Artículos de revistas sobre el tema "Leeds Monthly Meeting"

Abstract The unavailability of civil courts to hear cases relating to Muslim family law and other related matters persuaded community leaders and religious scholars in the United Kingdom to establish several Sharīʿah councils. This article explores the role played by these councils in resolving matrimonial disputes, especially the process and procedure of issuing an Islamic divorce. Library and empirical research methods were employed. Three main uk Sharīʿah councils were visited wherein mediation and arbitration sessions, as well as monthly meetings, were observed to examine how disputes are handled and decisions made. The study leads to several findings. Mediation and arbitration are the main methods used in the process, and despite the relative success of Sharīʿah councils, they face challenges resulting from the dichotomy and overlapping jurisdictions of Islamic and English family law and the non-alignment of divorce issued by uk courts and religious divorce.

Background:Patient and public involvement (PPI) is gaining increasing recognition as important in ensuring research is relevant and acceptable to participants. Rheuma Tolerance for Cure (RTCure) is a 5 year international collaboration between academia and industry; focusing on earlier detection and prevention of rheumatoid arthritis (RA) through the use of immune-tolerising treatments.Objectives:To bring lived experience and insight into scientific discussions; and to evolve collaboration between lay representatives and academia/industry.Methods:9 Patient Research Partners (PRPs) from 5 European countries were recruited via the EULAR PARE Network and institutions within the RTCure Consortium (8 PRPs with RA and 1 ‘at risk’). They were asked to enter into a legal agreement with the Consortium. PRPs participated in teleconferences (TCs) and were invited to attend face-to-face (F2F) meetings at least annually. Requests for input/feedback were sent from researchers to PRPs via the project’s Patient Engagement Expert [SK].Results:PRP involvement has given researchers and industry partners a new perspective on patient priorities, and focused thought on the ethics of recruitment for and participation in clinical trials of people ‘at risk’ of developing RA. PRPs have helped define the target populations, given their thoughts on what types of treatments are acceptable to people ‘at risk’ and have aided the development of a survey (sent to EULAR PARE members) regarding the use of animal models in biomedical research. Positive informal feedback has been received from researchers and industry regarding the contribution of PRPs to the ongoing project (formal evaluation of PPI in RTCure will be carried out in 2020 and at the project end in 2022).Challenges:Legal agreements- Many PRPs refused to sign the Consortium’s complex PRP Agreement; feeling it unnecessary, incomprehensible and inequitable. After extensive consultation with various parties (including EULAR and the Innovative Medicines Initiative) no similar contract was found. Views for its requirement even varied between legal experts. After 2 years of intense discussion, a simple non-disclosure agreement was agreed upon. Ideally any contract, if required, should be approved prior to project onset.Meeting logistics- Other improvements identified were to locate the meeting venue and accommodation on the same site to minimise travel, and to make it easier for PRPs to take breaks when required. This also facilitates informal discussions and patient inclusivity. We now have agreed a policy to fund PRPs extra nights before and after meetings, and to bring a carer if needed.Enabling understanding– Future annual meetings will start with a F2F meeting between PRPs and Work Package Leads. Researchers will be encouraged to start presentations with a summary slide in lay language. Additionally, an RTCure Glossary is in development.Enabling participation– SK will provide monthly project updates and PRP TCs will be held in the evening (as some PRPs remain employed). PRPs will be invited to all project TCs and F2F meetings. Recruitment is underway to increase the number of ‘at risk’ PRPs as their viewpoint is vital to this study.Conclusion:Currently PPI in RTCure is an ongoing mutual learning process. Universal guidance regarding what types of contracts are needed for PPI would be useful. Communication, trust and fruitful discussions have evolved through F2F meetings (both formal and informal) between PRPs, academia and industry. It is important that all parties can be open with each other in order to make PPI more meaningful.Acknowledgments:This work has received support from the EU/EFPIA Innovative Medicines Initiative 2 Joint Undertaking RTCure grant number 777357.Disclosure of Interests:Savia de Souza: None declared, Ruth Williams: None declared, Eva Johansson: None declared, Codruta Zabalan: None declared, Tom Esterine: None declared, Margôt Bakkers: None declared, Wolfgang Roth: None declared, Neil Mc Carthy: None declared, Meryll Blake: None declared, Susanne Karlfeldt: None declared, Martina Johannesson: None declared, Karim Raza Grant/research support from: KR has received research funding from AbbVie and Pfizer, Consultant of: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai, Speakers bureau: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai

244 Background: The Cancer Imaging Program (CIP) at Cancer Care Ontario was established in 2009 to improve the quality of cancer imaging in Ontario. Methods: After initial selection of a Provincial clinical lead in 2009, fourteen regional clinical leads were selected to represent all geographical regions of the province. Through a stakeholder survey and a priority setting process the following four high-level areas of priority emerged to support quality improvement of cancer imaging: (1) Developing and Fostering an Imaging Community of Practice, (2) Imaging Appropriateness, (3) Timely Access to Imaging, and (4) Standardized/Synoptic Reporting. Results: (1) An Imaging Community of Practice was established with the regional clinical leads, who participate in monthly meetings to build and strengthen inter-regional relationships and share information on regional activities and priorities; (2) Best practice standards for imaging in lung and colorectal cancer have been developed by consolidating and endorsing national and international guidelines. New imaging guidelines are being developed by the Program in Evidence-Based Care. Evidence-based recommendations being developed for focal tumour ablation procedures; (3) Three Interventional Radiology procedures (CT-guided lung biopsies, peripherally inserted central catheters and portacaths) have been selected for an ongoing wait time collection that captures monthly point-in-time data. The data has initiated discussions on appropriate benchmarks and identification of factors that may contribute wait times; and (4) Synoptic Radiology Reporting enables the collection of uniform and complete data to improve the information available to referring clinicians for diagnosis and treatment planning. Work is underway in the development of: implementation roadmap, evidence-based clinical checklists, infrastructure to store and share synoptic reports, and international standards for synoptic radiology reporting. Conclusions: The establishment of the CIP as a clinical program under a provincial cancer agency has enabled the development of an Imaging Community of Practice and allowed for work on provincial-wide initiatives that enable quality improvement of cancer imaging.

Purpose – When a patient unexpectedly has to go back to the operating theatre, there is often a perceived problem with the primary operation. An IRT30 is defined as any patient returning to the operating theatre within 30 days of the index procedure. IRT30 has been suggested to be a useful quality indicator of surgical standards and surgeon performance. The purpose of this paper is to evaluate the usefulness of this validated tool, by assessing all IRT30 over a 12-month period. Learning points for individual surgeons, surgical subspecialty units and the clinical governance leads were reviewed. Design/methodology/approach – Consecutive series of general and vascular surgical patients undergoing elective and emergency procedures between July 2012 and 2013. Prospective data collection of all IRT30s classified as Types 1-5 by a single-rater and in-depth discussion of Types 3-5 cases at the clinical governance meetings. The individual case learning points were recorded and the collective data monitored monthly. Findings – There were 134 IRT30s. In total 84 cases were discussed: Type 3 (n=80), Type 4 (n=4) and Type 5 (n=0). In total 50 cases were not discussed: Type 1 (n=27), Type 2 (n=23). Originality/value – It is crucial that surgeons continue to learn throughout their surgical career by reflecting on their own and their colleague’s results, complications and surgical performance. Analysing Types 3 and 4 IRT30s within the governance meetings has identified learning points related to both surgical technique and surgical decision making. By embracing these learning points, surgical technique and individual as well as group surgeon performance can be modified and opportunities for training and focused supervision created.

