Search

Little is known about the development of coach developers despite their importance in supporting coach learning. In response, this study explored the theories in practice of 23 English coach developers who undertook a continuing professional development course. The data were collected through semistructured interviews, focus groups, and observations of coach developers’ practice and engagement on the course. The data were analysed using a phronetic-iterative approach, with Argyris and Schön’s ideas on theories in practice, mostly espoused theories and theories-in-use, providing the primary heuristic framework. The findings identified how, before the continuing professional development course, the coach developers articulated espoused theories, but as the course progressed, there was a move to theories-in-use. This was due to their (re)constructed understanding of learning and the working environment. The findings are discussed in light of how the continuing professional development course, and tutors’ pedagogic approaches, influenced the coach developers’ knowledge and understanding. Based on these findings, it seems there is much to gain from supporting coach developers with a deconstruction and reconstruction of theories in practice.

Introduction: We undertook this study to know the sensitivity, specificity and post-test probabilities of hip aspiration when diagnosing periprosthetic hip infections. We also examined “dry tap” (injection with saline and aspiration) results and aspiration volumes. Methods: This is a retrospective cohort study of patients aspirated for suspected periprosthetic joint infection between July 2012 and October 2016. All aspirations were carried out by one trained surgical care practitioner (SCP). All aspirations followed an aseptic technique and fluoroscopic guidance. Aspiration was compared to tissue biopsy taken at revision. Aspiration volumes were analysed for comparison. Results: Between January 2012 and September 2016, 461 hip aspirations were performed by our SCP. Of these 125 progressed to revision. We calculated sensitivity 59 % (confidence interval (CI) 35 %–82 %) and specificity 94 % (CI 89 %–98 %). Pre-test probability for our cohort was 0.14. Positive post-test probability was 0.59 and negative post-test probability 0.06. Aspiration volume for infected (n=17) and non-infected (n=108) joints was compared and showed no significant difference. Dry taps were experienced five times; in each instance the dry tap agreed with the biopsy result. Conclusions: Our data show that hip aspiration culture is a highly specific investigation for diagnosing infection but that it is not sensitive. Aspiration volume showed no significant difference between infected and non-infected groups. Each time a joint was infiltrated with saline to achieve a result, the result matched tissue sampling.

OBJECTIVE The aims of this study were to review the National Spina Bifida Patient Registry (NSBPR) data set to study the rates of tethered spinal cord release (TCR) among patients with myelomeningocele and variability between centers, to compare TCR rates between males and females, and to study the relationships between TCR rates and other condition-specific characteristics. METHODS The NSBPR registry was queried to identify all patients with myelomeningocele. TCR rates were calculated over time using survival analyses; rates between centers and between males and females were compared. Cox proportional hazards models were constructed to identify relationships between TCR rates and sex, functional lesion level, ambulation status, treated hydrocephalus, and prior Chiari decompression. RESULTS Of 6339 patients with information about their operations, 1366 (21.5%) underwent TCR, with significant variability between centers. The majority (75.8%) underwent a single TCR. The annual TCR rate was linear between birth and 13 years (1.8%/year) but declined sharply from 14 to 21 years (0.7%/year). There was no period of time at which the TCR rate accelerated. There were no significant differences in TCR rates between males and females. TCR rate was not related to functional lesion level but was lower among nonambulators compared with community ambulators (p = 0.005) and among those with treated hydrocephalus (HR 0.30, p < 0.001), and higher among those having prior Chiari decompression (HR 1.71, p < 0.001). CONCLUSIONS These results extend the results of prior single-institution studies, demonstrate significant treatment variability between institutions, and challenge the traditional concept that tethering is related to spinal cord stretching due to spinal growth.

For some professionally, vocationally, or technically oriented careers, curricula delivered in higher education establishments may focus on teaching material related to a single discipline. By contrast, multidisciplinary, interdisciplinary, and transdisciplinary teaching (MITT) results in improved affective and cognitive learning and critical thinking, offering learners/students the opportunity to obtain a broad general knowledge base. Chemistry is a discipline that sits at the interface of science, technology, engineering, mathematics, and medicine (STEMM) subjects (and those aligned with or informed by STEMM subjects). This article discusses the significant potential of inclusion of chemistry in MITT activities in higher education and the real-world importance in personal, organizational, national, and global contexts. It outlines the development and implementation challenges attributed to legacy higher education infrastructures (that call for creative visionary leadership with strong and supportive management and administrative functions), and curriculum design that ensures inclusivity and collaboration and is pitched and balanced appropriately. It concludes with future possibilities, notably highlighting that chemistry, as a discipline, underpins industries that have multibillion dollar turnovers and employ millions of people across the world.

Catheryn Partington, Sandra Guillen and Liz Bode discuss the case of a dog with tachypnoea they saw while working in the cardiology department at the Small Animal Teaching Hospital, University of Liverpool.

