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Pre-capillary pulmonary hypertension (PHT) is characterised by progressive pulmonary vascular obliteration and loss of vascular reserves. In health, regional lung perfusion redistributes under the influence of gravity due to the presence of recruitable vessels. We investigated a combined single photon emission computed tomography/CT (SPECT/CT) method for assessing the pulmonary circulation by quantifying the gravity dependent redistribution of lung perfusion.Characterisation of patients versus healthy controls.15 patients with pre-capillary PHT and 11 healthy controls.University hospital clinic.Regional lung perfusion was measured using SPECT/CT in two different postures (supine vs upright). A perfusion redistribution index (PRI) was used to quantify the cranial-caudal shift in regional lung perfusion resulting from gravitational (postural) change.PRI was compared between cases and controls, and correlated with markers of disease severity in cases.Patients with pre-capillary PHT had notably reduced PRI compared to controls (0.02±0.06 vs. 0.28±0.15 normalised perfusion/cm, p0.0001). PRI was significantly associated with prognostic parameters such as 6 min walk distance (r=0.60, p=0.018), functional class (p=0.008), and tricuspid annular plane systolic excursion (r=0.58, p=0.022). The receiver operating characteristic curve showed that PRI differentiated patients with pre-capillary PHT from controls with AUC=0.94 (p0.001).With SPECT/CT, gravity dependent redistribution of lung perfusion can be quantified using the PRI derived from supine and upright perfusion analysis. The potential utility of PRI for the non-invasive detection of PHT and assessment of disease severity warrants further study.

Rationale and Objectives Lymphoscintigraphy may be used for diagnosing secondary lymphedema. Dermal backflow, the presence of radiotracer in dermal lymphatics, is a key clinical feature. Although often reported as present or absent, a scale that assesses the severity of dermal backflow has been previously developed. The aim of this study was to determine the reliability of these two methods of assessment. Materials and Methods Sixteen experienced nuclear medicine physicians assessed the quantity of dermal backflow of 57 lymphoscintigraphy scans using a 4-point descriptive scale that was dichotomized for secondary analysis. Each scan included images from four time points for women previously diagnosed with secondary lymphedema (n = 47) and controls (n = 5); five scans were presented twice to examine intraobserver reliability. This was further investigated as 13 physicians viewed the scans again on an Apple iPad2. The physicians rated their confidence in their scoring. Readers were blinded to clinical history. Results Although both the 2- and 4-point scale had moderate interobserver reliability, the reliability of the 2-point scale was slightly higher (4-point: Fleiss κ = .418, standard error [SE] = .008); 2-point: Fleiss κ = .574, SE = .013). Low interobserver reliability was found when only control subjects were considered (Fleiss κ = 0.055, SE = 0.034). Intraobserver reliability of the five repeated images varied from poor to perfect (Cohen κ = .063 to 1.00), whereas moderate to substantial intraobserver reliability (Cohen's κ = .342 to .752) was found when comparing devices. The readers were highly confident of their scores. Conclusions Overall, moderate intraobserver and interobserver reliability was found for quantifying dermal backflow with both the 2- and 4-point scale.

The secondary school system in England has undergone a radical transformation since 2010 with the rapid expansion of independent academies run by private companies (‘academy trusts’) and funded directly by central government. This paper examines the development of academies and their predecessors, city technology colleges, and explores the extent and nature of continuity and change. It is argued that processes of layering and policy revision, together with austerity measures arising from economic recession, have resulted in a system-wide change with private, non-profit-making companies, funded by central government, rapidly replacing local authorities as the main providers of secondary school education.

The Issue We needed cost effective in-house communication skills education to suit all levels of staff and volunteers to ensure they had the knowledge, skills and confidence to communicate effectively with patients, their families and with each other. Why it is important All of our staff and volunteers will at some time be supporting people in distress. Clinical staff often have ‘big’ conversations with their patients – breaking bad news etc. They can only do this if they have the right communication skills and the confidence to use them. What was done We developed a three- tier programme of interactive communication skills workshops called CLEARER. Communication CARE A two-hour workshop at an introductory level to develop basic skills for communicating compassionately and sensitively with others. CLEAR A four-hour workshop at a foundation level to develop skills to hold clear, sensitive and honest conversations about care options, explore patient experiences, needs, priorities and choices. CLEAREST A full day workshop at an intermediate level aimed at qualified clinical staff that develops skills reflecting, analysing and applying communication strategies to ensure effective compassionate conversations in challenging circumstances. Workshops have been delivered regularly since 2013. Evaluation Participants completed post workshop evaluations and were observed in practice using their skills. Outcomes Staff reported increased confidence in having ‘big’ conversations and supporting people in distress. Feedback form patients and their families indicates staff and volunteers do communicate effectively and compassionately. Future The demand for workshops from outside the hospice exceeded the capacity to provide them. To address this issue we have worked with our Clinical Commissioning Groups (CCGs) who were looking to provide communication skills education to people working in health and social care. The CCGs are adopting our CLEARER Communication Programme and supporting the training of facilitators to deliver the workshops.