AimsSt Charles is one of the largest inpatient mental health units in London with 8 wards and covers the boroughs of Kensington & Chelsea and Westminster. This project aimed was set up so that 95% of patients in St Charles Mental Health Centre would have a complete cardiometabolic health assessment by December 2020. This would include Weight, Smoking, Alcohol, Substance Use, Hypertension, Cholesterol and Diabetes assessments with necessary interventions recorded. The outcome of the intervention would improve overall physical health and life expectancy.MethodPeople with serious mental illness experience significantly worse physical health and shorter life expectancy of up to 10 to 15 years than the general population. CNWL is making Physical Health of patients in Mental Health Services a priority. Performance in this area has been challenging across the Trust because of: –Buy in from clinicians.–Staff did not feel empowered to discuss interventions with patients.–High sickness and absence as a result of COVID was found to directly correlate with reduced physical health monitoring/recording.–Lack of training in completing the SystmOne physical health templateThe following cardiometabolic risk monitoring interventions were recorded on SystemOne (electronic documentation platform) and performance reviewed using Tableau : Weight, Smoking, Alcohol, Substance Use, Hypertension, Cholesterol and Diabetes assessments with necessary interventions recorded.ResultPrior to the commencement of this project, the wards in St Charles Mental Health Centre completed physical health assessments on roughly 8% of the patients in February 2020. The QI project was implemented in June 2020. By September 2020, physical health recording across 8 wards across St Charles had increased to 89% following successful implementation of the interventions.ConclusionThe following interventions resulted in a significant improvement in physical health cardiometabolic risk monitoring at a busy inpatient mental health setting: –Monthly physical heath meetings to enable shared learning with ward doctors, nurses and healthcare assistants.–Ongoing one-to-one and group support to train staff with completing and recording physical health assessments.–Tableau Physical Health Report regularly reviewed with MDT during ward round meetings.–Physical health leads given supernumerary days to run physical health clinics on the wards.–Fortnightly Physical health monitoring meetings with the Director of Nursing and Head of Governance.

Regional surgical quality Collaboratives are improving surgical quality and cutting costs by building regional relationships that leverage information sharing to improve outcomes. The South Carolina Surgical Quality Collaborative (SCSQC) is a new regional surgical quality Collaborative focused on improving general surgery outcomes in South Carolina. It is a joint effort which brings together the skills and resources of Health Sciences South Carolina, the South Carolina Hospital Association, and the Blue Cross Blue Shield of SC Foundation to create a web-based data collection system to provide real-time outcomes data to participating surgeons, and establishing a supportive network for sharing best practices and promoting data driven quality improvement. Members of the SCSQC abstracted more than 8000 general surgery cases from eight participating hospitals in its first year. These facilities are spread across the state of South Carolina and range from large academic referral centers to small community hospitals. The resulting data should be representative of much of the surgical care provided in South Carolina. Monthly conference calls and quarterly face-to-face meetings occur with site Surgeon Leads, site Surgical Clinical Quality Reviewer, and Collaborative leaders. Each site is pursuing a quality improvement project addressing issues identified from analysis of their initial data. Early results on these efforts are encouraging. The SCSQC is a new regional surgical quality Collaborative, which leverages multiple state resources, builds on the successes of similar Collaboratives in Michigan and Tennessee, with the goal to improve the quality and value of general surgical care for South Carolinians.

Abstract Background With increasing national focus on reducing inappropriate antimicrobial use, state and national regulatory mandates require hospitals to develop robust antimicrobial stewardship programs (ASP). Methods BJC HealthCare is a 13 hospital healthcare system serving the St. Louis, mid-Missouri, and Southern Illinois region and includes adult and pediatric academic medical centers, as well as community and critical access hospitals. In 2015, BJC system leaders engaged relevant clinical and executive stakeholders at each hospital to champion formation of a multidisciplinary system ASP Council. A comprehensive gap analysis was performed to assess current stewardship resources and activities. BJC system clinical leads facilitated the development of hospital specific leadership support statements, identification of hospital pharmacy and medical leaders, and all mandated educational components. To facilitate tracking, reporting and improvement activities, a robust antimicrobial use data dashboard was created. Each hospital has a dedicated ASP team that is supported by the system clinical leads. Hospital learnings are shared at monthly system ASP meetings allowing for broad dissemination. Results By leveraging system resources, all 13 BJC HealthCare hospitals met all Joint Commission requirements by January 2017. BJC’s model of ASP allows for the development of broad-based stewardship activities including development of education modules for patients and providers, and clinical decision support tools while allowing individual hospitals to implement activities based on local needs and resource availability. Local hospital teams have developed treatment guidelines, targeted antibiotic pharmacy review, “handshake” stewardship models, and allergy testing protocols. Central support of local hospital ASP has resulted in a 7.6% system decrease in tracked antimicrobial use, including a 16.5% reduction in quinolone usage. Additionally, the C. difficilestandardized infection ratio decreased from 1.08 to 0.622 since program initiation. Conclusion Despite significant differences in hospital resources, a system-supported ASP model focused on implementing the CDC core elements can result in significant reductions in antimicrobial use. Disclosures J. Newland, Merck: Grant Investigator, Research grant; Allergan: Grant Investigator, Research grant

