Optimising physiotherapy for people with lateral elbow tendinopathy - Results of a mixed-methods pilot and feasibility randomised controlled trial (OPTimisE).

BACKGROUND: The OPTimisE intervention was developed to address uncertainty regarding the most effective physiotherapy treatment strategy for people with Lateral Elbow Tendinopathy (LET). OBJECTIVES: To assess the feasibility of conducting a fully-powered randomised controlled trial (RCT) evaluating whether the OPTimisE intervention is superior to usual physiotherapy treatment for adults with LET. DESIGN: A mixed-methods multi-centred, parallel pilot and feasibility RCT, conducted in three outpatient physiotherapy departments in the UK. METHOD: Patients were independently randomised 1:1 in mixed blocks, stratified by site, to the OPTimisE intervention or usual care. Outcomes were assessed using pre-defined feasibility progression criteria. RESULTS: 50 patients were randomised (22 Female, 28 Male), mean age 48 years (range 27-75). Consent rate was 71% (50/70), fidelity to intervention 89% (16/18), attendance rate in the OPTimisE group 82% (55/67) vs 85% (56/66) in usual care, outcome measure completion 81% (39/48) at six-month follow-up. There were no related adverse events. Patients and physiotherapists reported that the OPTimisE intervention was acceptable but suggested improvements to the trial design. 49 patients were recruited from physiotherapy referrals vs one from primary care records. Outcome measure return rates were higher when completed online (74%) compared to postal questionnaire (50%). Exploratory analysis showed improvements in both groups over time. CONCLUSIONS: It is methodologically feasible to conduct a fully powered RCT comparing the clinical and cost-effectiveness of the OPTimisE intervention versus usual physiotherapy treatment. Considering the similar improvements observed in both groups, careful consideration is needed regarding the priority research question to be addressed in future research.

MRI prediction of fetal lung volumes and the impact on counselling.

AIM: To assess whether lung volume percentages in congenital diaphragmatic hernia (CDH) differ depending on which formula is used to calculate the expected volume for gestation and any potential impact this may have on perinatal counselling. MATERIALS AND METHODS: Forty-seven patients with left-sided CDH who had undergone fetal magnetic resonance imaging (MRI) at Sheffield Teaching Hospitals were reviewed. The lung volumes were measured on MRI and compared with the volumes that would be expected at the given gestation for each patient. Expected values were calculated using four formulae from the literature and the authors' in-house method. These measurements were used to calculate the percentage total lung volume observed compared with the expected lung volume in a healthy fetus of the same gestation. The differences in percentage lung volumes using these five methods were then compared with how they relate to predicted rates of survival. How predicted survival would change depending on which formula was used to calculate the percentage lung volume was investigated with a view to how this may change the counselling given to a family. RESULTS: In 10/47 (21%) patients, there was no change in the predicted percentage chance of survival depending on which formula was used to calculate the predicted lung volume. In 37/47 (79%), the predicted chance of survival changed depending on which formula was used to calculate the expected lung volume at the given gestation. In 20 (47%) of these cases, the change in predicted survival depending on which formula used was 45% (i.e., from 25% to 70% survival in four and from 50% to 95% survival in 16) and in two cases (4%) this difference was 70% (i.e., from 25% predicted survival to 95% predicted survival). CONCLUSION: There are several different methods for calculating expected lung volumes for any given gestation. When used to estimate the percentage lung volume in patients with CDH, there is a large difference in values depending on which method is used. This in turn leads to a large variation in predicted survival with some patients in this study having either a 25% or 95% chance of survival depending on which method is used. This has a huge impact on perinatal counselling and the difficult decisions made by families.

Current physiotherapy practice in the management of tennis elbow: A service evaluation.

