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Full-Text Articles in Medicine and Health Sciences

Empowering Peer Mentorship: Best Practices, Caitlyn Menard Bs, Ots Jan 2026

Empowering Peer Mentorship: Best Practices, Caitlyn Menard Bs, Ots

Student Research Design & Innovation Symposium

Sustaining a spinal cord injury (SCI) leads to a loss of performance skills and restricts the ability to participate in meaningful activities as one could prior to injury. Community-dwelling individuals with SCI, encounter unmet needs related to psychological health, lifestyle, community mobility, and self-efficacy, emphasizing the true importance of community programs in addressing and supporting the long-term management of SCI. Occupational therapy professionals are skilled at connecting the dots between the person and their environment. Using an occupational therapy lens, this doctoral capstone aims to answer this research question: How do different peer mentoring methods facilitate community re-engagement within the …


Hallucinogen Use Prevalence And Comorbidities, Mj Kasprzak Jan 2026

Hallucinogen Use Prevalence And Comorbidities, Mj Kasprzak

Student Research Design & Innovation Symposium

While hallucinogens are now being used in mental health treatment, research examining recreational hallucinogen use over time, especially in relation to mental health comorbidities and demographic disparities, remains limited. This study aims to examine hallucinogen use trends over time among young adults, with a specific focus on demographic disparities and mental health comorbidities. This was an analysis of the 2022 and 2024 Rhode Island Young Adult Surveys, cross-sectional, self-report surveys administered to n=2,030 adults aged 18-25 who live in Rhode Island for at least part of the year. Among the 2,030 respondents, 9.9% reported hallucinogen use. The prevalence increased from …


Adsorptive Gas Sensor Response Forecasting To Enable Breath-By-Breath Analysis, Samuel Bellaire, Samir Ahmed Rawashdeh, Kirby P. Mayer, Jamie L. Sturgill Jan 2026

Adsorptive Gas Sensor Response Forecasting To Enable Breath-By-Breath Analysis, Samuel Bellaire, Samir Ahmed Rawashdeh, Kirby P. Mayer, Jamie L. Sturgill

Physical Therapy Faculty Publications

MOS gas sensors have proven to be useful in electronic noses, which utilize these sensors to detect volatile organic compounds in human breath to detect various lung diseases. Unfortunately, the long settling time of MOS gas sensors is ill-suited to measuring human breath, where complete breathing cycles are often shorter than 5 s. Existing studies circumvent this limitation by collecting gas samples and injecting them into a sealed chamber to react with the sensors. However, it would be convenient if breath-by-breath analysis could be conducted without the need to store breath samples. To accomplish this, we present a novel forecasting …


Exploring The Influence Of Quadriceps Peak Torque And Rate Of Torque Development On Running Mechanics After Anterior Cruciate Ligament Reconstruction, Amit M. Gohil, Gregory S. Hawk, Darren L. Johnson, Christopher S. Fry, Brian W. Noehren Jan 2026

Exploring The Influence Of Quadriceps Peak Torque And Rate Of Torque Development On Running Mechanics After Anterior Cruciate Ligament Reconstruction, Amit M. Gohil, Gregory S. Hawk, Darren L. Johnson, Christopher S. Fry, Brian W. Noehren

Physical Therapy Faculty Publications

Background: After anterior cruciate ligament reconstruction (ACLR), chronic changes in knee joint biomechanics during higher level tasks, such as running, may negatively impact long-term knee joint health. Among the factors that contribute to these chronic changes, the influence of quadriceps strength on knee joint biomechanics during running is not well understood.   Hypothesis: Higher involved limb quadriceps strength (peak torque and rate of torque development [RTD]) and limb symmetry index (LSI) will be positively associated with greater peak knee flexion angle and peak knee extensor moment during running.   Study Design: Cross-sectional study.   Level of Evidence: Level 3.   Methods: Peak knee extensor …


Sexual Dysfunction In Women With Endometriosis In A Low-Middle-Income Country, Edna Chacha, Charles Muteshi, Felix Oindi, Elsie Wandera Jan 2026

Sexual Dysfunction In Women With Endometriosis In A Low-Middle-Income Country, Edna Chacha, Charles Muteshi, Felix Oindi, Elsie Wandera

Obstetrics and Gynaecology, East Africa

Background Endometriosis affects up to 10% of reproductive-age women and significantly impairs quality of life including sexual function, intimate relationships, fertility, and psychological wellbeing. While its impact has been extensively studied in Western populations, there is limited Sub-Saharan African data exploring how the disease affects female sexual health and distress. This study aimed to assess sexual function and sexual distress among women with endometriosis at a tertiary hospital in Kenya.

