High-risk Approach Research Articles

Sensitivity of the familial high-risk approach for the prediction of future psychosis: a total population study.

Children who have a parent with a psychotic disorder present an increased risk of developing psychosis. It is unclear to date, however, what proportion of all psychosis cases in the population are captured by a familial high-risk for psychosis (FHR-P) approach. This is essential information for prevention research and health service planning, as it tells us the total proportion of psychosis cases that this high-risk approach would prevent if an effective intervention were developed. Through a prospective cohort study including all individuals born in Finland between January 1, 1987 and December 31, 1992, we examined the absolute risk and total proportion of psychosis cases captured by FHR-P and by a transdiagnostic familial risk approach (TDFR-P) based on parental inpatient hospitalization for any mental disorder. Outcomes of non-affective psychosis (ICD-10: F20-F29) and schizophrenia (ICD-10: F20) were identified in the index children up to December 31, 2016. Of the index children (N=368,937), 1.5% (N=5,544) met FHR-P criteria and 10.3% (N=38,040) met TDFR-P criteria. By the study endpoint, 1.9% (N=6,966) of the index children had been diagnosed with non-affective psychosis and 0.5% (N=1,846) with schizophrenia. In terms of sensitivity, of all non-affective psychosis cases in the index children, 5.2% (N=355) were captured by FHR-P and 20.6% (N=1,413) by TDFR-P approaches. The absolute risk of non-affective psychosis was 6.4% in those with FHR-P, and 3.7% in those with TDFR-P. There was notable variation in the sensitivity and total proportion of FHR-P and TDFR-P cases captured based on the age at which FHR-P/TDFR-P were determined. The absolute risk for psychosis, however, was relatively time invariant. These metrics are essential to inform intervention strategies for psychosis risk requiring pragmatic decision-making.

A study on awareness and perception about perinatal death auditing among health care workers in two districts of Karnataka State, India

ABSTRACT Background: To start perinatal death auditing, doctors should have good knowledge about it. Objectives: To know the awareness and perceptions of doctors about different aspects of perinatal death auditing like 1) different types of contributors; 2) high-risk approach; 3) consequences; 4) documentary requirements; and 5) existing system of mortality meeting/child death reviews. Methodology: The perinatal death auditing project was implemented in two districts of Karnataka state. As a part of the pre-intervention survey, awareness and perceptions of doctors and a few health care administrators were explored. They were requested to participate in the study. Those who consented were approached in their hospitals and interviewed. Trained medical social workers conducted the interviews. Awareness was scored from 0 to 3 with 0 being no knowledge and 3 being good knowledge. Perceptions were scored from 0 to 3 with 0 being no negative perceptions and 3 being fear of legal consequences. The responses were documented, scored, and described. Results: Though 22 doctors were eligible, only 16 consented to participate in the study. Knowledge of doctors about different contributors was inadequate. They were apprehensive about legal consequences. They knew that documentation could protect them and be useful in a court of law. They were not clear about the conduct of mortality meeting/existing system of child death reviews. Conclusion: Knowledge was inadequate. They were apprehensive about legal consequences. Training of doctors and allaying apprehensions are required for starting perinatal death auditing.

Cardiac magnetic resonance to evaluate 3D ventricular substrate depth: Prognostic implications for VT ablation approach