Background Systems for measuring the performance of general practices are extremely limited. Objectives The aim was to develop, pilot test and evaluate a measure of productivity that can be applied across all typical general practices in England, and that may result in improvements in practice, thereby leading to better patient outcomes. Methods Stage 1 – the approach used was based on the Productivity Measurement and Enhancement System (ProMES). Through 16 workshops with 80 general practice staff and 72 patient representatives, the objectives of general practices were identified, as were indicators that could measure these objectives and systems to convert the indicators into an effectiveness score and a productivity index. This was followed by a consensus exercise involving a face-to-face meeting with 16 stakeholders and an online survey with 27 respondents. An online version of the tool [termed the General Practice Effectiveness Tool (GPET)] and detailed guidance were created. Stage 2 – 51 practices were trained to use the GPET for up to 6 months, entering data on each indicator monthly and getting automated feedback on changes in effectiveness over time. The feasibility and acceptability of the GPET were examined via 38 telephone interviews with practice representatives, an online survey of practice managers and two focus groups with patient representatives. Results The workshops resulted in 11 objectives across four performance areas: (1) clinical care, (2) practice management, (3) patient focus and (4) external focus. These were measured by 52 indicators, gathered from clinical information systems, practice records, checklists, a short patient questionnaire and a short staff questionnaire. The consensus exercise suggested that this model was appropriate, but that the tool would be of more benefit in tracking productivity within practices than in performance management. Thirty-eight out of 51 practices provided monthly data, but only 28 practices did so for the full period. Limited time and personnel changes made participation difficult for some. Over the pilot period, practice effectiveness increased significantly. Perceptions of the GPET were varied. Usefulness was given an average rating of 4.5 out of 10.0. Ease of use was more positive, scoring 5.6 out of 10.0. Five indicators were highlighted as problematic to gather, and 27% of practices had difficulties entering data. Feedback from interviews suggested difficulties using the online system and finding time to make use of feedback. Most practices could not provide sufficient monthly financial data to calculate a conventional productivity index. Limitations It was not possible to create a measure that provides comparability between all practices, and most practices could not provide sufficient financial data to create a productivity index, leaving an effectiveness measure instead. Having a relatively small number of practices, with no control group, limited this study, and there was a limited timescale for the testing and evaluation. Implications The GPET has demonstrated some viability as a tool to aid practice improvement. The model devised could serve as a basis for measuring effectiveness in general practice more widely. Future work Some additional research is needed to refine the GPET. Enhanced testing with a control sample would evaluate whether or not it is the use of the GPET that leads to improved performance. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Objective – This paper describes the experiences of four prominent North American research libraries as they implemented Balanced Scorecards as part of a one-year initiative facilitated by the Association of Research Libraries (ARL). The Balanced Scorecard is a widely accepted organizational performance model that ties strategy to performance in four areas: finance, learning and growth, customers, and internal processes. Methods – Four universities participated in the initiative: Johns Hopkins University, McMaster University, the University of Virginia, and the University of Washington. Each university sent a small group of librarians to develop their Scorecard initiatives and identified a lead member. The four teams met with a consultant and the ARL lead twice for face-to-face training in using the Scorecard. Participants came together during monthly phone calls to review progress and discuss next steps. Additional face-to-face meetings were held throughout the year in conjunction with major library conferences. Results – The process of developing the Scorecards included the following steps: defining a purpose statement, identifying strategic objectives, creating a strategy map, identifying measures, selecting appropriate measures, and setting targets. Many commonalities were evident in the four libraries’ slates of strategic objectives. There were also many commonalities among measures, although the number chosen by each institution varied significantly, from 26 to 48. Conclusion – The yearlong ARL initiative met its initial objectives. The four local implementations are still a work in progress, but the leads are fully trained and infrastructure is in place. Data is being collected, and the leadership teams are starting to see their first deliverables from the process. The high level of commonality between measures proposed at the four sites suggests that a standardized slate of measures is viable.

Abstract Background National guidelines for the prevention of surgical site infections (SSI) recommend against antibiotic prophylaxis following wound closure for clean and clean-contaminated surgical procedures. Prolonged antibiotic prophylaxis can lead to antibiotic resistance and adverse drug events without reducing SSI rates. The objective was to reduce the rate of antibiotic prophylaxis following surgical incision closure for specified procedures in the Divisions of Neurosurgery (NRS), Otolaryngology (OTO), and General Surgery (GS) at Children’s Hospital of Philadelphia (CHOP). Methods We identified all NRS, OTO, and GS procedures conducted at CHOP from July 1, 2016 to June 20, 2017. Collaborative meetings between surgical quality improvement team leads and the antimicrobial stewardship program (ASP) were convened to identify procedures most suitable for the intervention, including Chiari decompressions and tethered cord repair (NRS); tympanoplasty and tracheostomy (OTO); and laparoscopic and thoracoscopic procedures (GS). The intervention, started in March 2018, included (1) education of surgeons on perioperative prescribing guidelines, (2) order set modification, and (3) individualized monthly audit with feedback reports of inappropriate postoperative prescribing (via email copying all surgeons within the division). We monitored rates utilizing SPC charts of postoperative antibiotic use (defined as administration within 24 hours of procedure end) and evaluated SSI rates pre and post-intervention with a Poisson regression. Results Following the intervention, postoperative antibiotic use reached special cause resulting in a mean decline for laparoscopy (19.6% to 11.7%), thoracoscopy (35.6% to 17.9%), tympanoplasty (90.5% to 11.4%), tethered cord repair (95% to 25.5%), and Chiari decompression (97% to 45.9%). There was no mean shift in postoperative antibiotic use for tracheostomy (25.5%). 30-day SSI rates did not change pre- and post-intervention (P = 0.36). Conclusion A quality improvement initiative conducted to implement national guidelines recommending against postoperative antibiotic prophylaxis showed a significant reduction in postoperative antibiotic prophylaxis without a concomitant rise in SSI rates. Disclosures All authors: No reported disclosures.

Background. Every student has the potential to do well in school. Failing to provide good nutrition puts them at risk for missing out on meeting that potential and leads to long-term irreversible damage to cognitive development. However, taking action today to provide healthier choices in schools can help set students up for a successful future full of possibilities. So, this study is aimed at assessing the effect of nutritional status on academic performance of school-aged children. Methods. A school-based cross-sectional study was conducted from Feb 05- March 30, 2017 in Lalibela town. A total of 505 primary school students were included in the study. The child anthropometric measures were calculated using AnthroPlus software version 1.0.4 WHO 2007 standards. Bivariable and multivariable ordinal logistic regression were fitted. The proportional odds ratio (POR) with a 95% CI and P value < 0.05 were considered statistically significant. Results. The overall prevalence of stunting, underweight, and thinness was 29.5%, 35.7%, and 29.5%, respectively. In this study, 14.7% of the study participants had low academic achievement in the semester. The multivariable analysis showed that rural residence (POR=0.39; 95% CI: (0.21, 0.75)), not studying regularly (POR=0.49; 95% CI: (0.29, 0.82)), severe underweight (POR=0.25; 95% CI: (0.09, 0.71)), and severe stunting (POR=0.03; 95% CI: (0.01, 0.37)) were associated with decreased odds of high average semester score achievement of school-aged children. Additionally, higher maternal educational status (POR=2.12; 95% CI: (1.10, 4.07)) and family income from 550 to 2999 ETB (POR=1.71; 95% CI: (1.04, 2.81)) were associated with increased odds of high semester average score achievement. Conclusion. Nearly one-third of school-aged children in Lalibela town were stunted, thin, and underweight. Rural place of residence, not studying regularly study, underweight, and stunting were associated with decreased academic achievement. While, family monthly income from 550 to 2999 ETB and higher maternal education status were associated with increased academic achievement.

AimsThe COVID-19 pandemic has had a drastic effect on the mental health of the global population that is likely to be felt for years to come. One group particuarly likely to be affected by this in the immediate future are the healthcare professionals working on the frontline of the NHS pandemic response. As members of a foundation cohort of these junior doctors we aimed to create a way to quanitfy the wellbeing of ourselves and our colleagues at this challeging time. We aimed to use a combination of numerous tools to monitor foundation doctors in Blackburn during this crisis. This would inform which measures would be best suited to be put in place to protect this cohort from early burnout and poor mental health in the future.MethodWe designed a survey of 25 questions which we invited our foundation colleagues to fill in anonymously during the first and second waves of the pandemic in response to times when foundation doctors were redeployed to aid the frontline. The survey has been based on the PHQ9, GAD7, Epworth Sleepiness scale, Physician wellbeing index, Medical students wellbeing index, Maslach burnout inventory BMA burnout questionnaire and the QOL scale.ResultFrom a cohort of around 140 foundation doctors we had 46 participants in our trial of this tool; 46% had been redeployed and 54% not redeployed. Over 50% of survey respondents reported high stress, poor motivation and depersonalisation over the two weeks at the peak of the pandemic, key early signs of burnout. Lack of interest in their work, poor sleep and anhedonia were increased across both groups (redeployed and non redeployed). The interventions after the first wave data which repondents found beneficial included; financial reassurances during redeployments, protected non clinical areas for rest, a named individual senior staff member for wellbeing support.ConclusionKey issues the survey raised were fed back to foundation programme leads in monthly meetings. This allowed us with our foundation leads to make targeted changes in order to support foundation doctors at this time. Without the data from this tool which we tailored to the foundation experience we believe these rapidly worsening issues during the pandemic would not have been addressed so swiftly. We then resurveyed the foundation cohort to assess which of these interventions have been most widely used and appreciated.

