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Background: Stroke profoundly affects quality of life (QOL), including loss of employment, reduced social activity, shrinking social networks and low mood. Dysgraphia (impaired writing) is a common symptom of aphasia yet is rarely targeted in rehabilitation. Recent technological advances might challenge this, since much communication is now conducted digitally through writing. The rehabilitation of writing may therefore help to address the wider consequences of stroke and aphasia. Aims: Can assistive technology (AT) training for people with dysgraphia: (1) improve written output, and are gains achieved only with AT? (2) improve reading comprehension scores, and are gains achieved only with AT? and (3) affect social participation, mood or QOL Methods and Procedures: Design A mixed‐methods, repeated measures, small group study design was adopted (qualitative outcomes will be reported elsewhere). Participants: Recruited from community settings, for example, Stroke Association communication support groups. Inclusion criteria: over 18 years old, aphasia due to stroke, acquired dysgraphia, writing more impaired than speech, fluent English prior to stroke, access to computer and Internet. Exclusion criteria: currently receiving speech and language therapy, significant cognitive impairment, neuromuscular/motor‐speech impairments/structural abnormalities, developmental dyslexia, uncorrected visual/auditory impairments. Procedures: Screening and diagnostic assessments at time T1 (first baseline). Outcome measures at T1; repeated at T2 (second baseline), T3 (end of intervention), T4 (3‐month follow up). Social participation assessment and cognitive monitoring at T2, T3, T4. Intervention: Seven–ten hours individual therapy weekly and additional email support. Participants were trained to operate Dragon NaturallySpeaking (speech to text package) and ClaroRead (read writing aloud). Outcome measures were administered on pen and paper (control) and on computer, with AT enabled only at T3, T4. Outcomes and Results: Computer narrative writing was significantly improved by AT training (Friedman's χ2 (3) = 8.27, p = 0.041), indicating a compensatory effect of AT. Though reading comprehension significantly improved in the computer condition (Friedman's χ2 (3) = 21.07, p = 0.001), gains could not be attributed to the AT. Gains were achieved only when measures were administered on the keyboard, with AT enabled. Thus, a compensatory rather than remediatory effect was suggested. Social network size significantly increased; there were no significant changes in mood/QOL. Individual success rates varied. Conclusion and Implications: The customisable AT training was acceptable to participants and resulted in significantly improved narrative writing. Compensatory AT interventions are a useful adjunct to remediatory writing interventions and may particularly support functional writing. WHAT THIS PAPER ADDS: What is already known on this subject: Writing is rarely spared in aphasia and may present as the most impaired communication modality. Yet, people with aphasia report that writing is seldom included in their rehabilitation. Many communication activities are now conducted digitally through writing, therefore rehabilitation of this is more important than ever before. This study sought to address whether an assistive technology (AT) software package can improve writing and whether any changes were compensatory or remediatory. What this study adds to existing knowledge: This group study found that AT training led to gains in written discourse and social network in people with aphasia and dysgraphia. Gains were not replicated in handwritten tasks, suggesting this was a compensatory therapeutic approach. What are the clinical implications of this work?: AT programs such as this may present speech and language therapists with a practical, pragmatic adjunct to writing or typing therapy, particularly for clients with chronic, intractable impairments for whom remediatory therapy may have a low chance of success. [ABSTRACT FROM AUTHOR]

