Developing a quality curriculum in a technological era

There is considerable rhetoric internationally around the need for national curricula to reflect the changes that are taking place in the world outside school. This raises questions about what a quality curriculum in a technological era should look like, and equally challenging issues about how to achieve the necessary changes in schooling in order for such a curriculum to be realised. This paper summarises the views of 11 experts from seven countries. It introduces a sociocultural framework that highlights the complexity of achieving alignment between policies and practice spanning the national to local school to classroom levels. Three key issues that underpin alignment are then explored, each of which link with the issue of trust:stakeholders engagement;teacher professionalism;summative assessment. By exploring and exemplifying these three issues the paper indicates potential ways of addressing them and provides 'tools to think with' to enhance future curriculum development initiatives.

Would gestational age and presence of brain anomalies affect interobserver reliability of fetal head biometry? Using off-line analysis of 3-D dataset

The objective was to assess interobserver reliability of fetal head biometry using archived three-dimensional (3-D) volumes and the impact of gestational age and presence of brain anomalies on examiners' performance. Seventy nine 3-D volume datasets of fetal head were examined: 27 were normal and 52 had brain abnormalities. Off-line analysis was done by three fetal medicine experts (E1, E2 and E2), all were blinded to history and patient details. Measurements of the biparietal diameter (BPD), head circumference (HC), lateral ventricle (Vp) and transcerebellar diameter (TCD) were compared between examiners and to two-dimensional (2-D) measurements. Comparisons were made at two gestational age groups (≤22 and >22 weeks) and in presence and absence of brain anomalies. The intraclass coefficient showed a significantly high level of measurement agreement between 3-D examiners and 2-D, with values >0.9 throughout (p < 0.001). Bias was evident between 3-D examiners. E2 produced smaller measurements. The mean percentage difference between this examiner and the other two in BPD, HC, Vp and TCD measurements was significant, of 1.6%, 1%, 4.9% and 1.8%, respectively. E1 measured statistically larger for HC and TCD. E3 measured significantly larger for only BPD. The presence of anomalies was of no influence on the 3-D examiners' performance except for E3 who showed bias in BPD measurements only in cases with brain anomalies. Unlike other examiners, bias of E2 was only seen at gestational age group ≤22 weeks. Limits of agreement in measurements between observers were narrow for all parameters but were widest for the Vp measurements, being ±23% of the mean difference. Despite the above bias, the actual mean difference between examiners was small and unlikely to be of any clinical significance. Off-line measurement of fetal head biometry using 3-D volumes is reliable. In our study, presence of brain anomalies was unlikely to influence the reproducibility of measurements. Gestational age seemed to be of an impact on examiners' bias. Among experts this bias may be of no clinical significance.

Evaluation of offline analysis of archived three-dimensional volume datasets in the diagnosis of fetal brain abnormalities

OBJECTIVE

To retrospectively evaluate the reliability of offline manipulation of archived three-dimensional (3D) ultrasound volumes in the assessment of the normal fetal brain and the diagnosis of fetal brain abnormalities.

METHODS

Seventy-nine 3D volume datasets, archived at the time of scanning, from women attending a tertiary center, were analyzed. They comprised 52 cases with brain abnormalities and 27 normal controls. Postnatal magnetic resonance imaging or postmortem examination confirmed the final diagnosis in all cases with brain anomalies. Offline analysis of the 79 anonymized 3D volume datasets was carried out by three fetal medicine experts, examiner one (E1), examiner two (E2) and examiner three (E3), using 4D View software. The experts were blinded to any prior diagnosis or history. Data were collected on a specially designed data sheet and entered into a specialized database for analysis. Results were compared between examiners, with the initial two-dimensional (2D) diagnosis and with the final definitive diagnosis by calculation of percentage agreement and kappa coefficients.

RESULTS

Of the 52 cases with brain anomalies, the correct diagnosis was reached in 88.5% (46/52), 98.1% (51/52) and 92.3% (48/52) of cases on analysis of the 3D volumes by E1, E2 and E3, respectively, whereas only 82.7% (43/52) of cases were correctly diagnosed on the initial 2D examination when compared with the definitive diagnosis. Fetuses without brain anomalies were identified as such by the three experts with 100% agreement. There was good agreement between the initial 2D examination and the analysis of 3D volumes by each of the experts: 86.1% for E1 (κ = 0.7), 89.9% for E2 (κ = 0.79) and 88.6% for E3 (κ = 0.76).

CONCLUSIONS

3D volume datasets are an appropriate and reliable format for storing data from examination of the fetal brain. Offline analysis of 3D datasets is a reliable method that can be used to help in the assessment of brain anomalies and could be a useful adjunct to realtime 2D ultrasonography.

Prenatal diagnosis of fetal abdominal lymphangioma by ultrasonography

We present a case of abdominal lymphangioma in a fetus together with a review of the literature. Diagnosis was made at 20 weeks' gestation by antenatal ultrasonography. In keeping with other reports, the lesion was located on the left and serial ultrasonography demonstrated rapid growth with extension into the lower extremity.

