To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
National standards to ensure effective transition and smooth transfer of adolescents from paediatric to adult services are available but data on successful transition in CHD are limited. The aim of this study is to assess the effectiveness of our transition pathway.
Adolescents with CHD, aged 15–19 years, who attended the joint cardiac transition clinic between 2009 and 2018 were identified from the Patient Administration Systems. Patient attendance at their first adult CHD service appointment at Royal Papworth Hospital was recorded.
179 adolescents were seen in the joint cardiac transition clinic in the 9-year study period. The median age of the patients when seen was 16 (range 15–19) years. 145 patients were initially planned for transfer to the Royal Papworth Hospital adult CHD service. Three patients were subsequently excluded and the success of the transfer of care in 142 patients were analysed. 112 (78%) attended their first follow-up in the adult CHD clinic as planned, 28 (20%) attended after reminders were sent out with 5/28 requiring multiple reminders, and only 2 (1.4%) failed to attend. Overall, transfer of care was achieved in 140 (98.6%) patients.
A dedicated joint cardiac transition clinic involving multi-professional medical and nursing teams from paediatric and adult cardiology services appears to achieve high engagement rates with the adult services. This approach allows a ‘face’ to be put on a named clinician delivering the adult service and should be encouraged.
Nitrogen fixation from pasture legumes is a fundamental process that contributes to the profitability and sustainability of dryland agricultural systems. The aim of this research was to determine whether well-managed pastures, based on aerial-seeding pasture legumes, could partially or wholly meet the nitrogen (N) requirements of subsequent grain crops in an annual rotation. Fifteen experiments were conducted in Western Australia with wheat, barley or canola crops grown in a rotation that included the pasture legume species French serradella (Ornithopus sativus), biserrula (Biserrula pelecinus), bladder clover (Trifolium spumosum), annual medics (Medicago spp.) and the non-aerial seeded subterranean clover (Trifolium subterraneum). After the pasture phase, five rates of inorganic N fertilizer (Urea, applied at 0, 23, 46, 69 and 92 kg/ha) were applied to subsequent cereal and oil seed crops. The yields of wheat grown after serradella, biserrula and bladder clover, without the use of applied N fertilizer, were consistent with the target yields for growing conditions of the trials (2.3 to 5.4 t/ha). Crop yields after phases of these pasture legume species were similar or higher than those following subterranean clover or annual medics. The results of this study suggest a single season of a legume-dominant pasture may provide sufficient organic N in the soil to grow at least one crop, without the need for inorganic N fertilizer application. This has implications for reducing inorganic N requirements and the carbon footprint of cropping in dryland agricultural systems.
A 9 mm Occlutech septal occluder Flex II device was retrieved in a 4-year-old 22 kg child; A 6 Fr Cook® Flexor sheath (child) was inserted into a 9 Fr Occlutech® ASD Delivery Set (mother). Once the tip of the smaller sheath was close to the device, a 4 Fr right Judkins catheter was introduced with a snare. The right atrial hub was captured and withdrawn to the level of the 6 Fr sheath which was then withdrawn into the 9 Fr sheath before being removed completely. The “mother and child” technique offers a greater likelihood of slenderising and retrieving embolised devices.
This paper contributes to recent revisions to the English School (ES) which have sought to redress its Eurocentrism. It argues that, despite providing necessary accounts of non-Western international societies and the agency of non-European polities in the expansion of global international society, there remains a gap in capturing the agency of postcolonial states in contributing to order negotiation and management in contemporary international order. It proposes a social role negotiation framework to address the gap, which it situates within a holistic conceptual framework that supplements an ES understanding of international order between states with a world-system perspective on how states are embedded within global capitalism, and a neo-Gramscian focus on social forces as the key agents contesting and shaping states' foreign policy orientation. It highlights two major types of postcolonial state agency within international order: contesting and limiting great powers' legitimate exercise of power; and establishing responsibilities towards building and managing order vis-a-vis great powers. The paper illustrates the utility of the social roles framework with the example of ASEAN in Southeast Asian and Asia-Pacific order.
Paediatricians with Expertise in Cardiology assess children with a full history, examination, and often perform an echocardiogram. A minority are then referred to an outreach clinic run jointly with a visiting paediatric cardiologist. The accuracy of the echocardiography diagnosis made by the Paediatrician with Expertise in Cardiology is unknown.