BACKGROUND: Tennis elbow is a common painful condition that may affect daily function and ability to work. Physiotherapy is the most commonly used primary intervention but there is a wide range of treatment options within the umbrella of physiotherapy. Our aim was to report on the treatments that are currently used by physiotherapists in a UK National Health Service (NHS) setting. METHODS: A retrospective service evaluation was conducted at two NHS hospital trusts by reviewing patient attendance records over a 1-year period. All patients with tennis elbow were included, except those referred for postoperative rehabilitation. Patient notes were analysed using a predefined assessment template. RESULTS: A total of 65 patient records were identified, with patients having a mean age 48 years and mean symptom duration of 5.4 months. The mean treatment duration was 64 days, over 3.7 sessions. The most commonly used treatments were education and exercise, although the type and dosing of exercise varied greatly. Passive modalities such as ice, taping, manual therapy, acupuncture and electrotherapy were still used. CONCLUSIONS: Wide variations in treatment approaches were identified. There was no consistency in the choice of modality used, the type of exercise or the dose of exercise prescribed. The use of passive modalities and corticosteroid injections was found to remain commonplace, despite a lack of supporting research evidence. There is a clear need for evidence-based guidance for physiotherapists treating patients with tennis elbow.

The MRI features of placental adhesion disorder and their diagnostic significance: systematic review.

AIM: To identify the most frequently used MRI features in the diagnosis of placenta adhesion disorder (PAD) in the antenatal period and their significance. MATERIALS AND METHODS: The online databases Medline via PubMed and Ovid, Google Scholar, and Scopus were searched using the keywords and subject headings MRI*, magnetic resonance imaging*, prenatal diagnosis and placenta accreta*, morbidly adherent placenta* or placenta. Cases where MRI was carried out at/after 20 weeks gestation with detailed information available in relation to criteria and sequences used were included in the review. Exclusion criteria were case report study and studies that used intravenous contrast agents. Information regards sensitivity and specificity for each feature was taken, or calculated where possible, from the papers. Any new features were identified. The overall contribution of each feature to the diagnostic process was noted. RESULTS: Six hundred and fourteen potentially relevant articles were identified of which only 11 met the inclusion criteria. The commonest MRI criteria used were T2 dark intraplacental bands, heterogeneity of placenta, abnormal uterine bulging, and disruption of the uteroplacental zone. A newly described criterion is disorganised vasculature of placenta. MRI sensitivity and specificity varied between 75-100% and 65-100% respectively. CONCLUSION: MRI diagnosis of PAD relies on unstandardised criteria of diagnosis that enable systematic image interpretation of invasion status in all studies and enable the reproducibility. However, it is still has a high diagnostic accuracy and frequently aids in surgical planning, emphasising its value in supporting ultrasound. Most studies are of a small sample size. Additional multicentre studies are recommended to enhance the generalisability of the findings and asses the value of the newly described criteria.

Diffusion-weighted imaging and magnetic resonance proton spectroscopy following preterm birth.

AIM: To study the associations between magnetic resonance proton spectroscopy (MRS) data and apparent diffusion coefficients (ADC) from the preterm brain with developmental outcome at 18 months corrected age and clinical variables. MATERIALS AND METHODS: A prospective observational cohort study of 67 infants born before 35 weeks gestational age who received both magnetic resonance imaging of the brain between 37 and 44 weeks corrected gestational age and developmental assessment around 18 months corrected age. RESULTS: No relationships were found between ADC values and MRS results or outcome. MRS ratios involving N-acetyl aspartate (NAA) from the posterior white matter were associated with "severe" and "moderate to severe" difficulties, and fine motor scores were significantly lower in participants with a visible lactate doublet in the posterior white matter. The presence of a patent ductus arteriosus (PDA) was the only clinical factor related to NAA ratios. CONCLUSION: Altered NAA levels in the posterior white matter may reflect subtle white matter injury associated with neuro-developmental difficulties, which may be related to a PDA. Further work is needed to assess the longer-term neuro-developmental implications of these findings, and to study the effect of PDAs on developmental outcome in later childhood/adolescence.

CT of the neonatal head.

