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Background Vestibular schwannomas (VS) are benign intracranial tumors originating from the vestibular division of the eighth cranial nerve. Treatment options include microsurgery, radiotherapy, and surveillance. Endoscopy is becoming more widely used as an adjunct in skull base surgery and may influence outcomes in surgically managed VS. Methods A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies involving endoscope-assisted and fully endoscopic procedures for sporadic VS resection were identified. Facial nerve function, hearing preservation, extent of resection, and complications were analyzed. Results Thirty-one studies were included (27 endoscope-assisted, four fully endoscopic). Subgroup analyses were performed to assess outcomes according to tumor size and surgical approach. Overall, endoscopic facial nerve preservation rates were comparable to microsurgical treatment. A subgroup analysis suggested that functional facial nerve preservation rates may be higher when endoscopic assistance is used for smaller (Koos I-II) tumors using the retrosigmoid or translabyrinthine approach. The gross total resection rate for small tumors was higher in retrosigmoid ES-assisted microsurgery (96.2%) compared to rates in the literature for the standard, open retrosigmoid approach. Hearing outcomes were more variable and were under-reported. Conclusions Current data suggest that ES-assisted resection of sporadic VS is not inferior to microsurgical resection with respect to facial nerve outcomes and extent of resection. However, some ES series report poor hearing outcomes, which are under-reported in the literature. Further prospective studies are required to ascertain if endoscopic assistance can improve outcomes for VS resection, particularly for smaller (Koos I-II) tumors.

Hyperkalaemia is a common biochemical finding that can allude to preanalytical or truly pathological causes. Here, we present a case of a 41-year-old female patient who has regularly presented with incidences of isolated hyperkalaemia since 2012, with otherwise normal renal function and no other associated symptoms. Investigations into the patient’s family history revealed similar biochemical findings in her brother and eldest son. Familial causes of hyperkalaemia were investigated and an eventual diagnosis of pseudo-hypoaldosteronism type 2C was established. This is a rare congenital renal tubular disorder – also known as Gordon syndrome – that can cause a characteristic triad of symptoms that include hyperkalaemia, metabolic acidosis and hypertension. The presence and severity of each of these symptoms is dependent upon the disease-causing mutation that occurs in WNK4, WNK1, CUL3 or KLHL3 genes. These mutations alter the regulation of sodium/chloride co-transporter (NCC) expression on the luminal membrane of the principal cells of the distal convoluted tubule, disrupting normal homeostatic regulation of electrolyte reabsorption and excretion. The resolution for treating this condition is the administration of a thiazide diuretic, which directly counteracts the effects of NCC co-transporter overexpression and consequently aims to resolve the symptoms that arise as a result of this aberrant signalling. The case described here uniquely presents an extremely rare pathogenic variant in the conserved acidic motif of WNK1 resulting in a clear electrolyte phenotype with no hypertension.

Surveillance imaging is a valid management option for selected vestibular schwannomas (VS). An ideal protocol for radiologic monitoring would highlight growth-related risk factors and tailor management accordingly. This study aims to identify variables associated with the growth of sporadic VS to enhance surveillance imaging, enable early intervention, and optimize outcomes.The review was conducted according to the PRISMA guidelines. A systematic review of 5 databases (PubMed, Ovid, Cochrane Library, Web of Science, and Google Scholar) was performed to identify negative and positive growth predictors of sporadic vestibular schwannomas. The search was limited to studies reported between January 2015 and January 2020. We conducted an individual patient data meta-analysis using a 1-stage multivariate mixed-effect logistic regression model.A total of 437 studies were identified, of which 25 met our criteria for full-text analysis. Articles that measured VS with comparable methods were determined eligible for meta-analysis inclusion. The selected articles were highly heterogeneous in their use of grading scales and assessment of tumor size. Our review showed that size at diagnosis (odds ratio, 1.15; 95% confidence interval, 1.11-1.18; P0.0001) and intracanalicular localization (odds ratio, 0.49; 95% confidence interval, 0.26-0.90; P = 0.023) were associated with VS growth.The factors most frequently reported as being associated with growth within the literature were size of VS at diagnosis and localization of an intracanalicular component. Greater attention should be placed on these criteria within the surveillance imaging algorithm for VS.

With the widespread use of imaging techniques, the possibility that an asymptomatic unruptured intracranial aneurysm (UIA) is detected has increased significantly. There is no established consensus regarding follow-up, duration, and frequency of such imaging surveillance. The objectives of this study include assessing the growth rate and rupture risk of small (less than 7mm) UIAs, identifying associated risk factors and providing an aneurysm surveillance protocol in appropriately selected patients. Systematic searches of Medline, Embase, and Cochrane Central were undertaken from database inception to March 2020 for published studies reporting the growth and rupture risks of small UIAs. Twenty-one studies reporting 8428 small UIAs were included in our meta-analysis. The pooled mean age was 61 years (95% CI: 55–67). The mean follow-up period for growth and rupture ranged from 11 to 108 months, with the pooled mean follow-up period across 14 studies being 42 months (95% CI: 33–51). Pooled overall growth rate was 6.0% (95% CI: 3.8–8.7). Pooled growth rates for aneurysms < 5mm and < 3 mm were 5.2% (95% CI: 3.0–7.9) and 0.8% (95% CI: 0.0–6.1), respectively. Pooled overall rupture rate was 0.4% (95% CI: 0.2–0.7). From the meta-regression analysis, having multiple aneurysms, smoking, hypertension, and personal history of SAH did not significantly predict growth, and a personal history of SAH, smoking, hypertension, and multiple aneurysms were not statistically significant predictors of rupture. Our findings suggest that small UIAs have low growth and rupture rates and very small UIAs have little or no risk for rupture. In the setting of incidental small UIAs, patients with multiple and/or posterior circulation aneurysms require more regular radiological monitoring.

