Risikovurdering ved antikoagulasjonsbehandling hos pasienter med atrieflimmer : Implementering av HAS-BLED i tillegg til CHA₂DS₂-VASc ved Hjerteavdelingen på AHUS

Tema/problemstilling: Temaet for oppgaven er å gjøre en bedre vurdering av blødningsrisiko ved hjelp av HAS-BLED-scoring før igangsetting av oral antikoagulasjonsbehandling ved nyoppdaget atrieflimmer. Vi planlegger å gjennomføre prosjektet i samarbeid med hjertemedisinsk avdeling på Ahus. Kunnskapsgrunnlaget: HAS-BLED er det beste standardiserte prediksjonsverktøyet for vurdering av blødningsrisiko og er blitt validert gjennom en omfattende svensk kohortstudie. HAS-BLED er implementert i UpToDate-retningslinjene, i ESC sine nyeste retningslinjer og i kanadiske retningslinjer. Det forventes også at HAS-BLED vil inkluderes i de nye norske retningslinjene for antikoagulasjonsbehandling som publiseres i løpet av 2013. Dagens praksis og indikatorer: Dagens praksis ved hjertemedisinsk avdeling baserer seg i hovedtrekk på en klinisk, skjønnsmessig vurdering av blødningsrisiko. Vi har definert ulike struktur-, prosess- og resultatindikatorer for å registrere, monitorere og evaluere endring. Prosjektet krever i utgangspunktet lite investering og strukturelle endringer. Endringene vi foreslår går ut på å fasilitere endring og gjøre ressurser tilgjengelig. For å måle graden av måloppnåelse foreslår vi først og fremst å bruke epikriser som kilde. Prosess, ledelse og organisering: Som en mal for prosessen bak å innføre HAS-BLED har vi tatt utgangspunkt i Kotters åtte punkter for en forandringsprosess. Disse åtte punktene kan i tillegg deles inn i fem ulike faser; initiativfasen, oppstartsfasen, planleggingsfasen, gjennomføringsfasen og avslutningsfasen. Vi har også kartlagt forventet motstand mot innføringen av HAS-BLED. Diskusjon/ konklusjon: Vi anser prosjektet å være aktuelt og relevant i arbeidet med kvalitetsforbedring av helsetjenestene. Bruk av HAS-BLED vil både gi en bedre vurdering av risikofaktorer for blødning og gjøre det enklere å påvirke risikofaktorer som det er mulig å endre. Samtidig som det er et spennende prosjekt, ser vi noen svakheter i kunnskapsgrunnlaget og mulige utfordringer knyttet til gjennomføringen av prosjektet. Vi vil allikevel konkludere med at vi anbefaler å innføre HAS-BLED på hjertemedisinsk avdeling, med forbehold om at man begrenser ressursbruken

Investigation of inversion, accumulation and junctionless mode bulk Germanium FinFETs

The characteristic performance of n-type and p-type inversion (IM) mode, accumulation (AC) mode and junctionless (JL) mode, bulk Germanium FinFET device with 3-nm gate length (LG) are demonstrated by using 3-D quantum transport device simulation. The simulated bulk Ge FinFET device exhibits favorable short channel characteristics, including drain-induced barrier lowering (DIBL<10mV/V), sub threshold slope (SS∼64mV/dec.). Electron density distributions in ON-state and OFF-state also show that the simulated devices have large ION/IOFF ratios. Homogenous source/drain doping is maintained and only the channel doping is varied among different operating modes. Also, a constant threshold voltage |VTH|∼0.31V is maintained. Moreover, the calculated quantum capacitance (CQ) values of the Ge nanowire emphasizes the importance of quantum confinement effects (QCE) on the performance of the ultra-scaled devices

Joint topology optimization, power control and spectrum allocation for intra-vehicular multi-hop sensor networks using dandelion-encoded heuristics