Computed tomography (CT) is used less often than other techniques on neonatal units. However, in the acute setting, CT can be invaluable in diagnosing or excluding potentially life-threatening conditions and guiding initial management in neonates. Common indications for scanning include trauma, suspected non-accidental injury, infection, or an acute hypoxic or metabolic event. The aim of this review is to provide an overview of the normal neonatal head at CT and compare this to the common pathological abnormalities. Several key features of each condition will be highlighted. It is important to note that some pathological conditions can have overlapping features at CT and, therefore, the clinical history and additional investigations are also of key importance in determining the diagnosis.

Fetuses with ventriculomegaly diagnosed in the second trimester of pregnancy by in utero MR imaging: what happens in the third trimester?

BACKGROUND AND PURPOSE: Although MR imaging of the fetal brain has been shown to provide additional diagnostic information, the optimal timing of the study and the value of repeat studies remain unclear. The primary purpose of this study was to look for structural abnormalities of the fetal brain shown at 30-32 weeks' gestational age but not on the 20-24 weeks' study in fetuses originally referred with isolated VM. In particular, we wished to study the hypothesis that third-trimester fetal MR imaging studies would not show extra brain abnormalities compared with the second-trimester studies in this group. MATERIALS AND METHODS: Ninety-nine women were admitted for a fetal MR study between 20-24 weeks' gestational age, and 46 of these women agreed to return for a second MR imaging examination at 30-32 weeks' gestational age. The other women were either lost to follow-up or declined the invitation to return. Two experienced observers measured the width of the trigones, and the results were compared, to test reliability. Changes in the degree of VM are reported along with changes in the diagnosis of structural brain abnormalities. RESULTS: There was excellent reproducibility of trigone measurements between the 2 observers, with a mean absolute difference of <1 mm in the 40 fetuses that were ultimately shown to have isolated VM. Twenty-eight of 40 fetuses studied had mild VM on the first iuMR imaging examination, but in just more than half, the category of VM changed between the studies (5 had become normal-sized, 7 had progressed to moderate, 3 had become severe, and 13 remained mild). In 1 case, hypogenesis of the corpus callosum was recognized at 30-32 weeks but had not been reported on the 20-24 weeks' examination; the other 5 fetuses had brain pathology recognized on both fetal MR studies. CONCLUSIONS: Trigone measurements can be made in a highly repeatable fashion on iuMR imaging. We have not shown any major advantage in repeating iuMR imaging at 30-32 weeks' gestation in terms of improved diagnosis of other structural brain abnormalities. With the converse of that argument, however, our data suggest that there is no advantage in delaying iuMR imaging studies to 30-32 weeks in the hope of improving detection rates.

A prospective study of fetuses with isolated ventriculomegaly investigated by antenatal sonography and in utero MR imaging.

BACKGROUND AND PURPOSE: Fetal ventriculomegaly (VM) is important because of its high prevalence and high risk of association with other brain abnormalities. The purpose of this article was to investigate the hypotheses that including in utero MR imaging (iuMR) in the diagnostic pathway for fetuses with isolated VM on antenatal imaging will show other brain abnormalities in a high proportion of cases and that these will have a significant effect on clinical management. MATERIALS AND METHODS: One hundred forty-seven pregnant women were recruited prospectively from 8 fetomaternal centers in Britain. All of the fetuses had VM diagnosed on sonography but no other abnormality. iuMR was performed, and the results of the examinations were compared with those of sonography. Two fetomaternal experts made independent assessments of the effects of any new diagnoses on clinical management. RESULTS: Categoric assessments of ventricular size were the same in approximately 90% of fetuses. Other abnormalities were shown in 17% of fetuses. The most frequent additional brain abnormality shown on iuMR was agenesis of the corpus callosum. Severe VM was associated with an approximately 10-fold increase in the risk of another brain abnormality being present when compared with fetuses with mild VM. The most profound effects on clinical management, however, were found in cases of mild VM. CONCLUSIONS: This work supports our hypotheses by showing a high detection rate of other brain pathology when iuMR was used to supplement antenatal sonography (17%). In a high proportion of cases, the detection of the extra pathology would have led to significant changes in clinical management.