Internal dose assessment intercomparison exercises are useful tools: to verify the performance of an Internal Dosimetry Service; to promote the harmonization of dose assessments; and to identify weaknesses where further improvements are necessary. However, no such international inter-comparisons have been performed for more than 10 years. In the period May 2014 - May 2016, the "Technical Recommendations for Monitoring Individuals for Occupational Intakes of Radionuclides" were developed at the initiative of the European Commission, and later published within the EC Radiation Protection series, as RP 188. In 2017 the Working Group "Internal Dosimetry" of the European Radiation Dosimetry Group (EURADOS) organised a new intercomparison action, named ICIDOSE 2017, with the main aim of testing the practical applicability of these Technical Recommendations (RP188). Four case-studies were proposed to participants: an artificially created case of inhalation of 60Co to simulate a simple special monitoring case; a real case of inhalation of 125I, with simple routine monitoring; a real and more complex case of incorporation of 234+235+238U, featuring both confirmatory and special monitoring; and a complex real case of an accidental incorporation of 241Am, including multiple administrations of DTPA. Results were received from 66 participants from 26 countries; these were compared to reference or recommended solutions, developed for each case based on the application of RP 188. The results were discussed at a workshop in October 2018, at the Federal Office for Radiation Protection (BfS, Munich, Germany). The observed spread of the submitted results was improved from those obtained from similar cases in previous intercomparison exercises, showing that the availability of RP 188 significantly contributes to the harmonization of the internal dose assessment process.

Introduction: Recruitment of patients to participate in randomized control trials (RCT) is a challenging task, especially for trauma trials in which the identification and recruitment are time-limited. Multiple strategies have been tried to improve the participation of doctors and the recruitment of patients. The aim was to study the effect of a trainee principal investigator (TPI) on the efficacy of recruitment for a multicenter hip fracture RCT. Methods: A retrospective study comparing the number of junior doctors participating in the WHiTE 8 COPAL RCT and patients recruited before and after the introduction of formal TPI role at a major trauma center in the UK. Data was collected for nine months “before” (Nov 2018-July 2019) and six months “after” (Sept 2019-Feb 2020) the role of TPI was assigned. Results: From November 2018 to February 2020, a total of 292 patients were eligible for recruitment into this trial, out of which 196 (67.12 %) were successfully recruited. Excluding the research team, there were seven junior doctors actively recruiting in the “before period” in comparison with 10 in the “after period.” Significantly more patients were recruited by junior doctors after a TPI was assigned. Overall, more percentage of eligible patients were recruited into the trial after a TPI was assigned, and this was statistically significant. Conclusion: The allocation of a formal TPI significantly improved the recruitment of patients in a national RCT. TPI can work alongside the principal investigator and research team to be a valuable link person coordinating and engaging local trainees to take part in trials.

Objective Blocking is associated with prediction of the allocation sequence and subversion. This paper explores if blocking strategies lead to an increase in baseline age heterogeneity (a marker for potential subversion) and, whether the use of blocking is changing over time. Study Design and settings The British Medical Journal, Journal of the American Medical Association, The Lancet and the New England Journal of Medicine were hand searched to identify open RCTs published in January between 2001-2020. To explore heterogeneity of baseline age meta-analyses were performed on trials implementing blocking, minimisation and simple randomisation. Results 179 open RCTs were identified: Nine (5.0%) undertook simple randomisation, 104 (58.1%) blocking, 25 (13.9%) minimisation and one (0.6%) both. Baseline age heterogeneity of 24% (p=0.02) was observed in all trials implementing blocking, 62% (p= 0.001) in trials implementing a fixed block of four, 40% (p=0.07) implementing variable blocks including a two and 0% for both simple randomisation and minimisation. Small block sizes are implemented in modern trials. Conclusion Variable block sizes including two are associated with subversion and should not be implemented. If centre only stratification is necessary, it should be used alongside larger blocking schemes. Authors should consider alternative methods to restrict randomisation. Keywords: research design, bias, allocation concealment, randomisation. randomised controlled trials, methodology

Clival chordomas are rare tumours with a notochordal origin that are classically multilocular gelatinous lesions. Due to their location, endoscopic endonasal resection is an option to optimize extent of resection whilst also balancing risk to critical neurovascular structures. Nonetheless, patients may be at high risk of recurrence therefore the potential for adjuvant treatment with radiotherapy or proton beam therapy should always be considered.

This article explores consumers’ experiences of place atmospheres through a study into football matches, a context in which atmosphere is pertinent. While existing marketing literature concerning atmospherics largely conceptualises atmosphere as controllable, singular, and confined to the consumption environment and experience under investigation, we instead contribute a more spatially and temporally porous theorisation. Drawing insights from both consumer research and geography surrounding affect, embodiment and atmosphere, we unpack the spatial and temporal aspects of atmosphere in relation to consumers’ past memories, disrupted routines, and anticipations of future. The article contributes, therefore, to bourgeoning literature within marketing and consumer research regarding the consumption in – and of – places.