Methods A cross-sectional study was conducted involving 108 women aged 18 to 49 with confirmed endometriosis from January to June 2022. The study used validated self-administered questionnaires: Female Sexual Function …


Improving Staff Perceptions Of Effective Communication Through Frequent Micro-Team Huddles: A Quality Improvement Initiative, Sara Krslovic Jan 2026

Improving Staff Perceptions Of Effective Communication Through Frequent Micro-Team Huddles: A Quality Improvement Initiative, Sara Krslovic

Master's Theses and Capstones

Abstract 

Background: Effective communication among interdisciplinary team members is essential for safe, coordinated patient care. An outpatient primary care clinic identified inconsistent and non-inclusive communication within assigned micro-teams, particularly between nurses and providers, creating an opportunity to implement a structured communication strategy.

Local Problem: Communication within micro-teams lacked a standardized process, and nurses were often excluded from routine communication with providers. Prior to implementation, no formal micro-team huddles had occurred within the previous six months.

Methods: A four-week quality improvement initiative was conducted using the Plan-Do-Study-Act (PDSA) framework. Weekly, micro-team huddles were implemented between nurses, providers, and the medical assistant …


Improving Early Ambulation After Cardiac Surgery Using Nurse Education And Workflow Cues: A Quality Improvement Project, Nathan Seeley Jan 2026

Improving Early Ambulation After Cardiac Surgery Using Nurse Education And Workflow Cues: A Quality Improvement Project, Nathan Seeley

Master's Theses and Capstones

Background: Early ambulation following cardiac surgery is an evidence-based practice that promotes postoperative recovery, reduces complications, and supports earlier discharge (Cook et al., 2024; Engelman et al., 2019; Kanejima et al., 2020). Despite its recognized benefits, consistent implementation remains challenging in busy inpatient settings due to workflow demands, competing priorities, and patient-related barriers.

Local Problem: Inconsistent early ambulation practices were identified on the Cardiac Surgical Step-Down Unit, creating an opportunity to improve adherence to evidence-based postoperative mobility practices.

Methods: This quality improvement project used the Plan-Do-Study-Act (PDSA) model to evaluate the impact of a brief nurse-focused educational intervention on early …


Improving Operating Room First-Case On-Time Starts And Reducing Turnover Times: A Quality Improvement Project, Ashley Cote Jan 2026

Improving Operating Room First-Case On-Time Starts And Reducing Turnover Times: A Quality Improvement Project, Ashley Cote

Master's Theses and Capstones

Abstract

Background: Delays in first case on-time starts (FCOTS) contribute to decreased operating room (OR) efficiency, increased healthcare costs, workflow disruptions, and reduced staff and patient satisfaction. Evidence suggests that standardized workflows, improved communication, and Lean Six Sigma methodologies can improve perioperative efficiency and reduce delays.

Local Problem: Baseline data from a local OR microsystem demonstrated an FCOTS rate of 77%, below the organizational benchmark of 80%. Root cause analysis identified inconsistent preoperative workflows, communication gaps, and variable staff adherence to standardized processes as primary contributors to delayed first-case starts.

Methods: A quality improvement project utilizing the Define, Measure, Analyze, …


A Quality Improvement Initiative: Implementing An Effective Massive Transfusion Protocol Cognitive Aid Tool Within An Operating Room & Post-Anesthesia Care Unit Setting, Jenna L. Farrell Jan 2026

A Quality Improvement Initiative: Implementing An Effective Massive Transfusion Protocol Cognitive Aid Tool Within An Operating Room & Post-Anesthesia Care Unit Setting, Jenna L. Farrell

Master's Theses and Capstones

Abstract

Background: Massive Transfusion Protocol (MTP) activations are low-frequency, high-acuity events in the post-anesthesia care unit (PACU) setting.  These events necessitate the rapid formation of codes teams, interdisciplinary communication amongst unfamiliar providers, critical decision-making, high-volume rapid blood transfusions, and critical laboratory marker monitoring.