A case of a Dandy-Walker variant: the importance of a multidisciplinary team approach using complementary techniques to obtain accurate diagnostic information.

Dandy-Walker malformation is a rare abnormality of the central nervous system (CNS) with a reported incidence of 1 in 25,00-35,00 live births and a slight female predominance. It accounts for 1-4% of cases of antenatally detected hydrocephalus. Dandy Walker variant forms part of the spectrum of Dandy Walker malformation. It is characterized by partial agenesis of the vermis, resulting in communication between the fourth ventricle and the cisterna magna. Dandy Walker malformation demonstrates an enlarged posterior fossa, with high insertion of the torcula herophili, as well as other features. In the diagnostic workup, ultrasound is reliable and accurate for making the diagnosis. In utero, fetal MRI can be used to confirm the diagnosis and also to identify any associated abnormalities. In cases of termination of pregnancy, autopsy will offer the diagnosis and provide additional information to assess the risk for future pregnancies and to help in counselling the parents. Autopsy is considered the gold standard for accurate diagnosis of the fetal abnormality. We report the unexpected finding of complete absence of the cerebellum due to maceration at autopsy, even though it was clearly demonstrated (but abnormal) on the antenatal ultrasound scan and MRI, as well as on post-mortem MRI. To the best of our knowledge, this has not been reported previously. Our case demonstrates the relevance of MRI when approaching a post-mortem examination with CNS malformation, and indicates that the "gold standard" might not always be autopsy.

The value of in-utero magnetic resonance imaging in ultrasound diagnosed foetal isolated cerebral ventriculomegaly.

AIM: To assess whether magnetic resonance imaging (MRI) is a useful adjunct to ultrasound (US) when imaging cases of foetal isolated cerebral ventriculomegaly. To assess whether, in such cases, ventricular morphology is a useful indicator for the underlying pathology, as has recently been suggested. MATERIALS AND METHODS: A retrospective analysis was undertaken of 30 cases of isolated ventriculomegaly diagnosed using US and referred for in utero MRI. The gestational age of each case was noted and the MRI report. Both ventricles were measured and each case was categorized according to severity and morphology. The MRI report was compared to the final diagnosis. RESULTS: Of the 30 cases evaluated 18 had mild ventriculomegaly (<15 mm; gestational age range 20-31 weeks, mean 22.8, median 22) and 12 had severe ventriculomegaly (>15 mm; gestational age range 21-37 weeks, mean 28, median 28.5). Additional abnormalities were found in 50% of cases overall (44% mild, 58% severe) using MRI. CONCLUSIONS: Using MRI additional abnormalities were identified in 50% of the foetuses. The morphology of the cases did not suggest underlying pathology in this group. In utero MRI is a useful adjunct to US in cases of foetal cerebral ventriculomegaly referred after initial diagnosis using US.

The use of magnetic resonance in the hospital and coronial pediatric postmortem examination.

The role of magnetic resonance imaging (MRI) has rapidly progressed from being a research tool to an ancillary pre-autopsy imaging technique and now an adjunct of the postmortem (PM) examination. In this review, we describe our experience with the use of PM MRI over the last 6 years in more than 300 fetal PM examinations, initially as research and finally the most recent use in 30 pediatric coronial autopsies. The pediatric pathologist and the neonatal and fetal radiologist retrospectively measured the impact on diagnosis at each stage of the development of the technique together. All imaging techniques have the advantage of being non-invasive, more acceptable to the public, especially certain religious groups and provide a permanent record of the features observed.

In utero magnetic resonance of non-isolated ventriculomegaly: Does ventricular size or morphology reflect pathology?

