The use of intensity modulated optical spectroscopy to measure cerebral saturation and haemoglobin concentration in the human fetus during labour.

Background: Although intrapartum hypoxia-ischaemia is an important cause of death and permanent brain injury, current available methods for the detection of damaging fetal hypoxia are unsatisfactory and unreliable. Electronic fetal heart rate monitoring (EFM) is considered to be the "gold standard" for intrapartum fetal surveillance. However, monitoring of the fetal heart rate provides an indirect measure of fetal hypoxia and provides little indication of the adequacy of cerebral perfusion. Consequently, EFM has a false positive rate of 99.8% in the detection of fetuses that subsequently develop cerebral palsy. A direct consequence of the poor specificity of fetal heart rate monitoring is a high rate of unnecessary Caesarean sections with associated fetal and maternal morbidity. Most fetuses subjected to intrapartum hypoxia will be protected from brain injury by appropriate changes in cardiovascular distribution. It is the aim of fetal surveillance to detect the minority of fetuses in whom this response is absent and who are at risk of permanent brain injury. Intrapartum fetal pulse oximetry is a promising new method of fetal surveillance, enabling measurement of fetal arteriolar saturation but the technique provides no direct information on cerebral oxygen delivery. Intrapartum measurement of fetal cerebral saturation and changes in blood volume has been described using conventional near infrared spectroscopy (NIRS). However, the clinical relevance of these values may be limited. This is because these values are derived from changes in the concentrations of oxyhaemoglobin (HbCh) and deoxyhaemoglobin (Hb) from an arbitrary baseline. Furthermore, the contribution of artefact to NIRS measurements of Hb and HbC>2 changes, arising from possible changes in the geometry of the NIRS fetal probes during uterine contractions, has not been clearly defined. Using novel methods of collection and analysis of NIRS data, the technique of Intensity Modulated Optical Spectroscopy (IMOS) has the unique potential to provide direct information on fetal cerebral oxygenation and perfusion during labour from measured absolute values of fetal cerebral Hb02 and Hb. Furthermore, the technique of IMOS has the potential to provide more information on the contribution of probe movement during uterine contractions to conventional NIRS data.;Aims: The aims of this project were therefore to use this new technique of intensity modulated optical spectroscopy to (a) provide the first measurements of absolute cerebral blood volume and cerebral saturation in healthy normoxic human fetuses during labour and (b) to compare these values with those calculated from fetuses that develop hypoxia-ischaemia during labour and (c) to assess the contribution of probe movement during uterine contractions.;Methods: After assessing and optimising the technical performance of a specially designed and constructed intensity modulated optical spectrometer, a specially designed optical probe was placed against the scalp of 29 fetuses after rupture of amniotic membranes during labour and connected to the spectrometer.;Results: Of these 29 fetuses, data were collected from 18 fetuses during the first and second stage of labour through to delivery. Of these 18, data was suitable for analysis in 10 of these fetuses. In these 10 fetuses, a mean (+/-1 S.D.) value of cerebral saturation of 59 +/-12 % and a mean absolute cerebral blood volume of 2.8 +/-1.0mls/100g over 3 uterine contractions were derived from the mean concentrations of Hb and Hb02 of 30 +/-18 and 46 +/-21 umol/1, respectively. Concentration changes rather than artefact appeared to dominate the NIR signal in the calculation of these values.;Conclusion: This work has provided the first measurements of absolute values of fetal cerebral oxygenation and of cerebral perfusion, whilst the contribution of artefact to the data, certainly in the healthy fetus, appears to be negligible. However, despite these advances in near infrared technology and knowledge of intrapartum fetal cerebral haemodynamics, the number of fetuses studied with near infrared spectroscopy, in particular IMOS, remains small. In order for IMOS to be subjected to larger studies to assess it's usefulness as a realistic adjunct to fetal heart rate monitoring, advances in the technology are still required