PURPOSE: Patients with single ventricle anatomy palliated with Fontan operation are at risk for thromboembolism, arrhythmia, and heart failure rendering pregnancy high risk or even contraindicated. Infertility and high rates of first trimester miscarriage are not uncommon. In vitro fertilization (IVF) with or without gestational surrogacy can be an option, but poses risks during ovarian stimulation, oocyte retrieval, and the post-procedural period. We present six cases of women with complex congenital heart disease status post Fontan operation who underwent successful IVF. METHODS: Case series from a single-center tertiary care setting. RESULTS: Indications for referral were cardiac or fertility concerns for pregnancy of the congenital cardiologist. One woman had mild volume overload after oocyte retrieval requiring furosemide and one experienced post-operative colitis. There were no thrombotic complications. CONCLUSIONS: A multidisciplinary team-based approach can result in successful oocyte retrieval and IVF in women with complex congenital heart disease and Fontan physiology.

Background: Coach education discourse has largely suppressed learners’ involvement in learning. To address this, there have been calls for more humanistic approaches to form the basis of formal lea...

Objective Healthcare delivery models describe the organisation of healthcare practitioners and other resources to provide health care for a defined patient population. The organisation of health care has a predominant effect on the receipt of timely and appropriate health care. Efforts to improve healthcare delivery should be evidence informed, and large numbers of evaluations of healthcare delivery models have been undertaken. This paper presents a scoping review of Australian evaluations of new healthcare delivery models to inform a discussion of the appropriate use of such evidence to improve the efficiency and sustainability of the Australian health system. Methods A systematic scoping review was undertaken, following an a priori published protocol. PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for primary comparative studies of healthcare delivery models undertaken in Australia and published between 2009 and 2018. Primary prevention studies, such as health promotion activities, were excluded. Results Of 14 923 citations, 636 studies were included in the scoping review. Of these, 383 (60%) were randomised control trials. There were 18 clinical specialties in which over 10 evaluations were identified. Most models involved allied health practitioners or nurses. Conclusion Evaluations of healthcare delivery models provide important evidence that can be used to improve the use of the most important and costly assets of health systems, namely the healthcare practitioners who deliver health care. A nationally coordinated system is required to support local health services to assess the local value of alternative healthcare delivery models. What is known about the topic? The organisation and delivery of health care is continuously evolving in response to changes in the demand and supply of health care. New healthcare delivery models are often evaluated in specific locations, but it is not clear how such evidence informs the delivery of care in other locations. What does this paper add? This paper reports the findings of a scoping review of Australian evaluations of healthcare delivery models, highlighting the large and increasing number of such evaluations that have been published in the past 10 years. What are the implications for practitioners? Opportunities to improve health system efficiency are likely being lost due to the underuse of the available Australian evidence on new healthcare delivery models. Local health services need support to interpret such evidence in their local context, which could be provided through the development of a national framework for local evaluation.

The micro-level enactment of elite sport policy has received little critical coverage in the sociology of sport subdiscipline. This paper provides original insights into how coaches working in prof...

May Measurement Month is a global campaign aimed at raising public awareness of hypertension and to improve the management of hypertension—the main risk factor for cardiovascular diseases in the population. Screening was carried out at 400 sites on a national scale. More than 500 volunteers, including physicians (80%) and students of medical universities (20%) participated in the screening. To familiarize them with the research tools and standard blood pressure (BP) measurement method, they were trained by the members of the Georgian Society of Hypertension and the National Center for Disease Control and Public Health’s staff. Medical societies, health-care professionals, public health workers, social mass media, and other stakeholders were actively involved in the recruitment process. A total of 13 267 (38.5% males and 61.5% females) individuals were screened. The mean age of participants was 54.7 years (SD 15.9). All participants were Caucasian. After imputation of missing BP readings, 8510 (64.1%) were found to have hypertension, out of whom 7269 (85.4%) were aware of their condition, 7232 (85.0%) were on medication, and 1278 (15.0%) were not taking any medication. Of those taking antihypertensive medication, 34.8% had their BP controlled (

The Cabo Verdean population is aging and, consequently, non-communicable diseases, namely cardiovascular diseases, are increasing, with hypertension being an important risk factor. Following Cabo Verde's engagement with the May Measurement Month (MMM) campaign, in 2019, it was possible to improve the screening capacity, at the same time that a major social mobilization campaign was carried out to improve the population's knowledge about raised blood pressure (BP) and its consequences. With activities on nine islands, telemedicine was used to train researchers and volunteers. The MMM app was used to collect participant data. Individuals aged ≥18 years were recruited through opportunistic sampling. Each participant completed a questionnaire on demographic, lifestyle and environmental factors and had three BP measurements and weight and height measurements. Hypertension was defined as a systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg (mean of the second and third readings), or when using antihypertensive medication. When respondents did not provide three BP readings, multiple imputation using chained equations was used to calculate the mean of the second and third readings. A total of 17 627 individuals [mean age of 42.7 (SD 16.2); 63.8% women] were screened. After multiple imputation, 5990 (34.0%) had hypertension, of which 68.4% knew the diagnosis previously and 51.3% used antihypertensive drugs. The reported use of antihypertensive medication and a previous diagnosis of hypertension were strong predictors of higher levels of systolic and diastolic BP. Corrective actions were taken with an updated national protocol for hypertension treatment in primary health care. The II Non-Communicable Diseases Survey corroborated MMM national data that we see as an ideal initiative to reach the public, raising awareness about this important cardiovascular risk factor and providing political decision instruments.

