Promoting normality in the management of the perineum during the second stage of labour

The management of the perineum during birth has multiple long-term effects on women and their families. The midwife has a key role to play and often the techniques they employ vary significantly, as does their justification of these practices. This article seeks to examine current evidence to explore what is known to contribute to lower perineal trauma rates and what practices should be avoided to protect childbearing women. The conclusions drawn show that the updating of
practice and antenatal education may be required so that woman are given the information they need to make an informed choice as to what they want for their own body, child and experience.

Reflection of Qualitative Methods: “memoring” fieldwork experience in organisational research with photographs

The paper is a reflection on the use of photographs in multiple case study research. It explores the crossovers between interpreting visual artefacts, the qualitative approach to case study research in organisations, and the move from cases to theory guided by the grounded theory tenets. The paper proposes an additional use of photographs as a visual method to those in the literature, as a device for data analysis. Photograph-based analysis techniques are explored, using e sequence of individual images and photo collages on case data, moving from interpretation of single to multiple case themes. This makes the case of using photograph analysis as an interpretation device for case research to illuminate theory development.

Experience of Managing Head and Neck Cancer Patients Amongst Specialty Trainees in Restorative Dentistry

Background: Upon completion of Specialty Training in Restorative Dentistry, trainees (StRs) should
be proficient in maxillofacial prosthodontics to meet the restorative needs of head and neck cancer patients (HANC), and in preparation for the Intercollegiate Specialty Fellowship Examination (ISFE).1,2
Objective: The aim of this study is to collate and compare data relating to the training of Restorative Dentistry Rs in the management of HANC patients across different geographical locations within the British Isles. Methods: Current trainees were invited to complete an online questionnaire by the Specialty Registrars in Restorative Dentistry Group (SRRDG). Participants were asked to rate their confidence and experience in assessing and planning treatment for HANC patients, attending theatre and manufacturing surgical obturators, and in providing implants for appropriate cases. Respondents were also asked to appraise clinical and didactic teaching within their unit, and to rate their confidence of passing oncology- based questions in a future ISFE. Results: Responses were obtained from 21 StRs (n=21) training in all five countries within the British Isles. Most respondents were based in England (76%). A third were in their 5th year of training. Less than half reported that they were confident
of independently assessing (48%) or treatment planning (38%) HANC patients. More than half of StRs (52%) indicated that they were not confident of attending theatres alone and manufacturing a surgical obturator. One third (33%) rated their experience of treating oncology patients with implants as poor or very poor, including three in their 5th year of training. Less than one third rated didactic teaching in maxillofacial prosthodontics at their unit as good or excellent. Only 4 respondents indicated that they were confident of answering an ISFE oncology question on management of healthcare delivery. Six StRs expressed concerns over a lack of case-based exposure.
Conclusion: Experience and training in maxillofacial prosthodontics is inconsistent for StRs across the British Isles with many lacking in clinical exposure.

Pancreatic cancer: medical management (novel chemotherapeutics)

Pancreatic adenocarcinoma is the fourth leading cause of cancer death and has an extremely poor prognosis: The 5-year survival probability is less than 5% for all stages. The only chance for cure or longer survival is surgical resection; however, only 10% to 20% of patients have resectable disease. Although surgical techniques have improved, most who undergo complete resection experience a recurrence. Adjuvant systemic therapy reduces the recurrence rate and improves outcomes. There is a potential role for radiation therapy as part of treatment for locally advanced disease, although its use in both the adjuvant and neoadjuvant settings remains controversial. Palliative systemic treatment is the only option for patients with metastatic disease. To date, however, only the gemcitabine plus erlotinib combination, and recently the FOLFIRINOX regimen, have been associated with relatively small but statistically significant improvements in OS when compared directly with gemcitabine alone. Although several meta-analyses have suggested a benefit associated with combination chemotherapy, whether this benefit is clinically meaningful remains unclear, particularly in light of the enhanced toxicity associated with combination regimens. There is growing evidence that the exceptionally poor prognosis in PC is caused by the tumor's characteristic abundant desmoplastic stroma that plays a critical role in tumor cell growth, invasion, metastasis, and chemoresistance. Carefully designed clinical trials that include translational analysis will provide a better understanding of the tumor biology and its relation to the host stromal cells. Future directions will involve testing of new targeted agents, understanding the pharmacodynamics of our current targeted agents, searching for predictive and prognostic biomarkers, and exploring the efficacy of different combinations strategies.