The issue The need for high-quality, flexible, cost effective communication skills education for all groups of staff and all levels of experience was identified by the Clinical Commissioning Groups (CCGs) in our locality. In our hospice we deliver our own communication skills education programme (CLEARER Communication) with three levels of workshops – CARE, CLEAR and CLEAREST. These are very well evaluated and fitted the identified need. However, there was not enough capacity to meet the demand. Why it is important We can provide excellent care when staff have knowledge, skills and confidence to communicate effectively and compassionately with patients, their families and each other. Education at the right level to achieve this must be readily accessible. What is being done Working with the CCGs, we identified 10 workshop facilitators from partner organisations and planned their training. We successfully bid for funding from the Multi-Professional Education and Training (MPET) budget held by the CCGs to train facilitators, fund administrative support and deliver the workshops. The new facilitators will also build confidence by co-facilitating the CARE, CLEAR and CLEAREST workshops with the programme lead. Then they will each deliver all three workshops each quarter. Evaluation will be via pre and post course questionnaires, evaluation forms and impact assessments. Expected outcomes Workshop places will increase from 100 per year to 2000. We expect to see an increase in knowledge, skill and confidence of participants. Ways of assessing impact on patient care are under development. Consistency and quality will be monitored by the programme lead. Sustainability MPET Funding will allow the programme to be delivered free to staff of partner organisations until end 2018. Charging staff from other organisations will provide an income stream to support ongoing provision.

Leadership is a word often heard in any workplace, and healthcare services are no different. Much has been written about leadership styles and theories, with a search of one online retailer revealing 153,589 books available on the subject. How many midwives have those books on their shelves? In a time when maternity services are rising to meet new pressures and demands, many commentators are calling for leadership to drive the profession on. How do we, as midwives, reflect on our own leadership style and the impact it has on others? Here we discuss the importance of leadership in midwifery as a profession, and to individuals, regardless of grade or position. We use an example of a project within our service to illustrate the opportunities for leadership to flourish throughout a whole team in order to achieve an end goal.

Subtype H7 avian–origin influenza A viruses (AIVs) have caused at least 500 confirmed human infections since 2003 and culling of >75 million birds in recent years. Here we antigenically and genetically characterized 93 AIV isolates from North America (85 from migratory waterfowl [1976–2010], 7 from domestic poultry [1971–2012], and 1 from a seal [1980]). The hemagglutinin gene of these H7 viruses are separated from those from Eurasia. Gradual accumulation of nucleotide and amino acid substitutions was observed in the hemagglutinin of H7 AIVs from waterfowl and domestic poultry. Genotype characterization suggested that H7 AIVs in wild birds form diverse and transient internal gene constellations. Serologic analyses showed that the 93 isolates cross-reacted with each other to different extents. Antigenic cartography showed that the average antigenic distance among them was 1.14 units (standard deviation [SD], 0.57 unit) and that antigenic diversity among the H7 isolates we tested was limited. Our results suggest that the continuous genetic evolution has not led to significant antigenic diversity for H7 AIVs from North America. These findings add to our understanding of the natural history of IAVs and will inform public health decision-making regarding the threat these viruses pose to humans and poultry.