BackgroundOsteoarthritis of the knee is a common condition that is expected to rise in the next two decades leading to an associated increase in total knee replacement (TKR) surgery. Although there is little debate regarding the safety and efficacy of modern TKR, up to 20% of patients report poor functional outcomes following surgery. This study will investigate the functional outcome of two TKRs; the JOURNEY II Bi-Cruciate Stabilised knee arthroplasty, a newer knee prosthesis designed to provide guided motion and improve knee kinematics by more closely approximating a normal knee, and the GENESIS II, a proven existing design.AimTo compare the change in Patient-reported Outcome Measures (PROMs) scores of the JOURNEY II BCS and the GENESIS II from pre-operation to 6 months post operation.MethodsCAPAbility is a pragmatic, blinded, two-arm parallel, randomised controlled trial recruiting patients with primary osteoarthritis due to have unilateral TKR surgery across two UK hospitals. Eligible participants (n = 80) will be randomly allocated to receive either the JOURNEY II or the GENESIS II BCS knee prosthesis. Baseline measures will be taken prior to surgery. Patients will be followed at 1 week, 6 to 8 weeks and 6 months post-operatively. The primary outcome is the Oxford Knee Score (OKS) at 6 months post-operatively. Secondary outcomes include: other PROMs, biomechanical, radiological (computerised tomography, (CT)), clinical efficacy and safety outcomes. An embedded qualitative study will also investigate patients’ perspectives via interview pre and post surgery on variables known to affect the outcome of TKR surgery. A sub-sample (n = 30) will have additional in-depth interviews to explore the themes identified. The surgeons’ perspectives on the operation will be investigated by a group interview after all participants have undergone surgery.DiscussionThis trial will evaluate two generations of TKR using PROMS, kinematic and radiological analyses and qualitative outcomes from the patient perspective.Trial registrationInternational Standard Randomised Controlled Trials Number Registration, ID:ISRCTN32315753. Registered on 12 December 2017.

ObjectivesTo explore how people with chronic kidney disease who are pre-dialysis, family members and healthcare professionals together navigate common shared decision-making processes and to assess how this impacts future treatment choice.DesignCoproductive qualitative study, underpinned by the Making Good Decisions in Collaboration shared decision-model. Semistructured interviews with a purposive sample from February 2019 - January 2020. Interview data were analysed using framework analysis. Coproduction of logic models/roadmaps and recommendations.SettingFive Welsh kidney services.Participants95 participants (37 patients, 19 family members and 39 professionals); 44 people supported coproduction (18 patients, 8 family members and 18 professionals).FindingsShared decision-making was too generic and clinically focused and had little impact on people getting onto home dialysis. Preferences of where, when and how to implement shared decision-making varied widely. Apathy experienced by patients, caused by lack of symptoms, denial, social circumstances and health systems issues made future treatment discussions difficult. Families had unmet and unrecognised needs, which significantly influenced patient decisions. Protocols containing treatment hierarchies and standards were understood by professionals but not translated for patients and families. Variation in dialysis treatment was discussed to match individual lifestyles. Patients and professionals were, however, defaulting to the perceived simplest option. It was easy for patients to opt for hospital-based treatments by listing important but easily modifiable factors.ConclusionsShared decision-making processes need to be individually tailored with more attention on patients who could choose a home therapy but select a different option. There are critical points in the decision-making process where changes could benefit patients. Patients need to be better educated and their preconceived ideas and misconceptions gently challenged. Healthcare professionals need to update their knowledge in order to provide the best advice and guidance. There needs to be more awareness of the costs and benefits of the various treatment options when making decisions.

Background Idiopathic membranous nephropathy (IMN) is one of the most common causes of nephrotic syndrome in adults. A proportion of patients will experience spontaneous remission and the decision to offer immunosuppression is guided by the presence of adverse prognostic features. Data relating to the efficacy of different immunosuppressive protocols is lacking, in particular there are little data available on the efficacy or benefits of an intravenous (IV) cyclophosphamide-based regimen. Since 2010, our unit has been using a treatment regimen based on IV cyclophosphamide and oral prednisolone for patients with IMN associated with adverse prognostic features. The outcomes of these patients were compared with a historic cohort of similar patients who did not receive immunosuppressive therapy. Methods Between January 2010 and 2014, a total of 41 patients were treated with pulse IV cyclophosphamide and oral prednisolone. The historical comparator group included 47 similar patients diagnosed between 2006 and 2010 who did not receive immunosuppression. Two-year follow-up data were collected. The primary outcome measure was time to remission of nephrotic syndrome (defined as normalization of serum albumin). Secondary outcomes included rate of progression of kidney disease as well as incidence of treatment-related adverse events. Results As compared with supportive care alone, treatment with IV cyclophosphamide and oral prednisolone was associated with a significantly higher number of patients achieving remission. Within 18 months of therapy, 74% of treated patients had achieved a normal serum albumin level. Though there was a trend towards a more rapid decline in estimated glomerular filtration rate in the untreated cohort, this did not reach statistical significance. The IV cyclophosphamide-based regimen was well tolerated, with few significant treatment-associated side effects. Conclusion IV cyclophosphamide is a safe and effective treatment for IMN.

Background It is unclear whether discharging patients from renal clinic to primary care is safe. Aim To determine the characteristics, primary care monitoring and renal outcomes of patients discharged from renal clinic. Design and setting A retrospective study of 2236 adults discharged from a tertiary renal clinic between 2013–2018. Method Patient demographics, primary renal disease, laboratory results and timeline dates were collected from the renal IT system. Timing of blood tests, renal progression, needing dialysis and patient survival were analysed. Reasons for discharge and cause of disease progression were reviewed in patients developing new estimated glomerular filtration rate Results Patients were older (median age 75; interquartile range 63–84) with non-progressive, seemingly non-proteinuric renal disease. Median time to repeat blood test post-discharge was 75 days with 90% tested within 12 months. Sixty-six percent saw an improvement in kidney function post-discharge and only 13% had a decline of >10 ml/min/1.73 m2. Only 132 patients (6%) developed new advanced chronic kidney disease (estimated glomerular filtration rate < 20 ml/min/1.73 m2) of whom 40% were palliative, 36% had developed acute kidney injury and 23% discharged for failing to attend clinic. One hundred and thirty-four patients (6%) were referred back to nephrology and eight started dialysis of whom six were discharged for failure to attend clinic. Conclusion Most discharged patients are low risk of progressive renal disease and need infrequent monitoring. Non-adherent patients discharged for failing to attend appear to be at risk of poor outcomes and new strategies are needed to better support this population.