Knowledge Management Techniques to Augment Textual CBR (PhD Thesis)

The past decade had witnessed an unprecedented growth in the amount of available digital content, and its volume is expected to continue to grow the next few years. Unstructured text data generated from web and enterprise sources form a large fraction of such content. Many of these contain large volumes of reusable data such as solutions to frequently occurring problems, and general know-how that may be reused in appropriate contexts. In this work, we address issues around leveraging unstructured text data from sources as diverse as the web and the enterprise within the Case-based Reasoning framework. Case-based Reasoning (CBR) provides a framework and methodology for systematic reuse of historical knowledge that is available in the form of problemsolution
pairs, in solving new problems. Here, we consider possibilities of enhancing Textual CBR systems under three main themes: procurement, maintenance and retrieval. We adapt and build upon the stateof-the-art techniques from data mining and natural language processing in addressing various challenges therein. Under procurement, we investigate the problem of extracting cases (i.e., problem-solution pairs) from data sources such as incident/experience
reports. We develop case-base maintenance methods specifically tuned to text targeted towards retaining solutions such that the utility of the filtered case base in solving new problems is maximized. Further, we address the problem of query suggestions for textual case-bases and show that exploiting the problem-solution partition can enhance retrieval effectiveness by prioritizing more useful query suggestions. Additionally, we illustrate interpretable clustering as a tool to drill-down to domain specific text collections (since CBR systems are usually very domain specific) and develop techniques for improved similarity assessment in social media sources such as microblogs. Through extensive empirical evaluations, we illustrate the improvements that we are able to
achieve over the state-of-the-art methods for the respective tasks.

The value of tests in the diagnosis and management of glaucoma.

PURPOSE:

To assess the noneconomic value of tests used in the diagnosis and management of glaucoma, and explore the contexts and factors that determine such value.

DESIGN:

Perspective.

METHODS:

Selected articles from primary and secondary sources were reviewed and interpreted in the context of the authors' clinical and research experience, influenced by our perspectives on the tasks of reducing the global problem of irreversible blindness caused by glaucoma. The value of any test used in glaucoma is addressed by 3 questions regarding: its contexts, its kind of value, and its implicit or explicit benefits.

RESULTS:

Tonometry, slit-lamp gonioscopy, and optic disc evaluation remain the foundation of clinic-based case finding, whether in areas of more or less abundant resources. In resource-poor areas, there is urgency in identifying patients at risk for severe functional loss of vision; screening strategies have proven ineffective, and efforts are hindered by the inadequate allocation of support. In resource-abundant areas, the wider spectrum of glaucoma is addressed, with emphasis on early detection of structural changes of little functional consequence; these are increasingly the focus of new and expensive technologies whose clinical value has not been established in longitudinal and population-based studies. These contrasting realities in part reflect differences among the value ascribed, often implicitly, to the tests used in glaucoma.

CONCLUSIONS:

The value of any test is determined by 3 aspects: its context of usage; its comparative worth and to whom its benefit accrues; and how we define historically what we are testing. These multiple factors

Specialty Registrars’ Experience of Managing Head and Neck Cancer Patients

Objective The aim of this study was to collate and compare data on the training of Specialty Registrars in Restorative Dentistry (StRs) in the management of head and neck cancer (HANC) patients across different training units within the UK and Ireland. Methods Current trainees were invited to complete an online questionnaire by the Specialty Registrars in Restorative Dentistry Group (SRRDG). Participants were asked to rate their confidence and experience of assessing and planning treatment for HANC patients, attending theatre alone and manufacturing surgical obturators, and providing implants for appropriate cases. Respondents were also asked to appraise clinical and didactic teaching at their unit, and to rate their confidence of passing a future Intercollegiate Specialty Fellowship Examination (ISFE)-station assessing knowledge of head and neck cancer. Results Responses were obtained from 21 StRs (n=21) training within all five countries of the British Isles. Most respondents were based in England (76%), with one StR in each of Scotland, Wales, Northern Ireland and the Republic of Ireland. A third (33%) were in their 5th year of training. Almost half of the StRs indicated that they were confident of independently assessing (48%) new patients with HANC, with fewer numbers reporting confidence in treatment planning (38%). The majority (52%) of respondents indicated that they were not confident of attending theatre alone and manufacturing a surgical obturator. A third (33%) rated their experience of treating HANC patients with implants as ‘poor’ or ‘very poor’, including three StRs in their 5th year of training. Less than one third (<33%) rated didactic teaching in maxillofacial prosthodontics at their unit as ‘good’ or ‘excellent’, and only 7 StRs indicated that they were confident of passing an ISFE-station focused on HANC. Conclusion Experience and training regarding patients with head and neck cancer is inconsistent for StRs across the UK and Ireland with a number of trainees reporting a lack of clinical exposure.

