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Edited by
Paul A. Banaszkiewicz, Queen Elizabeth Hospital and North East NHS Surgical Centre (NENSC), Gateshead,Kiran Singisetti, Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust
This chapter will guide a candidate in core paediatric topics that regularly appear in Section 1 of the FRCS(Tr&Orth) exam. The chapter deals with paediatric clinical questions based around high quality clinical scenarios. Detailed explanations of the SBA options with a clear logical approach to selecting the most appropriate option.
Venovenous collaterals are abnormal connections between the systemic and pulmonary venous systems. They are commonly seen in the Fontan circulation and may lead to significant hypoxaemia. Transcatheter closure of venovenous collaterals is a potential but controversial treatment as the long-term benefits and outcomes are not well understood.
Methods:
This retrospective cohort study utilised data from the Australian and New Zealand Fontan Registry. Patients who underwent transcatheter venovenous collateral occlusion for hypoxemia from the year 2000 onwards were included. Atriopulmonary and Kawashima-type Fontan circulations were excluded to reflect a more contemporary Fontan cohort.
Results:
Nineteen patients (age 19.3 ± 7.8 years, 53% female) underwent transcatheter venovenous collateral occlusion. Compared to baseline, mean oxygen saturation was improved at latest follow-up (90.5% vs 87.0%; p = 0.003). Nine patients achieved a clinically significant response (defined as an increase of at least 5% to 90% or greater), and this was associated with lower baseline Fontan pressures (12.9 v 15.6 mmHg; p = 0.02). No heart failure hospitalisations, arrhythmia, transplant referrals, or mortality were observed during the median follow-up period of 4 years. Two patients experienced thromboembolic events and five patients underwent re-intervention.
Conclusion:
Transcatheter occlusion of venovenous collaterals in Fontan patients with chronic hypoxaemia resulted in a modest increase in oxygenation over a median follow-up of 4 years and longer-term prognosis did not appear to be adversely affected. Lower Fontan pressures at baseline were associated with a greater improvement in oxygenation.
Quantification of oral intake within the hospital setting is required to guide nutrition care. Multiple dietary assessment methods are available, yet details regarding their application in the acute care setting are scarce. This scoping review, conducted in accordance with JBI methodology, describes dietary assessment methods used to measure oral intake in acute and critical care hospital patients. The search was run across four databases to identify primary research conducted in adult acute or critical care settings from 1st of January 2000-15th March 2023 which quantified oral diet with any dietary assessment method. In total, 155 articles were included, predominantly from the acute care setting (n = 153, 99%). Studies were mainly single-centre (n = 138, 88%) and of observational design (n = 135, 87%). Estimated plate waste (n = 59, 38%) and food records (n = 43, 28%) were the most frequent assessment methods with energy and protein the main nutrients quantified (n = 81, 52%). Validation was completed in 23 (15%) studies, with the majority of these using a reference method reliant on estimation (n = 17, 74%). A quarter of studies (n = 39) quantified completion (either as complete versus incomplete or degree of completeness) and four studies (2.5%) explored factors influencing completion. Findings indicate a lack of high-quality evidence to guide selection and application of existing dietary assessment methods to quantify oral intake with a particular absence of evidence in the critical care setting. Further validation of existing tools and identification of factors influencing completion is needed to guide the optimal approach to quantification of oral intake in both research and clinical contexts.
An increasing number of children, adolescents and adults with intellectual disabilities and/or autism are being admitted to general psychiatric wards and cared for by general psychiatrists.
Aims
The aim of this systematic review was to consider the likely effectiveness of in-patient treatment for this population, and compare and contrast differing models of in-patient care.
Method
A systematic search was completed to identify papers where authors had reported data about the effectiveness of in-patient admissions with reference to one of three domains: treatment effect (e.g. length of stay, clinical outcome, readmission), patient safety (e.g. restrictive practices) and patient experience (e.g. patient or family satisfaction). Where possible, outcomes associated with admission were considered further within the context of differing models of in-patient care (e.g. specialist in-patient services versus general mental health in-patient services).
Results
A total of 106 studies were included and there was evidence that improvements in mental health, social functioning, behaviour and forensic risk were associated with in-patient admission. There were two main models of in-patient psychiatric care described within the literature: admission to a specialist intellectual disability or general mental health in-patient service. Patients admitted to specialist intellectual disability in-patient services had greater complexity, but there were additional benefits, including fewer out-of-area discharges and lower seclusion rates.