Background: Osteoarthritis of the knee is a common condition that is expected to rise in the next two decades leading to an associated increase in total knee replacement (TKR) surgery. Although there is little debate regarding the safety and efficacy of modern TKR, up to 20% (Baker et al 2007) of patients report poor functional outcomes following surgery. This study will look at the functional outcome of two TKR; the JOURNEY II Bi Cruciate Stabilised knee, a newer prosthesis designed to provide guided motion and improve knee kinematics by more closely approximating a normal knee and the GENESIS II, a proven existing design. Aim: The aim of the CAPAbility study is to compare the change in patient reported outcome scores, of the JOURNEY II BCS and the GENESIS II from pre-operation to six months post-operation. Methods: CAPAbility is a pragmatic, blinded, two-arm parallel, randomised controlled trial recruiting patients with primary osteoarthritis due to have unilateral knee replacement surgery across two UK hospitals. Eligible participants (n = 80) will be randomly allocated to receive either the JOURNEY II or the GENESIS II BCS knee prosthesis. Baseline measures will be taken prior to surgery, with patients followed at one week, six to eight weeks and six months post-operatively. The primary outcome is the Oxford Knee Score (OKS) at six months post-operatively. Secondary outcomes include: other patient-reported outcome measures (PROMs), biomechanical, radiological (computer tomography, (CT)), clinical efficacy and safety outcomes. An embedded qualitative study will also investigate patients’ perspectives via interview pre and post-surgery on variables known to affect the outcome of knee replacement surgery. A sub-sample (n=30) will have additional in-depth interviews to explore themes identified. The surgeons’ perspectives on the operation will be investigated by a group interview after all participants have had surgery. Discussion: This trial will evaluate two generations of TKR by PROMS and kinematic analysis with additional CT measurements and qualitative outcomes from the patient perspective. Trial registration. ISRCTN32315753, 12 December 2017. http://www.isrctn.com/ISRCTN32315753 Keywords: Total Knee Arthroplasty; knee replacement; functional ability; knee prosthesis; kinematics; primary 0steoarthritis.

Peripheral neuropathy, organomegaly, endocrinopathy, monoclonal protein and skin changes (POEMS) syndrome is a rare disease, and only in a minority of cases, causes an impairment of kidney function. Here, we describe a case of a 55-year-old man with a history of POEMS syndrome who presented with acute kidney injury following a routine blood test. On further investigation, a relapse in POEMS syndrome was diagnosed, uniquely isolated to renal involvement.

Background The incidence of chronic kidney disease (CKD) is rising and is likely to continue to do so for the foreseeable future, with the fastest growth seen among adults ≥75 years of age. Elderly patients with advanced CKD are likely to have a higher burden of comorbidity and frailty, both of which may influence their disease outcome. For these patients, treatment decisions can be complex, with the current lack of robust prognostic tools hindering the shared decision-making process. The current study aims to assess the impact of comorbidity and frailty on the outcomes of patients referred for pre-dialysis education. Methods We performed a single-centre study of patients (n = 283) referred for pre-dialysis education between 2010 and 2012. The Charlson Comorbidity Index (CCI) and Clinical Frailty Scale (CFS) were used to assess comorbid disease burden and frailty, respectively. Follow-up data were collected until February 2015. Results The CCI and CFS scores at the time of referral to the pre-dialysis service were independent predictors of mortality. Within the study follow-up period, 76% of patients with a high CFS score at the time of pre-dialysis education had died, with 63% of these patients not commencing dialysis before death. Conclusion A relatively simple frailty scale and comorbidity score could be used to predict survival and better inform the shared decision-making process for patients with advanced kidney disease.

Aims/Objectives/BackgroundIn Manchester Royal Infirmary, a major trauma centre, there are many patient presentations which require fast acting analgesia. Often these presentations, such as shoulder dislocations, require conscious sedation in order to be safely, effectively and humanely treated.Penthrox was introduced to the emergency department in December 2019. It was hoped that it would be used as an alternative to conscious sedation in patients requiring procedures. It was postulated that by having another analgesic method available, patients would have a greater likelihood of being discharged without the requirement for conscious sedation. This would therefore not require waiting for a Resus bed and therefore reduce length of stay in the department.Methods/DesignData was prospectively gathered for patients who received Penthrox in the months of December 2019 to July 2020 using a questionnaire that was filled in by clinicians.Audit forms were collated as well as attendance data (including length of stay) for shoulder dislocations Dec 19 - Feb 19.Pain scores were subjectively scored out of 10 and, using t-tests, compared for significance.Length of stay, checklist completion, progression to concious sedation, further pain relief requirements and indications were also analysed.Results/ConclusionsSubjectively reported pain scores were significantly reduced when comparing before and during procedure (There was no significant association between checklist completion and progression to concious sedation.Difference between length of stay did not quite meet statistical significance (mean = 163.62 using penthrox, mean = 225 without penthrox. p = 0.06).There were no significant adverse events.In conclusion Penthrox is a safe and welcome addition to the ED formulary.