Abstract Background Hematopoietic stem cell transplantation (HSCT) is challenging because of economic, educational, and organizational reasons. Argentina is a middle-income country. HSML is a public pediatric hospital with an HSCT unit halted its services in July 2014. Among the reasons for suspending the services were healthcare providers(HCP) burn out, miscommunication, and tasks breakdown. The HSCT service resumed in December 2014. Objectives The primary objective was to describe and share the experiences in resuming the HSCT service by using a multicomponent strategic plan and interventions. The secondary objective was to review the outcomes. Methods Our strategic plan consisted of four main components: (1) Use of quality improvement tools for quality assessment and management (Six Sigma quality improvement processes, root-cause analysis, process maps, and brain storming); (2) participate in international collaborative networks (St. Jude Global Alliance and PRINCIPAL networks, the BFM-Forum-SCT, Sick-Kids Hospital, Canada); (3) participate in national and international training programs; and (4) improve healthcare delivery and organization processes, including infection care and prevention (develop and standardize all HSCT care delivery procedures). Results and Outcomes Healthcare facilities and services auditing and accreditation: An infection prevention and control program was started. This program managed: air and ventilation system improvement (air-conditioning, HEPA filters, positive pressure) and the creation of 47 standardized operating procedures. The HSCT wards were audited 3 times, and received accreditation (2018) by a national accreditation agency in Argentina. Human resources: 7 new doctors and 4 nurses were hired, the nurse:patient ratio was 1:2. 4 doctors attended a course for SPSS software®management; 6 doctors attended different American Society of Hematology H-Clinical Research Institute meetings. Personnel felt a reduction in the level of burn-out after the implementation of a plan designed by all stakeholders. Family information: 28 families received training for management of immunosuppressed patients. Scientific production: 4 clinical trials were accepted in indexed journals, 23 abstracts were presented in scientific meetings, and 27 educational national and international meetings were attended by personnel. Data management: Creation of a patient database (n = 310 patients), and registration of infection episodes for monthly assessment and monitoring patterns of infections (n = 776 events). Outcomes: During 2015–2019, 73 children were transplanted: autologous 11 (15%), match sibling donor (MSD) 35 (48%) and match unrelated donors (MUD) 27 (37%) Median age was 6 years of age (IQR 2–9), 53% were male, and 60% were acute leukemias. At a mean median time of 12 months (IQR 5–18), the overall survival by Kaplan–Meier for MSD and MUD was similar (62.3 ± 10.7% and 54.2 ± 15.0%, log-rank P = 0.54). The cumulative incidence of treatment-related mortality (log-rank P = 0.31), cumulative incidence of relapse (LR P = 0.99) were comparable as well. Infection rates were 40.5% and 69.6% in MSD vs. MUD (OR 3.36; 95% CI 1.14–9.98; P = 0.038). Conclusion The strategic plan implemented allowed us to offer optimal care to children in a public hospital without further financial cost and more satisfied HCPs. Results are comparable to published literature. Implementation of quality improvement interventions leads to the success of our program. Education and collaboration with national and international networks assisted improvement of the standard of care.

Introduction: The CARPALL study (NCT02443831) employed a novel CD19CAR (CAT-41BBz CAR) with a faster off rate than the Kymriah FMC63-41BBz CAR (CAT 3.1x10-3s-1, FMC 6.8 x 10-5s-1), with equivalent on-rate (CAT 2.2 x 105, FMC 2.1 x 105). We herein report updated outcomes and CAR T cell persistence with an additional 6 months follow up from a submitted manuscript (Ghorashian et al., Nat Med, submitted) Methods: Patients aged &lt;25 years with high risk, relapsed CD19+ B-ALL were eligible on this multi-centre, open label, non-randomised phase I study of autologous CAT-41BBz CAR T cells. Patients were followed to a data cut-off of 07/18/2019. CAT-41BBz CAR T cells were generated by magnetic bead activation of leucapheresed PBMCs, lentiviral transduction, followed by bioreactor expansion and magnetic bead removal prior to cryopreservation. All patients received lymphodepletion (fludarabine + cyclophosphamide) followed by 1x106/kg CAR T cells. Presence of CAR T cells in the blood and bone marrow (BM) was assessed (flow cytometry and qPCR) monthly for 6 months, then 6 weekly to 1 year and then 3 monthly. BM MRD was assessed (IgH qPCR, flow cytometry) at the same time-points up to 2 years to establish durability of responses as a stand-alone therapy. Primary end-points were incidence of grade 3-5 toxicity and the proportion of patients achieving molecular remission. Results: Of 17 patients recruited, 14 were treated due to manufacturing failure in 3 patients.The median age was 9 years (range 1-19 years). All patients had advanced ALL with a median of 4 prior therapy lines. 10 of 14 patients (71%) had relapsed post allogeneic SCT. Prior to lymphodepletion, 4 patients had &gt;5% BM disease, 6 had disease between 5x10-2and 1x10-5, 4 were BM MRD negative having had recurrent isolated CNS disease. Median transduction efficiency was 31% (range 16.5 to 96.4%). 12/14 treated patients received the anticipated dose of 1x106CAR T cells/kg (2 received 0.9x106/kg). Considering all evaluable patients, (n=14 for CAR T cell persistence by qPCR, n=13 by flow) the geometric mean of Cmax was 128 912/µg DNA and of the area under the curve between D0 and D28 was 1,721,355 copies/ µg DNA (Table 1). At the point of maximal expansion, a median of 35% of circulating T cells were CAR+. Median half-life was 34 days (range 3-102). CAR T cells continued to be detectable by qPCR in 11 of 14 (79%) patients at last assessment and by flow cytometry up to 30 months post infusion in 8 of 13(61%). Median duration of CAR T persistence by flow was 261 days (range 7-917). 3 patients failed to have persistence of CAR T cells beyond 1 month. T cell mediated anti-CAR specific cytotoxic activity was detected in 2/2 evaluable patients. Updated persistence data will be presented at the meeting Cytokine release syndrome (CRS) occurred in 13 (93%, grade 1 n=9, grade 2 n=4). None developed ≥grade 3 CRS, had CRS-related ICU admission, or received Tocilizumab. CRS was associated with modest elevations of IL-6, IFN-γand IL-10. Grade 2 neurotoxicity was observed in 3 patients and resolved spontaneously. One patient had grade 4 leucoencephalopathy presumed due to chemotherapy as well as grade 5 sepsis. Ten patients (71%) had grade 3-4 cytopenia persisting beyond day 28 or recurring afterthis. 12/14 (86%) patients achieved molecular complete or continuing complete remission at a median of 30 days post infusion (range 30-90 days, Table 2). At a median follow-up of 20.3 months, 4/14 (29%) evaluable patients remain MRD negative. 5 relapsed with CD19-disease, 1 with CD19+ disease. The median duration of EFS (based on death or morphological relapse) has not been reached, 12 month EFS = 52%, OS = 70% (Figures 1, 2 and Table 3). Conclusion: We noted excellent CAR T cell expansion and persistence in a ALL cohort treated with the fast off-rate CAT-41BBz CAR despite their lower BM disease at treatment compared to other studies. The kinetics documented for all evaluable patients showed a 5-fold greater CAR T cell expansion and 2-fold longer half-life than responders in published series utilising tisagenlecleucel in a similar ALL cohort (Mueller et al., Blood 2017). Patients had a favourable toxicity profile with no severe (grade 3-4) CRS and equivalent disease outcomes to the ELIANA study despite having similarly advanced disease (Maude et al., NEJM 2018292). These data suggest long lived CAR T cell persistence supports stand-alone therapy for ALL with durable responses. Disclosures Ghorashian: Celgene: Honoraria; novartis: Honoraria; UCLB: Patents & Royalties: UCLB. Kramer:UCLB: Patents & Royalties. Ciocarlie:Servier: Other: Financial Support. Farzaneh:Autolus Ltd: Equity Ownership, Research Funding. Pule:Autolus: Employment, Equity Ownership, Patents & Royalties. Amrolia:UCLB: Patents & Royalties.