Abstract Background The decision to perform a high-risk endo-epicardial approach for VT ablation is controversial and mostly based on previous endocardial failure or very specific etiologies. We systematically evaluated the 3D distribution of the automatically-detected conducting channels by CMR with the aim of assessing whether tissue thickness in those areas could allow for an endocardial-only approach independently of the etiology of the cardiomyopathy. This could have an important impact in terms of procedural planning. Purpose To study CMR channel depth as a predictor of VT recurrence after endocardial VT ablation. Methods Fifty-one consecutive patients with left scar-related VT undergoing ablation after CMR (October 2018 to June 2022) were included (median age 65.56±11.46 years, 94.1% male, median ejection fraction 31.82±8.76%, ischemic cardiomyopathy 72.5%). CMR channels were calculated with ADAS3D software. The depth of CMR channels was assessed based on the involved layers and the total wall thickness (WT) of the affected segment. Patients were prospectively followed for VT recurrence for one year. Results One-year VT recurrence was 13.7%. Overall, 159 CMR channels were analyzed (3.10±2.01 channels per patient). Univariate analysis showed that both the maximal depth of channel and the presence of an epicardial channel were the only predictors of VT recurrence during follow-up (OR 1.85 (1.11, 3.13), p=0.02 and OR 1.22 (1.05, 1.41), p=0.04 respectively). The presence of a channel with a maximal depth of more than 7.2mm from the endocardium had a sensitivity= 100%, specificity= 61.36%, negative predictive value (NPV)= 100% and positive predictive value (PPV)=29.0% with an area under the curve of 0.81 for VT recurrence. The presence of an epicardial channel showed, as well, sensitivity=100% and NPV=100% but a worse specificity (27.27%) and PPV (17.95%) compared with maximal depth of the channel. Non-ischemic cardiomyopathy was not significantly associated with a higher risk of VT recurrence after endocardial ablation in our study (OR 2.25 (0.43, 11.66), p 0.34). Conclusions The maximal depth of CMR channels is a predictor of VT recurrence in the follow up in patients with left scar-related VT who underwent endocardial ablation. A cutoff of maximal CMR channel depth of 7.2mm could be a better tool to select VT ablation approach than considering the type of cardiomyopathy or the presence of epicardial substrate.Examples of CMR channel depthProbability of VT recurrence

Association between physical activity and allostatic load among pregnant women.

Allostatic load (AL) in pregnant women is associated with maternal and infant health outcomes. Whether physical activity (PA) is a modifiable factor associated with AL during pregnancy is unknown. In this cross-sectional study, including 725 pregnant women in 3 different trimesters, 8 biomarkers were included, and the high-risk quartile approach based on sample distribution was used to construct AL index (ALI). ALI <2 was defined as a low level and ≥2 as a high level. Student's t-test or Mann-Whitney U test and chi-squared test or Fisher exact test were used to compare differences in AL with different demographic characteristics among pregnant women. The relationship between PA and AL in pregnant women was analyzed using a binary logistic regression model. The results show that the detection rate of high-risk AL during pregnancy was 47.3%. In the adjusted model, sufficient PA was related to a lower AL than insufficient PA (OR=.693, 95%CI:.494,.971; p=.033). Compared with low- and high-intensity PAs, moderate-intensity PA was associated with lower AL (OR=.645, 95%CI:.447,.930; p=.019). The results suggest that PA is a modifiable factor related to AL, and intervention is recommended to be carried out in the first trimester to prevent the increased likelihood of high AL as pregnancy progresses. In addition, health care personnel should encourage pregnant women to participate in PA, especially moderate-intensity PA, in order to obtain lower AL and promote maternal and child health.

Infected right ventricular outflow tract pseudoaneurysm in an infant with tetralogy of Fallot: Successful palliation using a Gore VBX® covered stent

ABSTRACT Pseudoaneurysm formation within the right ventricular outflow tract (RVOT) is a rare but serious complication following cardiac surgeries involving the RVOT. This report presents the case of a 3-month-old, 4 kg infant with tetralogy of Fallot and pulmonary atresia, previously treated with ventricular septal defect closure and right ventricle (RV)–pulmonary artery homograft placement. The patient presented critically ill with septic shock and suprasystemic RV pressure. A high-risk surgical approach was averted through the endovascular exclusion of the pseudoaneurysm using a Gore VBX® balloon expandable covered stent, in addition to stenting of bilateral proximal branch pulmonary arteries to alleviate RV hypertension. This case underscores the multifactorial nature of RVOT pseudoaneurysm formation and the importance of a high index of suspicion for diagnosis. Management options, including surgical and transcatheter strategies, are discussed, focusing on the successful use of a covered stent for stabilization in a critically ill patient.

A likely HOXC4 predisposition variant for Chiari malformations.