Materials and methods
We conducted a retrospective review of clinic letters for children seen in the outreach clinic for the first time between March, 2004 and March, 2011. Children with CHD diagnosed antenatally or elsewhere were excluded. We recorded the echocardiography diagnosis made by the paediatric cardiologist and previously by the Paediatrician with Expertise in Cardiology.
The Paediatrician with Expertise in Cardiology referred 317/3145 (10%) children seen in the local cardiac clinics to the outreach clinic over this period, and among them 296 were eligible for inclusion. Their median age was 1.5 years (range 1 month–15.1 years). For 244 (82%) children, there was complete diagnostic agreement between the Paediatrician with Expertise in Cardiology and the paediatric cardiologist. For 29 (10%) children, the main diagnosis was identical with additional findings made by the paediatric cardiologist. The abnormality had resolved in 17 (6%) cases by the time of clinic attendance. In six (2%) patients, the paediatric cardiologist made a different diagnosis. In total, 138 (47%) patients underwent a surgical or catheter intervention.
Paediatricians with Expertise in Cardiology can make accurate diagnoses of CHD in children referred to their clinics. This can allow effective triage of children attending the outreach clinic, making best use of limited specialist resources.
Acritical life event such as a significant work injury imposes on the individual a heavy burden in terms of suffering, social exclusion, stigmatisation, negative role transition, and emotional, and financial costs. Such events, therefore, have multi-level implications relating to the functional restoration of workers, the professional efficacy of their service providers, industry productivity and economic viability at individual, organisational, community and state levels. In accord with this viewpoint, discussions have been held with a range of the key stakeholders, including employers, workers, case managers, WorkCover personnel and vocational and medical providers from which a larger research study has been designed. This paper sets the scene for an investigation into a learning partnership approach to claims / injury management and rehabilitation that is pragmatic, timely and consistent in fundamental principles, and which links well with the treating medical experts, employers, insuring agents, workers and close family members involved.
In the era of multi-modality imaging, this study compared contemporary, pre-operative echocardiography and cardiac MRI in predicting the need for intervention on additional lesions before surgical bidirectional cavopulmonary connection.
A total of 72 patients undergoing bidirectional cavopulmonary connection for single-ventricle palliation between 2007 and 2012, who underwent pre-operative assessment using both echocardiography and MRI, were included. The pre-determined outcome measure was any additional surgical or catheter-based intervention within 6 months of bidirectional cavopulmonary connection. Indices assessed were as follows: indexed dimensions of right and left pulmonary arteries, coarctation of the aorta, adequacy of interatrial communication, and degree of atrioventricular valve regurgitation.
Median age at bidirectional cavopulmonary connection was 160 days (interquartile range 121–284). The following MRI parameters predicted intervention: Z score for right pulmonary artery (odds ratio 1.77 (95% confidence interval 1.12–2.79, p=0.014)) and left pulmonary artery dimensions (odds ratio 1.45 (1.04–2.00, p=0.027)) and left pulmonary artery report conclusion (odds ratio 1.57 (1.06–2.33)). The magnetic resonance report predicted aortic arch intervention (odds ratio 11.5 (3.5–37.7, p=0.00006)). The need for atrioventricular valve repair was associated only with magnetic resonance regurgitation fraction score (odds ratio 22.4 (1.7–295.1, p=0.018)). Echocardiography assessment was superior to MRI for predicting intervention on interatrial septum (odds ratio 27.7 (6.3–121.6, p=0.00001)).
For branch pulmonary arteries, aortic arch, and atrioventricular valve regurgitation, MRI parameters more reliably predict the need for intervention; however, echocardiography more accurately identified the adequacy of interatrial communication. Approaching bidirectional cavopulmonary connection, the diagnostic strengths of MRI and echocardiography should be acknowledged when considering intervention.
