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A 48-year-old woman presented with heart failure and bioprosthetic pulmonary valve regurgitation 2 years after pulmonary valve replacement. Intracardiac echocardiography demonstrated uniform thickening of a single prosthetic valve leaflet suggesting leaflet thrombosis rather than bioprosthetic valve degeneration. After 3 months of anticoagulation, valve regurgitation and symptoms improved. (Level of Difficulty: Intermediate.), Central Illustration

This paper explores the impacts of decarbonisation of heat on demand and subsequently on the generation capacity required to secure against system adequacy standards. Gas demand is explored as a proxy variable for modelling the electrification of heating demand in existing housing stock, with a focus on impacts on timescales of capacity markets (up to four years ahead). The work considers the systemic changes that electrification of heating could introduce, including biases that could be introduced if legacy modelling approaches continue to prevail. Covariates from gas and electrical regression models are combined to form a novel, time-collapsed system model, with demand-weather sensitivities determined using lasso-regularized linear regression. It is shown, using a GB case study with one million domestic heat pump installations per year, that the sensitivity of electrical system demand to temperature (and subsequently sensitivities to cold/warm winter seasons) could increase by 50% following four years of heat demand electrification. A central estimate of 1.75 kW additional peak demand per heat pump is estimated, with variability across three published heat demand profiles leading to a range of more than 14 GW in the most extreme cases. It is shown that the legacy approach of scaling historic demand, as compared to the explicit modelling of heat, could lead to over-procurement of 0.79 GW due to bias in estimates of additional capacity to secure. Failure to address this issue could lead to {\pounds}100m overspend on capacity over ten years.

Introduction Breastfeeding is associated with improved maternal and child outcomes. Women with a higher body mass index (BMI), who comprise about 50% of the population, are at increased risk of poorer breastfeeding practices and are a population who would benefit from breastfeeding. Methods This protocol is for a multi-centre, randomised controlled trial of perinatal breastfeeding support among primiparous women with a BMI >25 kg/m2, using a previously-tested, multi-component intervention. The primary outcome is any breastfeeding at 3 months. The intervention will support mothers and their partners and spans from late pregnancy to six weeks postpartum. Intervention components include group antenatal breastfeeding education, individual face-to-face education in the immediate postnatal period, professional support to six weeks’ postpartum and weekly phone calls in the immediate postpartum period from an International Board Certified Lactation Consultant (IBCLC). The intervention will target attitudes towards breastfeeding, breastfeeding self-efficacy, and subjective norms around infant feeding with the aim to normalise the behaviour. Results We anticipate that the intervention will be well-accepted and feasible to carry out within four maternity units in the East of Ireland. Furthermore, essential formative qualitative work has been conducted to inform the intervention design and to ensure that it is contextually appropriate. Conclusion The proposed intervention will be invaluable to policy-makers in providing insights into what specific interventions are effective in improving breastfeeding rates for women with a raised BMI.

Coxiella burnetii is the causative bacterium of the zoonotic disease Q fever, which is recognised as a public health concern globally. Macropods have been suggested as a potential source of C. burnetii infection for humans. The aim of this cross-sectional study was to determine the prevalence of C. burnetii exposure in a cohort of Australian wildlife rehabilitators (AWRs) and assess Q fever disease and vaccination status within this population. Blood samples were collected from adult participants attending the Australian Wildlife Rehabilitation Conference in Sydney in July 2018. Participants completed a questionnaire at the time of blood collection. Antibody titres (IgG, IgA and IgM) against phase I and phase II C. burnetii antigens as determined by immunofluorescence assay, revealed that of the unvaccinated participants, 6.1% (9/147) had evidence of exposure to C. burnetii. Of the total participants, 8.1% (13/160) had received Q fever vaccination, four of whom remained seropositive at the time of blood collection. Participants reporting occupational contact with ruminants, were eight times more likely to have been vaccinated against Q fever, than those reporting no occupational animal contact (OR 8.1; 95% CI 1.85–45.08). Three AWRs (2%) reported having had medically diagnosed Q fever, two of whom remained seropositive at the time of blood collection. Despite the lack of association between macropod contacts and C. burnetii seropositivity in this cohort, these findings suggest that AWRs are approximately twice as likely to be exposed to C. burnetii, compared with the general Australian population. This provides support for the recommendation of Q fever vaccination for this potentially ‘at-risk’ population. The role of macropods in human Q fever disease remains unclear, and further research into C. burnetii infection in macropods including: infection rate and transmission cycles between vectors, macropods as reservoirs, other animals and humans is required.

