Congenital heart disease is growing up

Congenital heart disease is growing up: adult survivors, reaping the benefits of early surgical and percutaneous intervention, outnumber children in many developed countries. Many have little in the way of residual defects and can look forward to a long and healthy life. However, many others reach adulthood with increasingly complex surgically-modified disease – their truly long term outlook is unknown, but patients with complex anatomy and physiology will require careful and creative management, as described in the articles in this edition

Failures of imagination : terrorist incident response in the context of crisis management

Since the terrorist attacks on the World Trade Center, New York in September 2001, the focus on terrorism and the ability of society and organisations to withstand such incidents has sharpened considerably. At the same time, business continuity and dealing with crises have moved to the forefront of organisations' awareness, not least due to improved regulatory requirements and guidelines. However, this thesis contends that the current methodological framework for responding to terrorist incidents is flawed, resulting in the same issues becoming evident, over and over again. It is argued that an awareness and adoption of three key risk and crisis management methodologies: Fink's Crisis Management Methodology, Risk Communication and Isomorphic Learning, could improve the analysis of such incidents and hence better the response in future. Three significant terrorist attacks were analysed within the context of contemporary literature and two factors were found to be the main cause of difficulties in managing the response to each of the incidents: communication and an inability to achieve organisational learning. It was argued that part of the reason for this was that organisations did not consider a link between crisis and terrorist incident response management and that learning from past experiences did not go beyond the most superficial level in most instances. This thesis demonstrated how risk and crisis management methodologies could have addressed each of the issues that were identified in the case studies and clarified the contribution that they could make. Of primary importance was the recognition that events that may appear dissimilar are, on examination, frequently intrinsically similar and hence can provide valuable learning opportunities.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Vandalism-Militancy Relationship: The Influence of Risk Perception and Moral Disengagement

The file attached to this record is the author's final peer reviewed version.Risk perception and moral disengagement underpin crisis intensification and influence risk behaviours. After arguing about the crucial significance of the influence of risk perception and moral disengagement in addressing vandalism and militancy crisis, we provide conceptual clarification of moral disengagement, moral evaluation and social trust. The research clarifies the influence and implication of risk perception and moral disengagement in crisis management within the context of vandalism and militant incidents. Specifically, this study suggests that there are potential gains in crisis management if strategic options are anchored on crisis dimension, morality issues and risk perception. In fact, the study found that people are more likely to disengage from moral conducts and even become skilled at neutralising morally questionable behaviours and activities when the mechanisms of moral evaluation and disengagement routinely operate in them. The research findings indicate that environmental risks are perceived to be more important than economic or biological risks and that individuals’ susceptible to moral disengagement are not predestined to delinquency. Findings attest to environmental victimisation, moralistic punishment, and moral surveillance as active factors which risk and crisis leaders must address. The study advanced crisis management literature through analyses of moral disengagement implications in crisis situations and provides empirical evidence that errors in risk perception evaluation can lead to ineffective crisis response and application of failing strategic option when managing crisis. Furthermore, the research also establishes that conventional wisdom which suggests that vandals and militants are inhumane, and that capturing or alienating them will help prevent or reduce future crisis/disaster is ineffective and unsustainable. The implications and limitations of these findings are discussed

Aortic dissection in pregnancy in England : an incidence study using linked national databases

OBJECTIVES: To conduct the first population-level incidence study of aortic dissection in pregnancy using linked hospital-based data in England. SETTING: Hospital-based data (Hospital Episode Statistics (HES) linked with mortality data from the Office of National Statistics), national enquiries (Confidential Enquiries into Maternal Mortality) and surveys (UK Obstetric Surveillance System; UKOSS) of aortic dissection in pregnancy from 2003 to 2011 in England. PARTICIPANTS: Between 2003 and 2011, all female patients admitted with diagnoses of aortic dissection (not necessarily as the primary cause of admission) and of pregnancy, childbirth and puerperium, were included. OUTCOME MEASURES: Diagnosis of aortic dissection during pregnancy, operated or not operated, with outcome of death or live patient from 2003 to 2011 in England. RESULTS: There were significant differences in characteristics of databases with respect to study population, time of study, recorded event and follow-up of outcomes. On the basis of HES, annual incidence of aortic dissection was 1.23 (95% CI 1.22 to 1.24) per 100 000 maternities. Incidence of aortic dissection with death within 1 year was 0.30 (0.29 to 0.31) per 100 000 maternities. Incidence of aortic dissection increased from 0.74 (0.73 to 0.75) per 100 000 maternities in 2003–2005 to 1.52 (1.51 to 1.53) per 100 000 maternities in 2009–2011. In the Confidential Enquiries into Maternal Deaths, incidence of deaths was highest for 2003–2005 (0.43/100 000 maternities) and lowest for 1997–1999 (0.21/100 000 maternities). In the UK Obstetric Surveillance System, national incidence of aortic dissection was 0.80 (0.50 to 1.50) per 100 000 maternities between 2009 and 2011. CONCLUSIONS: The case of aortic dissection in pregnancy illustrates data limitations regarding complications in pregnancy from different sources in the UK, even for a diagnosis with seemingly few alternative coding and diagnostic possibilities. These limitations should be acknowledged when estimating incidence and outcome