This systematic review, with meta-analyses conducted where data were available, aimed to investigate the prevalence of symptoms of depression and anxiety in mild cognitive impairment (MCI), and to establish how symptoms of depression and anxiety relate to the progression from no cognitive impairment to MCI, and from MCI to dementia. Sixty studies were included in the review. Meta-analyses indicated that symptoms of depression and anxiety were more prevalent in people with MCI than in people with normal cognitive function, and increased the risk of progression from no cognitive impairment to MCI. There were mixed results regarding the effect of such symptoms on progression from MCI to dementia. The findings highlight the need for more research in this area, which can inform attempts to slow or halt the progression of cognitive impairment in later life, with resulting benefits for quality of life.
To describe endovascular stent placement using partially covered stents to preserve flow in head and neck vessels.
Endovascular stent placement has become established as a first-line therapy for native coarctation of the aorta or re-coarctation in older children and adults. Increasingly covered stents are becoming the preferred option over bare-metal stents because of the perceived lower risk of aneurysm formation. Open-cell bare-metal stents are chosen when there is a high likelihood of jailing a head and neck vessel. Here we describe partial uncovering of a covered stent before implantation to allow flow through the uncovered portion of the stent to the branch vessel but preserve the covering over the majority of the remaining stent.
We describe two cases with aortic arch hypoplasia and re-coarctation, both of which required two partially uncovered stents for a satisfactory result.
Endovascular stent placement is becoming the preferred option in the management of coarctation of the aorta in older children and adults. Strategies to deal with transverse arch hypoplasia and multiple levels of aortic arch obstruction frequently involving branch vessels or aneurysms need to be considered before these procedures are embarked upon. Partially uncovering stents may afford more protection than using bare-metal stents in the transverse and distal arch while preserving flow in head and neck branches, and is a technically straightforward procedure.
This paper promotes the notion that workplace claims/injury management and rehabilitation in South Australia should be a learning process for all stakeholders. It argues that this is often ignored by the system where organisational rigidity and fixed expectations exacerbate problems and reduce the opportunity for change, new ways of learning and reciprocity. This paper asserts that what enables successful cost-effective claims/injury management would be the open operation of the pooled wisdom, experiences and practices of the stakeholders. It upholds the view that the systems involved need to be more flexible in facilitating partnerships and new learning, which would require changes in terms of openness, opportunities for learning and interacting, and establishing common focused goals. In order to study these ‘learning partnerships’, this paper attempts to analyse the dynamic configurations of ‘social power’ in the specific contexts in which the various stake-holders interact.
This paper will analyse the provision of rehabilitation to injured workers with a registered WorkCover claim in South Australia. It presents the comments of key parties on the practice of rehabilitation, approaches to service delivery, and contradictions and paradoxes of the reality of the practice. The comments of workers, employers, case managers, medical practitioners, and of the rehabilitation providers themselves give ample evidence of the complexity of the demands placed upon providers in this system. Emphasis is placed upon their role in presenting the realities of the situation honestly to the worker and in effectively communicating to other stakeholders the particular strategies needed to overcome barriers to successful return-to-work outcomes.
This paper reports conversational interviews with key stakeholders in order to analyse the critical role of the treating medical practitioner in the management of injured workers with a registered WorkCover claim in South Australia. The comments expose the dilemma of treating general practitioners in their dual roles of “gatekeeper” and service provider against a backdrop of the ongoing demands and pressures from claims agents, vested interest groups, litigation, pervading antagonistic process relationships, inflexible work settings and the preoccupation with containing costs. The study highlights the need for treating medical practitioners to understand the WorkCover system and legislation. It is suggested further that their practice would benefit from holistic management, supportive care, clear language, respectful communication, timely medical updates and helpful professional attitudes. It was noted that many medical practitioners favour some redesign of medical management practice encompassing the development of a leadership role and the provision of progressive medical management plans in order to maximise successful return-to-work outcomes for injured workers.
This paper explores the complexities of the role of the workers' compensation case manager working for claims agents in South Australia. It provides a brief outline of the many skills required by case managers as they deal with the worker's injury, issues of compliance, the legislation, the social and psychological aspects of the worker's claim and the treatment and management of the worker's welfare. It describes the tensions brought about by the dual nature of the case manager's role that encompasses claims processing and injury management, and the conflicts between human and organisational motivations. These findings, although imprecise, demonstrate that in order to achieve sustainable return to work outcomes, case managers need to be competent, well-trained and team players capable of acting as mediators or brokers across the stakeholders. The aim of this paper is to explore the different views of the problems and possibilities of the role of the claims/injury manager from the perspective of the major stakeholders. Some views on the redesign of the role incorporating a partnership and holistic emphasis rather than the claims processing focus are suggested.
