Point Prevalence of Adult Intestinal Failure in Republic Of Ireland.

Parenteral Nutrition (PN) is a life-saving treatment used for patients with Intestinal Failure (IF). PN is complex and demands highly specialised care to avoid serious complications in the home setting. All tertiary centres in the Republic of Ireland (ROI) were contacted to assess the prevalence of IF requiring PN and complications, over a one year period. Sixty-seven patients were treated across 15 centres: a period prevalence of 14.6 and 9.6 patients per million for long-term PN and home PN respectively. Three-quarters of patients experienced at least one major complication with 18% mortality rate over the study period. There were 2.86 admissions per HPN patient, each lasting mean 13.4 days. One-third experienced catheter-related infections. There was a reduced length of stay during emergency re-admissions in high volume centres (mean 31 v 43 days, p=0.17). The establishment of a National Centre for IF/HPN in ROI is integral to reducing PN-associated complications.

Electron and Ion Heating Characteristics during Magnetic Reconnection in the MAST Spherical Tokamak.

Electron and ion heating characteristics during merging reconnection start-up on the MAST spherical tokamak have been revealed in detail using a 130 channel yttrium aluminum garnet (YAG) and a 300 channel Ruby-Thomson scattering system and a new 32 chord ion Doppler tomography diagnostic. Detailed 2D profile measurements of electron and ion temperature together with electron density have been achieved for the first time and it is found that electron temperature forms a highly localized hot spot at the X point and ion temperature globally increases downstream. For the push merging experiment when the guide field is more than 3 times the reconnecting field, a thick layer of a closed flux surface form by the reconnected field sustains the temperature profile for longer than the electron and ion energy relaxation time ~4-10 ms, both characteristic profiles finally forming a triple peak structure at the X point and downstream. An increase in the toroidal guide field results in a more peaked electron temperature profile at the X point, and also produces higher ion temperatures at this point, but the ion temperature profile in the downstream region is unaffected.

The Kuwait-Scotland eHealth Innovation Network (KSeHIN): a sustainable approach to quality improvement in healthcare.

BACKGROUND: The rising prevalence of obesity and diabetes in Kuwait represents a significant challenge for the country's healthcare system. Diabetes care in Scotland has improved by adopting a system of managed clinical networks supported by a national informatics platform. In 2010, a Kuwait-Dundee collaboration was established with a view to transforming diabetes care in Kuwait. This paper describes the significant progress that has been made to date. METHODS: The Kuwait-Scotland eHealth Innovation Network (KSeHIN) is a partnership among health, education, industry and government. KSeHIN aims to deliver a package of clinical service development, education (including a formal postgraduate programme and continuing professional development) and research underpinned by a comprehensive informatics system. RESULTS: The informatics system includes a disease registry for children and adults with diabetes. At the patient level, the system provides an overview of clinical and operational data. At the population level, users view key performance indicators based on national standards of diabetes care established by KSeHIN. The national childhood registry (CODeR) accumulates approximately 300 children a year. The adult registry (KHN), implemented in four primary healthcare centres in 2013, has approximately 4000 registered patients, most of whom are not yet meeting national clinical targets. A credit-bearing postgraduate educational programme provides module-based teaching and workplace-based projects. In addition, a new clinical skills centre provides simulator-based training. Over 150 masters students from throughout Kuwait are enrolled and over 400 work-based projects have been completed to date. CONCLUSION: KSeHIN represents a successful collaboration between multiple stakeholders working across traditional boundaries. It is targeting patient outcomes, system performance and professional development to provide a sustainable transformation in the quality of diabetes healthcare for the growing population of Kuwaitis with diabetes in Kuwait.

2D measurements of plasma electron density using coherence imaging with a pixelated phase mask.

In this paper, the pixelated phase mask (PPM) method of interferometry is applied to coherence imaging (CI)-a passive, narrowband spectral imaging technique for diagnosing the edge and divertor regions of fusion plasma experiments. Compared to previous CI designs that use a linear phase mask, the PPM method allows for a higher possible spatial resolution. The PPM method is also observed to give a higher instrument contrast (analogous to a more narrow spectrometer instrument function). A single-delay PPM instrument is introduced as well as a multi-delay system that uses a combination of both pixelated and linear phase masks to encode the coherence of the observed radiation at four different interferometer delays simultaneously. The new methods are demonstrated with measurements of electron density ne, via Stark broadening of the Hγ emission line at 434.0 nm, made on the Magnum-PSI linear plasma experiment. A comparison of the Abel-inverted multi-delay CI measurements with Thomson scattering shows agreement across the 3 × 1019 < ne < 1 × 1021 m-3 range. For the single-delay CI results, agreement is found for ne > 1 × 1020 m-3 only. Accurate and independent interpretation of single-delay CI data at lower ne was not possible due to Doppler broadening and continuum emission.

