Setting up an adult congenital heart programme

With the growing number of adult patients with congenital heart defects in the developing world, many institutions and practice groups are beginning or growing their adult congenital heart disease (ACHD) programmes. In this paper, we review:■ Practical considerations in establishing a clinic (Where will your patients come from? How many new referrals annually can you anticipate?);■ Transition and transfer challenges (can you avoid the loss to care of children with moderate and complex congenital heart defects? Is there an agreed age of transfer policy? Is there an available and effective transition process?);■ Institutional considerations (do you really have the support of your institution? Where should your program be located? Where will you admit your inpatients?);■ Patient care imperatives (how will you commit to excellent patient care? How will you meet the needs of your patients? Clearly designate which patients you will need to refer out and to which services they will be referred);■ The composition of the ACHD team (begin with two ACHD cardiologists and skilled echocardiography, consider a mix of pediatric trained and adult trained cardiologists, grow from there in a modular fashion if you can to include more multidisciplinary team members, and duplicate essentialservice positions); and■ Organisation and accreditation of ACHD care (ACHD services need to be managed differently than pediatric services across the full diagnostic and treatment clinicalspectrum)

Recommendations for cardiovascular magnetic resonance in adults with congenital heart disease from the respective working groups of the European Society of Cardiology

This paper aims to provide information and explanations regarding the clinically relevant options, strengths, and limitations of cardiovascular magnetic resonance (CMR) in relation to adults with congenital heart disease (CHD). Cardiovascular magnetic resonance can provide assessments of anatomical connections, biventricular function, myocardial viability, measurements of flow, angiography, and more, without ionizing radiation. It should be regarded as a necessary facility in a centre specializing in the care of adults with CHD. Also, those using CMR to investigate acquired heart disease should be able to recognize and evaluate previously unsuspected CHD such as septal defects, anomalously connected pulmonary veins, or double-chambered right ventricle. To realize its full potential and to avoid pitfalls, however, CMR of CHD requires training and experience. Appropriate pathophysiological understanding is needed to evaluate cardiovascular function after surgery for tetralogy of Fallot, transposition of the great arteries, and after Fontan operations. For these and other complex CHD, CMR should be undertaken by specialists committed to long-term collaboration with the clinicians and surgeons managing the patients. We provide a table of CMR acquisition protocols in relation to CHD categories as a guide towards appropriate use of this uniquely versatile imaging modalit

Special Project: Public Housing

Despite the general prosperity of this country, a cursory survey of any American town or city will reveal that many Americans live in housing which is substandard. Frequently one sees unpainted houses characterized by broken windows and inadequate sanitary facilities. In urban areas, the ever present tenement is often filled with too many people and not enough toilets; stairs are dangerous and refuse lies uncollected in the halls. Rooms without windows are common, while those blessed with windows frequently receive little light--the only view is another window of another building. Disease and discomfort are everywhere.These conditions, however, are neither new nor unnoticed.Throughout American history, individuals as well as various levels of government have attempted to remedy, or at least alleviate, the housing problem. This study will explore one such effort--the federally-financed, locally-administered public housing program created by the Housing Act of 1937. Consequently, throughout this study, the term public housing, describing any period after 1937,refers only to the product of this Act, unless otherwise indicated. This study does not concern federally-funded housing programs such as Federal Housing Authority mortgage guarantees, rehabilitation of existing dwellings, and self-help programs

