Isolated major aortopulmonary collateral as the sole pulmonary blood supply to an entire lung segment

Congenital systemic-to-pulmonary collateral arteries or major aortopulmonary collaterals are associated with cyanotic congenital heart disease with decreased pulmonary blood flow. Though it is usually associated with congenital heart diseases, there is an increased incidence of isolated acquired aortopulmonary collaterals in premature infants with chronic lung disease. Interestingly, isolated congenital aortopulmonary collaterals can occur without any lung disease, which may cause congestive heart failure and require closure. We present a neonate with an echocardiogram that showed only left-sided heart dilation. Further workup with a CT angiogram demonstrated an anomalous systemic artery from the descending thoracic aorta supplying the left lower lobe. He eventually developed heart failure symptoms and was taken to the catheterization laboratory for closure of the collateral. However, with the collateral being the only source of blood flow to the entire left lower lobe, he required surgical unifocalization. Isolated aortopulmonary collaterals without any other congenital heart disease or lung disease are rare. Our patient is the first reported case to have an isolated aortopulmonary collateral being the sole pulmonary blood supply to an entire lung segment. Due to its rarity, there is still much to learn about the origin and development of these collaterals that possibly developed prenatally

Infant Mortality in the United States: Socioeconomic Factors Predicting Infant Survival in Late Neo-natal and Post Neo-natal Infants from Birth Certificate Data

According to the Centers for Disease Control and Prevention, the infant mortality rate in the United States in 2018 was 5.6 deaths per 1000 live births. Infant mortality is defined as a child being born alive but dying before their first birthday. This study aimed to determine if adding socioeconomic factors to traditional predictive survival models improved the predictive power in terms of survival for late and post neonatal infants. Secondly, this study looked to develop a risk score to and predict which mothers would be classified as “High” or “Low” risk for infant death. Data were analyzed from a retrospective cohort study using 2016 Period Linked Birth/Infant Death Data Set from the Centers for Disease Control and Prevention. Kaplan-Meier curves, which model estimated survival functions, were created for the parameters of interest and compared unadjusted survival statistics using Log-rank test. A risk score was developed using Cox Proportional Hazards model from potential predictors. From the start of 2016 through the end of 2017 there were 20,334 infant deaths in the United States. Of these, 7979 (39.2%) occurred after the first week of life, 7477 without congenital abnormalities. Time dependent ROC were used to determine the AUC at each time point from a base model consisting of Apgar score at five minutes, gestation age at birth, and birthweight, and compared them to a model with socioeconomic factors added. Goodness of fit tests were also investigated to see how each model fits the data overall. Kaplan Meier curves of the risk categories on training and validation test sets were not statistically significantly different from each other for both the “High” and “Low” risk groups (Brier score 0.096) indicating that the prediction of risk category is very good. The model with socioeconomic factors included had better predictive power compared to the base model with very similar AUC values for months 1-5 and then higher AUC values for months 6-11. As well, goodness of fit tests showed that the socioeconomic status (SES) model fit the data much better (Base p\u3c 0.001, SES p= 0.046). Concordance was also a bit higher for the SES model compared to the Base model, 63.76% vs 63.14%. Kaplan Meier curves indicate that there is potential to utilize baseline clinical information to predict whether an infant should be considered as high risk for mortality within the first year of life. With this information, physicians will be able to direct their attention to patients that may require more social or medical interventions

The Law and Economics of Cybersecurity: An Introduction

One of the most controversial theoretical issues of our time is the governance of cybersecurity. Computer security experts, national security experts, and policy analysts have all struggled to bring meaningful analysis to cybersecurity; however, the discipline of law & economics has yet to be fully applied to the issue. This introduction presents work by leading national scholars who examine this complex national security challenge from a law and economics perspective. The focus spans from a discussion of pure market solutions to public-private issue analysis, providing a valuable basis for policy considerations concerning the appropriate governmental role on the issue of cybersecurity

Pulmonary arteriovenous malformations in children with hereditary hemorrhagic telangiectasia: A longitudinal study

Pulmonary arteriovenous malformations (PAVMs) often occur in children with hereditary hemorrhagic telangiectasia (HHT). A 14-year longitudinal study of PAVMs in children with HHT was undertaken to assess the prevalence, the clinical impact, and progression of these malformations. This was a retrospective, single-center study from May 2002 to December 2016 of 129 children with HHT diagnosed using Curacao criteria and/or confirmed by genetic testing. Transthoracic contrast echocardiography (TTCE) was the primary screening modality in all patients and PAVMs were diagnosed based on Barzilai criteria. Moderately positive TTCE (Barzilai criteria ≥ 2) was confirmed with subsequent contrast chest CT. New PAVMs were diagnosed with a positive TTCE after an initial negative TTCE. Embolization of PAVMs were performed according to HHT consensus guidelines. Of 129 children with HHT, 76 (59%) were found to have PAVMs. Sixty-seven (88%) were positive for PAVMs on initial screening. Of 63 children without PAVMs on initial screening, 31 were followed for \u3e1 year. Nine of the 31 (29%) developed new PAVMs after initial negative study. Thirty-eight (50%) of the total 76 children with PAVMs had or developed lesions large enough to be treated with embolization. Nine patients with PAVMs initially too small to be treated with embolization, developed progression of disease and ultimately were treated with embolization over time. The majority, 60% (23/38), of the children with large PAVMs had no related clinical symptoms. After embolization, 21% (8/38), of patients underwent repeat interventions. Genetic diagnosis, age, and gender were not associated with risk of having PAVM nor with need for repeat interventions. Nearly 60% of children with HHT develop PAVMs. The risk for new PAVMs to develop, small PAVMs to become large, and previously embolized PAVMs to require further intervention remains throughout childhood. Thus, children with HHT require continued follow-up until adulthood