Inherited variants predisposing patients to type 1 or 1.5 Chiari malformation (CM) have been hypothesized but have proven difficult to confirm. The authors used a unique high-risk pedigree population resource and approach to identify rare candidate variants that likely predispose individuals to CM and protein structure prediction tools to identify pathogenicity mechanisms. By using the Utah Population Database, the authors identified pedigrees with significantly increased numbers of members with CM diagnosis. From a separate DNA biorepository of 451 samples from CM patients and families, 32 CM patients belonging to 1 or more of 24 high-risk Chiari pedigrees were identified. Two high-risk pedigrees had 3 CM-affected relatives, and 22 pedigrees had 2 CM-affected relatives. To identify rare candidate predisposition gene variants, whole-exome sequence data from these 32 CM patients belonging to 24 CM-affected related pairs from high-risk pedigrees were analyzed. The I-TASSER package for protein structure prediction was used to predict the structures of both the wild-type and mutant proteins found here. Sequence analysis of the 24 affected relative pairs identified 38 rare candidate Chiari predisposition gene variants that were shared by at least 1 CM-affected pair from a high-risk pedigree. The authors found a candidate variant in HOXC4 that was shared by 2 CM-affected patients in 2 independent pedigrees. All 4 of these CM cases, 2 in each pedigree, exhibited a specific craniocervical bony phenotype defined by a clivoaxial angle less than 125°. The protein structure prediction results suggested that the mutation considered here may reduce the binding affinity of HOXC4 to DNA. Analysis of unique and powerful Utah genetic resources allowed identification of 38 strong candidate CM predisposition gene variants. These variants should be pursued in independent populations. One of the candidates, a rare HOXC4 variant, was identified in 2 high-risk CM pedigrees, with this variant possibly predisposing patients to a Chiari phenotype with craniocervical kyphosis.

Cost-Effectiveness Analysis of Personalized Hypertension Prevention.

While a population-wide strategy involving lifestyle changes and a high-risk strategy involving pharmacological interventions have been described, the recently proposed personalized medicine approach combining both strategies for the prevention of hypertension has increasingly gained attention. However, a cost-effectiveness analysis has been hardly addressed. This study was set out to build a Markov analytical decision model with a variety of prevention strategies in order to conduct an economic analysis for tailored preventative methods. The Markov decision model was used to perform an economic analysis of four preventative strategies: usual care, a population-based universal approach, a population-based high-risk approach, and a personalized strategy. In all decisions, the cohort in each prevention method was tracked throughout time to clarify the four-state model-based natural history of hypertension. Utilizing the Monte Carlo simulation, a probabilistic cost-effectiveness analysis was carried out. The incremental cost-effectiveness ratio was calculated to estimate the additional cost to save an additional life year. The incremental cost-effectiveness ratios (ICER) for the personalized preventive strategy versus those for standard care were -USD 3317 per QALY gained, whereas they were, respectively, USD 120,781 and USD 53,223 per Quality-Adjusted Life Year (QALY) gained for the population-wide universal approach and the population-based high-risk approach. When the ceiling ratio of willingness to pay was USD 300,000, the probability of being cost-effective reached 74% for the universal approach and was almost certain for the personalized preventive strategy. The equivalent analysis for the personalized strategy against a general plan showed that the former was still cost-effective. To support a health economic decision model for the financial evaluation of hypertension preventative measures, a personalized four-state natural history of hypertension model was created. The personalized preventive treatment appeared more cost-effective than population-based conventional care. These findings are extremely valuable for making hypertension-based health decisions based on precise preventive medication.

‘Sorry, we’re closed’: a fuzzy-set ideal-type analysis of pandemic childcare-policy responses in 28 European countries

Based on an original data set of early childhood education and care/school closures and reopenings, this article presents a fuzzy-set ideal-type analysis of pandemic childcare-policy responses in 28 European countries and explores the complex empirical variety of these policies across Europe. The analysis shows that European countries cluster into five models, comprising not only the opposite poles of strict closures (public-health approach) or absence of closures (high-risk approach) but also more ‘mixed’ approaches prioritising early childhood education and care/schools’ educational (educational approach) or work–care functions (lenient work–care approach or strict work–care approach). A few countries’ poor fit within these approaches indicates struggles in balancing different, often contradictory, policy goals during COVID-19. The findings reflect how (continued) provision of early childhood education and care/schools became a highly contested issue, especially as the pandemic evolved and public-health concerns were increasingly weighted against the implications for work–care balance and educational outcomes.

Mapping Immune-Tumor Bidirectional Dialogue Using Ultrasensitive Nanosensors for Accurate Diagnosis of Lung Cancer.

