Final Evaluation Report: Pilot for New Model of Midwifery Supervision

The focus of the evaluation was a bridging programme to prepare existing supervisors of midwives (SOMs) to become professional midwifery advocates (PMAs) in order to deliver a new model of supervision (A-EQUIP). It set out to assess the bridging programme and the A-EQUIP model. This report documents the following stages of the evaluation: 1. Establish baseline data, prior to the adoption of the A-EQUIP pilot a. Development and completion of a site pro-forma to provide contextual organisational data 2. Evaluation of the preparation of the A-EQUIP practitioner and assessment of the A-EQUIP model through the following mechanisms: a. Documentary analysis b. Supervisor/PMA survey c. Supervisee survey d. Supervisor/PMA interview

Unusual presentation of bilateral stifle osteochondritis dissecans in two labrador retrievers

There are few published reports of CT findings for the diagnosis of stifle osteochondritis dissecans (OCD) in the dog. This report describes the radiographic and multidetector CT (MDCT) findings of two cases with bilateral stifle osteochondrosis and OCD lesions. In both cases, radiographs did not provide a complete picture of the pathology and CT was needed for a definitive diagnosis. In case 1, CT showed bilateral defects on the caudomedial part of the lateral femoral condyles with joint mice within the cranial right stifle joint. In case 2, CT showed large bilateral joint mice within the intercondylar fossa originating from the medial aspect of the lateral femoral condyles as well as a defect on the right medial femoral condyle. MDCT provided an accurate diagnosis in both these cases and facilitated surgical planning

The ocular phenotype of stiff-skin syndrome

PURPOSE: Stiff skin syndrome (SSS; MIM#184900) is a rare autosomal dominantly inherited Mendelian disorder characterised by thickened and stone-hard indurations of the skin, mild hypertrichosis, and limitation of joint mobility with flexion contractures. It is autosomal dominant with high penetrance and results from mutations in the fibrillin 1 (FBN1; MIM*134797) gene. Here we present the associated ocular phenotype in a two generation nonconsanguineous Northern Irish family. METHODS: The affected patients underwent complete ophthalmic and orthoptic assessment and genetic testing. RESULTS: All three patients had ophthalmoplegia of varying degrees. Direct sequencing of the FBN1 gene detected a heterozygous pathogenic mutation (c.4710G>C; p.Trp1570Cys) in all affected patients. CONCLUSIONS: This is the first report of ophthalmoplegia in association with SSS

Effect of supplementation with n-3 polyunsaturated fatty acids and/or β-glucans on performance, feeding behaviour and immune status of Holstein Friesian bull calves during the pre- and post-weaning periods

peer-reviewedBackground Previous research in both calves and other species has suggested n-3 polyunsaturated fatty acids (PUFA) and β-glucans may have positive effects on immune function. This experiment measured performance, behaviour, metabolite and immunological responses to pre-weaning supplementation of dairy bull calves with n-3 PUFA in the form of fish oil and β-glucans derived from seaweed extract. 44 Holstein Friesian bull calves, aged 13.7 ± 2.5 d and weighing 48.0 ± 5.8 kg were artificially reared using an electronic feeding system. Each calf was offered 5 L (120 g/L) per day of milk replacer (MR) and assigned to one of four treatments included in the MR, (1) Control (CON); (2) 40 g n-3 PUFA per day (FO); (3) 1 g β-glucans per day (GL) and (4) 40 g n-3 PUFA per day & 1 g/d β-glucans (FOGL) in a 2 × 2 factorial design. Milk replacer and concentrate was offered from d 0–62 (pre-weaning), while concentrate provision continued for a further 31 d post-weaning period. Individual daily feed intake and feeding behaviour was recorded throughout, while bodyweight and blood analyte data were collected at regular intervals. Results Overall mean concentrate DMI from d 0–93 was 1.39, 1.27, 1.00 and 0.72 kg/d for CON, FO, GL and FOGL calves, respectively (SEM = 0.037; P < 0.0001). Calves supplemented with GL were significantly lighter (P < 0.0001) at both weaning (d 62) and turnout to pasture (d 93) than un-supplemented calves, with a similar effect (P < 0.0001) evident for calves receiving FO compared to un-supplemented contemporaries. Supplementation with GL reduced the number of unrewarded visits where milk was not consumed (P < 0.0001) while supplementation with FO increased mean drinking speed (P < 0.0001). Supplementation with GL resulted in greater concentrations of haptoglobin (P = 0.034), greater serum osmolality (P = 0.021) and lower lymphocyte levels (P = 0.027). In addition, cells from GL supplemented calves exhibited a lower response than un-supplemented contemporaries to both Phytohaemagglutinin A stimulated IFN-γ (P = 0.019) and Concanavalin A stimulated IFN-γ (P = 0.012) following in vitro challenges. Conclusions Pre-weaning supplementation of bull calves with either n-3 PUFA or β-glucan resulted in reduced voluntary feed intake of concentrate and consequently poorer pre-weaning calf performance. There was no evidence for any beneficial effect of either supplementation strategy on calves’ immune responses