A lack of data on patient choices and outcomes at the time of pre-dialysis planning limits meaningful shared decision making, particularly in older frailer patients. In this large retrospective cohort study of patients aged over 70 seen by the pre-dialysis clinic (2004-2016) of a large single centre in the United Kingdom (1,216 patients), age, sex, comorbidity, poverty and frailty were used to predict choice of renal replacement therapy (RRT) over maximum conservative management (MCM). The impact of patient choice of RRT versus MCM was used to predict survival from the time of choice using multivariable Cox proportional hazards regression. Older age, female sex, greater poverty and greater frailty were associated with choosing MCM, whilst comorbidity had no significant impact on choice. At 5 years of follow up, 49% of all patients had died without receiving RRT. Over 70% of the patients choosing MCM died with better kidney function than the median level at which those starting RRT initiated treatment. Frailty and age were better predictors of survival than comorbidity and in patients with at least moderate frailty, RRT offered no survival benefit over MCM. In conclusion, analysing outcomes from the time of choice may improve shared decision making. Frailty should be routinely assessed and collected and further work may help predict which patients are unlikely to survive or progress to end stage renal disease and may not need to be burdened with making a pre-dialysis choice.

Same-day emergency care is one of the many ways the NHS is working to provide the right care, in the right place, at the right time for patients. It aims to benefit both patients and the healthcare system by reducing waiting times and unnecessary hospital admissions. In our organisation patients presenting to the emergency department (ED) with common medical conditions like chest pain / shortness of breath (SOB), palpitations, headache, chest infection or deep vein thrombosis / pulmonary …

Rice is the world’s major staple food crop occupying over 12% of global cropland area which produces around 800 million tons. Nearly 90% of the world’s rice is produced and consumed in Asian countries. Therefore, information on agricultural plantation area, yield, and production are essential to ensure food security of nearly 3 billion people. At the moment this information is either lacking in many countries or only available post-harvest, this is too late to input into any effecting policy in a specific year. Therefore, there is a pressing need to provide accurate and reliable yield estimation well ahead of harvest. In this project we explore potential of multi source remote sensing data coupled with crop model to provide country scale yield estimation in Thailand. For optical sensor, the study utilised Landsat8 OLI/TIRS satellite data to develop common vegetation indexes (VIs) approach to derive essential crop biophysical variables such as Leaf Area Index. This is supplemented with information from microwave sensor such as Sentinel 1 to overcome issues with cloud. At the end, we produced a regular time series of crop biophysical variable across the growing season. These satellite-based estimates were validated with dedicated field campaign in three provinces covering the entire growing season. Initial results suggest a good agreement between the optical/microwave derived crop biophysical variables and ground data. Finally, these will be used as an input to the ORYZA 2000 crop model to adjust the model parameters and develop a high resolution yield prediction.

The name of Heinrich Cornelius Agrippa of Nettesheim was literally one to conjure within the sixteenth century. This chapter addresses two large questions about Christopher Marlowe and Agrippa. Many people in late sixteenth-century England did of course know of and read Agrippa. His two best known works were published within a few years of each other. Ideas of magical conspiracy and sedition are ones which Marlowe has incorporated into his play. Marlowe’s play will bear, indeed demands, commentary on its representation of magic, which is more detailed than any other sixteenth-century English play. Its depiction of magic is far more technically precise than that of the English Faust Book which can offer very little as the basis for the play’s detailed imagination of the contents of books of magic. The problematic relationship between the De Vanitate and De Occulta, particularly the seeming paradox of their quite different attitudes to magic, exercises scholars.

The acceptability of sentences in natural language is constrained not only grammaticality, but also by the relationship between what is being conveyed and such factors as context and the beliefs of interlocutors. In many languages the critical element in a sentence (its focus) must be given grammatical prominence. There are different accounts of the nature of focus marking. Some researchers treat it as the grammatical realization of a potentially arbitrary feature of universal grammar and do not provide an explicit account of its origins; others have argued, however, that focus marking is a (grammaticalized) functional solution to the problem of efficiently transmitting information via a noisy channel. By adding redundancy to highlight critical elements in particular, focus protects key parts of the message from noise. If this information-theoretic account is true, then we should expect focus-like behavior to emerge even in non-linguistic communication systems given sufficient noise and pressures for efficiency. We tested this in an experiment in which participants played a simple communication game in which they had to click cells on a grid to communicate one of two line figures drawn across the grid. We manipulated the noise, available time, and required effort, and measured patterns of redundancy. Because the lines in many cases overlapped, meaning that only some parts of each line could be used to distinguish it from the other, we were able to compare the extent to which effort was expended on adding redundancy to critical (non-overlapping) and non-critical (overlapping) parts of the message. The results supported the information-theoretic account of focus and shed light on the emergence of information structure in language.

Background We examined the prevalence of acute kidney injury (AKI) risk factors in the emergency medical unit, generated a modified risk assessment tool and tested its ability to predict AKI. \ud \ud \ud Methods A total of 1196 patients admitted to medical admission units were assessed for patient-associated AKI risk factors. Subsequently, 898 patients were assessed for a limited number of fixed risk factors with the addition of hypotension and sepsis. This was correlated to AKI episodes. \ud \ud \ud Results In the first cohort, the prevalence of AKI risk factors was 2.1 ± 2.0 per patient, with a positive relationship between age and the number of risk factors and a higher number of risk factors in patients ≥65 years. In the second cohort, 12.3% presented with or developed AKI. Patients with AKI were older and had a higher number of AKI risk factors. In the AKI cohort, 72% of the patients had two or more AKI risk factors compared with 43% of the cohort with no AKI. When age ≥65 years was added as an independent risk factor, 84% of those with AKI had two or more AKI risk factors compared with 55% of those with no AKI. Receiver operating characteristic analysis suggests that the use of common patient-associated known AKI risk factors performs no better than age alone as a predictor of AKI. \ud \ud \ud Conclusions Detailed assessment of well-established patient-associated AKI risk factors may not facilitate clinicians to apportion risk. This suggests that additional work is required to develop a more sensitive validated AKI-predictive tool that would be useful in this clinical setting.