Abstract Sickle Treatment and Outcomes Research in the Midwest (STORM) is a regional sickle cell network, funded by the Health Resources and Services Administration Treatment Demonstration Project (HRSA U1EMC27863), established to improve outcomes for individuals with sickle cell disease (SCD) living in Indiana, Illinois, Michigan, Minnesota, Ohio and Wisconsin. The STORM network is led by pediatric and adult hematologists who coordinate network activities in each state, along with a Regional Coordinating Center that organizes efforts throughout the Midwest. The goal of the STORM network is to increase the number of pediatric and adult primary care providers (PCP) who are knowledgeable about the management and treatment of SCD, and who are willing to prescribe and manage hydroxyurea therapy as a means to improve medical care for the approximately 15,000 individuals living with SCD in the Midwest. One PCP engagement strategy that has been implemented to increase provider knowledge in the region is replication of the Project ECHOTM (Extension for Community Healthcare Outcomes) telementoring model. Project ECHO was developed by the University of New Mexico to utilize low-cost, high-impact video technology to link expert inter-disciplinary specialist teams with primary care providers to improve management of chronic diseases. This guided practice telementoring model delivers complex specialty medical care to underserved areas, reduces health disparities, and increases workforce capacity. Project ECHO's methodology is based on 1) using telehealth technology to build healthcare resources where they are scarce; 2) sharing best practices to reduce variation in clinical care; 3) utilizing practice-based learning to develop specialty expertise among providers; and 4) monitoring and evaluating provider outcomes. Project ECHO has demonstrated improved healthcare outcomes in Hepatitis C and several other chronic diseases, and is now being piloted by STORM to test its feasibility and applicability for SCD by using a regional approach with CME accreditation. STORM network site physician leads in each state are recruiting multi-disciplinary primary care teams to participate as "spokes" in monthly SCD TeleECHO clinics. The "hub" led by the STORM Regional Coordinating Center, located at Cincinnati Children's Hospital Medical Center, coordinates implementation and evaluation of the telementoring clinics, delivered through monthly teaching sessions. STORM TeleECHO participants log onto an internet-based virtual meeting site, using a webcam to interact during the session. STORM TeleECHO clinics include brief didactic presentations from nationally-recognized SCD content experts with topics and curriculum based on the National Heart Lung and Blood Institute Evidence-Based Management of Sickle Cell Disease guidelines released in 2014. TeleECHO teaching clinics also include 1-2 de-identified, HIPAA protected case discussions (pediatric and adult) presented by providers who would like medical and psychosocial feedback on management of challenging clinical scenarios. Providers participating in the STORM TeleECHO complete an initial survey assessing knowledge and comfort levels, practice behaviors (including hydroxyurea prescribing practices) and clinic demographics. Satisfaction surveys are sent to participants after each session as part of the CME-credit evaluation. Follow-up surveys at 6 months and 1 year will assess satisfaction, knowledge, comfort level and changes in practice. STORM's TeleECHO was launched in March 2016. Preliminary data indicate an interest in STORM TeleECHO teaching sessions by both pediatric and adult providers across the Midwest region. Future efforts will expand the network to more PCPs in the region, while improving the applicability and utility of STORM TeleECHO in SCD through provider assessment. Disclosures Ware: Global Blood Therapeutics: Consultancy; Biomedomics: Research Funding; Bristol Myers Squibb: Research Funding; Addmedica: Research Funding; Nova Laboratories: Consultancy; Bayer Pharmaceuticals: Consultancy.

AimsThe GMC recommends that organisations ensure learners have an induction in preparation for each placement. We aimed to ensure that high quality induction was being delivered in psychiatry posts across the whole of the Severn Deanery. This included multiple localities (Bristol, Bath, Swindon, Devizes, Weston-Super-Mare, Gloucester, Cheltenham, Taunton and Yeovil) across three NHS trusts.BackgroundInduction plays a vital role in preparing doctors for their new roles. Crucially, some doctors are not only new to the specific role and site, but also new to the specialty (for example, Foundation Doctors and GP Trainees). In Severn, each locality takes responsibility for providing Junior Doctors with a locality-specific induction; these occur four times per year. Previous feedback from trainees in Severn was poor; as demonstrated by informal feedback and the August 2018's GMC survey results, showing some localities ‘required improvement’.MethodPre- and post-intervention measurements were ascertained by written questionnaires for Foundation Doctors, GP Trainees and Core Trainees in Psychiatry. Baseline questionnaires were completed in August/September 2019. Five ‘Plan, Do, Study, Act’ Cycles were completed over the following eighteen months. Examples of the changes made included incorporating ‘missed’ topics (such as wellbeing, seclusion reviews and exception reporting) and specific information to on-call responsibilities, reducing replicated information, and touring clinical sites. These changes were coordinated via monthly meetings between Locality Trainee Leads (LTLs).ResultThere was an overall improvement in trainee's satisfaction with induction. Outcomes also included the development of an induction checklist specific to each locality and a ‘gold standard’ list for what local induction should involve. This is hopefully soon to be ratified by the Medical Education department and Severn Deanery.ConclusionHaving worked on this project for over 18 months, sustainability of change remains a crucial issue. In response to this, we have established several recommendations: the LTL job role needs to be revised to include updating the written induction handbook in each locality and delivering face-to-face induction. Outgoing and incoming LTLs will plan each induction together, at least 4 to 8 weeks before the start date. Support from Medical Education regarding attendees at each induction is to be put in place. Handbooks will be shared across localities, so that the ‘core’ information is consistent. Ongoing feedback will ensure that Junior Doctors continue to receive a high quality and relevant induction.