Background: Research is beginning to shed light on the practices employed by speech‐language therapists (SLTs) for the management of acquired dysarthria. However, studies that explore SLTs' satisfaction with the effectiveness of current therapies and their interest in new treatment methods for this population have not been carried out. One potential new method is neuromuscular electrical stimulation (NMES): the pool of evidence for its use in rehabilitation is increasing, yet it has not been widely explored for use with dysarthria. Aim: To extend the understanding of acquired dysarthria management practices employed by SLTs across the globe and determine their satisfaction with current therapy options. To explore their interest in using NMES with this population. Methods and Procedures: A cross‐sectional international online survey was developed and disseminated to SLTs working with adults with acquired dysarthria through international professional associations. The survey collected information on demographic characteristics, dysarthria management practices, satisfaction with treatment effectiveness and interest in and knowledge of NMES. Survey responses were analysed using descriptive and inferential statistics, and quantitative content analysis. Outcomes and Results: A total of 211 SLTs (North America, 48.8%; Europe, 36%; Asia, 8.1%; Oceania, 5.7%; Africa, 0.9%; South America, 0.5%) completed the survey in full. Management practices varied considerably. There was a clear preference for informal assessments, mainly oral‐motor examinations, focusing on body functions and structures. The majority of respondents rejected the use of non‐speech oral motor exercises as a clinical or carryover exercise. Variable satisfaction with current speech subsystem treatments was noted; however, overall, there was a general dissatisfaction. Whilst a strong interest in the use of NMES for dysarthria was evidenced, it was noted that most SLTs lacked fundamental knowledge of NMES principles and application. Conclusion: SLTs' management practices and satisfaction with acquired dysarthria treatments differed substantially. Investigations of the potential use of NMES for dysarthria treatment are of interest. WHAT THIS PAPER ADDS: What is already known on the subject: Recent country‐specific surveys have explored speech‐language therapists' (SLTs') assessment and intervention practices for acquired dysarthria. These studies indicate that although clinical management for this speech disorder mainly involves informal assessment tools and impairment‐focused treatment, communication beyond the impairment, such as the activity and participation domains, is also frequently assessed and treated. What this paper adds to existing knowledge: The majority of SLTs are dissatisfied with the overall benefits of current acquired dysarthria treatment. Phonatory, respiration and speech rate therapies are perceived to be more effective than prosody, articulation and resonance treatments. Despite a general lack of theoretical knowledge, most SLTs are interested in neuromuscular electrical stimulation treatment for acquired dysarthria. What are the potential or actual clinical implications of this work?: New, evidence‐based treatments are needed for SLTs to be confident in the effectiveness of their acquired dysarthria treatment. [ABSTRACT FROM AUTHOR]

Background: In order to conduct research that is meaningful to speech and language therapy services and their patients, it is often desirable to conduct the research within routine clinical services. This can require considerable time and commitment from speech and language therapists (SLTs). It is therefore important to understand the impact that such participation in research can have. Aims: To explore the impact of research participation in the Big CACTUS study of self‐managed computerized aphasia therapy conducted in 21 UK NHS speech and language therapy departments. Methods & Procedures: An online survey was sent to SLTs who took the lead role for the study at their NHS Trust to evaluate the impact of study participation in three domains: capacity‐building, research development and health services. The questionnaire, based on the VICTOR framework for evaluating research impact, included Likert scale statements and closed and open‐ended questions. The results from open‐ended questions were coded and analysed using framework analysis in NVivo 12 and the data from closed questions were analysed descriptively. Outcomes & Results: A total of 12 SLTs returned the survey. Nine codes were identified from open‐ended questions and 20 predefined from the literature. Analysis of the responses demonstrated the perceived impact including improvements in practices and access to therapy, investments in infrastructure, increased SLT profile, and impact on research culture among SLTs. The usefulness of the intervention during the COVID‐19 pandemic was also highlighted. Conclusions & Implications: The results suggest participation in Big CACTUS has resulted in improvements in patient care and SLT research capacity and culture in speech and language therapy departments. What This Paper Adds: What is already known on the subject: Practice‐based research is encouraged to assist with the clinical relevance of the research findings. Participation in research can be seen as an activity that is additional to the core business of patient care and it can be difficult to secure time to participate or conduct research in clinical settings. Impact evaluation initiatives of individual trials facilitate early identification of benefits beyond the trial. What this paper adds to existing knowledge: This study describes specific examples of the impact on services, staff and patients from SLT participation and leadership in the Big CACTUS speech and language therapy trial in clinical settings. What are the potential or actual clinical implications of this study?: Clinical services participating in research may benefit from improved clinical care for patients both during and after the study, an improved professional reputation, and increased research capacity and culture within the clinical settings. [ABSTRACT FROM AUTHOR]