Conclusions
There was evidence that admission to in-patient services was associated with improvements in mental health for this population. There was some evidence indicating better outcomes for those admitted to specialist services.
Literary practice is a distinctive form of historical thinking and early medieval culture is an important component of literary creativity and innovation in the 1940s and 1950s. This chapter examines the opportunities early medieval English poetry afforded writers and scholars in Britain in the 1940s and 1950s. Modern writers in this period negotiated the medieval past in their work in different ways. Outright hostility sits alongside an awareness that thinking of the medieval is a necessary component of modern culture. To give a sense of this literary engagement, this chapter offers an account of Old English at the mid-century in relation to four profoundly different writers, Kingsley Amis (1922–1995), Gavin Bone (1907–1942), Bryher (Annie Winifred Ellerman, 1894–1983), and Angus Wilson (1913–1991). The work of these writers and scholars demonstrates that early medieval culture is part of a broader post-War inquiry into society, culture, sexuality, race and ethnocentrism.
The magnetic resonance linear accelerator system (MR Linac) is a novel piece of radiotherapy (RT) equipment allowing the routine application of daily MR-guided treatment adaptation. The hardware design required for such technical capabilities and the increased complexity of the treatment workflow entails a notable departure from cone beam computed tomography (CBCT)-based RT. Patient tolerability of treatment is paramount to RT practice where high compliance is required. Presented is a comparative analysis of how such modality specific characteristics may ultimately impact the patient experience of treatment.
Materials and Methods:
Forty patients undergoing RT for prostate cancer (PCa) on either the MR Linac (n = 20) or a CBCT-based linac (n = 20) were provided with a validated patient reported outcomes measures (PROM’s) questionnaire at fraction 1 and fraction 20. The 18-item questionnaire provided patient responses recorded using a 4-point Likert scale, 0 denoting a response of ‘Not at all’, 1 ‘Slightly’, 2 ‘Moderately’ and 3 signifying ‘Very’. The analysis provided insight into both comparisons between modalities at singular time points (fractions 1 and 20), as well as a temporal analysis within a single modality, denoting changing patient experience.
Results:
Patients generally found the MR Linac treatment couch more comfortable, however, found the increase in treatment duration harder to tolerate. Responses for all items remained stable between first and last fraction across both cohorts, indicating minimal temporal variation within a single modality. None of the responses were statistically significant at the 0·01 level.
Conclusion:
Whether radiotherapy for PCa is delivered on a CBCT linac or the MR Linac, there is little difference in patient experience with minimal experiential variation within a single modality.
To describe strategies used to recruit and retain young adults in nutrition, physical activity and/or obesity intervention studies, and quantify the success and efficiency of these strategies.
Design:
A systematic review was conducted. The search included six electronic databases to identify randomised controlled trials (RCT) published up to 6 December 2019 that evaluated nutrition, physical activity and/or obesity interventions in young adults (17–35 years). Recruitment was considered successful if the pre-determined sample size goal was met. Retention was considered acceptable if ≥80 % retained for ≤6-month follow-up or ≥70 % for >6-month follow-up.
Results:
From 21 582 manuscripts identified, 107 RCT were included. Universities were the most common recruitment setting used in eighty-four studies (79 %). Less than half (46 %) of the studies provided sufficient information to evaluate whether individual recruitment strategies met sample size goals, with 77 % successfully achieving recruitment targets. Reporting for retention was slightly better with 69 % of studies providing sufficient information to determine whether individual retention strategies achieved adequate retention rates. Of these, 65 % had adequate retention.
Conclusions:
This review highlights poor reporting of recruitment and retention information across trials. Findings may not be applicable outside a university setting. Guidance on how to improve reporting practices to optimise recruitment and retention strategies within young adults could assist researchers in improving outcomes.
Subglacial hydrological systems require innovative technological solutions to access and observe. Wireless sensor platforms can be used to collect and return data, but their performance in deep and fast-moving ice requires quantification. We report experimental results from Cryoegg: a spherical probe that can be deployed into a borehole or moulin and transit through the subglacial hydrological system. The probe measures temperature, pressure and electrical conductivity in situ and returns all data wirelessly via a radio link. We demonstrate Cryoegg's utility in studying englacial channels and moulins, including in situ salt dilution gauging. Cryoegg uses VHF radio to transmit data to a surface receiving array. We demonstrate transmission through up to 1.3 km of cold ice – a significant improvement on the previous design. The wireless transmission uses Wireless M-Bus on 169 MHz; we present a simple radio link budget model for its performance in cold ice and experimentally confirm its validity. Cryoegg has also been tested successfully in temperate ice. The battery capacity should allow measurements to be made every 2 h for more than a year. Future iterations of the radio system will enable Cryoegg to transmit data through up to 2.5 km of ice.