The regional pattern and extent of airway closure measured by three-dimensional ventilation imaging may relate to airway hyperresponsiveness (AHR) and peripheral airways disease in asthmatic subjects. We hypothesized that asthmatic airways are predisposed to closure during bronchoconstriction in the presence of ventilation heterogeneity and AHR. Fourteen asthmatic subjects (6 women) underwent combined ventilation single photon emission computed tomography/computed tomography scans before and after methacholine challenge. Regional airway closure was determined by complete loss of ventilation following methacholine challenge. Peripheral airway disease was measured by multiple-breath nitrogen washout from which Scond (index of peripheral conductive airway abnormality) was derived. Relationships between airway closure and lung function were examined by multiple-linear regression. Forced expiratory volume in 1 s was 87.5 ± 15.8% predicted, and seven subjects had AHR. Methacholine challenge decreased forced expiratory volume in 1 s by 23 ± 5% and increased nonventilated volume from 16 ± 4 to 29 ± 13% of computed tomography lung volume. The increase in airway closure measured by nonventilated volume correlated independently with both Scond (partial R2 = 0.22) and with AHR (partial R2 = 0.38). The extent of airway closure induced by methacholine inhalation in asthmatic subjects is greater with increasing peripheral airways disease, as measured by ventilation heterogeneity, and with worse AHR.

Plastic resin pellets collected from remote islands in the Pacific, Atlantic, and Indian Oceans and the Caribbean Sea were analyzed for polychlorinated biphenyls (PCBs), dichloro-diphenyltrichloroethane and its degradation products (DDTs), and hexachlorocyclohexanes (HCHs). Concentrations of PCBs (sum of 13 congeners) in the pellets were 0.1-9.9 ng/g-pellet. These were 1-3 orders of magnitude smaller than those observed in pellets from industrialized coastal shores. Concentrations of DDTs in the pellets were 0.8-4.1 ng/g-pellet. HCH concentrations were 0.6-1.7 ng/g-pellet, except for 19.3 ng/g-pellet on St. Helena, where current use of lindane is likely influence. This study provides background levels of POPs (PCBs

AIM A voluntary audit was undertaken to compare left ventricular ejection fraction (LVEF) calculations from gated heart pool studies using software packages currently available throughout Australia and New Zealand (ANZ). METHODS A data set previously developed by a task group of the Institute of Physics and Engineering in Medicine (IPEM) consisting of 12 planar gated studies with LVEF ranging from 17 to 67% was provided to each site with worksheets to record individual technologist's results as well as information about individual department's equipment, software used for calculation of LVEF and experience of the analysers. Data analysis included calculation of an overall mean LVEF and standard deviation (SD) for all patients, which were compared with the mean IPEM LVEF. A comparison among software packages was done to examine differences in mean LVEF. RESULTS Results were received from a total of 22 sites using six different software packages, with 187 processed studies included for analysis. Reproducibility of studies 4 and 8 showed good agreement, with an SD of 1.0 EF units (P=0.5290). Good correlation was found between the ANZ mean LVEF and the corresponding IPEM value per patient study, with R=0.98. The ANZ overall mean LVEF was 47%, which was higher that the IPEM mean by 4.9 EF units. The average difference among all software packages was +5.1 EF units. CONCLUSION Differences were found between the IPEM mean and the ANZ mean LVEF. Variability in LVEF values between software packages was demonstrated, with an average of 5.1 EF units. The ANZ overall mean for LVEF was 47.2%, being 4.9 EF units higher than the IPEM value.

The objective of the study is to retrospectively measure patient radiation dose resulting from whole body X-ray CT and FDG PET studies using a low-dose protocol performed on the Siemens Biograph mCT scanner. A total of 483 patient studies were reviewed. For each, the CT dose-length product was used to estimate radiation dose to the patient as a result of the whole body X-ray CT component of the PET/CT study. The net injected FDG dose was used to calculate the whole body effective dose based on ICRP recommendations. Dose calculations were also modified to take into account individual patient weight. The total effective dose received by each patient was taken as the sum of the PET and CT components of the study. The mean effective dose from the CT component of the diagnostic study was found to be 8.2 mSv (3.4-23.4 mSv), for a CT protocol of 120 kV(p) and effective tube current-time product of 80 mAs with automatic exposure control. For an average injected FDG activity of 304 MBq the mean PET effective dose was found to be 6.3 mSv when using the ICRP standard models, or 6.0 mSv when scaling effective dose to individual patient weight or patient blood volume. The average total effective dose across the entire patient cohort for a combined PET/CT study was found to be ~14.5 mSv (9.6-29.8 mSv). Low-dose protocols for whole-body PET/CT scanning result in an effective radiation dose to the patient of approximately 14.5 mSv. Additional reductions through the use of iterative CT reconstruction and optimized low-dose FDG protocols could see total effective doses for whole-body PET/CT fall to below 10 mSv.

