The RAPID-CTCA trial (Rapid Assessment of Potential Ischaemic Heart Disease with CTCA) - a multicentre parallel-group randomised trial to compare early computerised tomography coronary angiography versus standard care in patients presenting with suspected or confirmed acute coronary syndrome: study protocol for a randomised controlled trial.

BACKGROUND: Emergency department attendances with chest pain requiring assessment for acute coronary syndrome (ACS) are a major global health issue. Standard assessment includes history, examination, electrocardiogram (ECG) and serial troponin testing. Computerised tomography coronary angiography (CTCA) enables additional anatomical assessment of patients for coronary artery disease (CAD) but has only been studied in very low-risk patients. This trial aims to investigate the effect of early CTCA upon interventions, event rates and health care costs in patients with suspected/confirmed ACS who are at intermediate risk. METHODS/DESIGN: Participants will be recruited in about 35 tertiary and district general hospitals in the UK. Patients ≥18 years old with symptoms with suspected/confirmed ACS with at least one of the following will be included: (1) ECG abnormalities, e.g. ST-segment depression >0.5 mm; (2) history of ischaemic heart disease; (3) troponin elevation above the 99(th) centile of the normal reference range or increase in high-sensitivity troponin meeting European Society of Cardiology criteria for 'rule-in' of myocardial infarction (MI). The early use of ≥64-slice CTCA as part of routine assessment will be compared to standard care. The primary endpoint will be 1-year all-cause death or recurrent type 1 or type 4b MI at 1 year, measured as the time to such event. A number of secondary clinical, process and safety endpoints will be collected and analysed. Cost effectiveness will be estimated in terms of the lifetime incremental cost per quality-adjusted life year gained. We plan to recruit 2424 (2500 with ~3% drop-out) evaluable patients (1212 per arm) to have 90% power to detect a 20% versus 15% difference in 1-year death or recurrent type 1 MI or type 4b MI, two-sided p < 0.05. Analysis will be on an intention-to-treat basis. The relationship between intervention and the primary outcome will be analysed using Cox proportional hazard regression adjusted for study site (used to stratify the randomisation), age, baseline Global Registry of Acute Coronary Events score, previous CAD and baseline troponin level. The results will be expressed as a hazard ratio with the corresponding 95% confidence intervals and p value. DISCUSSION: The Rapid Assessment of Potential Ischaemic Heart Disease with CTCA (RAPID-CTCA) trial will recruit 2500 participants across about 35 hospital sites. It will be the first study to investigate the role of CTCA in the early assessment of patients with suspected or confirmed ACS who are at intermediate risk and including patients who have raised troponin measurements during initial assessment. TRIAL REGISTRATION: ISRCTN19102565 . Registered on 3 October 2014. ClinicalTrials.gov: NCT02284191

Evaluation Of Web-Based Flexible Learning: Findings And Implications

This paper explores web-based flexible delivery in the vocational education and training (VET) sector, focusing on the uptake of web-based technologies and the quality of teaching and learning that is emerging. The theoretical framework underpinning the evaluation was developed from Laurillard's (1997) 'conversational' theory in which the main types of reciprocal exchanges are idea to idea, action to action and idea to action. Tools for gauging on-line learning in VET were developed and trialed and it was established that the 'conversational' framework and its enhancements form an effective basis for evaluation. These tools help practitioners explore and expand the kinds of flexible learning 'conversations' for learners and are a useful way for course designers and teachers to categorise and compare groups and to conceptualise practice to cater better for student needs and objectives. Key findings include establishing that there was a high level of interest (in 1998) in the evaluation of web-based flexible learning amongst providers and teachers, but that actual provision was quite small. Teacher-centred approaches were dominant. Research implications include recommendations that further testing and refinement of mapping 'conversations' be carried out. Further research is also needed into how web-based flexible learning programs affect learners and the ways they learn

Evaluation Of Web-based Flexible Learning

With both teachers and students having increased access to the web from home and from the workplace, there is a trend to extend technology-based learning. Furthermore, the web is seen as a means of efficiently delivering education and training when and where it is needed, and communicating with large numbers of students who may be separated from each other and from the learning centre by time or distance. It also enables learners to access information at times and places of their choice. This suggests that the new web-based technologies offer good prospects for implementing flexible delivery options. Not only do web-based learning solutions offer effective responses to requirements for efficient information transfer, they also offer powerful alternatives for obtaining effective learning outcomes. Coinciding with the implementation of flexible delivery methodologies has been the onset of the information technology revolution and the development of digital communications technologies, such as email and the world wide web (www). In the context of educational services, web-based communications technology is not only seen as offering a supplement for traditional delivery methodologies, but also as being capable of revolutionising distance teaching and bringing on- and off-campus teaching modes closer into alignment. Anecdotal evidence appears to suggest that web-based approaches to flexible learning have been taken up enthusiastically within the Australian vocational education and training (VET) system. Nevertheless, little of a factual nature is known about the variety or effectiveness of these new practices, particularly from a student and learning point of view. In this report the focus is on the nature of the uptake of web-based technologies and the quality of teaching and learning emerging, since, while digital technologies can offer access to an enormous volume of information, this does not in itself translate into learning; nor does it ensure the development of expertise required for workplaces in a state of change