To bolster the awareness of high blood pressure (BP) and to monitor the trend of hypertension control rate. Similar to May Measurement Month (MMM) 2017 and 2018 campaigns, we conducted the MMM 2019 campaign in 643 community pharmacies across Taiwan, and recruited adults aged 20 years or over in May and June of 2019. After filling in an anonymous questionnaire regarding medical history and lifestyle habits and having 10-min sitting rest, pharmacists took triplicate upper-arm BP readings on participants using an automated oscillometric sphygmomanometer. The means of the second and third BP readings were used as the screening BP estimates. Hypertension was defined if one of the followings was met: use of antihypertensive medications, systolic BP ≥140 mmHg, or diastolic BP ≥90 mmHg. Controlled BP was defined as BP of

Mortality from haemorrhagic stroke and ischaemic heart disease per 10 000 people in Mongolia ranks among the highest in the world. The main risk factor being hypertension. We aimed to screen hypertension for the working people in their workplace who rarely visit primary clinics. Two hundred health care volunteers were trained for blood pressure (BP) measuring technique and providing healthy lifestyle advice. Screening was performed at 80 sites, the majority were workplaces, over a period of 60 days when the May Measurement Month (MMM) campaign launched in May 2019. Hypertension was defined by the standard MMM guidance, as systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg (based on the mean of the second and third measurement), or taking anti-hypertensive medication. Blood pressure measuring digital devices (Omron-M3, Microlife A6 PC) were all clinically verified and approved for clinical use. A total of 6522 individuals (majority 67.8% male and mean age 37.0 ± 10.4) were screened. The proportion of hypertensive adults was 32.5%, of whom, 62.2% were aware of their hypertension, and 50.1% were on medication. The control rate for those on treatment was 27.1%. Non-communicable disease risk factors were 51.2% (3342) overweight/obese (19.5% obese), 38.7% (2523) smoking, 64.4% (4200) alcohol consumption, 4.5% (294) previously diagnosed with diabetes, and 1.3% and 1.1% with a heart attack or stroke, respectively. We conclude that hypertension management needs to be prioritized and increased awareness is required in the population.

The Argentinean Society of Hypertension, in agreement with the May Measurement Month (MMM) initiative of the International Society of Hypertension, implemented for the third consecutive year a hypertension screening campaign. A volunteer cross-sectional survey was carried out in public spaces and health centres during the month of May 2019 across 33 cities in Argentina. Hypertension was defined as systolic blood pressure (BP) ≥140 mmHg and/or diastolic BP ≥90 mmHg based on the mean of the second and third BP measurements, or in those on treatment for high BP. A total of 94 523 individuals (53.9 ± 17.8 years old, 55 231women and 39 292 men), were evaluated. The age and sex standardized mean BP was 124.7/77.2 mmHg. Among participants, 34.7% were overweight (25-29.9 m/kg2) and 28.7% had obesity (≥30 m/kg2). Individuals identified as being overweight had BP 3/2 mmHg higher and individuals with obesity 6/4 mmHg higher than those with normal weight. The prevalence of hypertension was 52.5%. Although 81.1% were aware and 77.7% were on antihypertensive treatment, only 46.0% of all individuals with hypertension had their BP controlled. Moreover, 19.8% of those not on any antihypertensive medication were found with raised BP. The low level of control of hypertension generates the critical need for the development of community-based prevention strategies reinforcing strategies to increase the awareness and control of hypertension.

Hypertension awareness and control is poor in low- and middle-income countries. Thus, implementing strategies to increase hypertension detection is needed. Colombia participated as one of the 92 countries involved in the third campaign of the May Measurement Month in 2019. Blood pressure (BP) was measured in 48 324 volunteers from 13 departments in Colombia. In total, 27.9% individuals were identified with hypertension. Of those with hypertension, 63.7% were aware of their condition, 60.0% were on antihypertensive medication, and 38.4% had controlled BP. These results showed low levels of awareness, treatment, and control of hypertension in this sample of subjects volunteered to participate, suggest the urgent necessity of implementing programmes to improve the diagnosis and management of hypertension in Colombia.

