Establishing premises for inter-professional collaborative practice in school: inclusion, difference and influence.

PURPOSE: To ascertain stakeholders' agreement and disagreement about inter-professional collaboration (IPC) when supporting the child with a developmental language disorder (DLD) in school. MATERIALS AND METHODS: Two rounds of an online Delphi survey were undertaken with a purposive sample of 26 participants (researchers, practitioners and parents). Topics were informed by the views of children engaged in an earlier phase of the research. Agreement was set at an inter-quartile range of 1, with level of agreement measured using a five-point semantic differential scale. Qualitative data were examined using content analysis. RESULTS: There was strong agreement across the stakeholder groups about the child-led goals of IPC. Stakeholders also agreed that DLD is best viewed as a learning difference rather than a disorder. We identified ambivalence across the groups about the right of the child with DLD to have influence in decision-making about supports in school. CONCLUSIONS: We propose that IPC should be viewed as a means of ensuring the inclusion of the child in school. A shift in focus from remediating perceived deficits of the child, to affecting change in classroom practice, is also indicated. The need to reinforce the unconditional right of the child to have influence in decisions about supports is highlighted. Implications for IPC when meeting the needs of children with a developmental disability in school are outlined.IMPLICATIONS FOR REHABILITATIONThe goal of inter-professional collaboration should be to ensure the inclusion of the child with a developmental disability in school.Interventions delivered in school should focus on changing practice in the classroom, rather than on the child's perceived deficits.The child with a developmental disability should be given influence in collaborative decision-making to ensure supports are relevant and responsive to their needs.

European expert consensus on a structured approach to training robotic-assisted low anterior resection using performance metrics.

AIM: The aim was to develop and operationally define 'performance metrics' that characterize a reference approach to robotic-assisted low anterior resection (RA-LAR) and to obtain face and content validity through a consensus meeting. METHOD: Three senior colorectal surgeons with robotic experience and a senior behavioural scientist formed the Metrics Group. We used published guidelines, training materials, manufacturers' instructions and unedited videos of RA-LAR to deconstruct the operation into defined, measurable components - performance metrics (i.e. procedure phases, steps, errors and critical errors). The performance metrics were then subjected to detailed critique by 18 expert colorectal surgeons in a modified Delphi process. RESULTS: Performance metrics for RA-LAR had 15 procedure phases, 128 steps, 89 errors and 117 critical errors in women, 88 errors and 118 critical errors in men. After the modified Delphi process the final performance metrics consisted of 14 procedure phases, 129 steps, 88 errors and 115 critical errors in women, 87 errors and 116 critical errors in men. After discussion by the Delphi panel, all procedure phases received unanimous consensus apart from phase I (patient positioning and preparation, 83%) and phase IV (docking, 94%). CONCLUSION: A robotic rectal operation can be broken down into procedure phases, steps, with errors and critical errors, known as performance metrics. The face and content of these metrics have been validated by a large group of expert robotic colorectal surgeons from Europe. We consider the metrics essential for the development of a structured training curriculum and standardized procedural assessment for RA-LAR.

Quinolone-induced Biceps Tendon Rupture.

Presentation A 76-year-old man presented with acute left upper limb pain and subsequent large ecchymosis. Diagnosis An ultrasound study was performed which showed partial left biceps tendon rupture. Treatment He was managed conservatively with Orthopaedic input. The patient was given analgesia and reassured. Discussion Tendon rupture is an unusual but serious complication of quinolone exposure. This case highlights that this should be included in the differential for acute limb pain in patients who have been prescribed these drugs.

Engaging multiple stakeholders to improve speech and language therapy services in schools: an appreciative inquiry-based study.

