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Abstract Objective Aortic annulus rupture remains one of the most fatal complications of TAVR. While attempts have been made to describe and predict this complication, the data remains insufficient without evidence-based guidelines for management of this rare complication. Methods Here we describe a series of 3 aortic annulus ruptures after TAVR which were managed successfully to hospital discharge. Results Patient 1 suffered annulus rupture during balloon valvuloplasty prior to TAVR. The patient became hypotensive, and echocardiogram showed pericardial effusion. The patient underwent pericardiocentesis which transiently improved the blood pressure, but bleeding continued. The patient was transitioned to an open surgical aortic valve replacement due to ongoing hemorrhage. The chest was left open with delayed closure on post-op day 2. The patient was discharged on post-op day 15. Patient 2 was undergoing TAVR valve expansion. The patient became hypotensive. An echocardiogram revealed pericardial effusion. Pericardiocentesis yielded 200 mL of blood. SURGIFLO (Johnson & Johnson Wound Management, Somerville, NJ) was injected into the pericardial space. Aortic root angiography confirmed no further contrast extravasation. A pericardial drain was left in place for 2 days, and the patient was discharged on post-op day 7. Patient 3 received a TAVR valve and post-placement dilation due to paravalvular leak. The echocardiogram showed a pericardial effusion. Pericardiocentesis was performed, yielding 500 cc of blood. The patient’s healthcare proxy declined emergent surgery; thus, a pericardial drain was placed. No hemostatic agents were used, and drainage reduced over several hours. The drain was removed on post-op day 3, and the patient was discharged on post-op day 8. Conclusions Based on the timelines in these three cases, and interventions used, the following steps may be employed in the event of annulus rupture: identification of hemodynamic instability, echocardiogram to confirm pericardial effusion, emergent pericardiocentesis, pericardial drain placement for evacuation of the pericardial space and use of hemostatic agents, repeat aortogram to rule out ongoing extravasation. If hemostasis is unable to be achieved and/or the patient becomes hemodynamically unstable at any point, rapid transition to emergent surgical management is necessary. This management strategy proved successful for this case series and warrants further investigation.

In this perspective paper we use publicly-available data to show that, despite much positive rhetoric in support of reforms in Scotland to integrate health and social care, these reforms, in their current state, have failed to meet their stated objectives. Rather than regress to the previous system, we propose continued evaluation of even more radical forms of such integration. This analysis, and set of future proposals, are timely given current considerations with respect to a National Care Service in Scotland and recent similar reforms in England and in other countries.

Introduction: This paper analyses the important enablers, barriers and impacts of country-wide implementation of integrated health and social care in Scotland. It offers insights for other systems seeking to advance similar policy and practice. Description: Landmark legislation was based on a shared vision and narrative about improving outcomes for people and communities. Implementation has involved coordination of multiple policies and interventions for different life stages, care groups, care settings and local context within a dynamic and complex system. Discussion: Relational and citizen led approaches are critical for success, but it takes time to build trusting relationships, influence organisational and professional cultures and cede power. Assessing national impacts is challenging and progress at a national level can seem slower than local experience suggests, due in part to the relative immaturity of national datasets for community interventions. Five years on there are many examples of innovation and positive outcomes despite increasing demographic, workforce, and financial challenges. However, inequalities continue to increase. Conclusion: Realising the true value from integration will require a stronger focus on place-based prevention and early intervention to achieve a fairer Scotland where everybody thrives. Solidarity, equity, and human rights must guide the next phase of Scotland’s story.

Abstract Background Technology can potentially enable the implementation of a value-based healthcare system, where the impact of quality of care is offered at optimised cost for maximised patient benefit. Technology can deliver value by aiding in data collection to evaluate outcomes and measure costs on a patient and population level. Healthcare organisations, however, face several challenges and risks that result almost exclusively from the use of these technologies. Discussion Some challenges associated with healthcare technology include their unsustainability, due to lack of scale-up plans and timely evaluations. Other risks include noncompliance with data protection policies, inadequate data governance, and overestimated expectations resulting from the rapid introduction of new technologies. Conclusion Organisations need to consider the risks and challenges associated with the use of technology and develop comprehensive strategies that mitigate factors leading to non-adoption and to realise benefits for achieving a value-based healthcare system.