AIM: To confirm whether ventricular size or morphology reflects the underlying pathology in foetuses referred with a diagnosis of possible ventriculomegaly (Vm) and central nervous system (CNS) pathology. METHODS: Retrospective analysis of 40 in utero magnetic resonance (MR) examinations was undertaken. Ventricular size was measured on axial sections by two observers, and morphology was agreed by consensus. Results were analysed according to gestational age at referral, degree of Vm (mild 10-15 mm, moderate/severe >15 mm) and morphology. RESULTS: Nine cases had no Vm (mean gestational age 23.6 weeks, range 19-33), 17 had mild Vm (mean age 23.9 weeks, range 20-31), and 14 had moderate/severe Vm (mean age 25.9 weeks, range 20-35). All groups had a mix of morphology and pathology. Eighteen suspected cases of spina bifida were referred and 17 confirmed (mean age 22.6 weeks, range 19-30) using MR. The morphology was mixed, five cases (27.8%) had an angular appearance (this morphology was only seen in cases with spina bifida). Fourteen cases (77.8%) had Vm (eight mild, six severe). Of the thirteen cases of agenesis of the corpus callosum (ACC) suspected on ultrasound, seven were confirmed using MR (mean age 26.5 weeks, range 20-35). Of those seven cases with ACC confirmed on MR, and three additional cases only detected by in utero MR, five had colpocephaly, seven had Vm (four mild, three severe). CONCLUSION: Severity of Vm did not reflect the type, or presence, of underlying pathology. Morphology appears an indicator of pathology. Angular ventricles should initiate a search for spinal defects. Colpocephaly may indicate ACC.

Post-mortem MRI of the foetal spine and spinal cord.

AIMS: To compare the findings of post-mortem magnetic resonance imaging (MRI) of the foetal spine with autopsy with a view to using post-mortem MRI as an alternative or adjunct to autopsy, particularly in foetal and neonatal cases. MATERIALS AND METHODS: The brains and spines of 41 foetuses, with a gestational age range of 14-41 weeks, underwent post-mortem MRI before autopsy. Post-mortem MRI of the brain consisted of T2-weighted sequences in three orthogonal planes and MRI of the spine consisted of T2-weighted sequence in the sagittal and axial planes in all cases and coronal planes in selected cases. RESULTS: Thirty of 41 (78%) foetal spines were found to be normal at autopsy and on post-mortem MRI. Eleven of 41 (22%) foetal spines were abnormal: eight foetuses had myelomeningocoeles and Chiari 2 deformities, one foetus had limited dorsal myeloschisis, one foetus had caudal regression syndrome, and one had diastematomyelia. The post-mortem MRI findings concurred with the autopsy findings in 10/11 of the abnormal cases, the disagreement being the case of diastematomyelia that was shown on post-mortem MRI but was not diagnosed at autopsy. CONCLUSIONS: In this series, post-mortem MRI findings agreed with the autopsy findings in 40/41(98%) cases and in one case the post-mortem MRI demonstrated an abnormality not demonstrated at autopsy.

Normal fetal lumbar spine on postmortem MR imaging.

BACKGROUND AND PURPOSE: There is an increasing interest in use of postmortem MR imaging as an adjunct or alternative to autopsy. Before evaluating spinal pathology on postmortem MR imaging, it is important to have knowledge of the normal appearance of the fetal spine at different gestational ages. The aim of this study is to describe the MR imaging appearances of normal development of the fetal spine at different gestational ages. METHODS: Postmortem MR imaging was performed on 30 fetuses ranging from 14 to 41 gestational weeks. There was no structural abnormality of the spine in these fetuses on MR imaging or at autopsy. Fast spin-echo T2-weighted MR imaging of the lumbar spine was performed in the coronal plane in all cases and supplemented by sagittal and/or axial imaging. The following parameters were measured: height of the L1/2 disk and L2 vertebral body and area of ossification center in L2 vertebral body as well as area of vertebral body. The signal intensity of the disk space and the vertebral level of conus termination were also assessed. RESULTS: The height and area of the vertebral body increased linearly with gestational age (P <.01). The increase in disk space was proportionally greater than the increase in vertebral body height as gestational age increased (P <.01). The disk space appeared as a linear low-signal-intensity area in fetuses < or = 21 weeks gestation but increasingly developed high signal intensity in the disk after 21 weeks. The size of the ossification center increased with gestational age (P <.01), and the ratio of ossification center to the overall size of the vertebral body also increased with gestational age (P <.01). In fetuses less than 35 weeks of age, the conus lay between L2 and L5 level, whereas in fetuses more than 35 weeks of age, the conus lay between L1/2 and L2/3 level. CONCLUSION: Understanding the normal growth and signal-intensity characteristics of the fetal spine on postmortem MR imaging is essential before studying abnormal fetal spine.

