Subannular left ventricular pseudoaneurysm following mitral valve replacement

Delayed development of left ventricular pseudoaneurysm is a rare late complication of mitral valve prosthesis and requires early surgical intervention. Here we describe the occurrence of such a complication diagnosed 6-months after the valve surgery in a 60-year-old lady. The anatomic delineation of subannular left ventricular pseudoaneurysm using multiple imaging modalities including CT angiography is also being discussed

A framework for learning about improvement: embedded implementation and evaluation design to optimize learning

Abstract Improving health care involves many actors, often working in complex adaptive systems. Interventions tend to be multi-factorial, implementation activities diverse, and contexts dynamic and complicated. This makes improvement initiatives challenging to describe and evaluate as matching evaluation and program designs can be difficult, requiring collaboration, trust and transparency. Collaboration is required to address important epidemiological principles of bias and confounding. If this does not take place, results may lack credibility because the association between interventions implemented and outcomes achieved is obscure and attribution uncertain. Moreover, lack of clarity about what was implemented, how it was implemented, and the context in which it was implemented often lead to disappointment or outright failure of spread and scale-up efforts. The input of skilled evaluators into the design and conduct of improvement initiatives can be helpful in mitigating these potential problems. While evaluation must be rigorous, if it is too rigid necessary adaptation and learning may be compromised. This article provides a framework and guidance on how improvers and evaluators can work together to design, implement and learn about improvement interventions more effectively

Distress, anxiety, and depression in cancer patients undergoing chemotherapy

BACKGROUND: Chemotherapy for cancer is an intense and cyclic treatment associated with number of side-effects. The present study evaluated the effect of chemotherapy on distress, anxiety and depression. PATIENTS AND METHODS: A total of 117 patients were evaluated by using distress inventory for cancer (DIC2) and hospital anxiety and depression scale (HADS). Majority of the patients were taking chemotherapy for solid tumors (52; 44.4%). RESULTS: The mean distress score was 24, 18 (15.38%) were found to have anxiety while 19 (16.23%) had depression. High social status was the only factor found to influence distress while female gender was the only factor found to influence depression in the present study. CONCLUSION: The study highlights high psychological morbidity of cancer patients and influence of gender on depression. Construct of distress as evaluated by DIC 2 may have a possible overlap with anxiety

Impacts of climate alteration on the hydrology of the Yarra River catchment, Australia using GCMs and SWAT model

A rigorous evaluation of future hydro-climatic changes is necessary for developing climate adaptation strategies for a catchment. The integration of future climate projections from general circulation models (GCMs) in the simulations of a hydrologic model, such as the Soil and Water Assessment Tool (SWAT), is widely considered as one of the most dependable approaches to assess the impacts of climate alteration on hydrology. The main objective of this study was to assess the potential impacts of climate alteration on the hydrology of the Yarra River catchment in Victoria, Australia, using the SWAT model. The climate projections from five GCMs under two Representa-tive Concentration Pathway (RCP) scenarios—RCP 4.5 and 8.5 for 2030 and 2050, respectively— were incorporated into the calibrated SWAT model for the analysis of future hydrologic behaviour against a baseline period of 1990–2008. The SWAT model performed well in its simulation of total streamflow, baseflow, and runoff, with Nash–Sutcliffe efficiency values of more than 0.75 for monthly calibration and validation. Based on the projections from the GCMs, the future rainfall and temperature are expected to decrease and increase, respectively, with the highest changes projected by the GFDL-ESM2M model under the RCP 8.5 scenario in 2050. These changes correspond to significant increases in annual evapotranspiration (8% to 46%) and decreases in other annual water cycle components, especially surface runoff (79% to 93%). Overall, the future climate projections indicate that the study area will become hotter, with less winter–spring (June to November) rainfall and with more water shortages within the catchment

Measurement and valuation of health providers' time for the management of childhood pneumonia in rural Malawi - An empirical study

Background: Human resources are a major cost driver in childhood pneumonia case management. Introduction of 13-valent pneumococcal conjugate vaccine (PCV-13) in Malawi can lead to savings on staff time and salaries due to reductions in pneumonia cases requiring admission. Reliable estimates of human resource costs are vital for use in economic evaluations of PCV-13 introduction. Methods: Twenty-eight severe and twenty-four very severe pneumonia inpatients under the age of five were tracked from admission to discharge by paediatric ward staff using self-administered timesheets at Mchinji District Hospital between June and August 2012. All activities performed and the time spent on each activity were recorded. A monetary value was assigned to the time by allocating a corresponding percentage of the health workers' salary. All costs are reported in 2012 US$. Results: A total of 1,017 entries, grouped according to 22 different activity labels, were recorded during the observation period. On average, 99 min (standard deviation, SD = 46) were spent on each admission: 93 (SD = 38) for severe and 106 (SD = 55) for very severe cases. Approximately 40$ 2 per bed-day and, on average, US$29.5 per severe pneumonia admission and US$ 37.7 per very severe admission. Conclusions: Self-reporting was successfully used in this context to generate reliable estimates of human resource time and costs of childhood pneumonia treatment. Assuming vaccine efficacy of 41 % and 90 % coverage, PCV-13 introduction in Malawi can save over US$ 2 million per year in staff costs alone