Evaluation of Restorative Dentistry Specialty Registrars’ Clinical Experience of Developmental Disorders: A Survey

Background

Specialty Registrars in Restorative Dentistry (StRs) should be competent in the independent restorative management of patients with developmental disorders including hypodontia and cleft lip/palate upon completion of their specialist training.1 Knowledge and management may be assessed via the Intercollegiate Specialty Fellowship Examination (ISFE) in Restorative Dentistry.2

Objective

The aim of this study was to collate and compare data on the training and experience of StRs in the management of patients with developmental disorders across different training units within the British Isles.

Methods

Questionnaires were distributed to all StRs attending the Annual General Meeting of the Specialty Registrars in Restorative Dentistry Group, Belfast, in October 2015. Participants were asked to rate their confidence and experience of assessing and planning treatment for patients with developmental disorders, construction of appropriate prostheses, and provision of dental implants. Respondents were also asked to record clinical supervision and didactic teaching at their unit, and to rate their confidence of passing a future ISFE station assessing knowledge of developmental disorders.

Results

Responses were obtained from 32 StRs (n=32) training within all five countries of the British Isles. The majority of respondents were based in England (72%) with three in Wales, and two in each of Scotland, Northern Ireland, and the Republic of Ireland. Approximately one third of respondents (34%) were in the final years of training (years 4-6). Almost half of the StRs reported that they were not confident of independently assessing (44%) new patients with a developmental disorder, with larger numbers (72%) indicating a lack of confidence in treatment planning. Six respondents rated their experience of treating obturator patients as ‘poor’ or ‘very poor’. The majority (56%) rated their experience of implant provision in these cases as ‘good’ or ‘excellent’ with three-quarters (75%) rating clinical supervision at their unit as ‘good’ or ‘excellent’. Less than half (41%) rated the didactic teaching at their unit as ‘good’ or ‘excellent’, and only 8 StRs indicated that they were confident of passing an ISFE station focused on developmental disorders.

Conclusion

Experience and training regarding patients with developmental disorders is inconsistent for StRs across the British Isles with a number of trainees reporting a lack of clinical exposure.

Strategic management in the Telecom industry to create competitive advantage

O presente trabalho teve por objetivos a identificação de uma estratégia e o desenvolvimento de um modelo que permita às operadoras de telecomunicações a sua sustentabilidade, bem como a identificação de caminhos para a adaptação a uma realidade sempre em mudança como é a da indústria das telecomunicações. Numa primeira parte do trabalho elaborou-se uma revisão de literatura do atual estado da arte das principais estratégias relevantes e com aplicação à indústria de telecomunicações. A pesquisa realizada investigou a estrutura atual da indústria de telecomunicações e o estado da competitividade das operadoras de telecomunicações. Dos resultados desta foi possível constatar uma evolução constante da tecnologia e dos modelos de negócio neste ecossistema, assim como a presença de uma pressão concorrencial significativa exercida sobre as operadoras, quer por parte das empresas já existentes no mercado quer por parte das emergentes. As operadoras têm de transformar o seu modelo de rede e de negócios para se adaptarem às mudanças e às tendências da indústria e do mercado. Com base na revisão de literatura, elegeu-se a metodologia baseada num inquérito de pesquisa empírica para aferir o estado da indústria e derivar as estratégias possíveis. Este inquérito foi efetuado a especialistas da área de telecomunicações de diferentes subsectores e países para abordar todos os elementos estratégicos do modelo de negócio futuro. Os resultados da pesquisa revelaram que as empresas que operam no mercado da Internet (Over The Top - OTT) representam a maior ameaça sobre o futuro dos operadores de telecomunicações. Os operadores só vão conseguir responder através da modernização de sua rede, melhorando a qualidade, reduzindo o custo global, e investindo em produtos inovadores e diferenciados e em serviços. Os resultados do inquérito revelam-se de acordo com os pressupostos da Blue Ocean Strategy. A aplicabilidade da Blue Ocean Strategy foi aprofundada permitindo concluir que o valor inovador obtido simultaneamente através da redução de custos e da diferenciação permitem aumentar as vantagens dos operadores existentes em termos das infra-estruturas físicas detidas e das relações estabelecidas com os clientes. O caso particular da fibra óptica até casa (FTTH) foi considerado como aplicação da Blue Ocean Strategy a uma nova tecnologia que as operadoras podem implementar para criar novas soluções e abrir segmentos de mercado inexplorados. Os resultados do inquérito e da investigação realizada à aplicação da Blue Ocean Strategy foram combinados para propor um novo modelo de negócio para as operadoras de telecomunicações que lhes permite, não só responder aos desafios existentes, mas, também, ter uma melhor posição competitiva no futuro. Foi, ainda, realizado um estudo de caso que destacou como a Verizon Communications foi capaz de transformar a sua rede e o modelo de negócio em resposta ao aumento da pressão competitiva. Através do valor da inovação transferida aos seus clientes, a Verizon foi capaz de aumentar significativamente as suas receitas e satisfação do cliente.