BACKGROUND: Effective collaboration between speech and language therapists (SLTs) and teachers is essential in meeting the needs of children with developmental language disorders in school, but it is difficult to achieve. Currently, many children receive inadequate speech and language therapy services and/or support in school. The aim of this study was to engage key stakeholders (SLTs, teachers, parents and children with DLD) in the co-design of their ideal speech and language therapy service and support in school. The study was undertaken in order to inform the development of a conceptual model to guide collaborative practice when working with this population. METHODS: A qualitative study involving a diverse range of key stakeholders and using appreciative inquiry. This is a method which enables those involved to construct their 'ideal' about a topic of interest. Recruitment was carried out using purposive sampling. We conducted focus groups with practitioners (SLTs and teachers) and parents as well as semi-structured interviews with children who have DLD using 'draw and tell' techniques. A total of five focus groups and nine interviews were conducted with participants (n = 27). RESULTS: The children described their ideal supports as those which enabled them to connect, contribute and achieve. They describe ways in which environmental barriers in school needed to be addressed to allow them to do so. The professionals primarily described ways in which the language skills of the child could be improved. Both parents and practitioner groups described the importance of strengthening networks between service providers and service users. They also highlighted the need to promote a collaborative culture if stakeholders are to work effectively together across sectors. CONCLUSIONS: There were differences in perspectives about the ways in which speech and language therapy services and supports could be improved, demonstrating the importance of engaging a diverse group of stakeholders. Of note were the unique insights the children brought about the barriers they faced as a result of their difficulties. Based on our findings we propose that children should be given influence in decisions about the supports that they receive in school. Implications for policy, research and practice are discussed.

T-bet controls intestinal mucosa immune responses via repression of type 2 innate lymphoid cell function.

Innate lymphoid cells (ILCs) play an important role in regulating immune responses at mucosal surfaces. The transcription factor T-bet is crucial for the function of ILC1s and NCR+ ILC3s and constitutive deletion of T-bet prevents the development of these subsets. Lack of T-bet in the absence of an adaptive immune system causes microbiota-dependent colitis to occur due to aberrant ILC3 responses. Thus, T-bet expression in the innate immune system has been considered to dampen pathogenic immune responses. Here, we show that T-bet plays an unexpected role in negatively regulating innate type 2 responses, in the context of an otherwise intact immune system. Selective loss of T-bet in ILCs leads to the expansion and increased activity of ILC2s, which has a functionally important impact on mucosal immunity, including enhanced protection from Trichinella spiralis infection and inflammatory colitis. Mechanistically, we show that T-bet controls the intestinal ILC pool through regulation of IL-7 receptor signalling. These data demonstrate that T-bet expression in ILCs acts as the key transcriptional checkpoint in regulating pathogenic vs. protective mucosal immune responses, which has significant implications for the understanding of the pathogenesis of inflammatory bowel diseases and intestinal infections.

Establishing the European diagnostic reference levels for interventional cardiology.

Interventional cardiac procedures may be associated with high patient doses and therefore require special attention to protect the patients from radiation injuries such as skin erythema, cardiovascular tissue reactions or radiation-induced cancer. In this study, patient exposure data is collected from 13 countries (37 clinics and nearly 50 interventional rooms) and for 10 different procedures. Dose data was collected from a total of 14,922 interventional cardiology procedures. Based on these data European diagnostic reference levels (DRL) for air kerma-area product are suggested for coronary angiography (CA, DRL = 35 Gy cm2), percutaneous coronary intervention (PCI, 85 Gy cm2), transcatheter aortic valve implantation (TAVI, 130 Gy cm2), electrophysiological procedures (12 Gy cm2) and pacemaker implantations. Pacemaker implantations were further divided into single-chamber (2.5 Gy cm2) and dual chamber (3.5 Gy cm2) procedures and implantations of cardiac resynchronization therapy pacemaker (18 Gy cm2). Results show that relatively new techniques such as TAVI and treatment of chronic total occlusion (CTO) often produce relatively high doses, and thus emphasises the need for use of an optimization tool such as DRL to assist in reducing patient exposure. The generic DRL presented here facilitate comparison of patient exposure in interventional cardiology.

The effect of metrics-based feedback on acquisition of sonographic skills relevant to performance of ultrasound-guided axillary brachial plexus block.