Persistent right umbilical vein in a fetus with Noonan's syndrome: a case report

We present a case of persistent right umbilical vein with Noonan's syndrome. Persistence of the right umbilical vein with no intrahepatic portion is an uncommon finding with a review of the literature revealing only five other cases. In these cases drainage was directly into the right atrium, inferior vena cava (IVC) or IVC via the iliac vein. Of the reported cases Noonan's syndrome was confirmed in one case and suspected in a second. This report represents a third case of persistent right umbilical vein with confirmed Noonan's syndrome.

Myocardial motion imaging: a new application of power color flow and frequency-based color flow Doppler in fetal echocardiography

OBJECTIVE

Myocardial motion imaging is a new way of looking at the fetal heart using power color flow and frequency-based color flow Doppler to demonstrate heart wall movement in color. This study set out to assess the value of myocardial motion imaging in fetal echocardiography in a routine clinical setting.

DESIGN

In our hospital, all patients at high risk of carrying a fetus with a cardiac abnormality are offered detailed ultrasound scanning, including fetal echocardiography, at 20 weeks' gestation. A prospective study was carried out over a 2-month period and, in addition to conventional fetal echocardiography, myocardial motion imaging was also carried out on all patients, by means of both power color flow and frequency-based color flow Doppler ultrasound.

RESULTS

Myocardial motion imaging demonstrated fetal heart wall movement in 26 of the 27 patients. Myocardial motion imaging using power color flow gave a global view of fetal heart wall movement, demonstrating both atrial and ventricular contraction simultaneously. Myocardial motion imaging using frequency-based color flow Doppler demonstrated atrial and ventricular contractions separately. In addition, as the direction of fetal heart wall motion can be color coded, atrial contractions, ventricular relaxation and ventricular contraction were demonstrated, providing a functional assessment of fetal heart wall movement. Two cases of cardiac abnormality were also studied, one case of hypoplastic left heart syndrome and one case of atrioventricular septal defect. In both cases functional information was obtained using myocardial motion imaging, and the technique also highlighted the anatomical defect.

CONCLUSIONS

Myocardial motion imaging produces both a global view of fetal cardiac anatomy and a functional assessment of individual chamber contraction in the normal and abnormal heart. It may prove to be a useful adjunct to conventional color flow Doppler assessment of the fetal heart.

Antenatally detected urinary tract abnormalities: changing incidence and management

To define the incidence of urinary tract abnormalities detected by antenatal ultrasound and assess changes in postnatal management we conducted a retrospective survey using data bases of the nephro-urology unit, obstetric ultrasound and perinatal pathology departments. The birth population (105,542) of the two Nottingham teaching hospitals between January 1984 and December 1993 was divided into two 5-year cohorts, 1984-1988 and 1989-1993. Detailed fetal scanning at 18-20 weeks gestation was introduced in 1989. During this 10-year period, 201 abnormalities of the urinary tract were noted with a 2:1 male to female ratio. The incidence of abnormalities in the first 5 years was 1 in 964 compared to 1 in 364 in the last 5 years. There was a significant increase in the number detected before 20 weeks gestation (12% in 1984-1988 compared to 62% in 1989-1993). Despite the increased incidence of abnormalities detected, the termination rate remained static between the two 5-year cohorts. Only 3 fetuses had intra-uterine intervention and 173 were live-born. Eight infants subsequently died in association with other major congenital abnormalities. The incidence of transient abnormalities (antenatal dilatation with no abnormality noted on postnatal ultrasound) increased from 6% in 1984-1988 to 18% in the 1989-1993 cohort. A more conservative approach to postnatal management is reflected by 71% of infants having operations between 1984 and 1988 compared to 35% in 1989-1993.

CONCLUSION

The advent of detailed fetal scanning at 18-20 weeks gestation has significantly increased the detection rate of urinary tract abnormalities with no significant increase in pregnancy termination rates. The need for antenatal intervention is a rare event and most problems can be managed conservatively both pre- and postnatally.

A comparison of power colour flow with frequency based colour flow Doppler in fetal echocardiography

In this study a direct comparison was made between power colour flow and frequency based colour flow Doppler in the visualization of the ventricular septum and the pulmonary veins of the fetal heart at 18 to 20 weeks. A total of 16 cases were scanned using both power colour flow and frequency based colour flow Doppler. The entire ventricular septum was visualized in all cases using power colour, but in only two cases using frequency based colour Doppler. However, frequency based colour Doppler was capable of identifying part of the ventricular septum in 14 cases. In the assessment of the pulmonary veins, power colour demonstrated both right and left pulmonary veins clearly in 12 cases. There were no cases in which both the right and left pulmonary veins were demonstrated using frequency based colour Doppler.