Decentralizing IP mobility management in future networks

The massive adoption of sophisticated mobile devices and applications led to the increase of mobile data in the last decade, which it is expected to continue. This increase of mobile data negatively impacts the network planning and dimension, since core networks are heavy centralized. Mobile operators are investigating atten network architectures that distribute the responsibility of providing connectivity and mobility, in order to improve the network scalability and performance. Moreover, service providers are moving the content servers closer to the user, in order to ensure high availability and performance of content delivery. Besides the e orts to overcome the explosion of mobile data, current mobility management models are heavy centralized to ensure reachability and session continuity to the users connected to the network. Nowadays, deployed architectures have a small number of centralized mobility anchors managing the mobile data and the mobility context of millions of users, which introduces issues related to performance and scalability that require costly network mechanisms. The mobility management needs to be rethought out-of-the box to cope with atten network architectures and distributed content servers closer to the user, which is the purpose of the work developed in this Thesis. The Thesis starts with a characterization of mobility management into well-de ned functional blocks, their interaction and potential grouping. The decentralized mobility management is studied through analytical models and simulations, in which di erent mobility approaches distinctly distribute the mobility management functionalities through the network. The outcome of this study showed that decentralized mobility management brings advantages. Hence, it was proposed a novel distributed and dynamic mobility management approach, which is exhaustively evaluated through analytical models, simulations and testbed experiments. The proposed approach is also integrated with seamless horizontal handover mechanisms, as well as evaluated in vehicular environments. The mobility mechanisms are also speci ed for multihomed scenarios, in order to provide data o oading with IP mobility from cellular to other access networks. In the pursuing of the optimized mobile routing path, a novel network-based strategy for localized mobility is addressed, in which a replication binding system is deployed in the mobility anchors distributed through the access routers and gateways. Finally, we go further in the mobility anchoring subject, presenting a context-aware adaptive IP mobility anchoring model that dynamically assigns the mobility anchors that provide the optimized routing path to a session, based on the user and network context. The integration of dynamic and distributed concepts in the mobility management, such as context-aware adaptive mobility anchoring and dynamic mobility support, allow the optimization of network resources and the improvement of user experience. The overall outcome demonstrates that decentralized mobility management is a promising direction, hence, its ideas should be taken into account by mobile operators in the deployment of future networks.

Kids just wanna have fun: Children's experiences of a weight management programme

Objectives: To explore children's accounts of their experiences of the UK‘s largest childhood obesity programme, MEND (Mind, Exercise, Nutrition…Do it!) (See www.mendprogramme.org). Design: Semi-structured interviews were conducted with children who had completed the MEND obesity programme. Interviews were transcribed verbatim and analysed using Interpretative Phenomenological Analysis (IPA). Method Fourteen children spanning diverse areas of London comprised this study (eight male, six female), aged between 11 and 14 years and in secondary school. Participants were interviewed a year after completing one of the London-based MEND obesity programmes. Results: This article focuses on the most common and striking theme to emerge from the original dataset (The complete analysis may be found in L. Watson, Unpublished doctoral thesis): Fun. Subthemes were: ‘going with the flow’; active participation in activities that led to new experiences (‘actually doing it’ – seeing the fun side); the importance of others in the experience of fun (‘you do games in unity’ – ‘it's not as fun on your own’). Conclusion: Children have fun when engaged in interactive and varied activities with opportunity for individual feedback and improvement. When designing childhood obesity programmes, conditions that optimise children's experience of fun should be emphasised over didactic and risk-heavy information pertaining to childhood obesity.