Background: Ulna nerve compression at the elbow is the second most common neuropathy of the upper limb. It has been suggested that nerve conduction tests are required to correctly make the diagnosis. The aim of this study was to assess whether patients with normal nerve conduction testing benefitted from surgical release of the ulna nerve. Methods: 56 patients with symptoms of ulna nerve compression at the elbow were evaluated prospectively. All patients underwent electrophysiology testing followed by ulna nerve decompression irrespective of the results of the electrophysiology testing. Functional scores using the QuickDASH and PEM score were collected up to 12 months post-surgery. Results: No difference was found between the group with normal and the group with abnormal electrophysiology studies. Conclusions: We conclude that patients who clinically have ulna nerve compression still benefit from ulna nerve decompression despite normal nerve conduction tests.

IntroductionKidney disease is common, affecting up to 1 in 10 of the adult population, and the numbers are expected to rise over the next decade. There are three main treatments that are available to patients with kidney disease: transplantation, dialysis and supportive care without dialysis. Dialysis can occur in a dialysis unit or in a person’s home, but unit-based dialysis remains the most common initial treatment for patients in Wales. This is a cause for concern as most studies suggest that it is associated with the lowest quality of life and the highest mortality, and is a more expensive treatment option.This study aims to identify the factors that lead to patients choosing unit-based haemodialysis rather than home-based dialysis with a view to informing future changes in patient education and service commissioning in Wales. A secondary aim is to determine if the co-production of research leads to more sustainable services.Methods and analysisThis mixed-method study taking place between October 2018 and September 2020 will use a sequential explanatory design whereby the descriptive quantitative cross-sectional analysis of linked health and administrative data sets inform qualitative data collection from patients, carers and health and care professionals. Qualitative findings will be used to interpret or explain quantitative descriptive results. Additional strands to the study include a review of materials and education provided to patients and an economic review of treatment modalities.Ethics and disseminationThe study will be conducted in accordance with the principles expressed in the Declaration of Helsinki. It has full approval from Health and Care Research Wales Research Ethics Committee #5. As a co-productive study involving patients, clinicians, third sector partners and academics, findings from this study will be shared on a continual basis. Study results will be published in peer-reviewed journals and presented at national and international conferences.

Accurate and timely diagnosis of bacterial infection is crucial for effective and targeted treatment, yet routine microbiological identification is inefficient and often delayed to an extent that makes it clinically unhelpful. The immune system is capable of a rapid, sensitive and specific detection of a broad spectrum of microbes, which has been optimized over millions of years of evolution. A patient's early immune response is therefore likely to provide far better insight into the true nature and severity of microbial infections than conventional tests. To assess the diagnostic potential of pathogen-specific immune responses, we characterized the local responses of 52 adult patients during episodes of acute peritoneal dialysis (PD)-associated peritonitis by multicolor flow cytometry and multiplex ELISA, and defined the immunologic signatures in relation to standard microbiological culture results and to clinical outcomes. We provide evidence that unique local "immune fingerprints" characteristic of individual organisms are evident in PD patients on the day of presentation with acute peritonitis and discriminate between culture-negative, Gram-positive, and Gram-negative episodes of infection. Those humoral and cellular parameters with the most promise for defining disease-specific immune fingerprints include the local levels of IL-1β, IL-10, IL-22, TNF-α, and CXCL10, as well as the frequency of local γδ T cells and the relative proportion of neutrophils and monocytes/macrophages among total peritoneal cells. Our data provide proof of concept for the feasibility of using immune fingerprints to inform the design of point-of-care tests that will allow rapid and accurate infection identification and facilitate targeted antibiotic prescription and improved patient management.

The IDEAS Guidelines [Doerfel, H., et al General Guidelines for the Estimation of Committed Effective Dose from Incorporation Monitoring Data. Report FZKA 7243, Forschungszentrum Karlsruhe, GmbH (2006); Castellani, C. M., Marsh, J. W., Hurtgen, C., Blanchardon, E., Berard, P., Giusani, A. and Lopez, M. A. IDEAS Guidelines (Version 2) for the Estimation of Committed Doses from Incorporation Monitoring Data. EURADOS Report 2013-01, Braunschweig (2013)] provide a structured approach to the assessment of intakes of radionuclides. In order to check that the guidelines, when applied to typical monitoring programmes, lead to reliable assessments, a number of numerically-generated datasets have been constructed and assessed using the guidelines. The dose and intake obtained by the assessment can be compared with the 'true' dose and intake. In this way, the accuracy of the IDEAS assessment process can be examined when applied to monitoring programmes that are typically used in the nuclear industry. The simulations focus on assessments carried out as a result of elevated (239)Pu activities in routine urine samples, which lead to follow-up urine and faecal samples being provided. Cases where the assessor makes the correct initial assumption about lung solubility can be compared with cases where this initial choice is wrong. The results of these simulations and the implication for the use of monitoring programmes are discussed.

Community events, by their very nature, create emotions. They need to appeal to the community’s wants and desires, playing with their emotions to create enjoyment and memories. Successful longstanding community events, be they annual or otherwise, need to have an organising committee that understands this emotional connection on the one side and loyal consumers that engage with the event to make it sustainable on the other. This chapter builds on the work of Jepson, Clarke and Ragsdell (2014) in looking at the sustainability (i.e. the long-term viability) of local community-based events, through the delivery of community events within the context of social enterprises (SEs), community participation and individual engagement. This chapter highlights these key research areas with the use of a case study that investigates Peace in the Park (PitP), an annual community arts festival that is organised by volunteers and funded entirely by the people within the local community. The festival attracts up to 8,000 people annually, who come together to celebrate Sheffield’s freedom and creativity, raising thousands of pounds for community projects and promoting peace and social justice. The event has run successfully since 2003 but was forced to postpone in 2013 due to a lack of funding.