Local Problem: Due to the infrequent nature of hemorrhagic events in the PACU, nurses may have limited experience participating in these protocols at their institutions, resulting in potential for documentation errors from retrospective back charting, decreased confidence regarding blood product sequencing and laboratory draw timing, and increased cognitive workload overall.  This quality improvement (QI) project implemented …


Pathology: Asthma, Hailey Gaines Jan 2026

Pathology: Asthma, Hailey Gaines

A with Honors Projects

Asthma is a very common chronic disease that affects about 25 million people in the United States. It leads to inflammation and narrowing of the airways, which makes breathing more difficult. This presentation covers basic facts about asthma in CT and MRI along with who it effects.


Barriers And Facilitators Of Diabetes Educational Knowledge Retention Among Black Women: An Exploratory Sequential Mixed Method Study Of Black Diabetes Educators, Alicia Mott Jan 2026

Barriers And Facilitators Of Diabetes Educational Knowledge Retention Among Black Women: An Exploratory Sequential Mixed Method Study Of Black Diabetes Educators, Alicia Mott

Nursing Theses and Dissertations

Problem: There is a gap in understanding the culturally specific barriers affecting diabetes education knowledge (DEK) among Black women with Diabetes Mellitus (DM). This study explores the barriers and facilitators to improving education retention from the perspectives of diabetes mellitus educators and health care providers.

Theoretical Framework: The Campinha-Bacote Model (CBM) was utilized to identify the facilitators and barriers of Black women with DM.

Design: An exploratory sequential mixed method was used to identify barriers and facilitators of DEK among Black women. A sample of six Black diabetes experts participated in the qualitative study, and seven professionals participated in rounds …


Advancing Cns Tumor Management: Novel Modalities In Surgery, Radiation, And Chemotherapy, Armin David Tavakkoli Jan 2026

Advancing Cns Tumor Management: Novel Modalities In Surgery, Radiation, And Chemotherapy, Armin David Tavakkoli

Dartmouth College Ph.D Dissertations

Most tumors affecting the brain and spine are managed through a combination of surgical resection, radiation, and chemotherapy; however, operative morbidity from invasive surgery, the narrow therapeutic window of conventional radiotherapy, and poor blood-brain barrier penetration of systemic agents are critical barriers that hinder long term tumor control. This thesis presents three complementary strategies to advance brain and spine tumor therapy. First, we investigate laser interstitial thermal therapy (LITT) in the treatment of spinal tumors with metastatic epidural spinal cord compression, replacing “separation surgery” with a minimally invasive, image-guided approach that maximizes tumor ablation while preserving neurologic function. Second, we …


The Influence, Dependency, And Targeting Of Fatty Acid Uptake In Er+ Breast Cancer, Abigail E. Goen Jan 2026

The Influence, Dependency, And Targeting Of Fatty Acid Uptake In Er+ Breast Cancer, Abigail E. Goen

Dartmouth College Ph.D Dissertations

Estrogen Receptor-positive/ Human Epidermal Growth Factor 2-negative, breast cancer (ER+/HER2- BC) is the most prevalent subtype of BC, impacting millions of individuals. Although early screening and treatment with endocrine therapy has greatly enhanced survival, this subtype sustains a steady increase of risk for recurrent disease for decades after diagnosis, indicating the persistence of residual cancer cells that are capable of maintaining dormancy for >20 years prior to metastatic outgrowth. Dormant cells reprogram metabolic pathways which can be profoundly influenced by the tumor microenvironment in promoting quiescence or proliferation. Fatty acid oxidation dependency has been noted as a hallmark of drug …


Low Burden Of Clinically Relevant Anaemia And Thrombocytopenia Among Adolescents Living With Hiv Receiving Tenofovir/Lamivudine Plus Dolutegravir: The Cipher-Adola Study In Cameroon, Nadine Nguendjoung Fainguem, Yagai Bouba, Rachel Kamgaing, Jeremiah Efakika Gabisa, Aude Christelle Ka’E, Michel Carlos Tommo Tchouaket, Alex Durand Nka, Cynthia Ayafor, Lum Forgwei, Upal Roy Jan 2026