AimsIt is well-recognised by the RCPsych that mental illness is both a cause and consequence of social exclusion, and thus social inclusion is an important part of recovery and leads to better outcomes for patients.The Lewisham Assessment and Liaison team Neighbourhood 4 (A&L N4) is a CMHT service that acts as an intake team for all referrals into secondary care mental health services, with the purpose of assessment and brief intervention. Currently, if a patient is assessed to potentially benefit from our local social inclusion service, Lewisham Community Wellbeing (LCW), they are advised to self-refer. However, there is no follow-up as to whether patients go on to do this.Therefore, this audit aimed to calculate:How many patients are advised to self-refer to LCW (advised referral)How many of these patients make the self-referral to LCW (completed referral)MethodThe electronic notes for patients who were accepted by the A&L N4 team from July to September 2020 were retrospectively analysed to see if an LCW self-referral was advised. A list of these patients was then given to LCW to check whether they had self-referred.ResultA&L N4 worked with 82 patients during the study period. 16 patients were advised to self-refer to LCW- an advised referral rate of 19.5%. There was notable month-to-month variation in the advised referral rate- 29.6% in July vs. 9.4% in September.Of the 16 patients advised to self-refer to LCW, 5 did so- a completed referral rate of 31.3%.ConclusionThe completed referral rate of 31.3% is difficult to interpret given there are no standards in this area. On one hand, the self-referral process as it currently exists is functioning; on the other, some two-thirds of patients are not making the most of a service deemed to be of benefit to their recovery.To improve completed referral rates, efforts should be made to better ‘sell’ LCW to the patient. Potential ways of doing this would be through closer working with LCW- for example, LCW could join the clinical meetings more regularly to discuss new services they offer and feedback any patients A&L has referred. There should also be emphasis on making the self-referral process as straightforward as possible.A secondary finding was the notable monthly variation in advised referral rates. It is important to ensure the A&L team are consistently identifying the right patients for LCW, and again, closer liaison with LCW would help achieve this.

ObjectivesDescribe cases of female genital mutilation (FGM) presenting to consultant paediatricians and sexual assault referral centres (SARCs), including demographics, medical symptoms, examination findings and outcome.DesignThe well-established epidemiological surveillance study performed through the British Paediatric Surveillance Unit included FGM on the monthly returns.SettingAll consultant paediatricians and relevant SARC leads across the UK and Ireland.PatientsUnder 16 years old with FGM.InterventionsData on cases from November 2015 to November 2017 and 12 months later meeting the case definition of FGM.Main outcome measuresReturns included 146 cases, 103 (71%) had confirmed FGM and 43 (29%) did not meet the case definition. There were none from Northern Ireland.ResultsThe mean reported age was 3 years. Using the WHO classification of FGM, 58% (n=60) had either type 1 or type 2, 8% (n=8) had type 3 and 21% (n=22) had type 4. 13% (n=13) of the cases were not classified and none had piercings or labiaplasty. The majority, 70% had FGM performed in Africa with others from Europe, Middle East and South-East Asia. There were few physical and mental health symptoms. Only one case resulted in a successful prosecution.ConclusionsThere were low numbers of children presenting with FGM and in the 2 years there was only one prosecution. The findings may be consistent with attitude changes in FGM practising communities and those at risk should be protected and supported by culturally competent national policies

Background: This study was conducted to know the operational strategies of polio surveillance to study the current practices of polio vaccination, to find out practices of key health care staff regarding strategies in polio eradication Result: A significant difference between the knowledge of urban and rural area ANMs regarding. IPV is a not a substitute for OPV (p value<0.05). 63% & 75% ANMs of urban & rural resp. were unaware about OPV being phased out. Only 1 out of 16 ANMs knew the correct reason for tOPV to bOPV switch. All (100%) ANMs reported AEFI monthly, always attended meetings & encouraged their ASHAs for community mobilization. 25% ANMs of rural area considered reporting of AFP cases and checking vaccine requirements & stock maintenance only sometimes. Conclusion: Vaccines currently in use Indore district are bOPV & fIPV. IPV & fIPV are costly than OPVs. Shortage of bOPV (January to February 2018), IPV & fIPV was suffered due to manufacturing units not working. In this study OPV 3rd dose coverage is low as compared to OPV 1st dose coverage & OPV booster dose coverage has further declined. This practice leads to low population immunity for polio. In this study PPI coverage over the years has remained >=100%. However the RI coverage has ranged between 82-95%. It indicates towards possibility of lowering of population immunity and herd immunity because of not maintaining the RI coverage more 90% consistently. Keywords: Polio Vaccination, Practice, IPV, tOPV, bOPV.

Reducing Door to CT Times in Rural Hospitals Using a Collaborative Quality Improvement Approach Introduction: Rural hospitals are a critical component of stroke systems of care, and play a key role in the race to treatment within the time windows for stroke. Faster treatment leads to better outcomes for stroke patients and rural hospitals often face unique challenges. Despite limited resources to conduct quality improvement (QI), a group of 13 rural hospitals in a large western state undertook a project to identify opportunities and implement strategies to reduce delays along their leg of the race to treatment. The project focused on reducing the time from the door to the CT scan for stroke patients arriving at rural hospitals. The project’s aim was to achieve a 25-minute door-to-CT median time for 60% of stroke patients, and performance in the 75 th percentile for this national performance benchmark. Methods: The rural hospitals created a collaborative group from their existing QI committee. The group used evidence-based QI strategies, including leadership support, a SMART (specific, measurable, achievable, relevant, and time-based) goal, the plan-do-study-act model, Ishikawa diagrams, and data-driven interventions tailored to each organization. QI Analysts established a baseline for median door-to-CT times then collected monthly aggregate data using a national data collection tool for rural hospitals. Project leads regularly presented data at committee meetings and data were trended from baseline to project end. The project culminated in a conference to share the outcomes, challenges, and strategies used to achieve the project goals. Results: After implementing key QI interventions, the door-to-CT median time went from a baseline of 47 minutes to a median time of 25 minutes in the last two quarters. As a group, the hospitals achieved their goal of performing in the 75th percentile of a large national stroke registry. Conclusion: This project demonstrated that despite resource challenges, rural hospitals can successfully do data-driven QI for stroke and meet national benchmarks. The project implemented crucial elements for successful QI initiatives in rural regions: rurally relevant, self-designed, collaborative, leadership-supported and peer-led.