Predicting the impact of warming and acidifying on oceans on the early development life history stages of invertebrates although difficult, is essential in order to anticipate the severity and consequences of future climate change. This review summarises the current literature and meta-analyses on the early life-history stages of invertebrates including fertilisation, larval development and the implications for dispersal and settlement of populations. Although fertilisation appears robust to near future predictions of ocean acidification, larval development is much more vulnerable and across invertebrate groups, evidence indicates that the impacts may be severe. This is especially for those many marine organisms which start to calcify in their larval and/or juvenile stages. Species-specificity and variability in responses and current gaps in the literature are highlighted, including the need for studies to investigate the total effects of climate change including the synergistic impact of temperature, and the need for long-term multigenerational experiments to determine whether vulnerable invertebrate species have the capacity to adapt to elevations in atmospheric CO2 over the next century.

Combining the functional data provided by single-photon emission computed tomography (SPECT) with the anatomical information provided by CT has been shown to improve overall diagnostic accuracy in many areas of nuclear medicine. Although planar lung scans have often relied on correlation with a chest x-ray to help optimize scan interpretation, the advent of 3D lung imaging with SPECT provides the opportunity to combine lung perfusion data with CT images. This can be done by performing the study on a hybrid SPECT/CT scanner, with the CT acquisition typically performed with the use of low-dose parameters, rather than full diagnostic quality settings, or by software fusion with a fully diagnostic CT or a contrast-enhanced CT pulmonary angiogram. Such an approach has been shown to improve specificity and overall accuracy of ventilation/perfusion scintigraphy as well as facilitating more accurate clot localization. With the increased availability of hybrid SPECT/CT scanners, such an approach can be implemented in most imaging departments with little additional acquisition time or radiation dose. Misregistration caused by respiratory motion can impact combined studies, although this can be minimized with attention to patient breathing patterns during image acquisition. For patients with lung cancer, ventilation/perfusion SPECT/CT may have a role in allowing the optimal selection of radiotherapy fields and can improve the preoperative quantification of lung function before resection.

In this article we review protocols for ventilation-perfusion (V/Q) imaging with current generation technology. Although many groups have expressed interest in moving from planar lung V/Q imaging to single-photon emission computed tomography (SPECT) methods, few resources or guidelines exist for suggested protocols. Here, we provide an introduction to help establish protocols for planar and SPECT V/Q imaging and display that should be readily transferable into a clinical department's routine practice. We emphasize, in particular, the need for a good ventilation study and that acquiring planar images as well as SPECT can be negated by producing acceptable planar-like images from the SPECT data.

Background: We have previously developed and validated a method to achieve quantitative SPECT data based on CT-derived corrections, for the radionuclide 99m Tc in phantoms and in man for lung scanning. This clinical study was performed to investigate the accuracy of this method when applied to cardiac blood pool imaging. The study involves tagging the radionuclide 99m Tc to erythrocytes in a sample of the subject’s blood before it is re-injected. After a short time, the radiolabelled cells achieve an equilibrium concentration in the blood pool, such that SPECT imaging allows the radioactivity concentration of blood present in the left ventricle to be measured. Methods and results: Absolute concentration of radioactivity inside the left ventricle of the heart was compared to true concentrations measured directly from a peripheral venous blood sample taken from the subject at the time of scanning. In 12 subjects, the average difference between the measured and true concentrations was found to be within ∼1% of the true value with a range of (-6 to +5)%. Conclusions: This study demonstrates the accuracy of CT-based quantitative SPECT in clinical cardiac blood pool imaging, and we anticipate that similar accuracy could be achieved in the myocardium.

BACKGROUND: While there was initial disregard and argument that exposure to pain, stress and discomfort experienced by NICU babies is an inevitable and an inherent consequence related to the sickness, research has shown its long lasting consequences with alterations in brain structure, function and poor neurodevelopmental outcomes. However there is a lack of measurement systems and metrics to identify the magnitude of the problem, describe patterns and follow …

During the fourteenth and early fifteenth centuries in Florence there was a growth in the production and acquisition of small religious paintings for use in prayer in the home.1 Simultaneously, there was an increase in the availability of devotional literature, spiritual writings, and sermons composed for laypeople.2 How did the Florentine layperson of the late fourteenth and early fifteenth centuries combine word and image in a private ritual whose purpose was to lift the mind to God? In considering that question, I will refer to the diary, or Ricordi, of Giovanni Morelli (1371-1444), a merchant who was enrolled in the Arte della Lana.3 Mo

Traditional palliative care services have focused on individuals with cancer. The NHS National End of Life Care Programme, launched in December 2003, has been working to address this anomaly and to try to enhance end of life care provision for other patient groups. This article reports on work in the area of renal failure at Westmorland General Hospital, Cumbria, where the Preferred Priorities for Care tool has been introduced to support patients nearing the end of life.