Low Burden Of Clinically Relevant Anaemia And Thrombocytopenia Among Adolescents Living With Hiv Receiving Tenofovir/Lamivudine Plus Dolutegravir: The Cipher-Adola Study In Cameroon, Nadine Nguendjoung Fainguem, Yagai Bouba, Rachel Kamgaing, Jeremiah Efakika Gabisa, Aude Christelle Ka’E, Michel Carlos Tommo Tchouaket, Alex Durand Nka, Cynthia Ayafor, Lum Forgwei, Upal Roy

Health & Biomedical Sciences Faculty Publications

Background: Anaemia and thrombocytopenia adversely affect adolescent HIV outcomes, yet adolescent-specific data from the tenofovir/lamivudine/dolutegravir (TLD) era remain scarce, and access to full blood count (FBC) testing is limited in Cameroon. We evaluated the prevalence, severity, and factors associated with these cytopenias among adolescents living with HIV (ADLHIV) in the TLD era.

Methods: Multicentre cross-sectional study was conducted among ADLHIV (10-19 years) receiving TLD in the CIPHER-ADOLA cohort in Cameroon. Full blood count, viral load (VL) and CD4-count were performed. Factors associated with anaemia and thrombocytopenia were ascertained.

Results: A total of 252 ADLHIV was enrolled (50.8% male, 83.3% were …


Apoe4 Drives Maladaptive Heterogeneity And Immunometabolic Responses Of Astrocytes, Danielle S. Goulding, Holden C. Williams, Amy A. Gorman, Nicholas A. Devanney, Douglas A. Harrison, Adeline E. Walsh, Tony Tuck, Diana J. Zajac, Shannon L. Macauley, Steven Estus, Julia Tcw, Lance A. Johnson, Josh M. Morganti Jan 2026

Apoe4 Drives Maladaptive Heterogeneity And Immunometabolic Responses Of Astrocytes, Danielle S. Goulding, Holden C. Williams, Amy A. Gorman, Nicholas A. Devanney, Douglas A. Harrison, Adeline E. Walsh, Tony Tuck, Diana J. Zajac, Shannon L. Macauley, Steven Estus, Julia Tcw, Lance A. Johnson, Josh M. Morganti

Sanders-Brown Center on Aging Faculty Publications

Apolipoprotein E4 (APOE4) is the strongest risk allele associated with the development of late onset Alzheimer’s disease (AD). Across the CNS, astrocytes are the predominant expressor of APOE while also being critical mediators of neuroinflammation and cerebral metabolism. APOE4 has been consistently linked with dysfunctional inflammation and metabolic processes, yet insights into the molecular constituents driving these responses remain unclear. Utilizing complementary approaches across humanized APOE mice and isogenic human iPSC astrocytes, we demonstrate that ApoE4 alters the astrocyte immunometabolic response to pro-inflammatory stimuli. Our findings show that ApoE4-expressing astrocytes acquire distinct transcriptional repertoires at single-cell and spatially-resolved domains, which …


Adversarial Robustness In Biomedical Time-Series Models, Rohan Tiwari Jan 2026

Adversarial Robustness In Biomedical Time-Series Models, Rohan Tiwari

Bioengineering Theses

This study investigates adversarial vulnerabilities in deep learning models for biomedical time-series classification across two clinically important modalities: electrocardiography (ECG) and electroencephalography (EEG). Using the MIT-BIH Arrhythmia and CHB-MIT seizure datasets, I evaluate time-domain attacks (FGSM, PGD), Fourier-domain constrained attacks, and learned spectral perturbations designed to reveal modality-specific sensitivity patterns. Across both tasks, a consistent trend emerges low-frequency components (0–5 Hz) constitute a dominant axis of adversarial vulnerability, with perturbations in this range producing the steepest degradation in classification performance. In ECG models, protecting the physiologically relevant QRS band (5–20 Hz) significantly improves robustness, whereas EEG models remain highly sensitive …


Kinase Signaling In Liver Disease Via Clinical-Trial-On-A-Pamchip: A Distinctive Methodology For Drug Mechanisms And Personalized Medicine, Zachary A. Kipp, Evelyn A. Bates, Genesee J. Martinez, Wang-Hsin Lee, Sally N. Pauss, Terry D. Hinds, Jr. Jan 2026

Kinase Signaling In Liver Disease Via Clinical-Trial-On-A-Pamchip: A Distinctive Methodology For Drug Mechanisms And Personalized Medicine, Zachary A. Kipp, Evelyn A. Bates, Genesee J. Martinez, Wang-Hsin Lee, Sally N. Pauss, Terry D. Hinds, Jr.