The Digital TurnMuch of the 19th century disappeared from public view during the 20th century. Historians recovered what they could from archives and libraries, with the easy pickings-the famous and the fortunate-coming first. Latterly, social and political historians of different hues determinedly sought out the more hidden, forgotten, and marginalised. However, there were always limitations to resources-time, money, location, as well as purpose, opportunity, and permission. 'History' was principally a professionalised and privileged activity dominated by academics who had preferential access to, and significant control over, the resources, technologies and skills required, as well as the social, economic and cultural framework within which history was recovered, interpreted, approved and disseminated.Digitisation and the broader development of new communication technologies has, however, transformed historical research processes and practice dramatically, removing many constraints, opening up many opportunities, and allowing many others than the professional historian to trace and track what would have remained hidden, forgotten, or difficult to find, as well as verify (or otherwise), what has already been claimed and concluded. In the 21st century, the SEARCH button has become a dominant tool of research. This, along with other technological and media developments, has altered the practice of historians-professional or 'public'-who can now range deep and wide in the collection, portrayal and dissemination of historical information, in and out of the confines of the traditional institutional walls of retained information, academia, location, and national boundaries.This incorporation of digital technologies into academic historical practice generally, has raised, as Cohen and Rosenzweig, in their book Digital History, identified a decade ago, not just promises, but perils. For the historian, there has been the move, through digitisation, from the relative scarcity and inaccessibility of historical material to its (over) abundance, but also the emerging acceptance that, out of both necessity and preference, a hybridity of sources will be the foreseeable way forward. There has also been a significant shift, as De Groot notes in his book Consuming History, in the often conflicted relationship between popular/public history and academic history, and the professional and the 'amateur' historian. This has brought a potentially beneficial democratization of historical practice but also an associated set of concerns around the loss of control of both practice and product of the professional historian. Additionally, the development of digital tools for the collection and dissemination of 'history' has raised fears around the commercialised development of the subject's brand, products and commodities. This article considers the significance and implications of some of these changes through one protracted act of recovery and reclamation in which the digital made the difference: the life of a notorious 19th century professional agitator on both sides of the Atlantic, John De Morgan. A man thought lost, but now found."Who Is John De Morgan?" The search began in 1981, linked to the study of contemporary "race riots" in South East London. The initial purpose was to determine whether there was a history of rioting in the area. In the Local History Library, a calm and dusty backwater, an early find was a fading, but evocative and puzzling, photograph of "The Plumstead Common Riots" of 1876. It showed a group of men and women, posing for the photographer on a hillside-the technology required stillness, even in the middle of a riot-spades in hand, filling in a Mr. Jacob's sandpits, illegally dug from what was supposed to be common land. The leader of this, and other similar riots around England, was John De Morgan. A local journalist who covered the riots commented: "Of Mr. De Morgan little is known before or since the period in which he flashed meteorlike through our section of the atmosphere, but he was indisputably a remarkable man" (Vincent 588). Thus began a trek, much interrupted, sometimes unmapped and haphazard, to discover more about this 'remarkable man'. "Who is John De Morgan" was a question frequently asked by his many contemporary antagonists, and by subsequent historians, and one to which De Morgan deliberately gave few answers. The obvious place to start the search was the British Museum Reading Room, resplendent in its Victorian grandeur, the huge card catalogue still in the 1980s the dominating technology. Together with the Library's newspaper branch at Colindale, this was likely to be the repository of all that might then easily be known about De Morgan.From 1869, at the age of 21, it appeared that De Morgan had embarked on a life of radical politics that took him through the UK, made him notorious, lead to accusations of treasonable activities, sent him to jail twice, before he departed unexpectedly to the USA in 1880. During that period, he was involved with virtually every imaginable radical cause, at various times a temperance advocate, a spiritualist, a First Internationalist, a Republican, a Tichbornite, a Commoner, an anti-vaccinator, an advanced Liberal, a parliamentary candidate, a Home Ruler. As a radical, he, like many radicals of the period, "zigzagged nomadically through the mayhem of nineteenth century politics fighting various foes in the press, the clubs, the halls, the pulpit and on the street" (Kazin 202). He promoted himself as the "People's Advocate, Champion and Friend" (Allen). Never a joiner or follower, he established a variety of organizations, became a professional agitator and orator, and supported himself and his politics through lecturing and journalism. Able to attract huge crowds to "monster meetings", he achieved fame, or more correctly notoriety. And then, in 1880, broke and in despair, he disappeared from public view by emigrating to the USA.LostThe view of De Morgan as a "flashing meteor" was held by many in the 1870s. Historians of the 20th century took a similar position and, while considering him intriguing and culturally interesting, normally dispatched him to the footnotes. By the latter part of the 20th century, he was described as "one of the most notorious radicals of the 1870s yet remains a shadowy figure" and was generally dismissed as "a swashbuckling demagogue," a "democratic messiah," and" if not a bandit … at least an adventurer" (Allen 684). His politics were deemed to be reactionary, peripheral, and, worst of all, populist. He was certainly not of sufficient interest to pursue across the Atlantic. In this dismissal, he fell foul of the highly politicised professional culture of mid-to-late 20th-century academic historians. In particular, the lack of any significant direct linkage to the story of the rise of a working class, and specifically the British Labour party, left individuals like De Morgan in the margins and footnotes. However, in terms of historical practice, it was also the case that his mysterious entry into public life, his rapid rise to brief notability and notoriety, and his sudden disappearance, made the investigation of his career too technically difficult to be worthwhile.The footprints of the forgotten may occasionally turn up in the archived papers of the important, or in distant public archives and records, but the primary sources are the newspapers of the time. De Morgan was a regular, almost daily, visitor to the pages of the multitude of newspapers, local and national, that were published in Victorian Britain and Gilded Age USA. He also published his own, usually short-lived and sometimes eponymous, newspapers: De Morgan's Monthly and De Morgan's Weekly as well as the splendidly titled People's Advocate and National Vindicator of Right versus Wrong and the deceptively titled, highly radical, House and Home. He was highly mobile: he noted, without too much hyperbole, that in the 404 days between his English prison sentences in the mid-1870s, he had 465 meetings, travelled 32,000 miles, and addressed 500,000 people. Thus the newspapers of the time are littered with often detailed and vibrant accounts of his speeches, demonstrations, and riots.Nonetheless, the 20th-century technologies of access and retrieval continued to limit discovery. The white gloves, cradles, pencils and paper of the library or archive, sometimes supplemented by the century-old 'new' technology of the microfilm, all enveloped in a culture of hallowed (and pleasurable) silence, restricted the researcher looking to move into the lesser known and certainly the unknown. The fact that most of De Morgan's life was spent, it was thought, outside of England, and outside the purview of the British Library, only exacerbated the problem. At a time when a historian had to travel to the sources and then work directly on them, pencil in hand, it needed more than curiosity to keep searching. Even as many historians in the late part of the century shifted their centre of gravity from the known to the unknown and from the great to the ordinary, in any form of intellectual or resource cost-benefit analysis, De Morgan was a non-starter.UnknownOn the subject of his early life, De Morgan was tantalisingly and deliberately vague. In his speeches and newspapers, he often leaked his personal and emotional struggles as well as his political battles. However, when it came to his biographical story, he veered between the untruthful, the denial, and the obscure. To the twentieth century observer, his life began in 1869 at the age of 21 and ended at the age of 32. His various political campaign "biographies" gave some hints, but what little he did give away was often vague, coy and/or unlikely. His name was actually John Francis Morgan, but he never formally acknowledged it. He claimed, and was very proud, to be Irish and to have been educated in London and at Cambridge University (possible but untrue), and also to have been "for the first twenty years of his life directly or indirectly a railway servant," and to have been a "boy orator" from the age of ten (unlikely but true). He promised that "Some day-nay any day-that the public desire it, I am ready to tell the story of my strange life from earliest recollection to the present time" (St. Clair 4). He never did and the 20th century could unearth little evidence in relation