Lung cancer is one of the most common cancers with high mortality worldwide despite the development of molecularly targeted therapies and immunotherapies. A significant challenge in managing lung cancer is the accurate diagnosis of cancerous lesions owing to the lack of sensitive and specific biomarkers. The current procedure necessitates an invasive tissue biopsy for diagnosis and molecular subtyping, which presents patients with risk, morbidity, anxiety, and high false-positive rates. The high-risk diagnostic approach has highlighted the need to search for a reliable, low-risk noninvasive diagnostic approach to capture lung cancer heterogeneity precisely. The immune interaction profile of lung cancer is driven by immune cells' distinctive, precise interactions with the tumor microenvironment. Here, we hypothesize that immune cells, particularly T cells, can be used for accurate lung cancer diagnosis by exploiting the distinctive immune-tumor interaction by detecting the immune-diagnostic signature. We have developed an ultrasensitive T-sense nanosensor to probe these specific diagnostic signatures using the physical synthesis process of multiphoton ionization. Our research employed predictive in vitro models of lung cancers, cancer-associated T cells (PCAT, MCAT) and CSC-associated T cells (PCSCAT, MCSCAT), from primary and metastatic lung cancer patients to reveal the immune-diagnostic signature and uncover the molecular, functional, and phenotypic separation between patient-derived T cells (PDT) and healthy samples. We demonstrated this by adopting a machine learning model trained with SERS data obtained using cocultured T cells with preclinical models (CAT, CSCAT) of primary (H69AR) and metastatic lung cancer (H1915). Interrogating these distinct signatures with PDT captured the complexity and diversity of the tumor-associated T cell signature across the patient population, exposing the clinical feasibility of immune diagnosis in an independent cohort of patient samples. Thus, our predictive approach using T cells from the patient peripheral blood showed a highly accurate diagnosis with a specificity and sensitivity of 94.1% and 100%, respectively, for primary lung cancer and 97.9% and 94.4% for metastatic lung cancer. Our results prove that the immune-diagnostic signature developed in this study could be used as a clinical technology for cancer diagnosis and determine the course of clinical management with T cells.

Machine-learning-based high-benefit approach versus conventional high-risk approach in blood pressure management.

In medicine, clinicians treat individuals under an implicit assumption that high-risk patients would benefit most from the treatment ('high-risk approach'). However, treating individuals with the highest estimated benefit using a novel machine-learning method ('high-benefit approach') may improve population health outcomes. This study included 10 672 participants who were randomized to systolic blood pressure (SBP) target of either <120 mmHg (intensive treatment) or <140 mmHg (standard treatment) from two randomized controlled trials (Systolic Blood Pressure Intervention Trial, and Action to Control Cardiovascular Risk in Diabetes Blood Pressure). We applied the machine-learning causal forest to develop a prediction model of individualized treatment effect (ITE) of intensive SBP control on the reduction in cardiovascular outcomes at 3 years. We then compared the performance of high-benefit approach (treating individuals with ITE >0) versus the high-risk approach (treating individuals with SBP ≥130 mmHg). Using transportability formula, we also estimated the effect of these approaches among 14 575 US adults from National Health and Nutrition Examination Surveys (NHANES) 1999-2018. We found that 78.9% of individuals with SBP ≥130 mmHg benefited from the intensive SBP control. The high-benefit approach outperformed the high-risk approach [average treatment effect (95% CI), +9.36 (8.33-10.44) vs +1.65 (0.36-2.84) percentage point; difference between these two approaches, +7.71 (6.79-8.67) percentage points, P-value <0.001]. The results were consistent when we transported the results to the NHANES data. The machine-learning-based high-benefit approach outperformed the high-risk approach with a larger treatment effect. These findings indicate that the high-benefit approach has the potential to maximize the effectiveness of treatment rather than the conventional high-risk approach, which needs to be validated in future research.

Psychosis prediction 2.0: why child and adolescent mental health services should be a key focus for schizophrenia and bipolar disorder prevention research.

Existing approaches to psychosis prediction capture only a small minority of future cases. Recent research shows that specialist child and adolescent mental health services (CAMHS) offer a (previously unrecognised) high-risk and high-capacity approach for psychosis early identification, prediction and, ultimately, prevention.

Suicide and Suicide Prevention Activities Following the Great East Japan Earthquake 2011: A Literature Review.