Pharmacology and Nutritional Sciences Faculty Publications

The utilization of extensive datasets, such as those generated by DNA or RNA sequencing, has become a central focus in drug discovery and personalized medicine (PerMed). Nonetheless, these datasets are constrained by the absence of protein-functionality testing, which affects physiological responses. In this study, we employed PamGene PamStation technology to quantify protein function by kinase activity across more than 500 signaling pathways from patients with hepatocellular carcinoma (HCC). Using proteins derived from nine patients and five human HCC cell lines for drug discovery and the clinical trial-on-a-chip approach, we developed comprehensive PerMed scores from the PamStation data to differentiate individual …


“Medical Cannabis”: Advising Patients While Navigating Medical Ethics And Limited Evidence, Anna-Maria South, Shanna L. Babalonis, Laura C. Fanucchi, Michelle R. Lofwall Jan 2026

“Medical Cannabis”: Advising Patients While Navigating Medical Ethics And Limited Evidence, Anna-Maria South, Shanna L. Babalonis, Laura C. Fanucchi, Michelle R. Lofwall

Internal Medicine Faculty Publications

Cannabis is increasingly legalized in more areas of the USA and marketed under the misnomer “medical cannabis.” Yet, there are no official dosing guidelines or approved medical uses for plant cannabis by the Food and Drug Administration. Due to significant federal barriers, research on efficacy, safety, and adverse effects of cannabis is limited. Patients are interested in cannabis as potential treatment of medical issues and/or symptoms and clinicians should include a discussion of the risks of cannabis consumption. However, many risks are not yet known, and clinicians might be unaware of the emerging literature. This perspective summarizes the potential harms …


Prevalence And Characteristics For Mental Health Disorder Before And After Childhood Cancer Diagnosis—A Statewide Population-Based Study Among Medicaid Beneficiaries, Feitong Lei, Laurie E. Mclouth, Eric B. Durbin, Thomas T. Tucker, John L. Villano, Bin Huang Jan 2026

Prevalence And Characteristics For Mental Health Disorder Before And After Childhood Cancer Diagnosis—A Statewide Population-Based Study Among Medicaid Beneficiaries, Feitong Lei, Laurie E. Mclouth, Eric B. Durbin, Thomas T. Tucker, John L. Villano, Bin Huang

Internal Medicine Faculty Publications

Introduction: Pediatric cancer patients suffer mental health deficits. Patients who are vulnerable with respect to socioeconomic or other sociodemographic factors may be at heightened risk for worse mental health outcomes during cancer for many reasons including entering treatment with an existing mental health disorder. The purpose of this study was to describe the prevalence and trajectory of mental health before and after a childhood cancer diagnosis in a socio-demographically at-risk sample.

Methods: Data from the Kentucky Cancer Registry was utilized to identify patients aged 19 or under with a first primary childhood cancer diagnosis during 2001–2017. Linking KCR data with …


Facilitators Of And Barriers To Implementation Of A Tablet-Based Digital Health Program For Colorectal Cancer Screening In Primary Care: Qualitative Pragmatic Implementation Study, Mark Cromo, Aliza Randazzo, David P. Miller, Kristie Foley, Ajay Dharod, Anna C. Snavely, Elena Wright, Holly Brower, Mark Dignan Jan 2026

Facilitators Of And Barriers To Implementation Of A Tablet-Based Digital Health Program For Colorectal Cancer Screening In Primary Care: Qualitative Pragmatic Implementation Study, Mark Cromo, Aliza Randazzo, David P. Miller, Kristie Foley, Ajay Dharod, Anna C. Snavely, Elena Wright, Holly Brower, Mark Dignan

Internal Medicine Faculty Publications

Background: Colorectal cancer (CRC) incidence and mortality rates continue to be elevated even though effective screening methods are widely available. To increase CRC screening in primary care practices, our team developed a tablet-based digital health program (mPATH) designed to identify patients needing CRC screening, provide education, and empower patients to request a screening test via the program.

Objective: This study aimed to qualitatively assess facilitators of and barriers to implementing and maintaining mPATH in primary care clinics.