Annular-beam, 17 GHz free-electron maser experiment

Experiments have been conducted on a 15-17 GHz free electron maser (FEM) for producing a 500 MW output pulse with a phase stability appropriate for linear collider applications. The electron beam source was a 1 {mu}s, 800 kV, 5 kA, 6-cm-dia annular electron beam machine called BANSHEE. The beam interacted with the TM{sub 02} and TM{sub 03} mode Raman FEM amplifier in a corrugated cylindrical waveguide where the beam runs close to the interaction device walls to reduce the power density in the fields. This greatly reduced the kinetic energy loss caused by the beam potential depression associated with the space charge which was a significant advantage in comparison with conventional solid beam microwave tubes at the same beam current. The experiment was operated in a single shot mode with a large number of diagnostics to measure power, frequency and energy

Long-term safety and tolerability of cariprazine as adjunctivetherapy in major depressive disorder

Lack of treatment response is a critical problem in major depressive disorder (MDD). Cariprazine is a D3-preferring dopamine D3/D2 receptor partial agonist and 5-HT1A partial agonist. This phase 3, multicenter, open-label, long-term (26-week), flexible-dose (1.5-4.5 mg/day) study assessed the long-term safety and tolerability of cariprazine used adjunctively with antidepressant therapy in adult patients with MDD who had either completed a lead-in study (n=311) or had been newly recruited (n=131). A higher percentage of continuing patients (66.2%) than new patients (35.9%) completed the study. The most common reason for discontinuation was adverse events (AEs; 13.9%); 79% of patients experienced a treatment-emergent AE [most common: akathisia (15.9%,) headache (11.6%)]. Serious AEs occurred in 2% of patients; two deaths occurred (one traffic accident, one completed suicide, both considered unrelated to treatment). The mean changes in clinical laboratory, cardiovascular, and ophthalmologic parameters were generally not clinically relevant. The mean (SD) changes from the open-label baseline in Montgomery-Åsberg Depression Rating Scale total score and Clinical Global Impression-Severity score at week 26 were -7.3 (9.5) and -1.0 (1.2), respectively. By week 26, 53.3% of patients were in remission (Montgomery-Åsberg Depression Rating Scale total score≤10). The results suggest that cariprazine was generally safe and well tolerated as adjunctive therapy to treat MDD

Epicardial catheter ablation for ventricular tachycardia on uninterrupted warfarin: A safe approach for those with a strong indication for peri-procedural anticoagulation?

BACKGROUND: Current guidelines for epicardial catheter ablation for ventricular tachycardia (VT) advocate that epicardial access is avoided in anticoagulated patients and should be performed prior to heparinisation. Recent studies have shown that epicardial access may be safe in heparinised patients. However, no data exist for patients on oral anticoagulants. We investigated the safety of obtaining epicardial access on uninterrupted warfarin. METHODS: A prospective registry of patients undergoing epicardial VT ablation over two years was analysed. Consecutive patients in whom epicardial access was attempted were included. All patients were heparinised prior to epicardial access with a target activated clotting time (ACT) of 300-350s. Patients who had procedures performed on uninterrupted warfarin (in addition to heparin) were compared to those not taking an oral anticoagulant. RESULTS: 46 patients were included of which 13 were taking warfarin. There was no significant difference in clinical and procedural characteristics (except INR and AF) between the two groups. Epicardial access was achieved in all patients. There were no deaths and no patients required surgery. A higher proportion of patients in the warfarin group had a drop in haemoglobin of >2g/dL compared to the no-warfarin group (38.5% versus 27.3%, p=0.74) and delayed pericardial drain removal (7.8% versus 3.03%, p=0.47). There was no difference in overall procedural complication rate. No patients required warfarin reversal or blood transfusion. CONCLUSION: Epicardial access can be achieved safely and effectively in patients' anticoagulated with warfarin and heparinised with therapeutic ACT. This may be an attractive option for patients with a high stroke risk

Impact of attributed audit on procedural performance in cardiac electrophysiology catheter laboratory