Background: Since the Great East Japan Earthquake (GEJE), numerous studies have been conducted, but no comprehensive review study has been carried out. Thus, this literature review aimed to examine how the GEJE might affect suicide and suicidal behaviors from a long-term perspective. Methods: For the literature review, a search of electronic databases was carried out to find articles written in English and in Japanese that were related to suicide and its risk factors, as well as suicide prevention activities following the GEJE. Thirty-two articles were then selected for the review. Results: There were several findings, as follows: (1) gender differences in suicide rates in the affected area: nationwide, the suicide rates in men showed a delayed increase, whereas suicide rates in women increased temporarily immediately after the GEJE; (2) the suicide rates increased again in the recovery phase; (3) the background of the suicides was linked to both disaster-related experiences, and indirect reasons pertaining to the GEJE; and (4) intensive intervention combined with a high-risk and community-focused approach could prevent suicides following the disaster. Conclusions: Although further accumulation of knowledge about suicide and suicide prevention is essential, these findings can contribute to response, recovery, and preparedness in relation to future disasters.

A framework for drought adaption under deep uncertainties: Application of Portfolio theory (Markowitz 2.0)

Hydrological uncertainty, climate change, and water infrastructure development upstream transboundary basins may affect the safe access to water resources downstream, making socioeconomic and biophysical subsystems vulnerable. Therefore, it is vital to apply decision-making approaches to reduce vulnerability, especially in arid and semi-arid basins. This study evaluated an adaptation framework to reduce vulnerability through optimal water allocation in drought-prone areas. This framework was implemented in an area dependent on upstream transboundary water (Helmand River Basin). An integrated system dynamics model was developed using socioeconomic and biophysical factors identified by the Füssel Vulnerability Framework. The climatic variables of the basin were simulated and predicted by the output of AOGCM models. The trend of upstream annual precipitation and temperature changes during the 2021–2050 period based on the RCP4.5 emission scenario was −2% and +1.9 C compared to those in the historical period, respectively. The results indicated the drought intensification due to a 13% decrease in future runoff (2050) compared to the base period, leading to a reduction in value-added agriculture (8%) and the population (31%). Therefore, the latest version of portfolio optimization called Markowitz 2.0 was used. In order to decide on potential long-term growth versus short-term loss, an efficient frontier was formed between the expected return and the conditional value at risk (CVaR) based on the Markowitz 2.0 model. According to the model results, the development of the industrial sector as an approach with moderate (reasonable) risk could increase financial return by 43% and allocation to the environmental sector by 2.3 times. Finally, prioritizing the environmental sector was a high-risk approach with high returns that increased efficiency by 45%. The results showed that the proposed framework could help decision-makers, based on their risk-taking level, activate and develop decisions on water resource allocation and water-dependent productive sectors on the basis of efficient frontiers.

New Insights Into Long- Versus Short-Term Dual Antiplatelet Therapy Duration in Patients After Stenting for Left Main Coronary Artery Disease: Findings From a Prospective Observational Study.

The appropriate duration of dual antiplatelet therapy (DAPT) and risk-benefit ratio for long-term DAPT in patients with left main (LM) disease undergoing percutaneous coronary intervention remains uncertain. Four thousand five hundred sixty-one consecutive patients with stenting of LM disease at a single center from January 2004 to December 2016 were enrolled. Decision to discontinue or remain on DAPT after 12 months was left to an individualized decision-making based on treating physicians by weighing the patient's risks of ischemia versus bleeding and considering patient preference. The primary outcome was a composite of death, myocardial infarction, stent thrombosis, or stroke at 3 years. Key safety outcome was 3-year rate of Bleeding Academic Research Consortium 2, 3, or 5 bleeding. Of 3865 patients free of ischemic and bleeding events at 12 months, 1727 (44.7%) remained on DAPT (mostly clopidogrel based [97.7%]) beyond 12 months after LM percutaneous coronary intervention. DAPT>12-month versus ≤12-month DAPT was associated with a significant reduced risk of 3-year primary outcome (2.6% versus 4.6%; adjusted hazard ratio: 0.59 [95% CI, 0.41-0.84]). The same trend was found for other ischemic end points: death (0.9% versus 3.0%; Plog-rank<0.001), cardiovascular death (0.5% versus 1.7%; Plog-rank=0.001), myocardial infarction (0.8% versus 1.9%; Plog-rank=0.005), and stent thrombosis (0.4% versus 1.1%; Plog-rank=0.017). The key safety end point was not significantly different between 2 regimens (1.8% versus 1.6%; adjusted hazard ratio: 1.07 [95% CI, 0.65-1.74]). The effect of DAPT>12 month on primary and key safety outcomes was consistent across clinical presentations, high bleeding risk, P2Y12 inhibitor, and LM bifurcation percutaneous coronary intervention approach. In a large cohort of patients free from clinical events during the first year after LM percutaneous coronary intervention and at low apparent future bleeding risk, an individualized patient-tailored approach to longer duration (>12 month) of DAPT with aspirin plus a P2Y12 inhibitor (mostly clopidogrel) improved both composite and individual efficacy outcomes by reducing ischemic risk, without a concomitant increase in clinically relevant bleeding.