Background Across the UK, more people are projected to die in community settings over the next two decades. The role of the hospice inpatient unit (IPU) needs to be better understood in light of these shifts. The term complex needs is used for patients admitted to IPU, however, there is little clarity around these needs and how they trigger admission. Aim To understand why patients are admitted to IPU and to describe the palliative care services available to them beforehand. Method Prospective mixed methods study. Data were collected in two hospices in one city of Scotland. We examined case notes of 259 patients admitted to the IPU over four months and conducted 40 semi-structured interviews. (22 patients or a relative proxy, 11 health care professionals, 7 pro-forma interviews-source of referrals). Results Mean age was 71 years, 53% were female; 47% male. Most patients admitted were Scottish or White British (95%). Most were living with another person at the time of admission (72%); 28% lived alone. The vast majority had cancer (95%). Phase of illness was judged as deteriorating or unstable for over two-thirds at the time of admission. Most patients were receiving specialist palliative care support prior to admission – 73% had a community palliative care CNS (Clinical Nurse Specialist). Just under half had district nurse support (48%). Over one-fifth (21%) had no prior community palliative care involvement; most of these patients were referred from the hospital (81%). Length of stay was 12 days (median). 68% of admissions were for end-of-life care, with the patient dying during the admission. The hospice inpatient unit was the documented preferred place of death for 56% who died in that location. Thematic analysis of the qualitative data identified the key reasons for admissions, symptom control, anxiety and fear, social isolation and end-of-life care. Conclusion Admission to inpatient hospice is a last resort and often a response to a crisis situation. Greater palliative care support in home settings is needed so that more patients can remain at home when that is their preference.

Background The underlying pathogenesis of cerebral palsy (CP) remains poorly understood. The possibility of an early inflammatory response after acute insult is of increasing interest. Patterns of inflammatory and related biomarkers are emerging as potential early diagnostic markers for understanding the etiologic diversity of CP. Their presence has been investigated in plasma and umbilical cord blood but not in cerebrospinal fluid (CSF). Methods A clinical CP sample was recruited using a single-time point cross-sectional design to collect CSF at point-of-care during a standard-of-care surgical procedure (intrathecal pump implant). Patient demographic and clinical characteristics were sourced from medical chart audit. Results Significant (p ≤ 0.001) associations were found among neuroinflammatory, neuroendocrine, and nociceptive analytes with association patterns varying by birth status (term, preterm, extremely preterm). When between birth-group correlations were compared directly, there was a significant difference between preterm and extremely preterm birth subgroups for the correlation between tumour necrosis factor alpha (TNFα) and substance P. Conclusion This investigation shows that CSF can be used to study proteins in CP patients. Differences in inter-correlational patterns among analytes varying by birth status underscores the importance of considering birth status in relation to possible mechanistic differences as indicated by biomarker signatures. Future work should be oriented toward prognostic and predictive validity to continue to parse the heterogeneity of CP’s presentation, pathophysiology, and response to treatment.

Due to the closing of campuses, museums, and other public spaces during the pandemic, the typical avenues for recruitment, partnership, and dissemination are now unavailable to developmental labs. In this paper, we show how a shift in perspective has impacted our lab's ability to successfully transition to virtual work during the COVID-19 shut-down. This begins by recognizing that any lab that relies on local communities to engage in human research is itself a community organization. From this, we introduce a community-engaged lab model, and explain how it works using our own activities during the pandemic as an example. To begin, we introduce the vocabulary of mission-driven community organizations and show how we applied the key ideas of mission, vision, and culture to discussions of our own lab's identity. We contrast the community-engaged lab model with a traditional bi-directional model of recruitment from and dissemination to communities and describe how the community-engaged model can be used to reframe these and other ordinary lab activities. Our activities during the pandemic serve as a case study: we formed new community partnerships, engaged with child “citizen-scientists” in online research, and opened new avenues of virtual programming. One year later, we see modest but quantifiable impact of this approach: a return to pre-pandemic diversity in our samples, new engagement opportunities for trainees, and new sustainable partnerships. We end by discussing the promise and limitations of the community-engaged lab model for the future of developmental research.

Introduction Multi-source feedback (MSF) is an evaluation method mandated by the Accreditation Council for Graduate Medical Education (ACGME). The Queen’s Simulation Assessment Tool (QSAT) has been validated as being able to distinguish between resident performances in a simulation setting. The QSAT has also been demonstrated to have excellent MSF agreement when used in an adult simulation performed in a simulation lab. Using the QSAT, this study sought to determine the degree of agreement of MSF in a single pediatric (Peds) simulation case conducted in situ in a Peds emergency department (ED). Methods This Institutional Review Board-approved study was conducted in a four-year emergency medicine residency. A Peds resuscitation case was developed with specific behavioral anchors on the QSAT, which uses a 1-5 scale in each of five categories: Primary Assessment, Diagnostic Actions, Therapeutic Actions, Communication, and Overall Assessment. Data was gathered from six participants for each simulation. The lead resident self-evaluated and received MSF from a junior peer resident, a fixed Peds ED nurse, a random ED nurse, and two faculty (one fixed, the other from a dyad). The agreement was calculated with intraclass correlation coefficients (ICC). Results The simulation was performed on 35 separate days over two academic years. A total of 106 MSF participants were enrolled. Enrollees included three faculty members, 35 team leaders, 34 peers, 33 ED registered nurses (RN), and one Peds RN; 50% of the enrollees were female (n=53). Mean QSAT scores ranged from 20.7 to 23.4. A fair agreement was demonstrated via ICC; there was no statistically significant difference between sources of MSF. Removing self-evaluation led to the highest ICC. ICC for any single or grouped non-faculty source of MSF was poor. Conclusion Using the QSAT, the findings from this single-site cohort suggest that faculty must be included in MSF. Self-evaluation appears to be of limited value in MSF with the QSAT. The degree of MSF agreement as gathered by the QSAT was lower in this cohort than previously reported for adult simulation cases performed in the simulation lab. This may be due to either the pediatric nature of the case, the location of the simulation, or both.