Introduction: Few integrated care programmes sustain impact once dedicated funding and support cease. We report the impact of Reshaping Care for Older People (RCOP) in Scotland at two years post conclusion of the Change Fund. Description: RCOP sought long term transformational change from reactive services provided to older people towards preventative, anticipatory and coordinated care and support at home or closer to home, delivered with older people and their carers and enabled by technology to promote greater choice and control. Proposals crystallised around 2009 (baseline year). From April 2011, a £75 million annual Change Fund (around 1% of the annual >65s healthcare and social care budget) was ring-fenced for RCOP over 4 years using planned public expenditure. This dedicated Change Fund ended in April 2015 as new legislation established health and social care integration authorities to jointly commission services and use their integrated budgets to improve population health for all adults. Targeted population: Thirty one local partnerships (statutory, voluntary and independent sectors across healthcare, social care and housing) used their Change Fund to enhance well-being for older people and their carers; prevent, reduce or delay dependency; improve personal outcomes; and increase system resilience. They implemented a bundle of interventions across the RCOP pathway: preventative and anticipatory care; coordinated care and support at home; intermediate care at times of transition; and improvements in the quality of care in hospitals and care homes. Highlights: A team offered system coaching and coordinated a national improvement network to test new approaches, spread good practice, reduce variation and track progress on a core set of improvement measures. This team concluded March 2016, following a transition year supporting integration authorities to extend the RCOP approach to all adults. Outcomes for people over 65 years include: Progressive reduction in average number of emergency hospital beds occupied by over 65s each day compared to ‘expected’ had the age related rate at 2008/09 continued in line with population ageing – 989 fewer average daily occupied beds in 2012/13 compared to ‘expected’; 1533 fewer than ‘expected’ by 2016/17. Progressive reduction in average number of older people living in long term care homes than projected based on 2009 rate – 4476 less than ‘expected’ by 2014; 7213 less than ‘expected’ by 2017. Older people spent around 3.2 million more days at home than ‘expected’ in 2016/17. Estimated institutional costs avoided based on daily rate for care home and emergency hospital beds was approximately £480 million in 2016/17 (£1.3 million each day). Transferable lessons: Sustainability was enabled by legislation to integrate healthcare and social care. Guidance on how to extend RCOP approaches across the life stages and support for strategic planning and use of an integrated budget helped partnerships continue their successful RCOP initiatives and begin to adapt them to adults with multimorbidity. Conclusions: Planning for sustainability enabled RCOP gains to be held beyond the period of programme funding and support. However, further progress is required to scale the gains for all adults in the context of continued population ageing.

Equine transportation is associated with a variety of serious health disorders causing economic losses. However; statistics on horse transport are limited and epidemiological data on transport related diseases are available only for horses transported to abattoirs for slaughter. This study analysed reports of transport related health problems identified by drivers and horse owners for 180 journeys of an Australian horse transport company transporting horses between Perth and Sydney (~4000 km) in 2013–2015. Records showed that 97.2% (1604/1650) of the horses arrived at their destination with no clinical signs of disease or injury. Based on the veterinary reports of the affected horses; the most common issues were respiratory problems (27%); gastrointestinal problems (27%); pyrexia (19%); traumatic injuries (15%); and death (12%). Journey duration and season had a significant effect on the distribution of transport related issues ( p < 0.05); with a marked increase of the proportion of the most severe problems ( i.e. , gastrointestinal; respiratory problems and death) in spring and after 20 h in transit. Although not statistically significant; elevated disease rate predictions were seen for stallions/colts; horses aged over 10 years; and Thoroughbreds. Overall; the data demonstrate that long haul transportation is a risk for horse health and welfare and requires appropriate management to minimize transport stress.