In the last years the interest in multi-hop communications has gained momentum within the research community due to the challenging characteristics of the intra-vehicular radio environment and the stringent robustness imposed on critical sensors within the vehicle. As opposed to point-to-point network topologies, multi-hop networking allows for an enhanced communication reliability at the cost of an additional processing overhead. In this context this manuscript poses a novel bi-objective optimization problem aimed at jointly minimizing (1) the average Bit Error Rate (BER) of sensing nodes under a majority fusion rule at the central data collection unit; and (2) the mean delay experienced by packets forwarded by such nodes due to multi-hop networking, frequency channel switching time multiplexing at intermediate nodes. The formulated paradigm is shown to be computationally tractable via a combination of evolutionary meta-heuristic algorithms and Dandelion codes, the latter capable of representing tree-like structures like those modeling the multi-hop routing approach. Simulations are carried out for realistic values of intra-vehicular radio channels and co-channel interference due to nearby IEEE 802.11 signals. The obtained results are promising and pave the way towards assessing the practical performance of the proposed scheme in real setups

Phylogenetic Revision of Savoryellaceae and Evidence for Its Ranking as a Subclass

Morphology, phylogeny, and molecular clock analyses were carried out on Savoryellaceae in order to understand the placements of taxa in this family. Ascotaiwania and Neoascotaiwania formed a well-supported separate clade in the phylogeny of concatenated partial SSU, LSU, TEF, and RPB2 gene data. These two genera share similar morphological features, especially in their asexual morphs, indicating that they are congeneric. Hence, we synonymize Neoascotaiwania under Ascotaiwania. Ascotaiwania hughesii (and its asexual morph, Helicoon farinosum) and Monotosporella setosa grouped in a clade sister to Pleurotheciales and are excluded from Ascotaiwania which becomes monophyletic. A novel genus Helicoascotaiwania is introduced to accommodate Ascotaiwania hughesii and its asexual morph, Helicoon farinosum. A novel species, Savoryella yunnanensis is introduced from a freshwater habitat in Yunnan Province, China. Comprehensive descriptions and illustrations are provided for selected taxa in this family. In addition, we provide evolutionary divergence estimates for Savoryellomycetidae taxa and major marine based taxa to support our phylogenetic and morphological investigations. The taxonomic placement of these marine-based taxa is briefly discussed. Our results indicate that the most basal group of marine-based taxa are represented within Lulworthiales, which diverged from ancestral Sordariomycetes around 149 Mya (91–209) and Savoryellomycetidae around 213 Mya (198–303)

Forecasting tourism recovery amid COVID-19

The profound impact of the coronavirus disease 2019 (COVID-19) pandemic on global tourism activity has rendered forecasts of tourism demand obsolete. Accordingly, scholars have begun to seek the best methods to predict the recovery of tourism from the devastating effects of COVID-19. In this study, econometric and judgmental methods were combined to forecast the possible paths to tourism recovery in Hong Kong. The autoregressive distributed lag-error correction model was used to generate baseline forecasts, and Delphi adjustments based on different recovery scenarios were performed to reflect different levels of severity in terms of the pandemic’s influence. These forecasts were also used to evaluate the economic effects of the COVID-19 pandemic on the tourism industry in Hong Kong

Tight Junction Proteins and Signaling Pathways in Cancer and Inflammation: A Functional Crosstalk.

The ability of epithelial cells to organize through cell-cell adhesion into a functioning epithelium serves the purpose of a tight epithelial protective barrier. Contacts between adjacent cells are made up of tight junctions (TJ), adherens junctions (AJ), and desmosomes with unique cellular functions and a complex molecular composition. These proteins mediate firm mechanical stability, serves as a gatekeeper for the paracellular pathway, and helps in preserving tissue homeostasis. TJ proteins are involved in maintaining cell polarity, in establishing organ-specific apical domains and also in recruiting signaling proteins involved in the regulation of various important cellular functions including proliferation, differentiation, and migration. As a vital component of the epithelial barrier, TJs are under a constant threat from proinflammatory mediators, pathogenic viruses and bacteria, aiding inflammation and the development of disease. Inflammatory bowel disease (IBD) patients reveal loss of TJ barrier function, increased levels of proinflammatory cytokines, and immune dysregulation; yet, the relationship between these events is partly understood. Although TJ barrier defects are inadequate to cause experimental IBD, mucosal immune activation is changed in response to augmented epithelial permeability. Thus, the current studies suggest that altered barrier function may predispose or increase disease progression and therapies targeted to specifically restore the barrier function may provide a substitute or supplement to immunologic-based therapies. This review provides a brief introduction about the TJs, AJs, structure and function of TJ proteins. The link between TJ proteins and key signaling pathways in cell proliferation, transformation, and metastasis is discussed thoroughly. We also discuss the compromised intestinal TJ integrity under inflammatory conditions, and the signaling mechanisms involved that bridge inflammation and cancer