We present the case of a 5-month-old patient presenting with pleural migration of ventriculo-peritoneal shunt catheter who returned 2 months later with respiratory distress. Ultimately, the diagnosis of a Morgagni hernia was made. This diagnosis, though rare, should be entertained in certain clinical settings.

This paper addresses issues associated with leadership in Higher Education (HE), by drawing on research and debate in relation to the role of education in reproducing social inequalities, and on expertise developed through academic leadership roles in British art schools. It seeks to stimulate discussion about the commodification of HE, which is often perceived as a threat to its accessibility, and therefore to its positive impact in enhancing social mobility, and will argue that it is only a threat if we cling to a culturally conservative belief in value-free learning, which serves only to reproduce the values of the white middle-class intelligentsia. By addressing the question of how to respond to the changing profile of all HE students, in terms of the diverse social and cultural capital which they bring with them, (which shapes what and how they want to learn), this paper will challenge some of the prevailing views about student engagement, from the perspective of an academic whose leadership role includes responsibility for developing learning and teaching strategies to ensure student progression, achievement, and graduate outcomes, and for enhancing the quality of the student experience.

Aims Antibiotic-loaded bone cements (ALBCs) may offer early protection against the formation of bacterial biofilm after joint arthroplasty. Use in hip arthroplasty is widely accepted, but there is a lack of evidence in total knee arthroplasty (TKA). The objective of this study was to evaluate the use of ALBC in a large population of TKA patients. Materials and Methods Data from the National Joint Registry (NJR) of England and Wales were obtained for all primary cemented TKAs between March 2003 and July 2016. Patient, implant, and surgical variables were analyzed. Cox proportional hazards models were used to assess the influence of ALBC on risk of revision. Body mass index (BMI) data were available in a subset of patients. Results Of 731 214 TKAs, 15 295 (2.1%) were implanted with plain cement and 715 919 (97.9%) with ALBC. There were 13 391 revisions; 2391 were performed for infection. After adjusting for other variables, ALBC had a significantly lower risk of revision for any cause (hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.77 to 0.93; p < 0.001). ALBC was associated with a lower risk of revision for all aseptic causes (HR 0.85, 95% CI 0.77 to 0.95; p < 0.001) and revisions for infection (HR 0.84, 95% CI 0.67 to 1.01; p = 0.06). The results were similar when BMI was added into the model, and in a subanalysis where surgeons using only ALBC over the entire study period were excluded. Prosthesis survival at ten years for TKAs implanted with ALBC was 96.3% (95% CI 96.3 to 96.4) compared with 95.5% (95% CI 95.0 to 95.9) in those implanted with plain cement. On a population level, where 100 000 TKAs are performed annually, this difference represents 870 fewer revisions at ten years in the ALBC group. Conclusion After adjusting for a range of variables, ALBC was associated with a significantly lower risk of revision in this registry-based study of an entire nation of primary cemented knee arthroplasties. Using ALBC does not appear to increase midterm implant failure rates. Cite this article: Bone Joint J 2019;101-B:1331–1347.

Background Validated protocols for diagnostic testing and management of pregnant women with cardiovascular disease (CVD) do not exist. Our objective was to establish a prospective standardized protocol for the clinical evaluation of pregnant women with CVD. Methods The Standardized Outcomes in Reproductive Cardiovascular Care (STORCC) initiative prospectively enrolled pregnant women with CVD into a standardized diagnostic testing and assessment protocol. Detailed cardiac and obstetric data were collected during the antepartum, intrapartum, and postpartum periods. Each woman was assigned a STORCC color code of perceived risk at a monthly multidisciplinary conference. Results In 250 pregnancies of 207 women with CVD, the standardized care protocol was followed in 136 and routine care in 114. The median age of the subjects was 32 years, and the most common form of heart disease was congenital heart disease (77%). Women enrolled in standardized care protocol had high compliance with second- and third-trimester visits (93%) and postpartum visits (76%). Maternal cardiac complications occurred in 10%. The STORCC cardiac and obstetric color codes predicted adverse outcomes within each respective category (P = .02, .01). Conclusions The STORCC protocol for prospective diagnostic testing and follow-up of pregnant women with CVD was successfully established, and compliance was high. The strength of a standardized testing and care protocol as well as detailed classification of labor and delivery characteristics allows for robust analyses into specific questions regarding testing protocols, and mode and timing of delivery.