What connections might be found between those who write history and the different kinds of histories they write? An emphasis on gender often focuses on the dynamics of women’s collaborative authorship, whether produced anonymously or in the form of patron and client relationships. But it also highlights the fact that sole authorship is often associated with male writers; with masculinity. Beginning with the Earliest Life of Gregory the Great, an anonymous Life that may have been composed by a woman, the chapter next addresses Æthelweard’s Latin Chronicle, written by a secular, elite male author for and in collaboration with a female patron and family relation, Abbess Matilda of Essen. It concludes with another kind of history, that of the anonymous Old English poem, Widsith, and the insight that the sheer variety of early medieval historiography is also suggestive of the different uses of gender by its authors.
Due to correlations between purchasing patterns and diet disparities, differences in food shopping patterns and strategies across income levels and other socio-economic characteristics is a widely-studied research area. Most extant literature uses either primary or secondary data, which are often characterized by, respectively, limited geographical scope and considerable level of detail, or wide geographical reach but low detail. That literature also reveals contrasting results based on methods, data sources and geographic location. In this paper, we use three different datasets to characterize the differences in purchasing patterns across income levels, rural–urban status and other variables of food shoppers in the Northeastern USA and compare these trends with existing research. While many of the findings corroborate previous studies, new findings include less reliance on superstores overall, except for rural respondents, and a greater reliance on limited assortment supermarkets for SNAP and low-income households. Food purchasing differences are described by race and ethnicity, income and education, and children in the household. The analysis presented here includes a portion of the work performed by an interdisciplinary team of researchers engaged in the USDA National Institute of Food and Agriculture's Agriculture and Food Research Initiative project Enhancing Food Security in the Northeast (EFSNE). By using primary data from shoppers' intercept surveys, and secondary data from two large datasets, one of household food purchases and the other of food expenditures, we identify purchasing decisions holding at both the case-study (limited geography) and broader geographic (entire Northeast) levels, which both support previous findings and reveal the need for additional research in this area.
The objectives of this paper are to: (1) identify contextual factors such as policy that impacted the implementation of community-based primary health care (CBPHC) innovations among 12 Canadian research teams and (2) describe strategies used by the teams to address contextual factors influencing implementation of CBPHC innovations. In primary care settings, consideration of contextual factors when implementing change has been recognized as critically important to success. However, contextual factors are rarely recorded, analyzed or considered when implementing change. The lack of consideration of contextual factors has negative implications not only for successfully implementing primary health care (PHC) innovations, but also for their sustainability and scalability. For this evaluation, data collection was conducted using self-administered questionnaires and follow-up telephone interviews with team representatives. We used a combination of directed and conventional content analysis approaches to analyze the questionnaire and interview data. Representatives from all 12 teams completed the questionnaire and 11 teams participated in the interviews; 40 individuals participated in this evaluation. Four themes representing contextual factors that impacted the implementation of CBPHC innovations were identified: (I) diversity of jurisdictions (II) complexity of interactions and collaborations (III) policy, and (IV) the multifaceted nature of PHC. The teams used six strategies to address these contextual factors including: (1) conduct an environmental scan at the beginning (2) maintaining engagement among partners and stakeholders by encouraging open and inclusive communication; (3) contextualizing the innovation for different settings; (4) anticipating and addressing changes, delays, and the need for additional resources; (5) fostering a culture of research and innovation among partners and stakeholders; and (6) ensuring information about the innovation is widely available. Implementing CBPHC innovations across jurisdictions is complex and involves navigating through multiple contextual factors. Awareness of the dynamic nature of context should be considered when implementing innovations.
By
Clare A. Lees, King's College London.,
Lewi Mondal, Teesside University,
Helen Saunders, King's College London in 2017.,
Emily Ennis, University of Leeds after taking her bachelor's and master's degrees there.,
Susan Bruce, University of Cambridge and took her MA and PhD from Cornell.