Predicting Psychosis: Field Moves From Assessment of Clinical Risk to Search for Biomarkers

Predicting Psychosis: Field Moves From Assessment of Clinical Risk to Search for Biomarkers

The targeted high-risk case-finding approach versus universal screening for thyroid dysfunction during pregnancy: thyroid-stimulating hormone (TSH) and/or thyroid peroxidase antibody (TPOAb) test?

To compare the effects of different thyroid screening scenarios, using the universal and targeted high-risk case-finding approaches with different diagnostic tests on the prevalence of subclinical hypothyroidism (SCH), thyroid autoimmunity, and pregnancy outcomes after adjustments for the intervention. During a secondary analysis of data collected in Tehran Thyroid and Pregnancy Study, a total of 2277 women from the total population, including 1303 high-risk individuals for thyroid dysfunction. The Cochran-Mantel-Haenszel method, adjusted for the intervention, was also used to evaluate the relationships between different screening scenarios [i.e., universal approach using thyroid-stimulating hormone (TSH) and/or thyroid peroxidase antibody (TPOAb) tests and targeted high-risk case-finding approach using TSH and/or TPOAb tests] and pregnancy outcomes (i.e., preterm delivery and NICU admission). The universal approach using both TSH and TPOAb measurements was considered as the reference scenario. We analyzed outcomes of different screening methods in individuals treated with LT4, compared to those individuals who were not treated. Compared to the universal screening approach with both TSH and TPOAb measurements, the targeted high-risk case-finding approach overlooked approximately 42%, 62%, and 74% of women with elevated TSH (> 4 µlU/mL) when using both TSH and TPOAb tests, TSH alone, and TPO alone, respectively. After adjusting for the missed cases, 2.86% of women with preterm delivery and 2.76% of women with NICU admission were missed when they were screened using the targeted high-risk case-finding approach by measuring both TSH and TPOAb. The percentage of missed cases increased when applying the targeted approach with the TSH test alone, without measuring TPOAb. Overall, 4.16% and 4.02% of women with preterm delivery and NICU admission were overlooked in this scenario, respectively. After adjustments for the intervention, the probability of NICU admission in neonates of mothers, who were screened using the targeted high-risk case-finding approach with TPOAb measurement, was 2.31 folds higher than those screened by the reference scenario. This study suggests that although the targeted high-risk case-finding approach including both TSH and TPOAb tests, may overlook some women with SCH, it is a reasonable option since it is not associated with a higher risk of adverse pregnancy outcomes.