Post-mortem fetal MRI: what do we learn from it?

Post-mortem magnetic resonance (MR) imaging is of increasing interest not only as an alternative to autopsy but as a research tool to aid the interpretation and diagnosis of in utero MR images. The information from the post-mortem MR has allowed the development of imaging sequences applicable to in utero imaging and neonatal imaging. It has established brain development during gestation and has provided data on this to which in utero MR can be compared. The detail available from the post-mortem images is such that brain development can be studied in a non-invasive manner, a permanent record on the normal and abnormal areas is available and a greater understanding of developmental abnormalities is possible.

Post-mortem MRI as an adjunct to fetal or neonatal autopsy.

CONTEXT: Understanding what was wrong with a dead fetus or why a newborn child died can help the parents to grieve, while any findings can be used to inform the parents if there is a risk to future pregnancies and the level of risk. This information is mainly obtained from autopsies, but the number of parents agreeing to autopsy has dropped, which has prompted the search for adjuncts to autopsy. STARTING POINT: The UK's Chief Medical Officer outlined the rationale for exploring alternatives to autopsy in 2000 and 2001. After wide consultation, MRI was deemed to offer the most realistic chance of making a contribution. Results so far are promising, but of insufficient depth and quality to make firm recommendations about providing a service in the future. In 2004, the UK Department of Health therefore tendered for this research to be done in fetal and neonatal (and adult) cases, and this work is due to start in 2005. WHERE NEXT? High-quality anatomical information about the brain and spine of fetuses and neonates can be easily obtained with standard MRI scanners. Most developmental and acquired abnormalities can be seen on post-mortem MRI. More work needs to be done on organs not in the central nervous system, and heart malformations, in particular, might present diagnostic problems. A possible outcome could be whole-body MRI plus targeted biopsies of abnormalities taken under image guidance as an adjunct to formal autopsy.

Corroboration of in utero MRI using post-mortem MRI and autopsy in foetuses with CNS abnormalities.

AIMS: To corroborate the findings of in utero magnetic resonance imaging (MRI) with autopsy and post-mortem MRI in cases of known or suspected central nervous system (CNS) abnormalities on ultrasound and to compare the diagnostic accuracy of ante-natal ultrasound and in utero MRI. METHODS: Twelve pregnant women, whose foetuses had suspected central nervous system abnormalities underwent in utero MRI. The foetuses were imaged using MRi before autopsy. The data were used to evaluate the diagnostic accuracy of in utero MRI when compared with a reference standard of autopsy and post-mortem MRI in 10 cases and post-mortem MRI alone in two cases. RESULTS: The diagnostic accuracy of antenatal ultrasound and in utero MRI in correctly characterizing brain and spine abnormalities were 42 and 100%, respectively. CONCLUSION: In utero MRI provides a useful adjuvant to antenatal ultrasound when assessing CNS abnormalities by providing more accurate anatomical information. Post-mortem MRI assists the diagnosis of macroscopic structural abnormalities.

Comparison of ultrasound and magnetic resonance imaging in 100 singleton pregnancies with suspected brain abnormalities.