The risk of respiratory disease in the transported horse can increase as a consequence of immunosuppression and stress associated primarily with opportunistic bacterial proliferation and viral reactivation. This study examines the ecology of equid herpesviruses (EHV) in these horses, exploring reactivation and changes in infection and shedding associated with transport, and any potential contributions to transport-related respiratory disease. Twelve horses were subjected to an 8-h road-transport event. Antibodies to EHV-1 and EHV-4 were detected by ELISA in serum collected prior to, immediately after and 2 weeks post transport. Respiratory tract endoscopy and tracheal washes were collected prior to and 5 days after transportation. Nasal swabs collected prior to, immediately after, 1 and 5 days following transport were screened for EHV-1,-2,-4,-5 using qPCR. Six horses had persistent neutrophilic airway infiltrates post transportation, indicative of subclinical respiratory disease. No horses were qPCR positive for either of the alphaherpesviruses (i.e., EHV-1/-4) nor did any seroconvert to either virus. Four out of nine horses positive for either EHV-2 or EHV-5 on qPCR prior to transport developed neutrophilic airway inflammation. Five horses showed increasingly positive readings on qPCR (i.e., reduced Cq) for EHV-2 after transportation and seven out of eleven horses positive for EHV-2 after transport shared strains of high sequence similarity with other horses in the study. One EHV-2 virus detected in one horse after transport was genetically different which may be due to reactivation. The clinical significance of EHV-2 and EHV-5 remains in question. However these results indicate that transportation may lead to increased shedding, transmission and reactivation of EHV-2 and EHV-5 but not EHV-1/-4. Unlike previous work focusing on the role of alphaherpesviruses, this research suggests that investigation of the gammaherpesviruses (i.e., EHV-2/-5) in transport-related disease should not be dismissed, particularly given that these viruses can encode suppressive immunomodulators that may affect host health.

This study aimed to document the effects of an eight hour journey on behavioural, clinical, haematological, environmental and respiratory parameters, and to identify possible associations between factors. Twelve horses underwent clinical examination, respiratory endoscopy with tracheal wash (TW) aspiration, and collection of venous and arterial blood before (BJ) and after the journey (AJ). TW were submitted for conventional quantitative bacteriological evaluation and genetic microbiome analyses. Behaviour was assessed in stables prior to transportation and throughout the journey. Transportation caused mild, but significant, effects on fluid and electrolyte balance and an acute phase response, characterized by neutrophilia, hyperfibrinogenaemia and hyperglobulinaemia. The proportion of neutrophils in TW, tracheal mucus and TW bacterial concentration was increased AJ, with preferential replication of Pasteurellaceae. Horse behaviour en route predicted clinical and respiratory outcomes. The frequency of stress related behaviours was greatest in the first hour of the journey, and balance-related behaviours were most common in the final hour of the journey. Horses which lowered their heads less frequently en route and showed more stress-related behaviours had higher physiological stress (serum cortisol and heart rate on arrival), increased tracheal mucus and inflammation scores, and higher TW bacterial concentration AJ (P

BACKGROUND:Reporting of strategic healthcare-associated infections (HCAIs) to Public Health England is mandatory for all acute hospital trusts in England, via a web-based HCAI Data Capture System (HCAI-DCS). AIM:Investigate the feasibility of automating the current, manual, HCAI reporting using linked electronic health records (linked-EHR), and assess its level of accuracy. METHODS:All data previously submitted through the HCAI-DCS by the Oxford University Hospitals infection control (IC) team for methicillin-resistant and methicillin-susceptible Staphylococcus aureus (MRSA, MSSA), Clostridium difficile, and Escherichia coli, through March 2017 were downloaded and compared to outputs created from linked-EHR, with detailed comparisons between 2013-2017. FINDINGS:Total MRSA, MSSA, E. coli and C. difficile cases entered by the IC team vs linked-EHR were 428 vs 432, 795 vs 816, 2454 vs 2450 and 3365 vs 3393 respectively. From 2013-2017, most discrepancies (32/37 (86%)) were likely due to IC recording errors. Patient and specimen identifiers were completed for >98% of cases by both methods, with very high agreement (>97%). Fields relating to the patient at the time the specimen was taken were complete to a similarly high level (>99% IC, >97% linked-EHR), and agreement was fairly good (>80%) except for the main and treatment specialties (57% and 54% respectively) and the patient category (55%). Optional, organism-specific data-fields were less complete, by both methods. Where comparisons were possible, agreement was reasonably high (mostly 70-90%). CONCLUSION:Basic factual information, such as demographic data, is almost-certainly better automated, and many other data fields can potentially be populated successfully from linked-EHR. Manual data collection is time-consuming and inefficient; automated electronic data collection would leave healthcare professionals free to focus on clinical rather than administrative work.