Sistemas de informação para a gestão turística

Nowadays, to be competitive in society means to have a technological framework that fi ts customer responses. In tourism, the need for ICT (Information and Communication Technologies) is even more important, since to sell the tourist product it is crucial to disclose the information that characterizes it, plus, it is necessary to organize, manage and deal with it in accordance with the tourists’ expectations. After the tourist product has been consumed, it is important to share the experience with other travellers. The process of purchase and consumption of a tourist product is possible only if tourists and professionals have access to the information required, and for this it is necessary to use systems that can: manage results, flights and customer loyalty, distribute information and travel planning, among other things. All these systems have tourist information management in common, which leads to the conclusion that they are indispensable to tourism. This paper presents several information systems that coexist in the tourism sector, as well as those used in tourist distribution channels. Finally we show the trends that these systems are causing in tourism.

Big data warehouse framework for smart revenue management

Revenue Management’s most cited definitions is probably “to sell the right accommodation to the right customer, at the right time and the right price, with optimal satisfaction for customers and hoteliers”. Smart Revenue Management (SRM) is a project, which aims the development of smart automatic techniques for an efficient optimization of occupancy and rates of hotel accommodations, commonly referred to, as revenue management. One of the objectives of this project is to demonstrate that the collection of Big Data, followed by an appropriate assembly of functionalities, will make possible to generate a Data Warehouse necessary to produce high quality business intelligence and analytics. This will be achieved through the collection of data extracted from a variety of sources, including from the web. This paper proposes a three stage framework to develop the Big Data Warehouse for the SRM. Namely, the compilation of all available information, in the present case, it was focus only the extraction of information from the web by a web crawler – raw data. The storing of that raw data in a primary NoSQL database, and from that data the conception of a set of functionalities, rules, principles and semantics to select, combine and store in a secondary relational database the meaningful information for the Revenue Management (Big Data Warehouse). The last stage will be the principal focus of the paper. In this context, clues will also be giving how to compile information for Business Intelligence. All these functionalities contribute to a holistic framework that, in the future, will make it possible to anticipate customers and competitor’s behavior, fundamental elements to fulfill the Revenue Management

A Service Model For Delivering Care Closer to Home.

Upton Surgery (Worcestershire) has developed a flexible and responsive service model that facilitates multi-agency support for adult patients with complex care needs experiencing an acute health crisis. The purpose of this service is to provide appropriate interventions that avoid unnecessary hospital admissions or, alternatively, provide support to facilitate early discharge from secondary care. Key aspects of this service are the collaborative and proactive identification of patients at risk, rapid creation and deployment of a reactive multi-agency team and follow-up of patients with an appropriate long-term care plan. A small team of dedicated staff (the Complex Care Team) are pivotal to coordinating and delivering this service. Key skills are sophisticated leadership and project management skills, and these have been used sensitively to challenge some traditional roles and boundaries in the interests of providing effective, holistic care for the patient. This is a practical example of early implementation of the principles underlying the Department of Health’s (DH) recent Best Practice Guidance, ‘Delivering Care Closer to Home’ (DH, July 2008) and may provide useful learning points for other general practice surgeries considering implementing similar models. This integrated case management approach has had enthusiastic endorsement from patients and carers. In addition to the enhanced quality of care and experience for the patient, this approach has delivered value for money. Secondary care costs have been reduced by preventing admissions and also by reducing excess bed-days. The savings achieved have justified the ongoing commitment to the service and the staff employed in the Complex Care Team. The success of this service model has been endorsed recently by the ‘Customer Care’ award by ‘Management in Practice’. The Surgery was also awarded the ‘Practice of the Year’ award for this and a number of other customer-focussed projects.

Co-production and co-creation using self-service technology: the application of service-dominant logic

Research on how customers engage in the co-creation processes envisaged by the Servicedominant logic paradigm is currently limited and even less work has been published on frameworks for organizations to manage the co-creation process. This conceptual paper examines a particular aspect of co-creation: co-production as a result of the application of self-service technology (SST). We propose a conceptual framework for co-production, which emphasizes the need to understand productivity from the point of view of the customer, and demonstrate how this can be applied in both consumer (b2c) and interorganizational(b2b) contexts. We conclude that service organizations might benefit from clearly identifying co-production with task-performance, and co-creation with the valueattributing aspects of the customer service experience. Both aspects generate a range of design and management challenges for suppliers particularly the need to understand the cocreation process 'outputs' desired by customers and the full costs of moving away from person to person interaction.