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

Background The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk–outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk–outcome pairs, and new data on risk exposure levels and risk–outcome associations. Methods We used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk–outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017. Findings In 2017, 34·1 million (95% uncertainty interval [UI] 33·3–35·0) deaths and 1·21 billion (1·14–1·28) DALYs were attributable to GBD risk factors. Globally, 61·0% (59·6–62·4) of deaths and 48·3% (46·3–50·2) of DALYs were attributed to the GBD 2017 risk factors. When ranked by risk-attributable DALYs, high systolic blood pressure (SBP) was the leading risk factor, accounting for 10·4 million (9·39–11·5) deaths and 218 million (198–237) DALYs, followed by smoking (7·10 million [6·83–7·37] deaths and 182 million [173–193] DALYs), high fasting plasma glucose (6·53 million [5·23–8·23] deaths and 171 million [144–201] DALYs), high body-mass index (BMI; 4·72 million [2·99–6·70] deaths and 148 million [98·6–202] DALYs), and short gestation for birthweight (1·43 million [1·36–1·51] deaths and 139 million [131–147] DALYs). In total, risk-attributable DALYs declined by 4·9% (3·3–6·5) between 2007 and 2017. In the absence of demographic changes (ie, population growth and ageing), changes in risk exposure and risk-deleted DALYs would have led to a 23·5% decline in DALYs during that period. Conversely, in the absence of changes in risk exposure and risk-deleted DALYs, demographic changes would have led to an 18·6% increase in DALYs during that period. The ratios of observed risk exposure levels to exposure levels expected based on SDI (O/E ratios) increased globally for unsafe drinking water and household air pollution between 1990 and 2017. This result suggests that development is occurring more rapidly than are changes in the underlying risk structure in a population. Conversely, nearly universal declines in O/E ratios for smoking and alcohol use indicate that, for a given SDI, exposure to these risks is declining. In 2017, the leading Level 4 risk factor for age-standardised DALY rates was high SBP in four super-regions: central Europe, eastern Europe, and central Asia; north Africa and Middle East; south Asia; and southeast Asia, east Asia, and Oceania. The leading risk factor in the high-income super-region was smoking, in Latin America and Caribbean was high BMI, and in sub-Saharan Africa was unsafe sex. O/E ratios for unsafe sex in sub-Saharan Africa were notably high, and those for alcohol use in north Africa and the Middle East were notably low. Interpretation By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning

A Novel Defence Mechanism Against Man-In-The-Browser Attacks Using Ais

Man-in-the-Browser (MitB) attacks are a category of Man-in-the-Middle attacks that is considered as the topmost menace to online banking by many professionals. In MitB, a proxy trojan implants itself into the browser of the user and alters thetransactions done by the user. This trojan is imperceptible to the user and also it changes its signature making it difficult to bespotted by antivirus program. Here attackensues before encryption and after decryption in thebrowser. In this paper, an Artificial immune system (AIS) based model is proposed which uses Natural Killer Cells (NK) to alleviate the attack of MitB trojan. Here user profile is created centered on the user’s history of transactions. Two types of NK cells are created- negative selection based NK cells (NSNK) and positive selection based NK cells (PSNK). The incoming transaction details are converted to Major Histocompatibility complex (MHC1) molecules. Then it is supplied to NK cells. If it is detected by NSNK, then it may be an unauthorized transaction and three-factor authentication is applied. If MHC1 is detected by PSNK, then it is considered as authentic and the transaction is free to occur using the default two-factor authentication mechanism

Evaluation of the surface water quality using global water quality index (WQI) models: perspective of river water pollution

Rapid industrialization, urbanization, global warming, and climate change are compromising surface water quality across the globe. Consequently, water conservation is essential for both environmental sustainability and human survival. This study assesses the water quality of the Jamuna River in Bangladesh at five distinct sites during wet and dry seasons. It employs six global water quality indices (WQIs) and contrasts the results with Bangladesh's Environmental Quality Standard (EQS) and the Department of Environment (DoE) criteria. The WQI models used are the Weighted Arithmetic WQI (WAWQI), British Columbia WQI (BCWQI), Canadian Council of Ministers of the Environment WQI (CWQI), Assigned WQI (AWQI), Malaysian WQI (MWQI), and Oregon WQI (OWQI). Fifteen physicochemical parameters were analyzed according to each WQI model's guidelines. The findings reveal that most parameters surpass the standard permissible values. The WQI model results indicate that the average water quality across the five sites falls into the lowest category. A comparison of the WQI models suggests potential correlations between WAWQI and AWQI, as well as between MWQI and OWQI. The straightforward presentation of the WQI models indicates that while the river water requires treatment for household and drinking use, it remains suitable for irrigation. The decline in water quality is likely attributable to human activities, urbanization, municipal waste disposal, and industrial effluents. Authorities must prioritize regular monitoring and assessment of water quality to address the identified challenges. Restoring the water to an acceptable standard will become increasingly difficult without proactive measures.Validerad;2023;Nivå 2;2023-11-27 (hanlid);Full text license: CC BY</p