Recruitment, single ventricular palliation, and complex biventricular repair for patients with Hypoplastic Left Heart Syndrome

BACKGROUND: Hypoplastic Left Heart Syndrome is a congenital birth defect that is defined by underdevelopment of the left heart during pregnancy. This is especially dangerous as the left heart holds the systemic flow of blood- the oxygenated blood. Not enough oxygen throughout the whole body causes cyanosis, which symptoms include bluish discoloration of the skin or mucous membrane due to low oxygen saturation. Single Ventricle Palliation followed by Biventricular Conversion is the most common surgical procedural pathway to correct this defect. The goal is to convert from a single ventricle circulation during single ventricle palliation to biventricular circulation via biventricular conversion, which is the normal heart anatomy. Single Ventricle Pallation consists of three stages: Stage 1 Norwood Procedure, Bidirectional Glenn, and Fontan. Biventricular Conversion can be performed after any of the three stages. In addition, further compromise of the left ventricle includes other factors such as a thickening of fibroblast-like cells on the endocardial layer called endocardial fibroelastosis. Therefore, additional surgical procedures, also known as recruitment procedures, combat these problems. It is critical to find a correlation between a specific procedure and post surgery success in left ventricle growth and function for these patients. OBJECTIVES: Patients with Hypoplastic Left Heart Syndrome at Boston Children’s Hospital have undergone single ventricle palliation with some patients proceeding to biventricular conversion. This study aimed to study the palliation stages individually and recruitment procedures (specifically endocardial fibroelastosis resection) on the effect of left ventricle growth. METHODS: Patients with Hypoplastic Left Heart Syndrome were studied retrospectively (before 2014) and prospectively (after 2014 until December 1, 2018). Single Ventricle Palliation and Biventricular Conversion were analyzed via descriptional analysis with evidence of left ventricular growth measured by left ventricular end diastolic volume and respective z-scores. Z-scores were used to standardize end diastolic volume values across variability in age, weight, and height. RESULTS: A total of 55 patients underwent single ventricle palliation and 39 ended with biventricular circulation via biventricular conversion. Overall, there was a 9.29 ml increase in end diastolic volume between Bidirectional Glenn and Fontan and a 0.795 increase in end diastolic volume z-score between Fontan and Biventricular Conversion. Next, those who did not have recruitment procedures experienced a 135.6%, 48.8%, and 0% growth at Stage 1, Bidirectional Glenn, and Fontan, respectively, before directly proceeding to biventricular conversion. Those with recruitment experienced a 44.5%, 90.4%, and 83.0% growth at Stage 1, Bidirectional Glenn, and Fontan, respectively, before directly proceeding to biventricular conversion. Finally, there was a 50.2% and 62.3% in left ventricular growth at Bidirectional Glenn and Fontan, respectively, after endocardial fibroelastosis resection compared to only a 6.9% growth at Stage 1. CONCLUSION: Bidirectional Glenn was the most effective palliation stage for left ventricular growth. Recruitment in patients at this stage was associated with growth that exceeds those who did not have recruitment. This stage also best demonstrates the ability and success of growing a small ventricle to be adequate for biventricular conversion. Left ventricular growth at Fontan circulation holds promising results that are a point of interest for more studies. Endocardial Fibroelastosis resection is more effective on left ventricular growth at Bidirectional Glenn and Fontan compared to Stage 1

The Verbal and Non-Verbal Indicators of Deceit in Financial and Political Fraud: A Case Study of Bernard L. Madoff, Chen Shui-Bien and Bo Xilai

From the earliest financial scams of the seventeenth century, through the headlinegrabbing Wall Street scandals of our time, financial fraud and embezzlement have damaged both domestic and global economic systems. Preventative measures are the best way to reduce fraud. Fraudsters are adaptive and will find ways to circumvent such measures. Detecting fraud is essential once the prevention mechanisms have failed. This dissertation investigated the inherent problems of financial fraud detection for high stake fraudsters in the corporate and political fields in the United States, China and Taiwan. Both verbal and non-verbal signs of deception were examined in the case studies of Bernie Madoff, Taiwanese ex-president Chen Shiu-Bian, and former Chinese politician Bo Xilai. I was interested in determining what factors are key to the success of a highstake liar? What are the behaviors to look for in liars? Do these behaviors apply to Madoff, Chen and Bo? What was it about their communication styles that convinced their followers and clients to believe them and ignore signs of fraud? Do high-stake liars have different or the same verbal cues and non-verbal cues across the American, Chinese and Taiwanese cultures? Are there consistent patterns and indicators of their body language? If there are, can we apply these same patterns to predicate the next high-stake fraud? My research results show that while observing both verbal and non-verbal communication styles, patterns develop, and these patterns can be used as indicators to help business intelligence and to predict future financial fraud