Vegetation fires are a key global terrestrial disturbance factor and a major source of atmospheric trace gases and aerosols. Therefore, many earth-system science and operational monitoring applications require access to repetitive, frequent and well-characterized information on fire emissions source strengths. Geostationary imagers offer important temporal advantages when studying rapidly changing phenomena such as vegetation fires. Here we present a new algorithm for detecting and characterising active fires burning within the imager footprints of the Geostationary Operational Environmental Satellites (GOES), including consideration of cloud-cover and calculation of fire radiative power (FRP), a metric shown to be strongly related to fuel consumption and smoke emission rates. The approach is based on a set of algorithms now delivering near real time (NRT) operational FRP products from the Meteosat Spinning Enhanced Visible and Infra-Red Imager (SEVIRI) imager (available from http://landsaf.meteo.pt/), and the GOES processing chain presented here is designed to deliver a compatible fire product to complete geostationary coverage of the Western hemisphere. Results from the two GOES imagers are intercompared, and are independently verified against the well regarded MODIS cloud mask and active fire products. We find that the detection of cloud and active fires from GOES matches that of MODIS very well for fire pixels having FRP > 30 MW, when the GOES omission error falls to less than 10%. The FRP of fire clusters detected near simultaneously by both GOES and MODIS have a bias of only 22 MW, and a similar bias is found when comparing near-simultaneous GOES East and GOES West FRP observations. However, many fire pixels having FRP 0.9), suggesting that the timely FRP data available from a GOES real-time data feed is likely to be a suitable fire emissions source strength term for inclusion in schemes aiming to forecast the concentrations of atmospheric constituents affected by biomass burning

The frequency and severity of episodes of peritonitis adversely affect the structure and function of the peritoneal membrane in patients treated with peritoneal dialysis (PD), but the underlying mechanisms are not well understood. Alterations in the phenotype and function of resident peritoneal cells may contribute. Because effector memory T cells play a pivotal role in maintaining peripheral tissue immunity, we hypothesized that these cells may initiate or perpetuate the peritoneal inflammatory response. Here, we characterized the phenotype and effector function of peritoneal memory T cells. We found that functional effector memory T cells capable of mounting long-term recall responses enrich the peritoneal cavity of PD patients. Peritoneal T cells were able to mount a Th1-polarized response to recall antigens, and these responses were greater in peritoneal T cells compared with T cells in the peripheral blood. We also observed that the peritoneal T cells had altered telomeres; some cells had ultrashort telomeres, suggesting a highly differentiated local population. In summary, we describe a resident population of memory T cells in the peritoneum of PD patients and speculate that these cells form part of the first line of defense against invading pathogens.

PurposeIl Cuore di Novi is an example of an innovative way of regenerating and revitalising a town centre in Italy in the face of intense competition from large out‐of‐town retail and residential developements. This has been achieved through a combination of research surveys linked to an organic approach to marketing strategy and effective engagement with the town's local authority and small‐ and medium‐sized retailers. The paper's aim is to discuss this development.Design/methodology/approachThis case study provides an example of retailer‐led town centre management in the Novi Ligure (Italy) and builds on previous work by Molinillo Jiménez, Sánchez del Río, Vilariño et al. and Coca‐Stefaniak et al.FindingsSouthern European models of retailer‐led town centre management, known in Italy as centro commerciale naturale and discussed by Valente, Zanderighi, Moras et al. and Codato et al. can be effective in competing with large out‐of‐town shopping centres through innovative place management and marketing techniques in town centres based on local know‐how, differentiation and customer service.Originality/valueThe case of Novi Ligure's successful retailer‐led town centre management scheme is unique in Italy in terms of its ability to integrate retail revitalisation with urban regeneration in a town centre. This scheme is ground‐breaking in Italy and provides further evidence of the success of Southern European bottom‐up retailer‐led place management models. This study is of value to practitioners and policy makers in place management, town centre management, local authority planning officers, urban regeneration consultants, academics, small‐ and medium‐sized independent retailers, community leaders and town centre residents.

With the increasing trend of childhood obesity, concerns have been raised about the influence of food advertising on children's eating habits. This paper describes a content analysis of food advertising on UK terrestrial children's television and of the nutritional quality of the food products advertised.

We describe and analyse a simple experiment based on interference of thermally distributed broadband photons which demonstrates quantitatively the gradual trade-off between knowledge of the trajectory of a quantum particle and its wave-like character as expressed via the inequality V 2 + K 2 ≤ 1. The experiment relies upon colour-selective detection of light passing through each slit of a Young's double-slit arrangement: path information K is deduced from the overlapping bandwidths of the interfering light and the classical first-order degree of coherence, and wave information V is obtained from the fringe visibility. A classical Fourier analysis of the experiment is given which reproduces the observed interferograms.

OBJECTIVE Elevated serum levels of lipoprotein(a), a risk factor for atherosclerosis (AS), are also associated with the presence of asymptomatic intracranial aneurysms. AS is present in some aneurysms, but its contribution to aneurysm formation and growth is unclear. Apolipoprotein(a) [apo(a)], the active moiety of lipoprotein(a), is present in atherosclerotic circle of Willis vessels but not in normal circle of Willis vessels. We wished to determine whether apo(a) is present in intracranial aneurysms independently of AS. METHODS With a purified anti-apo(a) monoclonal antibody, aneurysms (n = 25) and feeding vessels (n = 23) were examined for apo(a) expression by immunohistochemical analysis. Circle of Willis arteries with and without AS (n = 19), cavernous angiomas (n = 5), and arteriovenous malformations (n = 6) acted as control samples. RESULTS AS was present in 32% of aneurysms, and all of those aneurysms demonstrated mural immunopositivity for apo(a). However, aneurysms devoid of AS also demonstrated apo(a) immunopositivity. Apo(a) was demonstrated in 86% of available feeding vessels. Apo(a) deposition was not observed in cavernous angiomas but was present in arteriovenous malformations. Eleven Circle of Willis arteries (57.9%) were devoid of AS and demonstrated no apo(a) immunostaining, whereas the eight (42.1%) with AS were immunopositive for apo(a). CONCLUSION Apo(a) expression in intracranial aneurysms may occur independently of AS. Apo(a) in feeding vessels suggests a possible role for apo(a) in early events leading to aneurysm formation. Multilayered transmural apo(a) deposition in established aneurysms suggests apo(a) involvement in aneurysm growth, possibly via cycles of injury and repair. The absence of apo(a) in cavernous angiomas suggests that such injury might be pressure-mediated.