Postgraduate researchers (PGRs), both collectively and individually, represent one of the most important cohorts in English Studies. It takes a considerable investment of time and intellectual energy to produce research commensurate with a PhD, and that work supports the future of English Studies. The award of the PhD is a remarkable individual achievement that we rarely celebrate collectively as a discipline. As a cohort, postgraduate researchers are supported by their supervisors, academic departments and institutions; they are offered training that is both discipline-specific and that cultivates professional development and wider skills necessary for their future careers. Yet, postgraduates are also precarious. Funding for research is highly competitive and increasingly rare; opportunities to teach, if available, are often provided via shortterm contracts with few benefits and little or no support for research or professional development. That those who represent one significant future for English Studies in its broadest sense experience such precarity is increasingly recognised. The most recent example, perhaps, is the free membership extended by the University and College Union (UCU) to postgraduates on teaching contracts or working within teaching and support (see https://www.ucu.org.uk/free). Research councils such as the AHRC commit funding to postgraduates through a variety of routes such as Doctoral Training Partnerships (DTPs) and also provide opportunities, policy and support for career development. And subject organisations such as the EA and UE consider postgraduate support and development central to our work.
What of postgraduates themselves, however? In what sense are their voices heard whether as individuals or as a cohort similar to that of the ECA? English: Shared Futures (E:SF) provided an opportunity for postgraduates to present their work and for participants to engage with it. Aside from conference participation, however, the voice of the postgraduate researcher is most often heard within professional settings such as the department meeting, the Graduate Centre, College or School, or the research council. Listening to those who represent the various futures of our discipline outside these formal settings, however, is also vital. For this chapter, I invited three researchers, postgraduates or post-PhDs themselves, who had attended the E:SF conference to reflect on their experience in ways that they felt appropriate. I'm grateful to Emily Ennis, Lewi Mondal and Helen Saunders for their willingness to take up my invitation: their voices follow.
Arthropod communities in the tropics are increasingly impacted by rapid changes in land use. Because species showing distinct seasonal patterns of activity are thought to be at higher risk of climate-related extirpation, global warming is generally considered a lower threat to arthropod biodiversity in the tropics than in temperate regions. To examine changes associated with land use and weather variables in tropical arthropod communities, we deployed Malaise traps at three major anthropogenic forests (secondary reserve forest, oil palm forest, and urban ornamental forest (UOF)) in Peninsular Malaysia and collected arthropods continuously for 12 months. We used metabarcoding protocols to characterize the diversity within weekly samples. We found that changes in the composition of arthropod communities were significantly associated with maximum temperature in all the three forests, but shifts were reversed in the UOF compared with the other forests. This suggests arthropods in forests in Peninsular Malaysia face a double threat: community shifts and biodiversity loss due to exploitation and disturbance of forests which consequently put species at further risk related to global warming. We highlight the positive feedback mechanism of land use and temperature, which pose threats to the arthropod communities and further implicates ecosystem functioning and human well-being. Consequently, conservation and mitigation plans are urgently needed.
Whether monozygotic (MZ) and dizygotic (DZ) twins differ from each other in a variety of phenotypes is important for genetic twin modeling and for inferences made from twin studies in general. We analyzed whether there were differences in individual, maternal and paternal education between MZ and DZ twins in a large pooled dataset. Information was gathered on individual education for 218,362 adult twins from 27 twin cohorts (53% females; 39% MZ twins), and on maternal and paternal education for 147,315 and 143,056 twins respectively, from 28 twin cohorts (52% females; 38% MZ twins). Together, we had information on individual or parental education from 42 twin cohorts representing 19 countries. The original education classifications were transformed to education years and analyzed using linear regression models. Overall, MZ males had 0.26 (95% CI [0.21, 0.31]) years and MZ females 0.17 (95% CI [0.12, 0.21]) years longer education than DZ twins. The zygosity difference became smaller in more recent birth cohorts for both males and females. Parental education was somewhat longer for fathers of DZ twins in cohorts born in 1990–1999 (0.16 years, 95% CI [0.08, 0.25]) and 2000 or later (0.11 years, 95% CI [0.00, 0.22]), compared with fathers of MZ twins. The results show that the years of both individual and parental education are largely similar in MZ and DZ twins. We suggest that the socio-economic differences between MZ and DZ twins are so small that inferences based upon genetic modeling of twin data are not affected.
Patients with cardiovascular diseases are common in the emergency department (ED), and continuity of care following that visit is needed to ensure that they receive evidence-based diagnostic tests and therapy. We examined the frequency of follow-up care after discharge from an ED with a new diagnosis of one of three cardiovascular diseases.