Upgrades to the in-vessel calibration light source on JET.

Since 2010, an in-vessel calibration light source (ICLS) has been used periodically on JET to calibrate a range of diagnostics at UV, visible, and IR wavelengths. During shutdowns, the ICLS (which is essentially an integrating sphere) is positioned within the vacuum vessel by the remote handling (RH) system. Following the 2013 calibration runs, several changes were made to improve the efficiency and quality of the calibrations. Among these was the replacement of a 20 m "umbilical" cable which carried power and other electrical signals through a vessel port to/from a control cubicle. A lightweight 2 m cable now plugs directly into a single connector on the RH manipulator system, greatly reducing the time required for deployment and improving operational flexibility; e.g., the vessel access "floor" no longer needs to be installed. This change also means the system would be compatible with calibrations after a high neutron-fluence period of operation. An on-board micro-spectrometer now allows for real-time verification of the emitted spectrum. Finally, new "baffles" were designed and installed within the integrating sphere itself, greatly improving the spectral radiance uniformity at non-normal viewing angles (necessary due to orientation uncertainties with the RH system).

Instrumentation for the upgrade to the JET core charge-exchange spectrometers.

Charge-exchange spectroscopy on JET has become particularly challenging with the introduction of the ITER-like wall. The line intensities are weaker and contaminated by many nuisance lines. We have therefore upgraded the instrumentation to improve throughput and allow the simultaneous measurement of impurity and fuel-ion charge exchange by splitting the light between two pairs of imaging spectrometers using dichroic beam splitters. Imaging instruments allow us to stack 11 × 1 mm diameter fibres on the entrance slits without cross talk. CCD cameras were chosen to have 512 × 512 pixels to allow frame transfer times <0.2 ms which with minimum exposure times of 5 ms give tolerable smearing even without a chopper. The image plane is optically demagnified 2:1 to match the sensor size of these cameras. Because the image plane of the spectrometer is tilted, the CCD must also be tilted to maintain focus over the spectrum (Scheimpflug condition). To avoid transverse keystoning (causing the vertical height of the spectra to change across the sensor), the configuration is furthermore designed to be telecentric by a suitable choice of the lens separation. The lens configuration is built almost entirely from commercial off-the-shelf components, which allowed it to be assembled and aligned relatively rapidly to meet the deadline for in-vessel calibration in the JET shutdown.

In-vessel calibration of the imaging diagnostics for the real-time protection of the JET ITER-like wall.

The in situ absolute calibration of the JET real-time protection imaging system has been performed for the first time by means of radiometric light source placed inside the JET vessel and operated by remote handling. High accuracy of the calibration is confirmed by cross-validation of the near infrared (NIR) cameras against each other, with thermal IR cameras, and with the beryllium evaporator, which lead to successful protection of the JET first wall during the last campaign. The operation temperature ranges of NIR protection cameras for the materials used on JET are Be 650-1600 °C, W coating 600-1320 °C, and W 650-1500 °C.

Doppler color flow mapping in the diagnosis of ventricular septal rupture and acute mitral regurgitation after myocardial infarction.

Fifty consecutive patients with a newly acquired systolic murmur and severe cardiac decompensation following a recent myocardial infarction (27 with an anterior and 23 with an inferior infarct) were studied by a combination of two-dimensional echocardiography, spectral Doppler and Doppler color flow mapping. The initial ultrasound study defined a ventricular septal rupture in 43 patients and severe isolated mitral regurgitation in 7 patients (5 with papillary muscle rupture and 2 with severe papillary muscle dysfunction). All 50 patients had subsequent confirmation of the diagnosis by either cardiac catheterization or surgical inspection, or both. Two-dimensional echocardiography alone directly visualized a septal defect in only 17 (40%) of the 43 patients with ventricular septal rupture. In all 43 patients the mitral valve appeared normal on imaging. In six of the seven patients with isolated mitral regurgitation, two-dimensional echocardiography correctly demonstrated the structural abnormality of the mitral valve (five with flail anterior leaflet and one with posterior leaflet prolapse). The addition of Doppler color flow mapping greatly improved the diagnostic information in both patient groups. In all 43 patients with ventricular septal rupture, Doppler color flow mapping demonstrated both an area of turbulent transseptal flow and a diagnostic systolic flow disturbance within the right ventricle. In the seven patients with isolated papillary muscle rupture or dysfunction, Doppler color flow mapping not only demonstrated the presence of mitral regurgitation in all cases, but also identified the specific mitral leaflet abnormality by defining the direction of the regurgitant jet.(ABSTRACT TRUNCATED AT 250 WORDS)

Correction of type B interrupted aortic arch with ventricllar septal defect in infancy.