The objective of this study was to examine the effect of metrics-based vs. non-metrics-based feedback on novices learning predefined competencies for acquisition and interpretation of sonographic images relevant to performance of ultrasound-guided axillary brachial plexus block. Twelve anaesthetic trainees were randomly assigned to either metrics-based-feedback or non-metrics-based feedback groups. After a common learning phase, all participants attempted to perform a predefined task that involved scanning the left axilla of a single volunteer. Following completion of the task, all participants in each group received feedback from a different expert in regional blocks (consultant anaesthetist) and were allowed to practise the predefined task for up to 1 h. Those in the metrics-based feedback group received feedback based on previously validated metrics, and they practised each metric item until it was performed satisfactorily, as assessed by the supervising consultant. Subsequently, each participant attempted to perform ultrasonography of the left axilla on the same volunteer. Two trained consultant anaesthetists independently scored the video recording pre- and post-feedback scans using the validated metrics list. Both groups showed improvement from pre-feedback to post-feedback scores. Compared with participants in the non-metrics-based feedback group, those in the metrics-based feedback group completed more steps: median (IQR [range]) 18.8 (1.5 [17-20]) vs. 14.3 (4.5 [11-18.5]), p = 0.009, and made fewer errors 0.5 (1 [0-1.5]) vs. 1.5 (2 [1-6]), p = 0.041 postfeedback. In this study, novices' sonographic skills showed greater improvement when feedback was combined with validated metrics.

Investigation of an N-Terminal Prohormone of Brain Natriuretic Peptide Point-of-Care ELISA in Clinically Normal Cats and Cats With Cardiac Disease.

BACKGROUND: N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentrations may be increased in cats with various cardiac disorders. The point-of-care (POC) ELISA assay uses the same biologic reagents as the quantitative NT-proBNP ELISA. Previous studies have evaluated the sensitivity and specificity of the POC ELISA in cats with cardiac disease. OBJECTIVES: To prospectively evaluate the diagnostic utility of the POC ELISA in a select population of cats. ANIMALS: Thirty-eight client-owned cats presented to the University of Florida Cardiology Service for cardiac evaluation. Fifteen apparently healthy cats recruited as part of another study. METHODS: Physical examination and echocardiography were performed in all cats. The POC ELISA was assessed visually as either positive or negative by a reader blinded to the echocardiographic findings, and results were analyzed relative to quantitative assay results. RESULTS: Twenty-six cats were diagnosed with underlying cardiac disease, and 27 cats were considered free of cardiac disease. Cats with cardiac disease included: 21 with hypertrophic cardiomyopathy, 2 with unclassified cardiomyopathy, 2 with restrictive cardiomyopathy, and 1 with 3rd degree atrioventricular (AV) block. The POC ELISA differentiated cats with cardiac disease with a sensitivity of 65.4% and specificity of 100%. CONCLUSIONS AND CLINICAL IMPORTANCE: The POC NT-proBNP ELISA performed moderately well in a selected population of cats. A negative test result cannot exclude the presence of underlying cardiac disease, and a positive test result indicates that cardiac disease likely is present, but further diagnostic investigation would be indicated for a definitive diagnosis.

Lipids and polyunsaturated fatty acid levels in deliberate self-harm: a 10-year follow-up study.

OBJECTIVES: To evaluate if n-3 polyunsaturated fatty acids (PUFAs) and lipid levels are associated with episodes of self-harm or depression over a 10-year period. METHODS: We included 40 individuals who self-harmed and 40 controls. Episodes of self-harm and depression were ascertained and levels of depression, impulsivity, suicidal ideation and plasma lipid levels measured at baseline and at 10-year follow-up. RESULTS: Further episode(s) of self-harm occurred in 26% of cases. Omega-3 PUFAs or lipids were not predictive of depressive or self-harm episodes. Baseline eicosapentaenoic acid levels were modestly correlated with suicidal ideation at follow-up and dihomo-γ-linolenic acid and arachidonic acid were modestly correlated with motor impulsivity at follow-up in cases. CONCLUSIONS: Despite significant negative correlations at baseline between plasma lipids, n-3 PUFAs and psychopathology, these levels were not predictive of clinical outcome over a 10-year period. Further research however is required due to the relatively low sample size and the risk of selection bias due to loss to follow-up in this study.