S2071 Refractory Benign Esophageal Stricture - Management Dilemma

Introduction: Benign esophageal strictures can result from long-standing GERD, ablative or radiation therapy, caustic ingestion and etc. Management of strictures could be very challenging. We describe a case of a refractory esophageal stricture with aim to focus on management challenges. Case Description/Methods: A 36-year-old Indian female with a history of esophageal strictures secondary to caustic ingestion present to our GI clinic with complaints of worsening dysphagia to solids. She underwent multiple serial endoscopies with dilatation at an outside facility and subsequently was performing self-dilatation with bougie dilators, until no further relief of her symptoms. An esophagram revealed a narrow caliber mid and distal esophagus with 3 prominent stricture points. The proximal stricture could not be traversed on initial endoscopy with 9.9 mm gastroscope, therefore a 4.9 mm bronchoscope was used to assess the size and location of the 3 esophageal strictures which were noted at 25 cm, 30 cm and 35 cm from incisors. Serial dilations were performed with a CRE balloon dilator and triamcinolone injection at the refractory stricture site post dilation. The esophageal strictures were able to be dilated with serial dilatations and the gastroscope was able to traverse all 3 strictures without difficulty and patient experienced symptomatic relief. Patient was counseled regarding high risk of perforation with subsequent dilatation and given surgical consultations for second opinion and alternative management options. Discussion: Late management of caustic strictures makes dilatation more complex owing to fibrosis in esophageal wall. Perforation rates for caustic strictures is higher than standard benign stricture dilatation with anything from 0.4 up to 32% recorded in the literature. Refractory strictures are more common in caustic ingestion and the management has been reported with intralesional steroid injection or topical mitomycin C at the time of dilatation, and temporary stent placement. Prior to dilatation one must consider the following prior to endoscopically dilating such as etiology of stricture, degree of patient’s dysphagia, length, tortuosity and luminal diameter of the stricture. Our patient’s strictures were refractory to dilatation and intralesional steroid use. Stent placement is technically not feasible given different size and diameter of strictures as it enhances risk of perforation. Surgery although a high-risk approach but remains as curative resort for such cases.

Using a Virtual Engineering Environment for the Design and Development of a Compact Pilot Plant

This paper introduces a new implementation using virtual engineering approaches in support of the design and development of a compact pilot plant. Developing a compact pilot plant is a costly and high-risk approach. Risk and resource investments can be optimized by using commercially based virtual engineering, integrated simulation, and virtual prototyping environments in the design and development of a compact pilot plant. This paper identifies both the users of the virtual engineering environment as well as where in the system lifecycle it can be implemented. The environment will use and extend existing multiphysics models and simulation of products and characteristics through the development of system-level models and an investigation of virtual prototypes of component elements. The second level involves knowledge sharing across phases of the lifecycle of products, including all contributors and stakeholders in the virtual environment.

Estimating the Methane Potential of Energy Crops: An Overview on Types of Data Sources and Their Limitations

As the anaerobic digestion of energy crops and crop residues becomes more widely applied for bioenergy production, planners and operators of biogas plants, and farmers who consider growing such crops, have a need for information on potential biogas and methane yields. A rich body of literature reports methane yields for a variety of such materials. These data have been obtained with different testing methods. This work elaborates an overview on the types of data source available and the methods that are commonly applied to determine the methane yield of an agricultural biomass, with a focus on European crops. Limitations regarding the transferability and generalisation of data are explored, and crop methane values presented across the literature are compared. Large variations were found for reported values, which can only partially be explained by the methods applied. Most notably, the intra-crop variation of methane yield (reported values for a single crop type) was higher than the inter-crop variation (variation between different crops). The pronounced differences in reported methane yields indicate that relying on results from individual assays of candidate materials is a high-risk approach for planning biogas operations, and the ranges of values such as those presented here are essential to provide a robust basis for estimation.

Management of frailty under COVID-19 pandemic in Japan.

Frailty prevention is a cornerstone for the extension of healthy life expectancy. It is a multi-dimensional construct that includes physical, mental, and social aspects. Frailty is reversible and can be attenuated by intervention; therefore, its early detection is important in primary and community care. The mainstream of disability prevention in Japan, which comprises the Japanese and local governments as well as healthcare workers, was a high-risk approach until 2014. Given the revision on Japan's long-term care insurance law, current ageing health policies have shifted to more population centric approach. Implements group activities called "Kayoi-no-ba" has been valued in Japan as disability prevention initiative. The Kihon Checklist - a 25-item questionnaire - has been broadly used by health experts and researchers to assess frailty in Japan. However, a new 15-item questionnaire has been newly developed to identify frailty and other health-related problems in older people of 75 years and above. This will enable providing the necessary support to frail individuals at any healthcare facility in local communities. The increase in frailty prevalence in older people has been concern during the COVID-19 pandemic. Home-based physical exercise programs are expected to be effective for frailty prevention. Utilization of information and communication technologies, social network services, and video calls has attracted attention for being effective tools to facilitate communication for older people during the pandemic. Further, life course approaches are needed to clarify the midlife risk of frailty development in later life.