Methods: In a pragmatic implementation trial, clinics were randomized to receive only in-person training and technological support via phone or email (low touch) …


Adipose Tissue-Derived Small Extracellular Vesicles In Plasma Reveal Molecular Circuitries Underlying Glucose Intolerance, Shalini Mishra, Yixin Su, Ashish Kumar, Sangeeta Singh, Brian S. Finlin, Fang-Chi Hsu, Jingyun Lee, Cristina M. Furdui, Philip A. Kern, Swapan K. Das, Gagan Deep Jan 2026

Adipose Tissue-Derived Small Extracellular Vesicles In Plasma Reveal Molecular Circuitries Underlying Glucose Intolerance, Shalini Mishra, Yixin Su, Ashish Kumar, Sangeeta Singh, Brian S. Finlin, Fang-Chi Hsu, Jingyun Lee, Cristina M. Furdui, Philip A. Kern, Swapan K. Das, Gagan Deep

Internal Medicine Faculty Publications

Objective: Glucose tolerance (GT) is a major effector for adipose tissue (AT) remodeling in obesity, yet its molecular mechanisms remain incompletely defined. We hypothesized that the biophysical and molecular profiles of AT-derived small extracellular vesicles (sEVAT) change in response to glucose availability and differ by GT status.

Methods: sEVAT were isolated from plasma of individuals with normal GT (NGT) and impaired GT (IGT) (n = 5/group) at fasting (0 h) and 1 h post glucose challenge during oral glucose tolerance test (OGTT). sEVAT were characterized for size, concentration, surface expression of insulin receptor-α (INSRα), proteome, …


Smarter Nutrition: Right-Sizing Nutritional Monitoring In Patients On Crrt, David Zolezzi, Elizabeth Journey, Jayne Walters Jan 2026

Smarter Nutrition: Right-Sizing Nutritional Monitoring In Patients On Crrt, David Zolezzi, Elizabeth Journey, Jayne Walters

2026

No abstract provided.


Discrimination Distress And Current Combustible And Non-Combustible Tobacco Product Use Among Us Youth, 2023, Meman Diaby, Osayande Agbonlahor, Maggie K. Richardson, Joy L. Hart, Shyanika W. Rose, Delvon T. Mattingly Jan 2026

Discrimination Distress And Current Combustible And Non-Combustible Tobacco Product Use Among Us Youth, 2023, Meman Diaby, Osayande Agbonlahor, Maggie K. Richardson, Joy L. Hart, Shyanika W. Rose, Delvon T. Mattingly

Markey Cancer Center Faculty Publications

Introduction: Discrimination is the unfair treatment of people based on their identity. Youth who experience discrimination may cope with associated distress by using tobacco products, with amplified health consequences depending on the type of product.

Methods: We used data from the 2023 National Youth Tobacco Survey (n = 22 069) and derived an overall continuous measure from the 15-item Adolescent Discrimination Distress Index, as well as three continuous discrimination distress sub-indices: educational, institutional, and peer (range for each: 0–5). We defined current tobacco use as two outcomes: any past 30-day use of combustible (cigarettes, cigars, hookah, roll- your-own, pipe, bidis) …


Epilepsy, Children's Health School Services Jan 2026

Epilepsy, Children's Health School Services

School Guides

Educator guide about how to support students with epilepsy.


Cystic Fibrosis, Children's Health School Services Jan 2026

Cystic Fibrosis, Children's Health School Services

School Guides

Educator guide about how to support students with cystic fibrosis.


End Stage Renal Disease, Children's Health School Services Jan 2026

End Stage Renal Disease, Children's Health School Services

School Guides

Educator guide about how to support students with end stage renal disease.


Anorexia-Bulimia, Children's Health School Services Jan 2026

Anorexia-Bulimia, Children's Health School Services

School Guides

Educator guide about how to support students with anorexia and bulimia.


Arfid, Children's Health School Services Jan 2026

Arfid, Children's Health School Services

School Guides

Educator guide about how to support students with avoidant restrictive food intake disorder or ARFID.


Brain Tumors, Children's Health School Services Jan 2026

Brain Tumors, Children's Health School Services

School Guides

Educator guide about how to support students with brain tumors.


Congenital Heart Defects, Children's Health School Services Jan 2026

Congenital Heart Defects, Children's Health School Services

School Guides

Educator guide about how to support students with congenital heart defects.