Brain metastases (BM) are among the most devastating and debilitating complications of melanoma. This retrospective study was conducted to gain a better understanding of patient and disease characteristics that have the greatest impact on overall survival in melanoma patients with BM; therapeutic interventions were also assessed. The records of all patients diagnosed with cutaneous melanoma and BM who were seen at Memorial Sloan-Kettering Cancer Center between 1991 and 2001 were retrospectively reviewed. A variety of factors, including age at diagnosis of stage IV disease, gender, race, disease stage at diagnosis, presence of BM at diagnosis of stage IV disease, neurologic symptoms, radiographic findings, number of BM, status and site(s) of extracranial metastasis, and treatment modalities, were analyzed for correlation with overall survival using univariate and multivariate Cox regression models. The records of 355 patients with BM were included in the analysis. On univariate analysis, seven patient and disease characteristics were significantly associated with poorer survival: age > 65 years, extracranial metastases, BM at stage IV diagnosis, neurologic symptoms, four or more BM, hydrocephalus, and leptomeningeal metastases. Of these, age, extracranial metastasis, neurologic symptoms, and number of BM were significantly associated with poorer survival in a multivariate analysis. Multivariate analysis of treatment modalities suggested that patients who had surgery, radiosurgery, or chemotherapy with temozolomide had improved survival outcomes, although this analysis has limitations. The prognostic factors identified in this retrospective study should be considered when making treatment decisions for patients with BM and used as stratification factors in future clinical trials.

To compare interpretation of traditional planar ventilation-perfusion lung scan images with planar images reformatted from single photon emission computed tomography (SPECT) data using two different techniques.Planar and SPECT ventilation-perfusion (V/Q) data were acquired from 50 patients referred with suspected pulmonary embolism. In addition to traditional six-view planar images, six-view planar images were also generated from SPECT data using two methodologies: an angular summing technique (angular summed planar images) and a forward projection technique (reprojected planar images). Three experienced nuclear medicine clinicians reviewed the images in a blinded, randomized fashion. Results were analysed by comparing the two reprojected techniques with the traditional true planar scans, examining for differences in the defects seen (number, type and confidence), and the impact on final clinical interpretation.Compared with true planar scintigraphy, angular summed images demonstrated fewer mismatched defects (P0.0001), while the reprojected planar images had more matched defects (P=0.013). In addition, there was a significant change in the clinical interpretation of the angular summed planar images resulting in clinicians perceiving a decreased likelihood of pulmonary embolism (P0.016). No such difference in interpretation was observed for the reprojected planar images.Angular summed planar images result in a perceived decreased likelihood of pulmonary embolism compared with true planar images. In contrast, while reprojected planar images result in an increased number of matched defects compared to true planar scans, there was no change in the clinical interpretation. Caution should be exercised when interpreting SPECT derived angular summed planar images in isolation.

Purpose Lung scintigraphy using single photon emission computed tomography (SPECT) allows accurate regional measurement of the ventilation/perfusion (V/Q) relationship. Objective V/Q analysis has been shown to be useful in the diagnosis of pulmonary embolism (PE). By using anatomical information provided by co-registered computed tomography, we describe methodology for determining the extent of V/Q heterogeneity at a lobar level. We investigate this methodology using simulated data, and demonstrate its potential application in the clinical setting of PE. Methods Data representing an incremental perfusion defect involving the right lung, together with an unaffected ventilation dataset, were modelled using Monte Carlo simulation. For each increase in the size of the perfusion defect, the whole lung V/Q relationship was objectively determined. In addition, using an image mask of the pulmonary lobes, lobar V/Q relationships were also determined. V/Q heterogeneity was characterized using the log(10) standard deviation of the V/Q ratio (log SDVQR), ventilation (log SDV) and perfusion (log SDQ) distributions. Finally, this methodology was explored in clinical cases. Results As an increasing number of segments were involved by perfusion defects, there was a progressive increase in all objective parameters of V/Q heterogeneity. The relative change was greatest for log SDV. Analysis of both the simulated and clinical studies demonstrated sensitive changes in the lobar V/Q profiles to the presence of PE. Conclusions Segmentation and analysis of SPECT ventilation-perfusion scintigraphy at a lobar level can be used to quantify regional V/Q relationships. This objective methodology is sensitive to the presence of PE, and may be useful in a clinical setting.