This paper explores the impacts of decarbonization of heat on demand and subsequently on the generation capacity required to secure against system adequacy standards. Gas demand is explored as a proxy variable for modelling the electrification of heating demand in existing housing stock, with a focus on impacts on timescales of capacity markets (up to four years ahead). The work considers the systemic changes that electrification of heating could introduce, including biases that could be introduced if legacy modelling approaches continue to prevail. Covariates from gas and electrical regression models are combined to form a novel, time-collapsed system model, with demand-weather sensitivities determined using lasso-regularized linear regression. It is shown, using a Great Britain-based case study with one million domestic heat pump installations per year, that the sensitivity of electrical system demand to temperature (and subsequently sensitivities to cold/warm winter seasons) could increase by 50% following four years of heat demand electrification. A central estimate of 1.75 kW additional peak demand per heat pump is estimated, with variability across three published heat demand profiles leading to a range of more than 14 GW in the most extreme cases. It is shown that the legacy approach of scaling historic demand, as compared to the explicit modelling of heat, could lead to over-procurement of 0.79 GW due to bias in estimates of additional capacity to secure. Failure to address this issue could lead to £100m overspend on capacity over ten years.

Retailers serve as the main interface between business and society. This study explores the Corporate Social Responsibility priorities and performance of the largest 23 global retailers. This set of global retailers, who have a major impact on society, were studied in terms of social, environmental and sustainability practices and strategy, and there performance was analysed and evaluated. The study uses a four-dimensional Social, Economic, Environmental, Supply Chain model for sustainability performance evaluation. We rely on data collected from annual reports, and find that global retailers have addressed the business-society interface in relatively balanced ways for the different dimensions of CSR. Further, our findings indicate that global retailers in different regions have different CSR priorities. In particular, the data indicates that the US retailers place a lower priority on supply chain sustainability performance, followed by the Australians, while European retailers place a higher priority. The study concludes that while global retailers all pay attention to the same dimensions of CSR and do so differently in the different regions, the variation and lack of significant progress indicates that there is a role for stronger government regulation. This study contributes to the literature by shifting the analysis from country to a global level, is more objective in relying on reported data rather than interviews or surveys and provides a new analytical tool., Corporate social responsibility; Retail; Strategy; Sustainability; Supply chain; SDG; Sustainable development; Technology management; Entrepreneurship; Business policy; Management; Globalization; Industrialization

Background/Aims The objective of this manuscript is to present challenges and solutions that arose during a mid-sized single-site RCT of a rehabilitation intervention performed in an inpatient stroke rehabilitation setting. Methods Seventy-six participants from an inpatient stroke rehabilitation unit were randomized to experimental and control groups. All participants did 30–45 min of virtual reality (VR) daily for 10–12 sessions. The experimental group did VR targeting sitting balance while the control group did VR with limited arm movement. Challenges during the implementation of the RCT were documented and strategies to mitigate them were applied. Results Challenges were placed into five categories: 1. Recruitment. Our recruitment procedures required multiple steps prior to initiating direct patient contact; one solution would be to have patients consent to be approached about research upon admission to the inpatient unit. 2. Patient-specific Issues. Fatigue, pain, vision problems and engagement were managed through scheduling, increasing the workload slowly and personalized modifications to the VR. 3./4. Scheduling and Staffing. Recruitment and attendance at VR sessions were maximized through good communication, flexibility and cooperation, between research staff, clinical staff, volunteers, students and participants. 5. Technology. Because hospital internet service was poor, a mobile internet data plan was purchased to ensure the system's reliability. Conclusions We have identified challenges in delivering a rehabilitation intervention on an inpatient stroke rehabilitation unit and some of the measures taken to surmount these challenges. Through good planning, flexibility and collaboration, almost all of the challenges were successfully addressed. Clinical trial registration number URL: http://www.clinicaltrials.gov . Unique identifier: NCT02285933.

Recent advances in technology for both describing and interrogating the sequence and structure of animal genomes and their functional variation have presented opportunities for scientists to more clearly understand the complexity of bovine milk protein structure and utility and the control of milk protein gene expression. Using these technologies in conjunction with protein sequence data, we can begin to understand the significance of naturally occurring genetic variation influencing milk protein production and composition and how the proteins in colostrum and milk are processed/digested into biologically active peptides. The challenge is to translate this information into useful nutritional and nutraceutical products that help to underpin the commercial viability of the dairy industry. Recent advances in genetic technologies provide the potential for accurate selection of desirable traits in dairy cow populations through genomic methods. Milk composition may also be modified through gene editing, although consumer acceptance of genetically modified foods is still an issue. We present a review of the current status of bovine milk genomics, including functional genomics and gene editing approaches, and discuss the roles, characteristics, and key bioactivities of the major bovine milk proteins and their encrypted peptides.