Interprofessional Learning during an International Fieldwork Placement

The need for competent interprofessional health care professionals is well recognised. Various educational activities have been developed to facilitate the development of interprofessional competence. In this paper we describe an interprofessional, fieldwork experience conducted in a developing country, and the learning gained by the first cohort of students who completed the five week immersion. Eight final year students from Medicine, Occupational Therapy, Physiotherapy and Speech Pathology were interviewed pre- and post-placement by an independent researcher. The transcribed interviews were analysed thematically. Findings indicated that over the placement students gained an appreciation of the skills of the other disciplines and were able to move beyond a textbook definition of what a certain profession did to acquire a real understanding of interprofessional practice. However, students reported that this understanding was predicated on their first clarifying the extent to which they were working in a transdisciplinary or interdisciplinary team, and becoming more confident in their own disciplinary contribution without reliance on formal documentation or standardised assessments. Using daily team discussions, self-reflections and discussions with clinical educators, the students learned to prioritise their busy caseload, share resources and skills, and facilitate team members to achieve therapeutic goals. The interprofessional learning took place in an intercultural context where the students learned to work with children with severe disabilities, with staff with different classroom approaches, and with interpreters, while adjusting emotionally to the level of unmet need of many of the children. Based on the students' experiences, immersion in an intercultural fieldwork experience is a useful way to facilitate interprofessional learning

The effects of an eight over Cricket bowling spell upon pace bowling biomechanics and performance within different delivery lengths

Pace bowlers must often perform extended bowling spells with maximal ball release speed (BRS) while targeting different delivery lengths when playing a multi-day match. This study investigated the effect of an eight over spell upon pace bowling biomechanics and performance at different delivery lengths. Nine male bowlers (age = 18.8 ± 1.7 years) completed an eight over spell, while targeting different lengths (short: 7–10 m, good: 4–7 m, full: 0–4 m from the batter’s stumps, respectively) in a randomized order. Trunk, knee and shoulder kinematics and ground reaction forces at front foot contact (FFC), as well as run-up velocity and BRS were measured. Paired sample t-tests (p ≤ 0.01), Hedges’ g effect sizes, and statistical parametrical mapping were used to assess differences between mean variables from the first and last three overs. No significant differences (p = 0.05–0.98) were found in any discrete or continuous variables, with the magnitude of difference being trivial-to-medium (g = 0.00–0.73) across all variables. Results suggest pace bowlers sustain BRS through a single eight over spell while tolerating the repeatedly high whole-body biomechanical loads as suggested by maintaining the kinematics or technique at the assessed joints during FFC. Practically, the findings are advantageous for bowling performance and support current bowling load monitoring practices

The relationship between inertial measurement unit derived 'force signatures' and ground reaction forces during cricket fast bowling

This study assessed the reliability and validity of segment measured accelerations in comparison to front foot contact (FFC) ground reaction force (GRF) during the delivery stride for cricket pace bowlers. Eleven recreational bowlers completed a 30-delivery bowling spell. Trunk- and tibia-mounted inertial measurement units (IMUs) were used to measure accelerations, converted to force, for comparisons to force plate GRF discrete measures. These measures included peak force, impulse and the continuous force–time curve in the vertical and braking (horizontal) planes. Reliability and validity was determined by intra-class correlation coefficients (ICC), coefficient of variation (CV), Bland–Altman plots, paired sample t-tests, Pearson’s correlation and one-dimensional (1D) statistical parametrical mapping (SPM). All ICC (0.90–0.98) and CV (4.23–7.41%) were acceptable, except for tibia-mounted IMU braking peak force (CV = 12.44%) and impulse (CV = 18.17%) and trunk vertical impulse (CV = 17.93%). Bland–Altman plots revealed wide limits of agreement between discrete IMU force signatures and force plate GRF. The 1D SPM outlined numerous significant (p \u3c 0.01) differences between trunk- and tibia-located IMU-derived measures and force plate GRF traces in vertical and braking (horizontal) planes. The trunk- and tibia-mounted IMUs appeared to not represent the GRF experienced during pace bowling FFC when compared to a gold-standard force plate. © 2018, © 2018 Informa UK Limited, trading as Taylor & Francis Group

Development and psychometric testing of an instrument to evaluate cognitive skills of evidence based practice in student health professionals