Objective: The study investigated adherence with MMF treatment among patients attending rheumatology clinics at University Hospitals Coventry and Warwickshire NHS Trust (UHCW) with Autoimmune inflammatory rheumatic diseases (AIIRDs). Methods: This retrospective study collated hospital pharmacy data in patients who requested the prescription for MMF between January 2015 and December 2018. Clinical data were obtained from paper and electronic notes. Data were analysed using Microsoft Excel. Ethical approval was obtained through Coventry University. Results: We recruited 144 patients into this study with age range from 18 to 91 years, including 100 females and 44 males. There were 112 White patients, 22 of South Asian origin, 3 East Asian and 4 black patients. SLE (56), scleroderma (18), mixed connective tissue disease (15), myositis (13), vasculitis (13) were the commonest diagnoses. Overall adherence with Mycophenolate mofetil was 62%. The adherence rates were below 80% for all age groups with ∼60% of patients having adherence levels of >60%. Poor adherence with MMF correlated with 3‐fold increase in risk of flares compared to good adherence (p = 0.002). We also found a significant difference between Asian patients (mean adherence 47%) and White patients (mean adherence 65%, p < 0.001). Conclusion: Adherence with MMF has improved considerably compared to historical studies, although these remain suboptimal. Certain population groups such as young adults, elderly and Asian patients continue to have lower adherence and higher risk of flares. Strategies are needed to improve adherence levels overall and specifically in the high‐risk groups to reduce risk of flares and organ damage. [ABSTRACT FROM AUTHOR]

Background: Studies suggest swallow intervention programmes that incorporate visual biofeedback and motor programming principles can improve swallowing and quality of life for people with idiopathic Parkinson's disease (IPD) and dysphagia. Few studies have examined outcomes using instrumentation. Aims: Using fibreoptic endoscopic examination of swallowing (FEES), this study examines the effectiveness of a neurorehabilitation intervention involving biofeedback via surface electromyography (sEMG) to improve swallowing in people with IPD, and to explore the feasibility of the intervention approach. Methods & Procedures: We recruited 12 participants with IPD and dysphagia. A total of 10 completed the study. Intervention was delivered for 1 h per day, 5 days per week, for 4 weeks (20 h). Swallowing tasks using sEMG biofeedback incorporated principles of motor learning and neuroplasticity. Instrumental and non‐instrumental assessment, including quality‐of‐life measures carried out at four different time points (two pre‐treatment and two post‐treatment). The final assessment was at 3 months post‐intervention. Outcome & Results: Statistically significant improvement (p < 0.05) in oral intake methods (95% confidence interval (CI) = 4.70–5.50) and in pharyngeal residue from saliva (95% CI = 2.14–3.15) and solids (95% CI = 2.4–3.5) post‐intervention were confirmed using FEES with improvements at 3 months. The intervention protocol was well tolerated. Participants reported positive change in saliva control and duration of mealtimes as well as unanticipated improvements in voice and cognitive attention. Conclusions & Implications: An intensive neurorehabilitation with biofeedback shows positive effects in improving swallow function in IPD. This protocol is feasible with amendments to inform a larger clinical trial. What this paper adds: What is already known on the subject: Biofeedback has positive effects on increasing swallowing function and quality of life in people with IPD and dysphagia. sEMG is the most common method used to deliver swallowing biofeedback in this population. The quality of the evidence on the intervention, based on findings from a recent systematic review, is low. Included studies in this review were heterogeneous in terms of type and frequency of biofeedback, study design and outcome measures. The majority of outcome measures were subjective and higher quality studies to examine the efficacy of biofeedback using sEMG are needed. What this