Ventilation-perfusion scintigraphy is highly sensitive for pulmonary embolism (PE), but its clinical usefulness is limited by its nondiagnostic rate. Objective analysis of single photon emission computed tomography (SPECT) three-dimensional scintigraphy may improve its diagnostic performance compared with subjective interpretation.To determine the diagnostic accuracy of objective SPECT analysis in PE.We determined the ventilation/perfusion (V(.)/Q(.)) relationship using SPECT scintigraphy in a retrospective cohort of 73 patients. Measures of V(.)/Q(.) heterogeneity (logSD(Q(.)), logSD(V(.)), logSD(VQR)), including a novel parameter, the weighted median V(.)/Q(.) value, were calculated. Using receiver operating characteristic (ROC) analysis, each parameter's diagnostic accuracy was determined. The weighted median V(.)/Q(.) value was then assessed prospectively in a second cohort of 50 patients.In cohort 1, all parameters of V(.)/Q(.) heterogeneity were higher in patients with PE (p0.002). The weighted median V(.)/Q(.) had the highest area under the ROC curve (0.93; 95% confidence interval, 0.87-0.98). When applied to the prospective cohort, the area under the ROC curve was 0.87 (95% confidence interval, 0.75-0.99), with diagnostic cutoff values having negative and positive predictive values of 96 and 83%, respectively. In the retrospective and prospective cohorts, 82 and 73% of initially reported intermediate or low probability scans had diagnostic weighted median V(.)/Q(.) values, with 90 and 100% accuracy, respectively.Objective analysis of SPECT scintigraphy has a high diagnostic accuracy in patients with suspected PE. Objective analysis has the potential to reduce the number of nondiagnostic scan results, and may be useful for quantifying V(.)/Q(.) mismatch in other pulmonary disorders.

Background: Precapillary pulmonary hypertension (PrecapPH), characterised by obliteration of the pulmonary arteries, alters ventilation (V)-perfusion (Q) relationships. Limited studies have explored the non-invasive quantification of VQ heterogeneity using single photon emission computed tomography (SPECT) in PrecapPH. Objective: We measured and compared SPECT-derived VQ heterogeneity in health and PrecapPH . The influence of posture on cranial-caudal V and Q gradients were also assessed. Methods: Regional V and Q were quantified in supine and upright positions in: 1. Healthy controls (n = 13), 2. Pulmonary arterial hypertension (PAH) (n = 10) and 3. Chronic thromboembolic pulmonary hypertension (CTEPH) (n = 8). Measures of VQ heterogeneity (log SD Q, log SD V) were derived from normalized VQ counts at each voxel. The influence of posture on cranial-caudal V and Q gradients were measured. Results: The distributions of log SD Q for controls, PAH and CTEPH were (0.16±0.03, 0.22±0.03, 0.26±0.06: p SD V (0.17±0.03, 0.21±0.06, 0.31±0.15: p Conclusion: Wider heterogeneity in ventilation and perfusion in CTEPH is due to non-homogenous obstruction of pulmonary vascular bed. Quantification of VQ heterogeneity using SPECT can provide insights into the pathophysiological sequalae pulmonary vascular obstruction.

OBJECTIVES In lung cancer preoperative evaluation, functional lung imaging is commonly used to assess lobar function. Computed tomography ventilation (CT-V) imaging is an emerging lung function imaging modality. We compared CT-V imaging assessment of lobar function and its prediction of postoperative lung function to that achieved by (i) positron emission tomography ventilation (PET-V) imaging and (ii) the standard anatomical segment counting (ASC) method. We hypothesized (i) that CT-V and PET-V have similar relative lobar function and (ii) that functional imaging and anatomic assessment (ASC) yield different predicted postoperative (ppo) lung function and therefore could change clinical management. METHODS In this proof-of-concept study, 11 patients were subjected to pulmonary function tests, CT-V and PET-V imaging. The Bland-Altman plot, Pearson's correlation and linear regression analysis were used to assess the agreement between the CT-V-, PET-V- and ASC-based quantification of lobar function and in the ppo lung function. RESULTS CT-V and PET-V imaging demonstrated strong correlations in quantifying relative lobar function (r = 0.96; P < 0.001). A Wilcoxon-signed rank test showed no significant difference in the lobar function estimates between the two imaging modalities (P = 0.83). The Bland-Altman plot also showed no significant differences. The correlation between ASC-based lobar function estimates with ventilation imaging was low, r < 0.45; however, the predictions of postoperative lung function correlated strongly between all three methods. CONCLUSIONS The assessment of lobar function from CT-V imaging correlated strongly with PET-V imaging, but had low correlations with ASC. CT-V imaging may be a useful alternative method in preoperative evaluation for lung cancer patients.