An online survey was conducted to determine associations between transport management and transport-related injuries and diseases in horses in Australia. The survey was composed of three sections: respondents' demographic information, transport management strategies or procedures (before, during and after transportation) and transport diseases experienced in the previous two year period. Univariate and multivariate modelling was performed exploring associations between variables (respondents' details and transport management strategies) and the following transport-related diseases as outcomes: traumatic injuries, diarrhoea, heat stroke, muscular problems, laminitis, transport pneumonia and colic. The survey generated 797 responses. Traumatic injuries were the most common transport-related problem, with a reported incidence of 45.0%. Younger respondents (30 in a week) were more likely to report transport-related injuries. Injury risk was also linked to the use of protections and tranquilizers prior to transport, and checking horses after the journey. Diarrhoea (20.0%) and heat stroke (10.5%) were reported more by amateur than professional horse carers. Increased risk of heat stroke was linked to the restriction of hay and water prior to transportation. Muscular problems (13.0%) appeared to be exacerbated when horse health was not assessed before journey; whilst the risk of laminitis (2.9%) was around three fold greater when post transport recovery strategies were not applied. Associations were made between transport pneumonia (9.2%) and duration of journey, and with activity (horses involved in racing at greater risk). No associations were seen between the incidence of colic (10.3%) and the variables examined. Study findings should be interpreted with caution as they represent participant perceptions and recall. Nevertheless, results support many current recommendations for safe transportation of horses. They also highlight the need to further investigate many of identified management factors to refine existing policies and practices in equine transportation.

Emerging economies offer tremendous potential for organisations seeking to expand globally and to attain the associated rewards. However, organisations differ in their entrepreneurial tendencies to enter new markets and to introduce new products in emerging economies. Organisations also differ in their abilities to manage their development programs, that is, their execution of different types of projects that lead to success in emerging markets. Finally, organisations differ in which overall measures of program performance are consistent with their strategic objectives. This study provides a literature foundation and conceptual framework designed to understand which market entry and product line strategies and performance measures are appropriate for organisations pursuing strategic success in emerging markets. This study sets forward grounded propositions that different strategic types will vary in their market entry and product line strategies, in the project composition of their development programs, and in the orientations of performance measures used to evaluate their development programs. Prospectors, according to type, will enter emerging economies by introducing new product lines to new customer types, and by emphasizing new-to-the-world products. They will evaluate their development programs with Growth-oriented performance measures. Defenders will more typically occupy secure niches within emerging economies by emphasizing product improvement and cost reduction projects for current types of customers. They will evaluate their development programs with Efficiency-oriented performance measures. Analyzers will either target new customer types with proven products, or serve an existing market niche with new product lines. They will evaluate their development program performance with Strategy-oriented measures.

This study examines how ESG risks and opportunities can be systematically identified, assessed, and incorporated into the early-stage design and planning of natural resources projects. The focus for this study will be on the mining activities required to source the resources for the global decarbonization effort. The need for a framework to incorporate ESG risks and opportunities into the strategic mine planning process was first identified in the de Beers Sustainability Valuation Approach. The Social Value Capital Decision Model advanced by BHP represents an advance on the de Beers model. This is the first example of a structured methodology for systematically considering stakeholder values and incorporating these into the capital decision framework. To test the applicability of a new approach to mine design by using Quality Function Deployment (QFD), a case study involving a copper mine located in South America was developed. This case study demonstrates how QFD can provide clear line-of-sight to connect design decisions with priority stakeholder concerns. The framework provides a communications tool for aligning the ESG design process across functional silos within complex organizations. The development of appropriate software tools could assist in managing the inherent complexity associated with integrating stakeholder value concerns into early stage design decisions.