study adds: Recognizing the limitations of earlier studies, this within‐subject feasibility study examined the efficacy and effectiveness of an intensive biofeedback intervention using sEMG in a sample of people with dysphagia and IPD. Valid and reliable outcome measures were used and repeated after a 3‐month period. The feasibility of the methodological approach was also tested and a qualitative component was included in the study. Positive findings were evident. Qualitative information added new perspectives and provided direction for new outcomes to be included in future studies. This study helps to inform further research trials as well as clinical practice. Clinical implications of this study: This intensive intervention using principles of neuroplasticity and motor programming with sEMG biofeedback led not only to positive swallowing outcomes but also to unexpected benefits such as improved voice production and general attention skills. No adverse events were reported. Improvement in function was retained at 3 months post‐intervention. Despite the small sample size, participants described the benefits of the treatment, and enjoyed sEMG biofeedback tasks, especially using an sEMG game mode. This suggests that intensive biofeedback not only improved swallowing but also was acceptable to these participants. This intensive protocol has merit and is worth considering further in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Speech disorders in children with a cleft palate with or without a cleft lip (CP±L) are complex given the magnitude of influencing factors. Providing intervention to eliminate these speech errors is often challenging. Speech–language pathologists (SLPs) might have negative perceptions of the treatment of children with a CP±L. Aims: To explore how community SLPs perceive and experience the provision of speech intervention to children with a CP±L. Methods & Procedures: A total of 18 female community SLPs, aged between 23 and 62 years, were included in this study. Semi‐structured interviews were conducted. The interviews were analysed using an inductive thematic approach aiming to identify themes driven by the data. Trustworthiness of the data was achieved by including researcher triangulation (involving three researchers with different research backgrounds) and deviant case analysis of two cases. Outcomes & Results: Initial responses demonstrated that the community SLPs were excited and enthusiastic to treat children with a CP±L. Expanding on these initial reports, however, they revealed that their excitement turned into professional self‐doubt and insecurity when confronted with the treatment challenges inherent with this population. To cope with this self‐doubt, they outlined several responsibilities for the cleft team SLPs. They expressed a strong desire to receive confirmation and approval on their treatment practices from more experienced SLPs (i.e., the cleft team SLPs). Their perceptions were dominated by a polarized thinking pattern. Treatment approaches were divided in categories as 'right' or 'wrong' and 'good' or 'bad'. Conclusions & Implications: The community SLPs are lacking professional confidence when treating children with a CP±L. They put themselves in a subordinate position towards the cleft team SLPs and expect the latter to provide ready‐made answers to problems and questions. This expectation can perhaps be explained by their fear of making mistakes during therapy preventing treatment progress. If they handle in accordance with the experts' advice, they cannot blame themselves in cases where no treatment progress is seen. Educational programmes need to pay more attention to gaining professional confidence (in the search for the most optimal treatment approach for each individual patient) rather than merely focusing on competency‐based learning tools. What this paper adds: What is already known on the subject: Speech disorders in children with a cleft palate with or without a cleft lip (CP±L) are complex given the magnitude of influencing factors. Providing intervention to eliminate these speech errors is often challenging. What this paper adds to existing knowledge: This study explored how community SLPs' perceive and experience the provision of speech intervention to children with a CP±L. The perceptions of community SLPs are dominated by a polarized thinking pattern. Treatment approaches are divided into categories as "right" or "wrong" and "good" or "bad". They lack professional confidence when they treat children with a CP±L. The community SLPs put themselves in a subordinate position towards the cleft team SLPs and expect the latter to provide ready‐made answers to problems and questions. What are the potential or actual clinical implications of this work?: Educational programs in speech‐language pathology need to pay more attention to gaining professional confidence rather than merely focusing on competency‐based learning tools. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to determine whether physiotherapy and counselling students, who represent a future generation of two health professions, have differing views about complementary and alternative medicine (CAM). Methods: In order to determine physiotherapy and counselling students' self‐rated knowledge and beliefs about CAM and the factors which influence that understanding, a modified 10‐item CAM Health Belief Questionnaire was administered across all year groups to physiotherapy students and counselling students at two universities in Perth, Western Australia. The self‐rated paper‐based survey measured knowledge of CAM among physiotherapy and counselling students, evaluation of their beliefs regarding the use of CAM, factors that influence their knowledge and beliefs, and their likelihood of recommending CAM to future patients. Results: A response rate of 96.8% was achieved, with 387 physiotherapy students and 88 counselling students. Moderately positive beliefs about CAM were confirmed in both groups, with mean scores of 42.8/70 for physiotherapy students and 43.3/70 for counselling students. There were no significant differences between the student groups in overall self‐rated knowledge of CAM. The main factors that influenced the students' responses were personal experience for counselling students and scientific evidence for physiotherapy students. Other factors included university training, attitudes of lecturers, tutors and fellow students, cultural background, and opinions of external practitioners. Counselling students were more likely than physiotherapy students to recommend CAM therapies to their future patients. Conclusion: The results from this study demonstrate minimal self‐rated knowledge but moderately positive attitudes towards CAM by both physiotherapy and counselling students. [ABSTRACT FROM AUTHOR]

Aim To report the evidence on the effect of mechanical and/or chemical plaque control in the simultaneous management of gingivitis and caries. Material and Methods A protocol was designed to identify randomized ( RCTs) and controlled ( CCTs) clinical trials, cohort studies and prospective case series ( PCS), with at least 6 months of follow-up, reporting on plaque, gingivitis and caries. Relevant information was extracted from full papers, including quality and risk of bias. Meta-analyses were performed whenever possible. Results After the screening of 1,373 titles, 15 RCTs, 10 CCTs and 2 PCS were included. Low to moderate evidence support that combined professional and self-performed mechanical plaque control significantly reduces standardized plaque index [ n = 4; weighted mean difference ( WMD) = 1.294; 95% CI (0.445; 2.144); p = 0.003] and gingivitis scores [ n = 4; WMD = 1.728; 95% CI (0.631; 2.825); p = 0.002]. The addition of fluoride to mechanical plaque control is relevant for caries management [ n = 5; WMD = 1.159; 95% CI (0.145; 2.172); p = 0.025] while chlorhexidine rinses are relevant for gingivitis. Conclusion Mechanical plaque control procedures are effective in reducing plaque and gingivitis. The addition of fluoride to mechanical plaque control is significant for caries management. Chlorhexidine rinse has a positive effect on gingivitis and inconclusive role in caries. [ABSTRACT FROM AUTHOR]

Objective The aim of the present paper is to study the indications for fluid bolus therapy (FBT) and its associated physiological changes in ED patients. Methods Prospective observational study of FBT in a tertiary ED, we recorded indications, number, types and volumes, resuscitation goals and perceived success rates of FBT. Moreover, we studied key physiological variables before, 10 min, 1 h and 2 h after FBT. Results We studied 500 FBT episodes (750 [500-1250] mL). Median age was 59 (36-76) years and 57% were male. Shock was deemed present in 135 (27%) patients, septic shock in 80 (16%), and cardiogenic shock in 30 (6%). Overall, 0.9% saline (84%) was the most common fluid and hypotension the most common indication (70%). 'Avoidance of hospital/ICU admission' was the goal perceived to have the greatest success rate (85%). However, although mean arterial pressure (MAP) increased ( P < 0.01) and heart rate (HR) decreased ( P = 0.04) at 10 min ( P = 0.01), both returned to baseline at 1 and 2 h. In contrast, respiratory rate (RR) increased at 1 ( P < 0.01) and 2 h ( P = 0.03) and temperature decreased at 1 and 2 h (both P < 0.001). In patients with shock, 1 h after FBT, there was a median 3 mmHg increase in MAP ( P = 0.01) but no change in HR ( P = 0.44), while RR increased ( P < 0.01) and temperature decreased ( P = 0.01). Conclusions In ED, FBT is used mostly in patients without shock. However, after an immediate haemodynamic effect, FBT is associated with absent or limited physiological changes at 1 or 2 h. Even in shocked patients, the changes in MAP at 1 or 2 h after FBT are small. [ABSTRACT FROM AUTHOR]