The cycle-averaged ac Stark effect associated with the [A]2Σ+v′=2?[X]2Π1/2v′=0 two-photon absorption of NO at intensities between 7.7 and 15.2 TW cm-2 has been characterized in real time through a synergic combination of bichromatic laser experiments and quantum-dynamics calculations. Measurements of the fluorescence emitted by the Rydberg [A]2Σ+v′=2 level as a function of time between Stark and probe components of a bichromatic field exhibit a characteristic evolution in temporal peak structure with Stark-field intensity, which is interpreted in terms of a time-dependent Floquet analysis of the laser–matter interaction. The experimental observations are consistent with a dynamic Stark shift of Δes(ω1,ω2)≤0.23 eV of the optical transition at these intensities.

Objectives To investigate the reproducibility of peer ratings of consultant radiologists’ reports, as part of the new General Medical Council (GMC) Performance Procedures. Design An evaluation protocol was piloted, used in a blocked, balanced, randomized generalizability analysis with three blocks of three judges (raters), each rating 30 reports from 10 radiologists, and re-rated to estimate intrarater reliability with conventional statistics (kappa). Setting Rating was performed at the Royal College of Radiologists. Volunteers were sampled from 23 departments of radiology in university teaching and district general hospitals. Participants A nationally drawn non-random sample of 30 consultant radiologists contributing a total of 900 reports. Three trained and six non-trained judges were used in the rating analysis. Results A protocol was generated that was usable by judges. Generalizable results would be obtained with not less than three judges all rating the same 60 reports from a radiologist. Conclusions Any assessment of performance of technical abilities in this field will need to use multiple assessors, basing judgements on an adequate sample of reports.

The technique of powder metallurgy is becoming increasingly common in the electrical manufacturing industry. It not only eliminates a number of steps in the manufacturing process, but uses less energy and gives near-net shape results which require few, or no finishing steps. The process is suitable for soft magnetic composites, and appropriate heat treatments can further tailor properties to a specific application. This article gives an overview of the technology and makes reference to some advances in the materials used and the processes involved.

Methods of tibial plateau fracture fixation have evolved over the last decades; however the techniques used to reduce these fractures have remained relatively unchanged. Balloon tibioplasty, a minimally invasive novel technique used in the reduction of depressed tibial plateau fractures, has been gaining popularity. This technique offers a slow controlled expansion of the balloon with multidirectional force vectors and a large surface area allowing for more bone to be elevated simultaneously. The technique also creates a well-defined bone void of known volume while theoretically compressing the surrounding bone, potentially limiting the risk of cement extrusion as well as late subsidence of the elevated bone. Although an attractive option, as with all novel techniques there is a learning curve. The purpose of this article is to briefly describe our technique of balloon tibioplasty, potential contraindications, and to illustrate some possible complications, and provide some tips and tricks we have found useful to avoid them.

Discusses how the reorganization of local government, enforced by recent government legislation, has affected Humberside County Council′s leisure services department. Highlights the key issues to be addressed by library services in the reorganization process. Explains the preparations for change and new initiatives at both the corporate and departmental level aimed at improving communications during this process. Deals with service profiles, joint arrangements, budget disaggregation and staffing considerations. Explains staff transfer and recruitment procedures, with reference to statutory transfer orders (STOs) made by the Secretary of State. Concludes that the staff most involved in driving through the process of change do not have the security of being on a provisional STO, yet their positive commitment is essential if services are to be transferred effectively to new authorities.

Background Management of CKD is a major public health concern. The introduction of automated eGFR reporting has seen an increase in labelling of elderly patients with CKD. The prognostic significance of the CKD label in this population remains controversial. Aim To investigate rates of specialist intervention in the over 75's to determine whether these patients may be more appropriately managed in primary care, relieving the burden of excessive outpatient visits in this population. Methods Retrospective review of patient notes and laboratory reports over 25 consecutive renal outpatient clinics within a single NHS trust. Results 546 patients were studied. The mean age of patient was 68.7years (SD+/−14.9). The over 75's had more advanced renal disease compared to under 75's (mean eGFR 28.2 vs. 41.3ml/min/1.73m2), but there was no significant difference in eGFR stability between the older and younger cohort or in the overall rate of intervention (32.5% vs. 30.7% p=0.86). The over 75's had a lower mean haemoglobin (11.8 vs. 12.6, p=

We present a velocity-map imaging (VMI) setup for photoelectron imaging that utilizes low electric extraction fields. This avoids any complications that could arise from electrostatic interactions between the extraction field and the molecular properties that are probed and has a minimal effect on the trajectory of ions in ion beam experiments. By using an attractive potential supplied to the detector, and keeping the electrodes at ground (zero) potential, we show that fringe fields between the VMI arrangement and the vacuum chamber can be eliminated, which is important in experiments on ions.

A 30-year-old female patient presented to casualty with a 3-week history of left groin and abdominal pain, general malaise and fever. Of note, she was 18 weeks pregnant and had a history of intravenous drug abuse.On clinical examination, the patient was in septic shock and her abdomen was globally tender with guarding. There was no palpable hernia or mass with in the groin, …