Long-term outcomes of cardiac resynchronization therapy in adult congenital heart disease

Background and Aims: Randomized, controlled trials of cardiac resynchronization therapy (CRT) excluded patients with adult congenital heart disease (ACHD). We sought to explore long-term clinical outcomes. Methods and Results: In this single-center, observational study, events were collected from hospital records on patients with structural ACHD (sACHD) and adults with ischemic (ICM) or nonischemic (NICM) cardiomyopathy undergoing CRT. Patients with sACHD (n = 23, age: 41.6 ± 13.5 years [mean ± standard deviation]) and adults with ICM (n = 533) or NICM (n = 458) were followed-up for 4.1 years (median; interquartile range: 2.2-6.1). Total mortality was 5/23 (21.7%; 4.4 per 100 person-years) in sACHD, 221/533 (41.5%; 11.8 per 100 person-years) in ICM, and 154/458 (33.6%; 9.7 per 100 person-years) in NICM. In univariate analyses, total mortality in sACHD was lower than in ICM (hazard ratio [HR]: 0.38; 95% confidence interval [CI] 0.15-0.91), but similar to NICM (HR: 0.48, 95% CI 0.20-1.16). Cardiac mortality in sACHD was similar to ICM (HR: 0.78, 95% CI 0.32-1.92) and NICM (HR: 1.12, 95% CI 0.45-2.78). Heart failure (HF) hospitalization rates were similar to ICM (HR: 0.44, 95% CI 0.11-1.77) and NICM (HR: 0.75, 95% CI 0.18-3.08). In multivariate analyses, no differences emerged in total mortality, cardiac mortality, or HF hospitalization between sACHD and NICM or ICM, after adjustment for age, sex, New York Heart Association class, diabetes, atrial rhythm, QRS duration, QRS morphology, systemic ventricular ejection fraction, and medical therapy. Conclusion: Total mortality, cardiac mortality, and HF hospitalization after CRT in patients with sACHD was similar to adults with ICM or NICM

Delivery outcomes in women with congenital heart disease: results from the Cuban National Programme for pregnancy and heart disease

Abstract Objective To inform on delivery outcomes achieved in congenital heart disease (CHD) patients by the Cuban National Programme for pregnancy and heart disease. Methods Single-centre retrospective study on a prospectively collected cardiac pregnancy database at a tertiary referral hospital (January 2000–May 2017). Primary outcomes: pregnancy duration, outcome, maternal/fetal complications. Results Four hundred sixty-seven pregnancies in 462 recorded cases reached third trimester. Median age: 25 (21–29) years. Patients presented in NYHA class I (97%, n = 453) or II (3%, n = 14), 6% (n = 27) had arrhythmias, 1% (n = 4) had co-morbidities, 1% (n = 4) had impaired left ventricular function. There were 464 singleton pregnancies and 3 twin pregnancies. Of the singleton pregnancies, one resulted in stillbirth (0.2%). The rest were live births (n = 463), median weight 3200 (2900–3421) grams. Median pregnancy duration: 39.1 (38.6–40) weeks. Caesarean rate: 34% (n = 156). All twin pregnancies (n = 3) resulted in live births (n = 6) via caesarean section, of median weight 2710 (2458–2850) grams and median pregnancy duration 37 (36–38) weeks. Maternal cardiovascular complications (< 0.5%, n = 2), and obstetric complications (14%, n = 67) did not result in any mortality. Small-for-gestational-age was the commonest neonatal complication (10%, n = 48), with zero mortality. Three neonates (1%) had CHD. Post-delivery maternal NYHA functional status: class I in 84% (n = 393), class II in 16% (n = 73), and class III in one patient (< 0.5%). Conclusion In middle-income countries management of CHD pregnancies according to existing guidelines can achieve good maternal and fetal outcomes