<p>Abstract</p> <p>Background</p> <p>Health educators need rigorously developed instruments to evaluate cognitive skills relating to evidence based practice (EBP). Previous EBP evaluation instruments have focused on the acquisition and appraisal of the evidence and are largely based in the medical profession. The aim of this study was to develop and validate an EBP evaluation instrument to assess EBP cognitive skills for entry-level health professional disciplines.</p> <p>Methods</p> <p>The Fresno test of competence in evidence based medicine was considered in the development of the 'Knowledge of Research Evidence Competencies' instrument (K-REC). The K-REC was reviewed for content validity. Two cohorts of entry-level students were recruited for the pilot study, those who had been exposed to EBP training (physiotherapy students, n = 24), and who had not been exposed to EBP training (human movement students, n = 76). The K-REC was administered to one cohort of students (n = 24) on two testing occasions to evaluate test-retest reliability. Two raters independently scored the first test occasion (n = 24) to evaluate the inter-rater reliability of the marking guidelines. Construct validity was assessed by comparison of the two groups, 'exposed' and 'non-exposed', and the percentage of students achieving a 'pass' score in each of these groups. Item difficulty was established.</p> <p>Results</p> <p>Among the 100 participants (24 EBP 'exposed', and 76 EBP 'non-exposed' students), there was a statistically significant (<it>p </it>< 0.0001) difference in the total K-REC scores. The test-retest and inter-rater reliability of the individual items and total scores ranged from moderate to excellent (measured by Cohen's Kappa and ICC, range: 0.62 to perfect agreement).</p> <p>Conclusions</p> <p>The K-REC instrument is a valid and reliable evaluation instrument of cognitive skills of EBP in entry-level student health professionals. The instrument is quick to disseminate and easy to score, making it a suitable instrument for health educators to employ to evaluate students' knowledge of EBP or in the evaluation of entry-level EBP training.</p

Validation of the modified Fresno Test: assessing physical therapists' evidence based practice knowledge and skills

<p>Abstract</p> <p>Background</p> <p>Health care educators need valid and reliable tools to assess evidence based practice (EBP) knowledge and skills. Such instruments have yet to be developed for use among physical therapists. The Fresno Test (FT) has been validated only among general practitioners and occupational therapists and does not assess integration of research evidence with patient perspectives and clinical expertise. The purpose of this study was to develop and validate a modified FT to assess EBP knowledge and skills relevant to physical therapist (PT) practice.</p> <p>Methods</p> <p>The FT was modified to include PT-specific content and two new questions to assess integration of patient perspectives and clinical expertise with research evidence. An expert panel reviewed the test for content validity. A cross-sectional cohort representing three training levels (EBP-novice students, EBP-trained students, EBP-expert faculty) completed the test. Two blinded raters, not involved in test development, independently scored each test. Construct validity was assessed through analysis of variance for linear trends among known groups. Inter and intra-rater reliability, internal consistency, item discrimination index, item total correlation, and difficulty were analyzed.</p> <p>Results</p> <p>Among 108 participants (31 EBP-novice students, 50 EBP-trained students, and 27 EBP-expert faculty), there was a statistically significant (p < 0.0001) difference in total score corresponding to training level. Total score reliability and psychometric properties of items modified for discipline-specific content were excellent [inter-rater (ICC (2,1)] = 0.91); intra-rater (ICC (2,1)] = 0.95, 0.96)]. Cronbach's α was 0.78. Of the two new items, only one had strong psychometric properties.</p> <p>Conclusions</p> <p>The 13-item modified FT presented here is a valid, reliable assessment of physical therapists' EBP knowledge and skills. One new item assesses integration of patient perspective as part of the EBP model. Educators and researchers may use the 13-item modified FT to evaluate PT EBP curricula and physical therapists' EBP knowledge and skills.</p

Be SMART:examining the experience of implementing the NHS Health Check in UK primary care

Background: The NHS Health Check was designed by UK Department of Health to address increased prevalence of cardiovascular disease by identifying risk levels and facilitating behaviour change. It constituted biomedical testing, personalised advice and lifestyle support. The objective of the study was to explore Health Care Professionals' (HCPs) and patients' experiences of delivering and receiving the NHS Health Check in an inner-city region of England. Methods: Patients and HCPs in primary care were interviewed using semi-structured schedules. Data were analysed using Thematic Analysis. Results: Four themes were identified. Firstly, Health Check as a test of 'roadworthiness' for people. The roadworthiness metaphor resonated with some patients but it signified a passive stance toward illness. Some patients described the check as useful in the theme, Health check as revelatory. HCPs found visual aids demonstrating levels of salt/fat/sugar in everyday foods and a 'traffic light' tape measure helpful in communicating such 'revelations' with patients. Being SMART and following the protocolrevealed that few HCPs used SMART goals and few patients spoke of them. HCPs require training to understand their rationale compared with traditional advice-giving. The need for further follow-up revealed disparity in follow-ups and patients were not systematically monitored over time. Conclusions: HCPs' training needs to include the use and evidence of the effectiveness of SMART goals in changing health behaviours. The significance of fidelity to protocol needs to be communicated to HCPs and commissioners to ensure consistency. Monitoring and measurement of follow-up, e.g., tracking of referrals, need to be resourced to provide evidence of the success of the NHS Health Check in terms of healthier lifestyles and reduced CVD risk