Amorphous carbon interlayers for gold on elastomer stretchable conductors

NoGold on polydimethylsiloxane (PDMS) stretchable conductors were prepared using a novel approach by interlacing an hydrogenated amorphous carbon (a-C : H) layer between the deposited metal layer and the elastomer. AFM analysis of the a-C : H film surface before gold deposition shows nanoscale buckling, the corresponding increase in specific surface area corresponds to a strain compensation for the first 4–6% of bi-axial tensile loading. Without this interlayer, the deposited gold films show much smaller and uni-directional ripples as well as more cracks and delaminations. With a-C : H interlayer, the initial electrical resistivity of the metal film decreases markedly (280-fold decrease to 8 × 10−6 Ω cm). This is not due to conduction within the carbon interlayer; both a-C : H/PDMS and PDMS substrates are electrically insulating. Upon cyclic tensile loading, both films become more resistive, but return to their initial state after 20 tensile cycles up to 60% strain. Profiling experiments using secondary ion mass spectroscopy and x-ray photoelectron spectroscopy indicate that the a-C : H layer intermixes with the PDMS, resulting in a graded layer of decreasing stiffness. We believe that both this graded layer and the surface buckling contribute to the observed improvement in the electrical performance of these stretchable conductors

The association of incidental radiation dose to the heart base with overall survival and cardiac events after curative-intent radiotherapy for non-small cell lung cancer: results from the NI-HEART Study

AimsCardiac disease is a dose-limiting toxicity in non-small cell lung cancer radiotherapy. The dose to the heart base has been associated with poor survival in multiple institutional and clinical trial datasets using unsupervised, voxel-based analysis. Validation has not been undertaken in a cohort with individual patient delineations of the cardiac base or for the endpoint of cardiac events. The purpose of this study was to assess the association of heart base radiation dose with overall survival and the risk of cardiac events with individual heart base contours.Materials and methodsPatients treated between 2015 and 2020 were reviewed for baseline patient, tumour and cardiac details and both cancer and cardiac outcomes as part of the NI-HEART study. Three cardiologists verified cardiac events including atrial fibrillation, heart failure and acute coronary syndrome. Cardiac substructure delineations were completed using a validated deep learning-based autosegmentation tool and a composite cardiac base structure was generated. Cox and Fine–Gray regressions were undertaken for the risk of death and cardiac events.ResultsOf 478 eligible patients, most received 55 Gy/20 fractions (96%) without chemotherapy (58%), planned with intensity-modulated radiotherapy (71%). Pre-existing cardiovascular morbidity was common (78% two or more risk factors, 46% one or more established disease). The median follow-up was 21.1 months. Dichotomised at the median, a higher heart base Dmax was associated with poorer survival on Kaplan–Meier analysis (20.2 months versus 28.3 months; hazard ratio 1.40, 95% confidence interval 1.14–1.75, P = 0.0017) and statistical significance was retained in multivariate analyses. Furthermore, heart base Dmax was associated with pooled cardiac events in a multivariate analysis (hazard ratio 1.75, 95% confidence interval 1.03–2.97, P = 0.04).

Can ginger ameliorate chemotherapy-induced nausea? Protocol of a randomized double blind, placebo-controlled trial (Study protocol)

Background Preliminary research shows ginger may be an effective adjuvant treatment for chemotherapy-induced nausea and vomiting but significant limitations need to be addressed before recommendations for clinical practice can be made. Methods/Design In a double–blinded randomised-controlled trial, chemotherapy-naïve patients will be randomly allocated to receive either 1.2 g of a standardised ginger extract or placebo per day. The study medication will be administrated as an adjuvant treatment to standard anti-emetic therapy and will be divided into four capsules per day, to be consumed approximately every 4 hours (300 mg per capsule administered q.i.d) for five days during the first three cycles of chemotherapy. Acute, delayed, and anticipatory symptoms of nausea and vomiting will be assessed over this time frame using a valid and reliable questionnaire, with nausea symptoms being the primary outcome. Quality of life, nutritional status, adverse effects, patient adherence, cancer-related fatigue, and CINV-specific prognostic factors will also be assessed. Discussion Previous trials in this area have noted limitations. These include the inconsistent use of standardized ginger formulations and valid questionnaires, lack of control for anticipatory nausea and prognostic factors that may influence individual CINV response, and the use of suboptimal dosing regimens. This trial is the first to address these issues by incorporating multiple unique additions to the study design including controlling for CINV-specific prognostic factors by recruiting only chemotherapy-naïve patients, implementing a dosing schedule consistent with the pharmacokinetics of oral ginger supplements, and independently analysing ginger supplements before and after recruitment to ensure potency. Our trial will also be the first to assess the effect of ginger supplementation on cancer-related fatigue and nutritional status. Chemotherapy-induced nausea and vomiting are distressing symptoms experienced by oncology patients; this trial will address the significant limitations within the current literature and in doing so, will investigate the effect of ginger supplementation as an adjuvant treatment in modulating nausea and vomiting symptoms. Trial registratio