INTRODUCTION. The prevalence of defects and effective radiation dose from various myocardial perfusion imaging (MPI) strategies in congenital heart disease (CHD) is unknown. METHODS. We studied 75 subjects with complex CHD (ages 5 to 80 years) referred for MPI between 2002 and 2015. A rest and exercise or pharmacologic stress MPI was performed using (99m)Technetium sestamibi, (82)rubidium or (13)N-ammonia, and Sodium iodide SPECT (single-photon emission computed tomography), SPECT/CT or Cadmium zinc telluride (CZT) SPECT or PET (positron emission tomography)/CT scanners. Deidentified images were interpreted semi-quantitatively in three batches: stress only MPI, stress/rest MPI, and stress/rest MPI with taking into account a history of ventricular septal defect repair. Effective radiation dose was estimated for stress/rest MPI and predicted for 1-day stress-first (normal stress scans), and for 2-day stress/rest MPI (abnormal stress scans). RESULTS. The median age was 18.6 years. The most common type of CHD was transposition of the great arteries (63%). Rest/stress MPI was abnormal in 43% of subjects and 25% of the abnormal scans demonstrated reversible defects. Of the subjects with abnormal MPI, 33% had significant underlying anatomic coronary artery obstruction. Estimated mean effective radiation dose ranged from 2.1 ± 0.6 mSv for (13)N-ammonia PET/CT to 12.5 ± 0.9 mSv for SPECT/CT. Predicted effective radiation dose was significantly lower for stress-first MPI and for 2-day stress/rest protocols. CONCLUSIONS. Due to the relatively high prevalence of abnormal stress MPI, tailored protocols with a stress-first MPI as well as the use of 2-day protocols and advanced imaging technologies including CZT SPECT, novel image reconstruction software, and PET MPI could substantially reduce radiation dose in complex CHD.

Background Patients with single ventricle (SV) may often undergo aortic reconstruction that creates a stiff large vessel, increasing afterload and affecting exercise performance. The objective of this study was to determine the relationship of pulse wave velocity (PWV) and distensibility in reconstructed and normal aortic arches after Fontan with exercise variables. Methods PWV and distensibility of the descending aorta at the level of the diaphragm (DAo) were calculated with real-time exercise cardiac magnetic resonance in 48 patients with SV after Fontan (18 after aortic reconstruction; 30 without aortic reconstruction) and compared with metabolic exercise stress test variables. Results PWV was greater in the reconstructed group than in the non-reconstructed group (median 4.4 m/s [range: 2.3 to 9.8 m/s] versus 3.6 [range: 2.6 to 6.3 m/s], respectively, p = 0.003). Statistically significant inverse correlations were found between PWV and end-diastolic, end-systolic, and stroke volumes at rest and at exercise in the reconstructed group. In addition, inverse correlations also existed in the reconstructed group between distensibility of the DAo and the exercise variables such as peak oxygen pulse (R = 0.56, p = 0.02), peak oxygen consumption (R = 0.63, p = 0.008), oxygen consumption at ventilatory anaerobic threshold (R = 0.48, p = 0.04), and peak work (R = 0.54, p = 0.02). Similar correlations were not seen in patients with non-reconstructed aortas. Conclusions Patients with SV with reconstructed aortas have increased aortic stiffness, increasing afterload on the ventricle. Native DAo stiffness distal to the reconstruction is inversely correlated with exercise performance, presumably to decrease impedance mismatch to maintain homogeneity of the aortic wall. This information suggests a possible mechanism for decreased exercise performance in patients with SV with aortic reconstructions.

Brown tumours do not represent neoplastic process, but they are focal bony lesions due to bone remodelling from either primary or secondary hyperparathyroidism. Their incidence is also low. The current literature on brown tumour is mainly in the form of case reports that focus on single affected sites. This pictorial review describes the full imaging workup and pathway of suspected brown tumour in the setting of both primary and secondary hyperparathyroidism. It aims to illustrate the management strategy to aid both clinicians and radiologists in suspected cases of brown tumour. We highlight the complementary roles that different imaging modalities can play in different settings including the importance of parathyroid ultrasound, 99mTc-sestamibi scintigraphy and SPECT/CT in the localisation of the parathyroid adenoma. We present cases with full clinical and imaging workup in both the acute and chronic setting and scenarios that require exclusion of primary and secondary bone malignancies.