Primary sensory and motor cortex excitability are co-modulated in response to peripheral electrical nerve stimulation

Peripheral electrical stimulation (PES) is a common clinical technique known to induce changes in corticomotor excitability; PES applied to induce a tetanic motor contraction increases, and PES at sub-motor threshold (sensory) intensities decreases, corticomotor excitability. Understanding of the mechanisms underlying these opposite changes in corticomotor excitability remains elusive. Modulation of primary sensory cortex (S1) excitability could underlie altered corticomotor excitability with PES. Here we examined whether changes in primary sensory (S1) and motor (M1) cortex excitability follow the same timecourse when PES is applied using identical stimulus parameters. Corticomotor excitability was measured using transcranial magnetic stimulation (TMS) and sensory cortex excitability using somatosensory evoked potentials (SEPs) before and after 30 min of PES to right abductor pollicis brevis (APB). Two PES paradigms were tested in separate sessions; PES sufficient to induce a tetanic motor contraction (30–50 Hz; strong motor intensity) and PES at sub motor-threshold intensity (100 Hz). PES applied to induce strong activation of APB increased the size of the N20-P25 component, thought to reflect sensory processing at cortical level, and increased corticomotor excitability. PES at sensory intensity decreased the size of the P25-N33 component and reduced corticomotor excitability. A positive correlation was observed between the changes in amplitude of the cortical SEP components and corticomotor excitability following sensory and motor PES. Sensory PES also increased the sub-cortical P14-N20 SEP component. These findings provide evidence that PES results in co-modulation of S1 and M1 excitability, possibly due to cortico-cortical projections between S1 and M1. This mechanism may underpin changes in corticomotor excitability in response to afferent input generated by PES.Siobhan M. Schabrun, Michael C. Ridding, Mary P. Galea, Paul W. Hodges and Lucinda S. Chipchas

Understanding emotionally relevant situations in primary care dental practice: 1. Clinical situations and emotional responses

Background and aims. The stressful nature of dental practice is well established. Much less information is available on the coping strategies used by dentists and the emotions which underlie the stressful experience. Previous research has been almost exclusively questionnaire-based, limiting the range of emotions explored. This study used qualitative methods to explore the full extent of emotions and coping strategies associated with stressful events in primary dental practice. Method. Semi-structured interviews were conducted with 20 dentists in Lincoln and the surrounding area. Verbatim transcriptions were analysed using thematic analysis. Results. Participants reported a wide variety of stressful situations, consistent with the existing literature, which were associated with a diverse range of negative emotional responses including anxiety, anger and sadness. Dentists tended to have more difficulty identifying positive events and emotions. The designation of a situation as stressful or otherwise was dependent on the dentist's personal interpretation of the event. Data relating to the effects of stressors and the coping strategies used by dentists will be presented in subsequent papers. Conclusion. The situations which dentists find difficult are accompanied by a diverse set of emotions, rather than omnipresent 'stress.' This has implications for stress management programmes for those in dental practic

Understanding emotionally relevant situations in primary dental practice. 3. Emerging narratives

Background and aims. Dentists experience considerable occupational stress. Stressful clinical situations can provoke high levels of negative emotions, and situations which are associated with positive emotions tend to be overlooked by practitioners. Reflection regarding difficult situations is encouraged to facilitate learning. Cognitive behavioural therapy (CBT) formulations may be applied to situations appraised both positively and negatively. Analysis and interpretation of the dentist's coping behaviour and the consequent outcomes facilitate learning and reflection upon individual interactions with patients. Method. Twenty primary care dental practitioners in the greater Lincoln area participated in a semi-structured interview which explored their stressful and positive clinical experiences. Some of the episodes were analysed to create CBT formulations. Results and discussion. CBT formulations are presented and the learning points highlighted by this structured presentation are discussed. In particular, it is suggested that this structured reconstruction of events, which highlights dentists' emotions, responses and the transactional effects of coping responses, might well facilitate objective reflective learning either individually or as part of peer to peer support. It should facilitate dentists' emotional processing of events and may thus contribute to stress reduction. Conclusion. CBT formulations of positive and negative dental scenarios may be constructed. It is proposed that this is a useful technique to foster reflection and learning in clinical situations and should lead to improved communication skills and shared decision-making, resulting in fewer complaints and thereby reduced stress. It should also improve dentists' emotional processing