current maximum permissible concentration limit of 10 ppm for all the sites except for the SMC periphery and tractor driver at the indoor sites. Results suggest that H2S levels detected at indoor storage sites during SMC removal are lower compared to outdoor storage sites. Results indicate that there is a substantial health and safety risk associated with working in the vicinity of stored SMC when it is being disturbed and removed for land application, and that the risk is great for the tractor driver. This article discusses possible control measures and lists recommendations to reduce the risks.

The effect of protease and nonstarch polysaccharide enzymes on manure odor and ammonia emissions from finisher pigs.

A 2 × 2 factorial experiment was conducted to investigate the effect of dietary protease (0 and 200 mg/kg) and xylanase (0 and 200mg/kg) in reducing manure odor and NH(3) from finisher pigs. Sixteen pigs were assigned to 1 of 4 dietary treatments, (i) basal diet, (ii) basal diet + xylanase, (iii) basal diet + protease, or (iv) basal diet + xylanase + protease, for 24 d. The manure samples from pigs offered diets containing protease showed increased (P < 0.05) molar proportions of isobutyric acid, isovaleric acid, valeric acid, and branched-chain fatty acids in contrast to pigs offered diets without protease supplementation. The pigs offered diets with xylanase inclusion had reduced (P < 0.05) manure odor emissions compared to pigs offered diets without xylanase supplementation [598 vs. 1306 European odor units (OuE)/m(3)]. Pigs offered protease-supplemented diets alone had significantly higher NH(3) emissions compared to basal fed pigs. However, NH(3) emissions were reduced when protease was combined with xylanase. In summary, this study indicates that protease supplementation increased protein-derived VFA in manure and also increased manure NH(3) emissions when offered singularly. Consumption of diets containing xylanase reduced manure odor emissions.

False-positive PCR results linked to administration of seasonal influenza vaccine.

False-positive PCR results usually occur as a consequence of specimen-to-specimen or amplicon-to-specimen contamination within the laboratory. Evidence of contamination at time of specimen collection linked to influenza vaccine administration in the same location as influenza sampling is described. Clinical, circumstantial and laboratory evidence was gathered for each of five cases of influenza-like illness (ILI) with unusual patterns of PCR reactivity for seasonal H1N1, H3N2, H1N1 (2009) and influenza B viruses. Two 2010 trivalent influenza vaccines and environmental swabs of a hospital influenza vaccination room were also tested for influenza RNA. Sequencing of influenza A matrix (M) gene amplicons from the five cases and vaccines was undertaken. Four 2009 general practitioner (GP) specimens were seasonal H1N1, H3N2 and influenza B PCR positive. One 2010 GP specimen was H1N1 (2009), H3N2 and influenza B positive. PCR of 2010 trivalent vaccines showed high loads of detectable influenza A and B RNA. Sequencing of the five specimens and vaccines showed greatest homology with the M gene sequence of Influenza A/Puerto Rico/8/1934 H1N1 virus (used in generation of influenza vaccine strains). Environmental swabs had detectable influenza A and B RNA. RNA detection studies demonstrated vaccine RNA still detectable for at least 66 days. Administration of influenza vaccines and clinical sampling in the same room resulted in the contamination with vaccine strains of surveillance swabs collected from patients with ILI. Vaccine contamination should therefore be considered, particularly where multiple influenza virus RNA PCR positive signals (e.g. H1N1, H3N2 and influenza B) are detected in the same specimen.

A zero waste vision for industrial networks in Europe.

'ZeroWIN' (Towards Zero Waste in Industrial Networks--www.zerowin.eu) is a five year project running 2009-2014, funded by the EC under the 7th Framework Programme. Project ZeroWIN envisions industrial networks that have eliminated the wasteful consumption of resources. Zero waste is a unifying concept for a range of measures aimed at eliminating waste and challenging old ways of thinking. Aiming for zero waste will mean viewing waste as a potential resource with value to be realised, rather than as a problem to be dealt with. The ZeroWIN project will investigate and demonstrate how existing approaches and tools can be improved and combined to best effect in an industrial network, and how innovative technologies can contribute to achieving the zero waste vision.