PURPOSE: Audit has played a key role in monitoring and improving clinical practice. However, audit often fails to drive change as summative institutional data alone may be insufficient to do so. We hypothesised that the practice of attributed audit, wherein each individual's procedural performance is presented will have a greater impact on clinical practice. This hypothesis was tested in an observational study evaluating improvement in fluoroscopy times for AF ablation. METHODS: Retrospective analyses of fluoroscopy times in AF ablations at the Barts Heart Centre (BHC) from 2012-2017. Fluoroscopy times were compared pre- and post- the introduction of attributed audit in 2012 at St Bartholomew's Hospital (SBH). In order to test the hypothesis, this concept was introduced to a second group of experienced operators from the Heart Hospital (HH) as part of a merger of the two institutions in 2015 and change in fluoroscopy times recorded. RESULTS: A significant drop in fluoroscopy times (33.3 ± 9.14 to 8.95 ± 2.50, p < 0.0001) from 2012-2014 was noted after the introduction of attributed audit. At the time of merger, a significant difference in fluoroscopy times between operators from the two centres was seen in 2015. Each operator's procedural performance was shared openly at the audit meeting. Subsequent audits showed a steady decrease in fluoroscopy times for each operator with the fluoroscopy time (min, mean±SD) decreasing from 13.29 ± 7.3 in 2015 to 8.84 ± 4.8 (p < 0.0001) in 2017 across the entire group. CONCLUSIONS: Systematic improvement in fluoroscopy times for AF ablation procedures was noted byevaluating individual operators' performance. Attributing data to physicians in attributed audit can promptsignificant improvement and hence should be adopted in clinical practice

Transseptal puncture for left atrial ablation: Risk factors for cardiac tamponade and a proposed causative classification system

AIMS: Cardiac tamponade is a high morbidity complication of transseptal puncture (TSP). We examined the associations of TSP‐related cardiac tamponade (TRCT) for all patients undergoing left atrial ablation at our center from 2016 to 2020. METHODS AND RESULTS: Patient and procedural variables were extracted retrospectively. Cases of cardiac tamponade were scrutinized to adjudicate TSP culpability. Adjusted multivariate analysis examined predictors of TRCT. A total of 3239 consecutive TSPs were performed; cardiac tamponade occurred in 51 patients (incidence: 1.6%) and was adjudicated as TSP‐related in 35 (incidence: 1.1%; 68.6% of all tamponades). Patients of above‐median age [odds ratio (OR): 2.4 (1.19–4.2), p = .006] and those undergoing re‐do procedures [OR: 1.95 (1.29–3.43, p = .042] were at higher risk of TRCT. Of the operator‐dependent variables, choice of transseptal needle (Endrys vs. Brockenbrough, p > .1) or puncture sheath (Swartz vs. Mullins vs. Agilis vs. Vizigo vs. Cryosheath, all p > .1) did not predict TRCT. Adjusting for operator, equipment and demographics, failure to cross the septum first pass increased TRCT risk [OR: 4.42 (2.45–8.2), p = .001], whilst top quartile operator experience [OR: 0.4 (0.17–0.85), p = .002], transoesophageal echocardiogram [TOE prevalence: 26%, OR: 0.51 (0.11–0.94), p = .023], and use of the SafeSept transseptal guidewire [OR: 0.22 (0.08–0.62), p = .001] reduced TRCT risk. An increase in transseptal guidewire use over time (2016: 15.6%, 2020: 60.2%) correlated with an annual reduction in TRCT (R (2) = 0.72, p < .001) and was associated with a relative risk reduction of 70%. CONCLUSIONS: During left atrial ablation, the risk of TRCT was reduced by operator experience, TOE‐guidance, and use of a transseptal guidewire, and was increased by patient age, re‐do procedures, and failure to cross the septum first pass

High-Power, High-Frequency, Annular-Beam Free-Electron Maser

The authors have developed a 15--17 GHz free electron maser (FEM) capable of producing high power pulses with a phase stability appropriate for linear collider applications. The electron beam source is a 1 {micro}s, 800 kV, 5 kA, 6-cm-dia annular electron beam machine called BANSHEE. The beam interacts with the TM{sub 02} mode Raman FEM amplifier in a corrugated cylindrical waveguide where the beam runs close to the interaction device walls to reduce the power density in the fields. They studied the phase stability by analyzing the dispersion relation for an axial FEL, in which the rf field was transversely wiggled and the electron trajectories were purely longitudinal. Detailed particle-in-cell simulations demonstrated the transverse wiggling of the rf mode and the axial FEL interaction and explicit calculations of the growing root of the dispersion relation are included to verify the phase stability