Smallholdings in the rural areas of northwest Syria are a result of land fragmentation that is due to inheritance. Because of rapid population growth combined with land fragmentation, these smallholdings are increasing and cannot sustain the rural households whose sizes and needs are also increasing rapidly This situation has led to increasing numbers of males migrating to urban areas in Syria and to neighbouring countries looking for work opportunities. In addition, recent agricultural intensification trends seem to have led to the emergence of a waged labour force which, in the absence of male workers owing to significant rates of migration, is now predominantly female. Agricultural labour use depends upon household characteristics and resources (type of labour used, gender of labour waged/exchanged/familial). The article attempts to present a comprehensive analysis of household labour use in distinctive farming systems in one region of Syria that has undergone great change in recent decades, and examin...

395 Background: The 5 year (yr) overall survival (OS) of pancreas cancer (PC) is < 5%. Surgical resection is the only curative treatment (tx), most relapse within 2yrs. Neoadjuvant (NA) tx can benefit by eradicating micro-metastases, avoids futile surgery if metastases develop, improves dose intensity and may down stage disease. Currently, there are no data that clearly demonstrate improved OS with NA tx. Randomised trials are in progress. Methods: A retrospective analysis of all patients (pts) who received NA therapy across campuses,in Sydney, was performed. Pt records were identified and all were discussed in a MDT by a panel of PC specialists. Results: 588 PC pts were treated between August 2011-July 2016. After consideration of anatomy, pt characteristics and preference 82 pts (14%) received NA tx, 30% were resected upfront. 26 pts were ‘borderline’ and received sequential chemo-radiotherapy (ctxRT). Median age at diagnosis (dx) was 73 yrs, 50% were men. Median follow up time was 31.2 months (m). 84% pts were resected. There was 1 death at 90 days. An R0 was achieved in 74%. A detailed tx overview will be provided. Most received gemcitabine/abraxane. For those who had PET, low SUV pre-operative correlated with high pathological regression score, 3 pts 0%. Median OS for all pts was 25.9 m (95% CI 21.2, 30.2). Survival by stage: 1- 21.2 mo (11.8, 29.5); 2- 25.2 m; stage 3-4 (not reached). Pts who received ctx alone OS 25.3mo (17.2,29.5); ctxRT 29.0 m (17.3, NA) (p = 0.03). R0 survival was 29.0 m (21.2, NA) and R1, 23 m. 30% were alive at 3 yrs. Time to recurrence was 22.3 m (14.3, NA). Weight > 74kg was predictive of survival; OS 23.0 m v 29.5m (p = 0.002). There was a trend to survival benefit in females (p = 0.099) and baseline LDH < 280 (IU/L) (p = 0.07). Age at dx, ECOG (0 v 1), baseline albumin, bilirubin, Ca 19.9, NLR ( < 3.1) and CRP and stage at dx were not predictive of survival. Conclusions: This pt cohort demonstrates superior survival with NA therapy in selected pts across stages in a high volume multi-disciplinary PC centre. Outside a clinical trial, NA therapy is evolving to be our standard of care in fit pts with any degree of vessel involvement.

As a large NHS teaching trust we see 6,000 women a year who birth with us. Newly appointed as a modern matron, I noted that poor experience on our postnatal ward has always been a key issue in the complaints we receive and from the feedback that our women give to us. The ImPosE (improving postnatal experience) project was launched in December 2013. This brought together members of the multidisciplinary team who were committed to developing our postnatal ward and improving it for our women and their families. We used a quality management approach, putting 'customer' experience at the core, and implemented a varied package of changes as directed by feedback from service users.

The design of public policies aimed at human safety, environmental quality, and mitigation of economic harm--the balance between the role of government and of market forces--is a major challenge facing the 21st century. Two highly successful ideas from the 20th century have been most responsible for limiting and redefining the role of government-Coasian theory and contestability theory. Both theories provide practical corrective policies that, once adopted, allow market forces to beneficially hold sway. Coasian and contestability theories working together enable design of an improved regulatory framework for a broad set of new issues involving harm as we move into the 21st century.