The Chinese in Mississippi: A Race In-Between

There is this shot in the opening scene of the movie, Mississippi Burning, where you see two water fountains. One is broken, and chipped, and water is dripping from it. The other is modern, and shining. A white guy goes up to the nice one, and the black kid goes up to the old one. I remember saying to myself If I was in the scene, where would I drink?” As a kid, I remember going to the theater and not knowing where I was supposed to sit. Blacks were segregated then. Colored people had to sit upstairs, and white people sat downstairs... I guess I was always considered marginal with whites and blacks

CONSTANT GROWTH INVESTMENT STRATEGIES FOR US LARGE CAP COMPANIES

Using data from several sources, a new investment model, the Constant Growth of Expected Returns model (the CGER model) is tested as an investment strategy for individual investors. We utilize the constant growth of expected return (CGER) formula as the fundamental variable for analysis and build portfolios that we test over time compared to the Standard and Poor?s 500 Index as a benchmark. The largest companies that fit our criteria (for a maximum of 49 companies) for every year for the past twenty years (based on market cap and CGER) will be examined. And then, we compare realized returns to the S&P 500 for further analysis in different holding periods (monthly, quarterly, yearly) and three different investment strategies, namely, the High CGER Portfolio (HP), the Low CGER Portfolio (LP), and the High-Low Combination Portfolio (H-L Portfolio). We only use companies with positive earnings per share (EPS thereinafter), positive book value per share, and positive dividends. Our results show that the CGER model outperforms the S&P 500 index in various holding periods and the most impressive result came from the High CGER portfolio. By comparing the returns of the holding periods, we show that the most consistent results were garnered by utilizing both the High and Low CGER portfolios over different holding periods

Sentinel Node Biopsy for Head and Neck Cutaneous Melanoma

Sentinel lymph node biopsy is the most precise and accurate staging technique for malignant melanoma. This resulted from international collaborations and technical innovations across subspecialties and systematic and methodical study of real-time clinical problems. This article describes sentinel node biopsy from conception to current techniques. Indications for the procedure and evidence of its prognostic value are discussed. Controversies surrounding results of Multicenter Selective Lymphadenectomy Trial I and II and German Dermatologic Cooperative Oncology Group Selective Lymphadenectomy trial are reviewed. Head and neck melanoma is presented as a unique subsite for performing sentinel node biopsy and when considering completion cervical lymphadenectomy

The Changing Effect of HMO Market Structure: An Analysis of Penetration, Concentration, and Ownership Between 1994-2005

We analyze the role of three aspects of HMO market structure -- HMO penetration, HMO plan concentration, and HMO for-profit share on explaining hospital cost and revenue growth during the HMO expansion period (1994-1999) and backlash period (2000-2005). We find that HMO penetration effects differ over time: a 10 percentage point increase in HMO enrollment leads to 2.5 percent reduction in cost and revenues in the expansion period but only 0.4-1 percent reduction in the backlash period. Furthermore, this HMO backlash effect can be attributed to HMO dis-enrollment as well as the changing nature of HMO product. We find that revenue increases at a slower rate (by about 5 percent) in markets with relatively concentrated HMO markets power and more competitive hospital markets. Finally, increased for-profit HMO presence is associated with smaller cost and revenue growth, and the effect differs between low and high penetration markets.

Cognitive deficit and depressive symptoms in a community group of elderly people: a preliminary study

Com o objetivo de avaliar déficit cognitivo e presença de sinais e sintomas depressivos, 62 idosos registrados numa Unidade de Saúde Comunitária em Porto Alegre/RS foram entrevistados em suas casas. Foram avaliados pelo Mini Exame do Estado Mental (Mini Mental State), pela escala de Montgomery-Asberg, e por um questionário sobre condições de saúde, moradia e outras variáveis de vínculos sociais. Níveis mais altos de sintomas depressivos foram observados entre os idosos expostos a fatores de risco maiores para doença cérebro-vascular (diabete e doença coronariana), enquanto que pior desempenho cognitivo foi encontrado nos sujeitos que não contavam com um confidente (variável da rede social). Os resultados sugeriram que a identificação precoce dos grupos idosos de risco pode auxiliar na prevenção de problemas sociais e de saúde, mantendo os indivíduos na comunidade.Since the number and proportion of old people increases worldwide, health professionals and systems should be made aware and prepared to deal with their problems. Cognitive deficit and symptoms of depression are commom among the elderly, and may occur in relation to various risk factors such as health conditions and psychosocial variables. In order to study cognitive deficit and the presence of signs and symptoms of depression, 62 elderly community subjects enrolled at a Community Health Unit in Porto Alegre, southern Brazil, were interviewed. They were evaluated by means of the Mini Mental State Exam, the Montgomery-Asberg Depression rating scale, and a questionnaire on health conditions, living arrangements and social variables. Higher levels of symptoms of depression were observed among subjects exposed to major risk factors for cerebrovascular diseases (diabetes and coronary disease), while impaired cognitive performance was seen among individuals who could not count on the presence of a confidant (social network variable). The results suggest that the early identification of major risk groups among old people can help to prevent institutionalization and keep individuals in the community