Effects of Anacetrapib in Patients with Atherosclerotic Vascular Disease

BACKGROUND: Patients with atherosclerotic vascular disease remain at high risk for cardiovascular events despite effective statin-based treatment of low-density lipoprotein (LDL) cholesterol levels. The inhibition of cholesteryl ester transfer protein (CETP) by anacetrapib reduces LDL cholesterol levels and increases high-density lipoprotein (HDL) cholesterol levels. However, trials of other CETP inhibitors have shown neutral or adverse effects on cardiovascular outcomes. METHODS: We conducted a randomized, double-blind, placebo-controlled trial involving 30,449 adults with atherosclerotic vascular disease who were receiving intensive atorvastatin therapy and who had a mean LDL cholesterol level of 61 mg per deciliter (1.58 mmol per liter), a mean non-HDL cholesterol level of 92 mg per deciliter (2.38 mmol per liter), and a mean HDL cholesterol level of 40 mg per deciliter (1.03 mmol per liter). The patients were assigned to receive either 100 mg of anacetrapib once daily (15,225 patients) or matching placebo (15,224 patients). The primary outcome was the first major coronary event, a composite of coronary death, myocardial infarction, or coronary revascularization. RESULTS: During the median follow-up period of 4.1 years, the primary outcome occurred in significantly fewer patients in the anacetrapib group than in the placebo group (1640 of 15,225 patients [10.8%] vs. 1803 of 15,224 patients [11.8%]; rate ratio, 0.91; 95% confidence interval, 0.85 to 0.97; P=0.004). The relative difference in risk was similar across multiple prespecified subgroups. At the trial midpoint, the mean level of HDL cholesterol was higher by 43 mg per deciliter (1.12 mmol per liter) in the anacetrapib group than in the placebo group (a relative difference of 104%), and the mean level of non-HDL cholesterol was lower by 17 mg per deciliter (0.44 mmol per liter), a relative difference of -18%. There were no significant between-group differences in the risk of death, cancer, or other serious adverse events. CONCLUSIONS: Among patients with atherosclerotic vascular disease who were receiving intensive statin therapy, the use of anacetrapib resulted in a lower incidence of major coronary events than the use of placebo. (Funded by Merck and others; Current Controlled Trials number, ISRCTN48678192 ; ClinicalTrials.gov number, NCT01252953 ; and EudraCT number, 2010-023467-18 .)

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Short and long-term survival in type A aortic dissection justifies the operative risk and effort

Abstract Objectives. To evaluate the survival rate and complications after operation for acute aortic dissection type A. Design. Chart review of all consecutive patients with aortic dissection admitted during 1999–2008 (n 99) to Oslo University Hospital Ullevål, Oslo. Results. Thirty-day mortality was 14 patients and late mortality 21 patients. Twenty-nine patients had no postoperative complications. Cerebral affection was seen in 22 patients. Seventy-nine patients were operated on with deep hypothermic circulatory arrest. Mean circulatory arrest time was 23 minutes (range 12–47). Eighty-three of the patients were cannulated through the femoral artery, with a 30-day mortality rate of 17% (n 14) versus 0% for other cannulations (n 16); and a stroke rate of 24% (n 20) versus 17% (n&#1113088;2) in patients cannulated in the subclavian or axillary artery (no statistically significant difference in either mortality or stroke). Conclusions. Our study confirms that overall mortality and neurological complications are acceptable and the long-term survival rate is good in patients operated on for acute aortic dissection. Circulatory arrest time seems not to affect neurological complications when being relatively short