Thermodynamic and electrical transport investigation of URu2Si2-x P x.

Magnetic susceptibility, electrical resistivity, and heat capacity results are reported for the chemical substitution series URu2Si2-x P x for [Formula: see text]. This study expands in detail on work recently reported in Gallagher et al (2016 Nat. Commun. 10712), which focused on the small x region of this substitution series. Measurements presented here reveal persistent hybridization between the f- and conduction electrons and strong variation of the low temperature behavior with increasing x. Hidden order and superconductivity are rapidly destroyed for [Formula: see text] and are replaced for [Formula: see text] by a region with Kondo coherence but no ordered state. Antiferromagnetism abruptly appears for [Formula: see text]. This phase diagram differs significantly from those produced by most other tuning strategies in URu2Si2, including applied pressure, high magnetic fields, and isoelectronic chemical substitution (i.e. Ru → Fe and Os), where hidden order and magnetism share a common phase boundary. Besides revealing an intriguing evolution of the low temperature states, this series provides a setting in which to investigate the influence of electronic tuning, where probes that are sensitive to the Fermi surface and the symmetry of the ordered states will be useful to unravel the anomalous behavior of URu2Si2.

Construct validity of a novel assessment tool for ultrasound-guided axillary brachial plexus block.

The purpose of this study was to examine the construct validity and reliability of a novel metrics-based assessment tool, previously developed for ultrasound-guided axillary brachial plexus block. Five expert and eight novice anaesthetists performed a total of 18 ultrasound-guided axillary brachial plexus blocks on the same number of patients. A trained investigator video-taped procedures according to a pre-defined protocol. Two trained consultant anaesthetists independently scored the videos using the assessment tool. Compared with novices, experts completed more steps (mean 41.0 vs. 33.1, p = 0.001), had fewer procedural errors (2.8 vs. 7.9, p < 0.0001), had fewer critical errors (0.8 vs. 1.3, p = 0.030), and fewer total errors (3.5 vs. 9.1, p < 0.0001). The mean inter-rater reliability for scoring of experts' performance was 0.91, for novices' performance was 0.84, and for all performance combined (n = 18) was 0.88. This assessment tool is valid, and discriminates reliably between expert and novice performance for placement of ultrasound-guided axillary brachial plexus blocks.

High-throughput synthesis and characterization of nanocrystalline porphyrinic zirconium metal-organic frameworks.

We describe and employ a high-throughput screening method to accelerate the synthesis and identification of pure-phase, nanocrystalline metal-organic frameworks (MOFs). We demonstrate the efficacy of this method through its application to a series of porphyrinic zirconium MOFs, resulting in the isolation of MOF-525, MOF-545, and PCN-223 on the nanoscale.

Unfolding the physics of URu2Si2 through silicon to phosphorus substitution.

The heavy fermion intermetallic compound URu2Si2 exhibits a hidden-order phase below the temperature of 17.5 K, which supports both anomalous metallic behavior and unconventional superconductivity. While these individual phenomena have been investigated in detail, it remains unclear how they are related to each other and to what extent uranium f-electron valence fluctuations influence each one. Here we use ligand site substituted URu2Si(2-x)P(x) to establish their evolution under electronic tuning. We find that while hidden order is monotonically suppressed and destroyed for x≤0.035, the superconducting strength evolves non-monotonically with a maximum near x≈0.01 and that superconductivity is destroyed near x≈0.028. This behavior reveals that hidden order depends strongly on tuning outside of the U f-electron shells. It also suggests that while hidden order provides an environment for superconductivity and anomalous metallic behavior, it's fluctuations may not be solely responsible for their progression.