Methods
We performed a retrospective cohort study of patients with a new diagnosis of heart failure, atrial fibrillation, or hypertension, who were discharged from 157 non-pediatric EDs in Ontario, Canada, between April 2007 and March 2014. We determined the frequency of follow-up care with a family physician, cardiologist, or internist within seven and 30 days, and assessed the association of patient, emergency physician, and family physician characteristics with obtaining follow-up care using cause-specific hazard modeling.
Results
There were 41,485 qualifying ED visits. Just under half (47.0%) had follow-up care within seven days, with 78.7% seen by 30 days. Patients with serious comorbidities (renal failure, dementia, COPD, stroke, coronary artery disease, and cancer) had a lower adjusted hazard of obtaining 7-day follow-up care (HRs 0.77-0.95) and 30-day follow-up care (HR 0.76-0.95). The only emergency physician characteristic associated with follow-up care was 5-year emergency medicine specialty training (HR 1.11). Compared to those whose family physician was remunerated via a primarily fee-for-service model, patients were less likely to obtain 7-day follow-up care if their family physician was remunerated via three types of capitation models (HR 0.72, 0.81, 0.85) or via traditional fee-for-service (HR 0.91). Findings were similar for 30-day follow-up care.
Conclusions
Only half of patients discharged from an ED with a new diagnosis of atrial fibrillation, heart failure, and hypertension were seen within a week of being discharged. Patients with significant comorbidities were less likely to obtain follow-up care, as were those with a family physician who was remunerated via primarily capitation methods.
An excellent collection... breaks new ground in many areas. Should make a substantial impact on the discussion of the contemporary influence of Anglo-Saxon Culture. Conor McCarthy, author of Seamus Heaney and the Medieval Imagination
Britain's pre-Conquest past and its culture continues to fascinate modern writers and artists. From Henry Sweet's Anglo-Saxon Reader to Seamus Heaney's Beowulf, and from high modernism to the musclebound heroes of comic book and Hollywood, Anglo-Saxon England has been a powerful and often unexpected source of inspiration, antagonism, and reflection. The essays here engage with the ways in which the Anglo-Saxons and their literature have been received, confronted, and re-envisioned in the modern imagination. They offer fresh insights on established figures, such as W.H. Auden, J.R.R. Tolkien, and David Jones, and on contemporary writers such as Geoffrey Hill, Peter Reading, P.D. James, and Heaney. They explore the interaction between text, image and landscape in medieval and modern books, the recasting of mythic figures such as Wayland Smith, and the metamorphosis of Beowulf into Grendel - as a novel and as grand opera. The early medieval emerges not simply as a site of nostalgia or anxiety in modern revisions, but instead provides a vital arena for creativity, pleasure, and artistic experiment.
Contributors: Bernard O'Donoghue, Chris Jones, Mark Atherton, Maria Artamonova, Anna Johnson, Clare A. Lees, Sian Echard, Catherine A.M. Clarke, Maria Sachiko Cecire, Allen J. Frantzen, John Halbrooks, Hannah J. Crawforth, Joshua Davies, Rebecca Anne Barr
We explore the hypothesis that the abrupt drainage of Laurentide lakes and associated rapid switch of the North Atlantic thermohaline circulation 8200 yr ago had a catastrophic influence on Neolithic civilisation in large parts of southeastern Europe, Anatolia, Cyprus, and the Near East. The event at 8200 cal yr BP is observed in a large number of high-resolution climate proxies in the Northern Hemisphere, and in many cases corresponds to markedly cold and arid conditions. We identify the relevant archaeological levels of major Neolithic settlements in Central Anatolia, Cyprus, Greece and Bulgaria, and examine published stratigraphic, architectural, cultural and geoarchaeological studies for these sites. The specific archaeological events and processes we observe at a number of these sites during the study interval 8400–8000 cal yr BP lead us to refine some previously established Neolithisation models. The introduction of farming to South-East Europe occurs in all study regions (Thrace, Macedonia, Thessaly, Bulgaria) near 8200 cal yr BP. We observe major disruptions of Neolithic cultures in the Levant, North Syria, South-East Anatolia, Central Anatolia and Cyprus, at the same time. We conclude that the 8200 cal yr BP aridity event triggered the spread of early farmers, by different routes, out of West Asia and the Near East into Greece and Bulgaria.