Current policy in UK health services emphasizes that, where possible, people with intellectual disabilities should access the same services as people without intellectual disabilities. One of the barriers to this is the confidence of clinicians and therapists. In this paper, we report on the development of a scale to describe the confidence of therapists in working with people with intellectual disabilities (the Therapy Confidence Scale-Intellectual Disabilities [TCS-ID]). One-hundred and eighty-one therapists who provided talking therapies but who did not work primarily with people with intellectual disabilities completed the scale; 43 people completed the scale twice for test-retest reliability purposes. One-hundred and seven people also completed a scale of general therapy self-efficacy. The TCS-ID has a single factor structure accounting for 62% of the variance, Cronbach's alpha for the scale is 0.93 and test-retest reliability is 0.83. There are significant differences in confidence based upon participants experience in working with people with intellectual disabilities and their therapeutic orientation, and there is a significant association between the TCS-ID and the General Therapy Self-efficacy Scale. Sixty clinicians working in mainstream mental health services received training on adapting their therapeutic approaches to meet the needs of people with intellectual disabilities. The TCS-ID was used pre-training and post-training and demonstrated a significant increase in confidence for all group. We suggest that the scale has good psychometric properties and can be used to develop an understanding of the impact of training for mainstream therapist in working with people with intellectual disabilities. Copyright © 2014 John Wiley & Sons, Ltd. Key Practitioner Message There is increasing emphasis on people with intellectual disabilities receiving services from mainstream mental health services., There is no research describing the experiences and outcomes of people with intellectual disabilities receiving mainstream talking therapy services., The confidence that clinicians have in working with people with intellectual disabilities may be a barrier to them receiving mainstream services., The Therapy Confidence Scale-Intellectual Disabilities is a psychometrically sound scale for measuring the confidence of therapists in working with people with intellectual disabilities and is a useful outcome measure for training clinicians to work with people with intellectual disabilities. [ABSTRACT FROM AUTHOR]

Background Despite harmful drinking causing a significant burden on global health, there is a large treatment gap, especially in low- and middle-income countries. A major barrier to care is the lack of adequately skilled human resources to deliver contextually appropriate treatments. This paper describes the systematic process used to develop Counselling for Alcohol Problems ( CAP), a brief psychological treatment (PT) for delivery by lay counselors in routine primary care settings to men with harmful drinking in India. Methods CAP was developed using a methodology involving 3 sequential steps: (i) identifying potential treatment strategies; (ii) developing a theoretical framework for the treatment; and (iii) evaluating the acceptability and feasibility of the treatment. Results CAP is a 3-phase treatment delivered over 1 to 4 sessions based on a motivational interviewing ( MI) stance and involves the following strategies: assessment and personalized feedback, family engagement, drink refusal skills, skills to address drinking urges, problem-solving skills and handling difficult emotions, and relapse prevention and management. Data from a case series were used to inform several adaptations to enhance the acceptability of CAP to the recipients and feasibility of delivery by lay counselors of the treatment, for example expansion of the target group to include alcohol-dependent patients and the extension of the delivery settings to include home-based delivery. There was preliminary evidence of the effectiveness of CAP. Conclusions CAP is an acceptable brief PT for harmful drinking delivered by lay counselors in primary care whose effectiveness is currently being tested in a randomized controlled trial based in primary care in Goa, India. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives This study was designed to examine the factors that influence doctors' decision in initiating or switching from warfarin to dabigratran. Method A survey questionnaire was sent to 181 doctors who were most likely to prescribe dabigatran (e.g. cardiologists and general internists) at the University of California, San Francisco Medical Center between November 2011 and February 2012. Survey participants were asked to complete an electronic or a paper version of the questionnaire, which consisted of 17 multiple-choice questions. Fisher's exact test and Cochran- Mantel- Haenszel test were used to compare survey responses between cardiologists and general internists. Results A total of 65 survey responses were received (35.9% response rate). There were 13 cardiologists and 51 general internists who participated in the study. Cost (25%), renal function (21%) and CHADS2 score (18%) were the three factors doctors considered most often to determine a patient's eligibility for dabigatran in warfarin-naïve patients. On the other hand, histories of unstable international normalized ratio (37%) and missed appointments (17%) along with cost (19%) were most often considered in patients on warfarin. Cardiologists had prescribed dabigatran more often and had a significantly higher level of comfort with prescribing the drug than general internists ( P = 0.003; 77% vs. 27%). Conclusions Cost was the most important factor influencing doctors' decision to prescribe dabigatran. Safety and effectiveness of dabigatran as well as patient preference were additional factors influencing their decision. General internists were less comfortable with prescribing dabigatran than cardiologists. [ABSTRACT FROM AUTHOR]

Risk for Permanent Pacemaker After Transcatheter Aortic Valve Implantation. Background: Permanent pacemaker (PM) requirement is a known complication after transcatheter aortic valve implantation (TAVI). There are, however, no systematic data concerning this complication. Objective: To determine the incidence and potential predictors of permanent PM requirement after TAVI based on published literature. Methods: We conducted a MEDLINE search to identify potentially relevant literature dealing with PM requirement after TAVI. Data were collected on paper extraction forms by 2 independent investigators. Results: There were 32 relevant published studies comprising data of 5,258 patients without an implanted PM before TAVI. An Edwards-Sapiens® prosthesis (ESP) was implanted in 2,887 patients, whereas 2,371 patients received a CoreValve® prosthesis (CVP). The crude incidence of PM implantation after TAVI was 15%. Six hundred and fourteen of 2,371 (25.8%) CVP patients and 189 of the 2,887 (6.5%) ESP patients had to receive a permanent PM (odds ratio [OR] 4.91, 95% confidence interval [CI] 4.12-5.86, P < 0.001). Presence of right bundle branch block (RBBB) before TAVI was a significant predictor for development of complete atrioventricular (AV) block and subsequent PM need (OR 1.358, 95% CI 1.001-1.841, P = 0.02). More than 90% of all AV-block requiring PM implantation occurred immediately or within 7 days after TAVI. Conclusion: Patients undergoing TAVI with implantation of CVP are at significantly higher risk for development of AV block and subsequent need for permanent PM, particularly if RBBB preexists. Since AV block occurs in >90% within the first week after the procedure, careful monitoring should be performed for at least 7 days after TAVI. [ABSTRACT FROM AUTHOR]

Micronutrient powders (MNP) are an efficacious intervention in terms of reducing anaemia among young children, yet challenges remain regarding implementation at scale. Research that can guide effective implementation of nutrition interventions and facilitate integration into existing health care platforms is needed. This paper seeks to advance the implementation science knowledge base by presenting our multiphased strategy and findings for scaling‐up MNP in Rwanda. The multiphased implementation strategy, spanning a 5‐year period (2011–2016), included (a) a feasibility study involving formative research, (b) a 30‐day trial of improved practices (n = 60 households), (c) a 12‐month pilot that included an effectiveness study (n = 1,066 caregiver/child pairs), and (d) a staggered approach to national scale‐up. At the end of Phase 4, the programme had been implemented in 19 of Rwanda's 30 districts with the scale‐up in the final 11 districts completed in the following year. The caregivers of over 270,000 eligible children 6–23 months of age received a box of 30 MNP sachets in the final 3‐month assessment period, representing a coverage rate of 87%. Initial problems with the supply chain and distribution and ongoing challenges to monitoring and reporting have been the largest obstacles. Continued success will be dependent on adequate resources for capacity development, refresher training, and responsive monitoring. Rwanda is one of the first countries to successfully scale‐up home fortification subnationally with MNP. Lessons learned have implications for other countries. [ABSTRACT FROM AUTHOR]