Plasma Depletion and Mirror Waves Ahead of Interplanetary Coronal Mass Ejections

We find that the sheath regions between fast interplanetary coronal mass ejections (ICMEs) and their preceding shocks are often characterized by plasma depletion and mirror wave structures, analogous to planetary magnetosheaths. A case study of these signatures in the sheath of a magnetic cloud (MC) shows that a plasma depletion layer (PDL) coincides with magnetic field draping around the MC. In the same event, we observe an enhanced thermal anisotropy and plasma beta as well as anti-correlated density and magnetic fluctuations which are signatures of mirror mode waves. We perform a superposed epoch analysis of ACE and Wind plasma and magnetic field data from different classes of ICMEs to illuminate the general properties of these regions. For MCs preceded by shocks, the sheaths have a PDL with an average duration of 6 hours (corresponding to a spatial span of about 0.07 AU) and a proton temperature anisotropy ${T_{\perp p}\over T_{\parallel p}}\simeq 1.2$ -1.3, and are marginally unstable to the mirror instability. For ICMEs with preceding shocks which are not MCs, plasma depletion and mirror waves are also present but at a reduced level. ICMEs without shocks are not associated with these features. The differences between the three ICME categories imply that these features depend on the ICME geometry and the extent of upstream solar wind compression by the ICMEs. We discuss the implications of these features for a variety of crucial physical processes including magnetic reconnection, formation of magnetic holes and energetic particle modulation in the solar wind.Comment: fully refereed, accepted for publication in J. Geophys. Re

Perspectives on flu vaccination advertisement messaging in the era of COVID-19: Thematic analysis centering adult Black voices

Influenza (flu) is an infectious, respiratory disease that causes substantial burden and mortality, and Non-Hispanic Black people experience profound disparities in flu disease burden in the United States. One contributor to flu disease disparities is lower flu vaccination rates among Black populations. This qualitative study was conducted during the COVID-19 pandemic and used the Public Health Critical Race Praxis framework to center and elicit Black adults’ perspectives of desired flu vaccine messaging. This work builds upon efforts to increase access to flu vaccinations and recommendations are provided to aid in tailoring flu vaccine messaging via a health equity lens. Recommendations for flu messaging include: 1) increased transparency in calling out racial disparities in flu disease burden through the use of local statistics, 2) being upfront with provision of flu vaccine information in easy-to-understand language when addressing concerns, and 3) providing desired education around what the vaccine is doing to one’s body, what the ingredients are, potential side effects and normalizing side effects, and the duration of protection elicited by vaccination. Recommendations also highlight the importance of incorporating the family/community/social context in flu vaccination messaging and for targeted messaging to address the most vulnerable while also providing reasons why persons who may consider themselves to not be vulnerable to the flu (i.e., healthy, no risk factors) should be vaccinated (e.g., get vaccinated in order to reduce exposure risk to your grandmother)

Ventricular arrhythmias and sudden death in adults after a Mustard operation for transposition of the great arteries

Aims To examine the prevalence of sustained ventricular tachycardia (VT) and sudden death (SD) in adults with atrial repair of transposition of the great arteries (TGA) and to determine associated risk factors. Methods and results In a single-centre review, we studied the outcome of 149 adults (mean age 28 ± 7 years) who had undergone a Mustard operation for TGA. During a mean follow-up of 9 ± 6 years, sustained VT and/or SD occurred in 9% (13/149) of the cohort. Sustained VT/SD was more likely to occur in patients with associated anatomic lesions [hazard ratio (HR) 4.9, 95% CI 1.5-16.0], with NYHA class ≥III (HR 9.8, 95% CI 3.0-31.6) and with an impaired subaortic right ventricular (RV) ejection fraction (EF) (HR 2.2, 95% CI 1.2-4.0 per 10% decrease in EF). There was an inverse correlation between the RV-EF and both age and QRS duration. Patients with a QRS duration ≥140 ms were at highest risk of sustained VT/SD (HR 13.6, 95% CI 2.9-63.4). Atrial tachyarrhythmia was detected in 66 (44%) patients, but was not a statistically significant predictor of sustained VT/SD in our adult population (HR 2.7, 95% CI 0.6-13.0). Conclusion Sustained VT/SD in adults after a Mustard operation for TGA are more common than previously described. Age, systemic ventricular function, and QRS duration are interrelated and are associated with VT/SD. A QRS duration ≥140 ms helps to identify the high risk patien