The successful correction of a Type B interrupted aortic arch (IAA) with simultaneous closure of a ventricular septal defect (VSD) in a 6-month-old infant is described. With the use of profound hypothermia and limited cardiopulmonary bypass, a flap of pulmonary artery, together with the persistent ductus arteriosus (PDA), was dissected free and sutured so as to form a tube which then was anastomosed to the ascending aorta. The ventricular septal defect and the pulmonary arteriotomy then were closed. Cardiac catheterization 5 months later demonstrated a satisfactory reconstruction with no gradient between the ascending and descending aorta.

Simultaneous mitral valve replacement and ligation of persistent ductus arteriosus; a case report.

The successful simultaneous closure of a persistent ductus arteriosus and mitral valve replacement in a 65-year-old woman with pulmonary hypertension is reported. The approach through a left thoracotomy gave good exposure and momentary cessation of cardiopulmonary bypass made ligation of the calcified ductus possible. Although this seems to be a rare association, when mitral valve disease is significant the simultaneous closure of the duct and mitral valve surgery is the treatment of choice.

Myocardial infarction complicating aortic valve replacement.

One hundred consecutive aortic valve replacements were studied. Fifteen patients had a myocardial infarction as a result of the operation, and four of the five deaths in the series stemmed from this group. In the four deaths from infarction, autopsy revealed occlusion of a main coronary artery. This was attributable to coronary perfusion in three instances. All of the 11 survivors who sustained an infarct were free of angina and left ventricular failure 6 weeks after the operation. Patients with infarcts had longer bypass times and larger aortic systolic gradients than the patients who did not have an infarct. It is suggested that an infarct can occur as the result of occlusion of a main coronary artery; this is a fatal event commonly related to trauma from the coronary perfusion cannula. Alternatively, infarction may result from regional ischemia, perhaps without vessel occlusion, and is associated with long bypass times and with large aortic valve gradients. In such cases the prognosis is good. However, myocardial infarction was the major cause of death in this series.

Acquired ventricular septal defect.

The past 9 years' experience with ventricular septal rupture complicating myocardial infarction has been reviewed. Thirty-six patients were treated surgically, with 10 early deaths (28%) and one late death, for an 8 year actuarial survival rate of 63%. The mortality was highest for those defects which followed inferior infarction, 38% compared with 13% following anterior infarction. The infarction-operation interval also greatly influenced mortality; under 2 weeks, 43%; over 2 weeks, 18%. Concomitant coronary artery bypass grafts (13 patients) or left ventricular aneurysmectomy (14 patients) did not carry an increased mortality. Of 17 patients who presented with cardiogenic shock, eight died (47%). The intra-aortic balloon pump (IABP) was used in 16 patients (44%) and helped greatly in the management of the critically ill. With an estimated 17 acquired septal defects occurring each year in persons under 65 years of age in Wessex, awareness of this complication and of the favorable outcome of operation is essential among those who treat the aftereffects of myocardial infarction.

Late functional results after surgical closure of acquired ventricular septal defect.

To assess the longer term outlook for patients who have undergone surgery for acquired (postinfarction) ventricular septal defect, we interviewed and studied 60 survivors from a single regional cardiac center between 3 and 144 months after the operation. Including the patients who died within 1 month of the operation, the 5-, 10-, and 14-year survivals (with standard errors) were 69% (65% to 74%), 50% (44% to 57%), and 37% (27% to 46%). Eighty-two percent of patients were in New York Heart Association class I or II. Ten patients (17%) had a persisting but not hemodynamically significant ventricular septal defect. Mean left ventricular ejection fraction was reduced at 0.39 (standard deviation 0.15), but this did not correlate with either New York Heart Association class or exercise tolerance. Twenty-eight patients (47%) had asymptomatic arrhythmias (17 with ventricular premature beats). Angina and other medical problems were not prevalent.

Surgical treatment for infarct-related ventricular septal defects. Improved early results combined with analysis of late functional status.