Complex congenital heart defects are accurately detectable antenatally using fetal echocardiography. In continuing pregnancies with fetal cardiac abnormalities, regular follow-up with advancing gestation is essential. This report documents the changes that occurred in the fetal cardiac anatomy in a fetus detected during antenatal scanning to have an atrioventricular septal defect with isomerism of the left atrial appendages.
One hundred-ninety-four fetuses with irregular heart rates were seen over a five-year period at a tertiary center for fetal cardiology. The median gestation at referral was 31 weeks, with a range from 19 to 41 weeks. Of these fetuses, 157 had extrasystoles of either atrial or ventricular origin. Blocked atrial ectopic beats had led to slow ventricular rates (80–110 beats per minute) in 37 fetuses. The structure of the heart was normal in all except two fetuses. Postnatal outcome was known for 165 of the fetuses. Of these, 157 (95%) had an uneventful antenatal and postnatal course. Tachyarrhythmias developed in eight fetuses (5%) in either the prenatal (n=4) or postnatal (n=4) period. Five of 37 fetuses with blocked atrial ectopic beats (13%) developed a tachyarrhythmia. No fetus developed hydrops, and all infants survived. All cases had required treatment with antiarrhythmic drugs. The occurrence of an irregular heart rhythm in the fetus, therefore, is not always benign. Fetuses with blocked atrial ectopic beats require particularly close monitoring.
We describe an infant with duct-dependent cardiac disease diagnosed prenatally who was born prematurely, and at extremely low weight. Treatment by infusion of prostaglandin maintained ductal patency for 66 days, permitting weight to be gained whilst under the care of a regional unit for neonatal intensive care prior to transfer for palliative cardiac surgery.
Erectile dysfunction is a common, multi-factorial disorder.
To evaluate the efficacy, tolerability and frequency of use of sildenafil citrate in men with mild to moderate erectile dysfunction of no established organic cause.
This double-blind, randomised, placebo-controlled, flexible-dose, two-way crossover study was conducted at four centres in the UK in 44 men with mild to moderate erectile dysfunction of no clinically obvious organic cause. The study included two 28-day treatment periods, during which time sildenafil or placebo (25–75 mg, based on efficacy) was taken as required.
Compared with placebo, sildenafil was associated with increases in frequency of use, erections adequate for sexual intercourse and level of sexual satisfaction (P < 0.0001). More patients receiving sildenafil stated they would use the treatment again compared with those receiving placebo (P < 0.0001). There were no discontinuations due to sildenafil treatment.
Sildenafil is effective and well tolerated in men with mild to moderate erectile dysfunction of no clinically identifiable organic cause.
The structures of ordered and disordered β-eucryptite have been determined from Rietveld analysis of powder synchrotron x-ray and neutron diffraction data over a temperature range of 20 to 873 K. On heating, both materials show an expansion within the (001) plane and a contraction along the c axis. However, the anisotropic character of the thermal behavior of ordered β-eucryptite is much more pronounced than that of the disordered compound; the linear expansion coefficients of the ordered and disordered phases are αa = 7.26 × 10−6 K−1; αc = −16.35 × 10−6 K−1, and αa = 5.98 × 10−6 K−1; αc = −3.82 × 10−6 K−1, respectively. The thermal behavior of β-eucryptite can be attributed to three interdependent processes that all cause an increase in a but a decrease in c with increasing temperature: (i) Si/Al tetrahedral deformation, (ii) Li positional disordering, and (iii) tetrahedral tilting. Because disordered β-eucryptite does not exhibit tetrahedral tilting, the absolute values of its axial thermal coefficients are smaller than those for the ordered sample. At low temperatures, both ordered and disordered β-eucryptite exhibit a continuous expansion parallel to the c axis with decreasing temperature, whereas a remains approximately unchanged. Our difference Fourier synthesis reveals localization of Li ions below room temperature, and we suggest that repulsion between Li and Al/Si inhibits contraction along the a axes.