OBJECTIVEThe authors conducted a retrospective analysis of a consecutive series of children with intracranial subdural empyemas (SEs) and epidural abscesses (EAs) to highlight the important clinical difference between these two entities. They describe the delays and pitfalls in achieving accurate diagnoses and make treatment recommendations based on clinical and imaging findings.METHODSThey reviewed their experience with children who had presented with intracranial SE and/or EA in the period from January 2013 to May 2018. They recorded presenting complaint, date of presentation, age, neurological examination findings, time from presentation to diagnosis, any errors in initial image interpretation, timing from diagnosis to surgical intervention, type of surgical intervention, neurological outcome, and microbiology data. They aimed to assess possible causes of any delay in diagnosis or surgical intervention.RESULTSSixteen children with SE and/or EA had undergone evaluation by the authors’ neurosurgical service since 2013. Children with SE (n = 14) presented with unmistakable evidence of CNS involvement with only one exception. Children with EA alone (n = 2) had no evidence of CNS dysfunction. All children older than 1 year of age had sinusitis.The time from initial presentation to a physician to diagnosis ranged from 0 to 21 days with a mean and median of 4.5 and 6 days, respectively. The time from diagnosis to neurosurgical intervention ranged from 0 to 14 days with a mean and median of 3 and 1 day, respectively. Delay in treatment was due to misinterpretation of images, a failure to perform timely imaging, progression on imaging as an indication for surgical intervention, or the managing clinician’s preference. Among the 14 cases with SE, initial imaging studies in 6 were not interpreted as showing SE. Four SE collections were dictated as epidural even on MRI. The only fatality was associated with no surgical intervention. Endoscopic sinus surgery was not associated with reducing the need for repeat craniotomy.CONCLUSIONSRegardless of the initial imaging interpretation, any child presenting with focal neurological deficit or seizures and sinusitis should be assumed to have an SE or meningitis, and a careful review of high-resolution imaging, ideally MRI with contrast, should be performed. If an extraaxial collection is identified, surgical drainage should be performed expeditiously. Neurosurgical involvement and evaluation are imperative to achieve timely diagnoses and to guide management in these critically ill children.

Background The inclusion of pulses in traditional wheat-based food products such as bread, cakes, and pasta is increasing as the food industry and consumers are recognizing the nutritional benefits due to high protein, antioxidant activity, and good sources of dietary fiber of pulses. In all crops, including cereals, oilseeds, and pulses, variability in chemical composition is known to exist due to genetic differences and environmental effects. This study reports the effect of genotype and environment on seed composition and the rheological properties of field-pea genotypes for both field-pea flour and isolated starch. Results Genotype had a significant effect on the chemical composition (protein, total starch, water-soluble carbohydrates, and phenolic compounds), the mean starch granule size, and rheological properties (peak viscosity, breakdown viscosity, final viscosity, peak time, and pasting temperature) of the field peas. The growing environment also had a significant effect on starch granule size, phytic acid, water-soluble carbohydrates, some phenolic compounds, and pasting characteristics of field peas. Genotype × environment (G × E) interactions were observed for protein, some phenolic compounds, and some pasting characteristics. Conclusion Genotype and the growing environment had a significant effect on the chemical composition and rheological properties of the field pea. The variability in composition and quality traits could be exploited through plant breeding and optimized agronomic practices to increase production of field peas with the desired quality traits. © 2019 Society of Chemical Industry.

Background: The frequency of late-onset Huntington's disease (>59 years) is assumed to be low and the clinical course milder. However, previous literature on late-onset disease is scarce and inconclusive. Objective: Our aim is to study clinical characteristics of late-onset compared to common-onset HD patients in a large cohort of HD patients from the Registry database. Methods: Participants with late- and common-onset (30–50 years)were compared for first clinical symptoms, disease progression, CAG repeat size and family history. Participants with a missing CAG repeat size, a repeat size of ≤35 or a UHDRS motor score of ≤5 were excluded. Results: Of 6007 eligible participants, 687 had late-onset (11.4%) and 3216 (53.5%) common-onset HD. Late-onset (n = 577) had significantly more gait and balance problems as first symptom compared to common-onset (n = 2408) (P

Introduction: Treatment of patients with adult congenital heart disease (ACHD) with advanced therapies including heart transplant (HT) is often delayed due to paucity of objective prognostic markers for the severity of heart failure (HF). While the utility of Cardiopulmonary Exercise Testing (CPET) in non-ACHD patients has been well-defined as it relates to prognosis, CPET for this purpose in ACHD is still under investigation. Methods: We performed a retrospective cohort study of 20 consecutive patients with ACHD who underwent HT between March 2010 and February 2016. Only 12 of 20 patients underwent CPET prior to transplantation. Demographics, standard measures of CPET interpretation, and 30-day and 1-year post transplantation outcomes were collected. Results: Patient Characteristics. Twenty patients with ACHD were transplanted at a median of 40 years of age (range: 23-57 years). Of the 12 patients who underwent CPET, 4 had undergone Fontan procedures, 4 had tetralogy of Fallot, 3 had d-transposition of the great arteries, and 1 had Ebstein anomaly. Thirty-day and one-year survival was 100%. All tests included in the analysis had a peak respiratory quotient _1.0. The median peak oxygen consumption per unit time (_VO2) for all diagnoses was 18.2 mL/kg/min (46% predicted), ranging from 12.2 to 22.6. Conclusion: There is a paucity of data to support best practices for patients with ACHD requiring transplantation. While it cannot be proven based on available data, it could be inferred that outcomes would have been worse or perhaps life sustaining options unavailable if providers delayed referral because of the lack of attainment of CPET-specific thresholds.