Cellulitis is an acute infection of the dermal and subcutaneous layers of the skin, often occurring after a local skin trauma. It is a common diagnosis in both inpatient and outpatient dermatology, as well as in the primary care setting. Cellulitis classically presents with erythema, swelling, warmth, and tenderness over the affected area. There are many other dermatologic diseases, which can present with similar findings, highlighting the need to consider a broad differential diagnosis. Some of the most common mimics of cellulitis include venous stasis dermatitis, contact dermatitis, deep vein thrombosis, and panniculitis. History, local characteristics of the affected area, systemic signs, laboratory tests, and, in some cases, skin biopsy can be helpful in confirming the correct diagnosis. Most patients can be treated as an outpatient with oral antibiotics, with dicloxacillin or cephalexin being the oral therapy of choice when methicillin-resistant Staphylococcus aureus is not a concern.

Objective: The aim of this investigation is to determine the impact of hybrid single photon emission computed tomography/computed tomography (SPECT/CT) on the detection of parathyroid adenoma. Materials and methods: 16 patients presented with suspected parathyroid adenoma localised within the neck. All patients were injected with Tc-99m sestamibi and were scanned with a GE Infinia Hawkeye SPECT/CT. There were six negative and ten positive confirmed cases. Five expert radiologists specializing in nuclear medicine were asked to report on the 16 planar and SPECT data sets and were then asked to report on the same randomly ordered data sets with the addition of CT. Receiver operating characteristic (ROC) analysis was performed using the Dorfman-Berbaum-Metz multireadermulticase methodology and sensitivity and specificity values were generated. A significance level of p ≤ 0.05 was set for all comparisons. Results: ROC analysis demonstrated an AUC of 0.64 and 0.69 for SPECT and SPECT/CT respectively (p = 0.31). Mean sensitivity scores increased from 0.64 to 0.80 (p = 0.17) and specificity scores decreased from 0.57 to 0.40 (p = 0.17) with the addition of the CT data. Conclusion: This preliminary investigation suggests that extra CT information may increase lesion detection as well as false positive rates for SPECT-based investigations of a single parathyroid adenoma. However the difference in diagnostic efficacy between the two groups was not found to be statistically significant therefore requiring further investigation. These findings have implications beyond the clinical situation described here.

In the drier areas of Syria yields of barley, the principal crop, are low. Due to the variability in rainfall, fertilizer use is perceived as risky. Barley-fertilizer trials have been conducted on farmer's fields over a period of four years to investigate whether the large yield response to fertilizer observed on research sites could be achieved under farmers' conditions. Data were pooled across years and sites and response functions estimated. Simple optimization analysis shows that economic optimum fertilizer rates vary considerably with rainfall and relative prices. Historical rainfall data are combined with the estimated response functions, and stochastic dominance analysis is used to compare the riskiness of fertilizer treatments in terms of net benefits and benefit-cost ratios. Results show that, given the estimated expected rainfall in barley producing areas, fertilizer use, especially at low levels, may not be as risky as has been believed. Extensions of the methodology to include other environmental variables, or to target recommendations, are discussed.

To develop a method of producing lung ventilation and perfusion (V/Q) planar images using forward projection of reconstructed single-photon emission computed tomography (SPECT) images through approximate attenuation (micro) maps generated from the lung emission scans alone, as transmission-based micro maps may not be routinely available.Synthetic micro maps are derived from (99m)Tc photopeak and "scatter" windows for the attenuation correction of the SPECT images. The attenuation-corrected SPECT images are forward projected at appropriate angles to give the equivalent of planar images. This method allows high-count planar images, as well as the SPECT images, to be produced from a single SPECT acquisition. In addition, isolated "single lung" views of lateral and medial projections without "shine-through" from the contra-lateral lung, which have not been available previously, can be formed.Comparison of reprojected images produced from CT-derived or synthetic micro maps displayed similar detail and radiopharmaceutical distribution. In a blinded comparison of "true" planar images with those from reprojecting the SPECT data using the synthetic micro maps, no difference in mismatched defect detection was found, and hence it was confirmed that the reprojected planar images could replace true planar images with no loss in planar diagnostic sensitivity.The reprojected planar images provide high-count, high-quality images, which are comparable with conventional 2D images.