OBJECTIVE: To compare the diagnostic accuracy of the current reference standard-ultrasound with in utero magnetic resonance imaging, in a selected group of patients. DESIGN: Prospective study. SETTING: Five fetal maternal tertiary referral centres and an academic radiology unit. SAMPLE: One hundred cases of fetuses with central nervous system abnormalities where there has been diagnostic difficulties on ultrasound. In 48 cases the women were less than 24 weeks of gestation and in 52 cases later in pregnancy. METHODS: All women were imaged on a 1.5 T clinical system using a single shot fast spin echo technique. The results of antenatal ultrasound and in utero magnetic resonance were compared. MAIN OUTCOME MEASURES: The definitive diagnosis was made either at autopsy or by postmortem magnetic resonance imaging, in cases that went to termination of pregnancy, or a combination of postnatal imaging and clinical follow up in the others. RESULTS: In 52 of cases, ultrasound and magnetic resonance gave identical results and in a further 12, magnetic resonance provided extra information that was judged not to have had direct effects on management. In 35 of cases, magnetic resonance either changed the diagnosis (29) or gave extra information that could have altered management (6). In 11 of the 30 cases where magnetic resonance changed the diagnosis, the brain was described as normal on magnetic resonance. CONCLUSIONS: In utero magnetic resonance imaging is a powerful tool in investigating fetal brain abnormalities. Our results suggest that in selected cases of brain abnormalities, detected by ultrasound, antenatal magnetic resonance may provide additional, clinically useful information that may alter management.

Differential growth rates of the cerebellum and posterior fossa assessed by post mortem magnetic resonance imaging of the fetus: implications for the pathogenesis of the chiari 2 deformity.

PURPOSE: To evaluate post mortem magnetic resonance imaging of the fetus to provide data on the rate of growth of the cerebellum, bony posterior fossa, supratentorial bony compartment and cerebrum. MATERIAL AND METHODS: Twenty fetuses subsequently shown to have normal brain and spines on autopsy were studied using MRI post mortem. MRI from 20 normal pediatric brain examinations in children aged 6 years or younger were studied for comparison. Post mortem MRI was performed using a high-resolution fast spin echo technique providing T2 weighted images. The area of the cerebellar vermis, posterior fossa, supratentorial skull cavity and cerebral hemispheres was measured in the sagittal plane in all cases. These measurements were compared over the age ranges studied. RESULTS: We have shown that there are differences in the rate of growth and the apparent commencement of growth between the structures under study. The cerebellum appeared to start its significant growth at 16.5 weeks with a rate of 16 mm2/week throughout pregnancy, while the cerebral hemisphere appeared to commence significant growth at 13 weeks at a rate of 184 mm2/week throughout pregnancy. This is in contrast to the bony posterior fossa, whose growth paralleled the supratentorial bony compartment at all ages studied. CONCLUSION: We interpret our findings as showing relatively late commencement of cerebellar growth compared to the cerebral hemispheres, whereas the growth of the bony posterior fossa appears to be in advance and independent of cerebellar growth. Our results support the hypothesis that posterior fossa development depends on raised hydrostatic pressure in the CSF containing structures of the posterior fossa. When this mechanism fails, as in some cases of myelomeningocoele, a small posterior fossa is formed which characterizes the Chiari 2 malformation.

Influencing sceptical staff to become supporters of service improvement: a qualitative study of doctors' and managers' views.

OBJECTIVE: To explore scepticism and resistance towards changes in working practice designed to achieve service improvement. Two principal questions were studied: (1). why some people are sceptical or resistant towards improvement programmes and (2). what influences them to change their minds. METHODS: Semi-structured qualitative interviews were conducted with 19 clinicians and 19 managers who held national and regional roles in two national programmes of service improvement within the NHS involving systematic organisational changes in working practices: the National Booking Programme and the Cancer Services Collaborative (now the Cancer Services Collaborative Improvement Partnership). RESULTS: Scepticism and resistance exist in all staff groups, especially among medical staff. Reasons include personal reluctance to change, misunderstanding of the aims of improvement programmes, and a dislike of the methods by which programmes have been promoted. Sceptical staff can be influenced to become involved in improvement, but this usually takes time. Newly won support may be fragile, requiring ongoing evidence of benefits to be maintained. CONCLUSIONS: The support of health service staff, particularly doctors, is crucial to the spread and sustainability of the modernisation agenda. Scepticism and resistance are seen to hamper progress. Leaders of improvement initiatives need to recognise the impact of scepticism and resistance, and to consider ways in which staff can become positively engaged in change.