to any of his claims.The blend of the vague, the unlikely and the unverifiable-combined with an inclination to self-glorification and hyperbole-surrounded De Morgan with an aura, for historians as well as contemporaries, of the self-seeking, untrustworthy charlatan with something to hide and little to say. Therefore, as the 20th century moved to closure, the search for John De Morgan did so as well. Though interesting, he gave most value in contextualising the lives of Victorian radicals more generally. He headed back to the footnotes.Now FoundMeanwhile, the technologies underpinning academic practice generally, and history specifically, had changed. The photocopier, personal computer, Internet, and mobile device, had arrived. They formed the basis for both resistance and revolution in academic practices. For a while, the analytical skills of the academic community were concentrated on the perils as much as the promises of a "digital history" (Cohen and Rosenzweig Digital).But as the Millennium turned, and the academic community itself spawned, inter alia, Google, the practical advantages of digitisation for history forced themselves on people. Google enabled the confident searching from a neutral place for things known and unknown; information moved to the user more easily in both time and space. The culture and technologies of gathering, retrieval, analysis, presentation and preservation altered dramatically and, as a result, the traditional powers of gatekeepers, institutions and professional historians was redistributed (De Groot). Access and abundance, arguably over-abundance, became the platform for the management of historical information. For the search for De Morgan, the door reopened. The increased global electronic access to extensive databases, catalogues, archives, and public records, as well as people who knew, or wanted to know, something, opened up opportunities that have been rapidly utilised and expanded over the last decade. Both professional and "amateur" historians moved into a space that made the previously difficult to know or unknowable now accessible.Inevitably, the development of digital newspaper archives was particularly crucial to seeking and finding John De Morgan. After some faulty starts in the early 2000s, characterised as a "wild west" and a "gold rush" (Fyfe 566), comprehensive digitised newspaper archives became available. While still not perfect, in terms of coverage and quality, it is a transforming technology. In the UK, the British Newspaper Archive (BNA)-in pursuit of the goal of the digitising of all UK newspapers-now has over 20 million pages. Each month presents some more of De Morgan. Similarly, in the US, Fulton History, a free newspaper archive run by retired computer engineer Tom Tryniski, now has nearly 40 million pages of New York newspapers. The almost daily footprints of De Morgan's radical life can now be seen, and the lives of the social networks within which he worked on both sides of the Atlantic, come easily into view even from a desk in New Zealand.The Internet also allows connections between researchers, both academic and 'public', bringing into reach resources not otherwise knowable: a Scottish genealogist with a mass of data on De Morgan's family; a Californian with the historian's pot of gold, a collection of over 200 letters received by De Morgan over a 50 year period; a Leeds Public Library blogger uncovering spectacular, but rarely seen, Victorian electoral cartoons which explain De Morgan's precipitate departure to the USA. These discoveries would not have happened without the infrastructure of the Internet, web site, blog, and e-mail. Just how different searching is can be seen in the following recent scenario, one of many now occurring. An addition in 2017 to the BNA shows a Master J.F. Morgan, aged 13, giving lectures on temperance in Ledbury in 1861, luckily a census year. A check of the census through Ancestry shows that Master Morgan was born in Lincolnshire in England, and a quick look at the 1851 census shows him living on an isolated blustery hill in Yorkshire in a railway encampment, along with 250 navvies, as his father, James, works on the construction of a tunnel. Suddenly, literally within the hour, the 20-year search for the childhood of John De Morgan, the supposedly Irish-born "gentleman who repudiated his class," has taken a significant turn.At the end of the 20th century, despite many efforts, John De Morgan was therefore a partial character bounded by what he said and didn't say, what others believed, and the intellectual and historiographical priorities, technologies, tools and processes of that century. In effect, he "lived" historically for a less than a quarter of his life. Without digitisation, much would have remained hidden; with it there has been, and will still be, much to find. De Morgan hid himself and the 20th century forgot him. But as the technologies have changed, and with it the structures of historical practice, the question that even De Morgan himself posed – "Who is John De Morgan?" – can now be addressed.SearchingDigitisation brings undoubted benefits, but its impact goes a long way beyond the improved search and detection capabilities, into a range of technological developments of communication and media that impact on practice, practitioners, institutions, and 'history' itself. A dominant issue for the academic community is the control of "history." De Groot, in his book Consuming History, considers how history now works in contemporary popular culture and, in particular, examines the development of the sometimes conflicted relationship between popular/public history and academic history, and the professional and the 'amateur' historian.The traditional legitimacy of professional historians has, many argue, been eroded by shifts in technology and access with the power of traditional cultural gatekeepers being undermined, bypassing the established control of institutions and professional historian. While most academics now embrace the primary tools of so-called "digital history," they remain, De Groot argues, worried that "history" is in danger of becoming part of a discourse of leisure, not a professionalized arena (18). An additional concern is the role of the global capitalist market, which is developing, or even taking over, 'history' as a brand, product and commodity with overt fiscal value. Here the huge impact of newspaper archives and genealogical software (sometimes owned in tandem) is of particular concern.There is also the new challenge of "navigating the chaos of abundance in online resources" (De Groot 68). By 2005, it had become clear that:the digital era seems likely to confront historians-who were more likely in the past to worry about the scarcity of surviving evidence from the past-with a new 'problem' of abundance. A much deeper and denser historical record, especially one in digital form seems like an incredible opportunity and a gift. But its overwhelming size means that we will have to spend a lot of time looking at this particular gift horse in mouth. (Cohen and Rosenzweig, Web).This easily accessible abundance imposes much higher standards of evidence on the historian. The acceptance within the traditional model that much could simply not be done or known with the resources available meant that there was a greater allowance for not knowing. But with a search button and public access, democratizing the process, the consumer as well as the producer can see, and find, for themselves.Taking on some of these challenges, Zaagsma, having reminded us that the history of digital humanities goes back at least 60 years, notes the need to get rid of the "myth that historical practice can be uncoupled from technological, and thus methodological developments, and that going digital is a choice, which, I cannot emphasis strongly enough, it is not" (14). There is no longer a digital history which is separate from history, and with digital technologies that are now ubiquitous and pervasive, historians have accepted or must quickly face a fundamental break with past practices. However, also noting that the great majority of archival material is not digitised and is unlikely to be so, Zaagsma concludes that hybridity will be the "new normal," combining "traditional/analogue and new/digital practices at least in information gathering" (17).ConclusionA decade on from Cohen and Rozenzweig's "Perils and Promises," the digital is a given. Both historical practice and historians have changed, though it is a work in progress. An early pioneer of the use of computers in the humanities, Robert Busa wrote in 1980 that "the principal aim is the enhancement of the quality, depth and extension of research and not merely the lessening of human effort and time" (89). Twenty years later, as Google was launched, Jordanov, taking on those who would dismiss public history as "mere" popularization, entertainment or propaganda, argued for the "need to develop coherent positions on the relationships between academic history, the media, institutions…and popular culture" (149). As the digital turn continues, and the SEARCH button is just one part of that, all historians-professional or "amateur"-will take advantage of opportunities that technologies have opened up. Looking across the whole range of transformations in recent decades, De Groot concludes: "Increasingly users of history are accessing the past through complex and innovative media and this is reconfiguring their sense of themselves, the world they live in and what history itself might be about" (310). ReferencesAllen, Rob. "'The People's Advocate, Champion and Friend': The Transatlantic Career of Citizen John De Morgan (1848-1926)." Historical Research 86.234 (2013): 684-711.Busa, Roberto. "The Annals of Humanities Computing: The Index Thomisticus." Computers and the Humanities 14.2 (1980): 83-90.Cohen, Daniel J., and Roy Rosenzweig. Digital History: A Guide to Gathering, Preserving, and Presenting the Past on the Web. Philadelphia, PA: U Pennsylvania P, 2005.———. "Web of Lies? 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De Morgan, Elocutionist, and Tribune of the People. Leeds: De Morgan & Co., 1880.Vincent, William T. The Records of the Woolwich District, Vol. II. Woolwich: J.P. Jackson, 1890.Zaagsma, Gerban. "On Digital History." BMGN-Low Countries Historical Review 128.4 (2013): 3-29.