Raised blood pressure (BP) is the biggest risk factor that contributes to the global burden of disease and mortality. May Measurement Month (MMM) is a global initiative aimed to improved awareness of BP and has been a temporary solution to the lack of screening programmes. An opportunistic cross-sectional survey of volunteers aged ≥18 was carried out in May 2019. Blood pressure measurement, the definition of hypertension, and statistical analysis followed the standard MMM protocol. In total, 7112 individuals were screened (mean age 41.3 years; 50.4% female; 99.5% black) in 6 of the 18 Angolan provinces. In total, 99.6% of screenees provided three BP readings with an average BP of the 2nd and 3rd readings of 126/81 mmHg. After imputation, 2745 (38.6%) had hypertension of whom 1389 (59.8%) were aware of their diagnosis and 50.6% were on antihypertensive medication. Of those 1389 treated participants, 41.2% were controlled (

Background An increase in the number of people presenting to emergency departments (EDs) is contributing to ED overcrowding. In the early stages of the COVID-19 pandemic, there was a significant reduction in the number of ED presentations in Australia, creating an opportunity to learn from patients’ experiences of alternative management options. Objective The aim of this study is to report on the use and experience of health services by Australian adults experiencing a health issue during the COVID-19 pandemic for which they would have presented at an ED prior to the pandemic. Methods An online survey was conducted in May 2020. Reported health issues were categorized using an existing classification system. Data collected included demographics, care pathways, levels of concern at times of health issue and survey completion, and patient-reported experiences with care. Results A total of 1289 eligible respondents completed the survey. Almost 25% (309/1289) of respondents avoided an ED presentation, of which 58% (179/309) used an alternative form of health care and 42% (130/309) self-managed. Respondents making face-to-face or telehealth appointments with their general practitioner (GP) reported high levels of ED avoidance (135/286, 47%) and mostly positive experiences of care provided by GPs. A high proportion of those who self-managed reported high levels of concern at the time of completing the survey (42/130, 32%). Conclusions Telehealth consultations with GPs may be a more promotable alternative to the ED beyond the COVID-19 pandemic, providing easier access to a doctor with access to patients’ medical histories than an appointment for a face-to-face consultation. GP telehealth consultations may also address barriers to accessing health care for those with potentially the greatest need. The reported use and positive experiences with GP telehealth appointments should inform further research on their appropriateness as an alternative to the ED.

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. May Measurement Month (MMM) is a global initiative to raise awareness of high BP and act as a temporary solution to the lack of screening programmes worldwide. We aimed to screen for hypertension and cardiovascular risk factors in people aged ≥18 years in the community, thereby defining the proportion of subjects with elevated BP and assess the awareness and the effectiveness of its treatment. An opportunistic cross-sectional survey of volunteers aged ≥18 years was carried out in May 2019. Blood pressure measurement, the definition of hypertension and statistical analysis followed the standard MMM protocol. From May 2019 to June 2019, through 10 cities/provinces in Vietnam, 25 887 individuals with mean age 48.7 (SD ±17.7) years were screened. After multiple imputations, 8758 (33.8%) had hypertension. Of individuals not receiving antihypertensive medication, 3025 (15.0%) were hypertensive. Of individuals receiving antihypertensive medication, 2800 (48.8%) had uncontrolled BP. Raised BP [systolic BP (SBP) ≥140 mmHg and/or diastolic BP (DBP) ≥90 mmHg] was also associated with additional risk factors including smoking, alcohol intake, previous hypertension in pregnancy, and obesity. May Measurement Month 2019 was the most extensive BP screening campaign ever undertaken in Vietnam. Undiagnosed and uncontrolled hypertension in Vietnam remains a substantial health problem. Local campaigns applying standardized methods such as MMM 2019 will be beneficial to screen for the significant number of individuals with raised BP and increase the awareness of hypertension.

This chapter considers how law is made in the UK, who makes it, and the constitutional principles which give them the authority for making it and imposing it on society. There is a detailed account of the legislative procedure of the UK Parliament, and the different types of legislation enacted by Parliament. The legislative functions of the devolved administrations are mentioned. The law-making functions of judges, particularly through case law and the interpretation of statutes, are also considered, as is the impact of the Council of Europe on human rights. Finally, an outline of the law-making processes of the European Union is given.

This chapter discusses the role both of those professionally qualified to practise law—solicitors and barristers—and of other groups who provide legal/advice services but who do not have professional legal qualifications. It examines how regulation of legal services providers is changing and the objects of regulations. It notes the development of new forms of legal practice. It also considers how the use of artificial intelligence may change the ways in which legal services are delivered. The chapter reflects on the adjudicators and other dispute resolvers who play a significant role in the working of the legal system, and on the contribution to legal education made by law teachers, in universities and in private colleges, to the formation of the legal profession and to the practice of the law.

Magnetic resonance imaging (MRI) and CT perform an important role in the evaluation of neonates with congenital heart disease (CHD) when echocardiography is not sufficient for surgical planning or postoperative follow-up. Cardiac MRI and cardiac CT have complementary applications in the evaluation of cardiovascular disease in neonates. This review focuses on the indications and technical aspects of these modalities and special considerations for imaging neonates with CHD.

IntroductionValue-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond ‘what works’ towards more nuanced understanding of ‘what tends to work for whom under which circumstances’. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts.Methods and analysisThis exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context–mechanism–outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed.Ethics and disseminationEthical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.