A total of 101 patients (mean age 64.9 years) underwent surgical correction of postinfarction ventricular septal defect at this institution over a 15-year period (1973 to 1988). The overall early mortality rate was 20.8%, although the most recent experience with 36 patients (January 1987 to October 1988) has seen this decline to 11.1%. Factors found to influence early death significantly, when analyzed univariately, were as follows: (1) site of infarction (anterior 12.1%, inferior 32.6%, p = 0.02); (2) time interval between infarction and operation (less than 1 week 34.1%, greater than 1 week 10.5%, p = 0.008); (3) cardiogenic shock (present 38.1%, absent 8.5%, p = 0.001). Nonsignificant variables included preoperative renal function, age, and concomitant coronary artery bypass, although older age (greater than 65 years) became significant when examined in a multivariate fashion. Of the 80 hospital survivors, eight were subsequently found to have a recurrent or residual defect necessitating reoperation, with survival in seven. Late follow-up is 99% complete and reveals an actuarial survival rate for 100 patients of 71.1% at 5 years (95% confidence interval 60.6 to 80.0), and 40.0% at 10 years (95% confidence interval 21.7 to 58.4). A significant recent change in policy of not using coronary angiography in patients with a ventricular septal defect caused by anterior wall infarction has not resulted in any increase in either the early mortality or in the late prevalence of angina. The functional status of 38 surviving patients has been analyzed by a graded treadmill exercise protocol, whereas left ventricular functional assessment was by nuclear scan with additional information on mitral valve function by echocardiogram. Color Doppler flow mapping has been used to determine the presence of a residual defect. Most late survivors have limited exercise tolerance related to both cardiac and noncardiac factors. Left ventricular function is moderately impaired (mean ejection fraction = 0.39). However, many patients are elderly and have adapted to their residual symptoms without significant changes in life-style.

Rupture of a calcified true left ventricular aneurysm: echocardiographic diagnosis and successful repair.

This report describes a rupture of a calcified left ventricular aneurysm 10 years after initial infarction. Operation 10 days after rupture was complicated by extensive ventricular calcification, in particular, the ventricular septum. Repair was achieved by endocardial resection of calcium, preservation of the myocardium and linear approximation.

left ventricular segmental wall motion-a comparison between equilibrium radionuclide angiography and contrast angiography.

The qualitative assessement of left ventricular wall motion using a four-point scale has been compared between left ventricular contrast angiography and equilibrium radionuclide angiography in the 30 degrees right anterior oblique projection. Analysis was carried out for five segments of the left ventricle. Four modes of analysis of equilibrium radionuclide angiography were compared and the reproducibility assessed. Overall accuracy of equilibrium radionuclide angiography compared to contrast angiography was greater than 82% to within one degree of motion. One method using a cine display, averaged 97%. We suggest that equilibrium radionuclide angiography using the cine display is the non-invasive investigation of choice in the screening of patients with suspected regional wall motion abnormalities.

Enhanced visible and near-infrared capabilities of the JET mirror-linked divertor spectroscopy system.

The mirror-linked divertor spectroscopy diagnostic on JET has been upgraded with a new visible and near-infrared grating and filtered spectroscopy system. New capabilities include extended near-infrared coverage up to 1875 nm, capturing the hydrogen Paschen series, as well as a 2 kHz frame rate filtered imaging camera system for fast measurements of impurity (Be II) and deuterium Dα, Dß, Dγ line emission in the outer divertor. The expanded system provides unique capabilities for studying spatially resolved divertor plasma dynamics at near-ELM resolved timescales as well as a test bed for feasibility assessment of near-infrared spectroscopy.

Investigating fusion plasma instabilities in the Mega Amp Spherical Tokamak using mega electron volt proton emissions (invited).

The proton detector (PD) measures 3 MeV proton yield distributions from deuterium-deuterium fusion reactions within the Mega Amp Spherical Tokamak (MAST). The PD's compact four-channel system of collimated and individually oriented silicon detectors probes different regions of the plasma, detecting protons (with gyro radii large enough to be unconfined) leaving the plasma on curved trajectories during neutral beam injection. From first PD data obtained during plasma operation in 2013, proton production rates (up to several hundred kHz and 1 ms time resolution) during sawtooth events were compared to the corresponding MAST neutron camera data. Fitted proton emission profiles in the poloidal plane demonstrate the capabilities of this new system.

X-ray crystal spectrometer upgrade for ITER-like wall experiments at JET.

The high resolution X-Ray crystal spectrometer at the JET tokamak has been upgraded with the main goal of measuring the tungsten impurity concentration. This is important for understanding impurity accumulation in the plasma after installation of the JET ITER-like wall (main chamber: Be, divertor: W). This contribution provides details of the upgraded spectrometer with a focus on the aspects important for spectral analysis and plasma parameter calculation. In particular, we describe the determination of the spectrometer sensitivity: important for impurity concentration determination.