Outcome of antenatally detected cystic dysplastic kidney disease

Forty four fetuses with multicystic dysplastic kidney (MCDK) disease recognised on antenatal ultrasound were studied prospectively. In nine aborted fetuses and in five who died in the neonatal period the MCDK disease was bilateral or there were associated lethal abnormalities or syndromes. All surviving infants had unilateral disease and in six (20%) there was significant reflux into the normal contralateral kidney. Since 1988 the management of unilateral MCDK disease has been conservative with no child developing sepsis, hypertension, or malignancy. Serial ultrasound examinations suggest that MCDK lesions involute with time and conservative rather than operative management is favoured.

Effect of halofuginone on broiler skin strength when used in a shuttle anticoccidial program

Continuous feeding of the anticoccidial halofuginone to broilers is associated with reduced skin tensile strength and increased skin tearing during processing. The possible mitigating effect of shuttle administration of halofuginone and salinomycin to female broilers was evaluated. Halofuginone or salinomycin were included in the starter and grower diets in all four possible combinations, with anticoccidial omitted from the finisher diets. Starter, grower, and finisher diets were fed to broilers through 3, 6, and 7 wk of age, respectively. Skin strength of pullets fed a diet based on milo and corn (NW) vs a diet based on corn was also compared in a factorial arrangement. Two further treatments were also included: 1) halofuginone-only NW diet supplemented with 2,500 ppm ascorbic acid from 0 to 7 wk; and 2) NW diet reared on wire floor without anticoccidial treatment. Skin tensile strength was determined at 3, 6, and 7 wk of age. Dietary composition had no effect upon skin strength or BW of broilers. Addition of ascorbic acid to the diet containing halofuginone anticoccidial did not improve skin strength. Continuous feeding of halofuginone reduced skin strength whereas withholding anticoccidial and continuous feeding of salinomycin resulted in high skin strength. When halofuginone was used in shuttle feeding programs with salinomycin, there were no differences in skin strength at 7 wk of age compared to birds that were continuously treated with salinomycin. These results suggest halofuginone may be used in a shuttle program either during the starter or grower phase without adverse affect on skin tensile strength at slaughter.

Dietary and environmental factors affecting skin strength in broiler chickens

Two experiments were conducted to evaluate dietary and environmental factors involved in skin tensile strength of commercial broilers. In Experiment 1 the effect of added dietary fat (4 or 7%), environmental temperature (25 or 20.5 C after 21 d), and anticoccidial drug (halofuginone or salinomycin fed continuously) were examined factorially using male and female chicks. Skin tensile strength was measured at 21, 35, and 40 d of age. Thickness of the dermal layers was measured from skin taken at Day 35. In Experiment 2, the effect of added dietary fat (0 or 7%), environmental temperature (25 or 18.5 C after 21 d), and anticoccidial drug (halofuginone or salinomycin) were examined factorially using female chicks. Skin strength and collagen content of the skin were measured at 21, 38, and 42 d of age. Skin tensile strength increased with age in both experiments, but female skin strength was subject to periodic decline. Males had significantly strong skin than females. Levels of added fat or environmental temperature did not affect skin strength in either experiment. Continuous feeding of halofuginone significantly (P < .0001) decreased skin strength compared with that of birds fed salinomycin in both experiments. Halofuginone reduced skin strength in females more than males (25 and 9%, respectively). Dermis thickness was correspondingly reduced in the birds consuming halofuginone. In Experiment 2, soluble collagen contents were reduced at all ages in birds consuming halofuginone; insoluble collagen was significantly decreased at 21 d of age. Birds with weakened skin exhibited increased incidence of skin tears during slaughter in a commercial processing plant (P < or = .0043). These results suggest that halofuginone interferes with collagen synthesis, causing decreased collagen formation and reduced skin strength. Neither added dietary fat nor ambient temperature were involved.

The outcome of fetal ventriculomegaly

Over a 5 year period 38 cases of fetal ventriculomegaly were diagnosed at Queen's Medical Centre, Nottingham. There were 12 cases of spina bifida and all patients opted for a termination of pregnancy. There were 15 cases of isolated ventriculomegaly comprising seven cases of aqueduct stenosis, four abnormalities of the corpus callosum, one cavum septum pellucidum cyst, one case of porencephaly and two cases of mild lateral ventricular dilatation. The fetuses in this group had a relatively good outcome with five babies showing normal development, three with mild development delay and one with moderate developmental delay. There was one stillbirth and five patients opted for a termination of pregnancy. Associated abnormalities were seen in seven cases and these carried a poor prognosis with one fetus stillborn, one neonatal death, and three patients opted for a termination of pregnancy. Two babies were liveborn, one has severe developmental delay and the other one is normal. The four remaining cases included two Dandy Walker syndrome, one brain tumour and one case of subdural haemorrhage. There were three terminations of pregnancy and one stillbirth in this group. The outcome of fetal ventriculomegaly depends on the presence of associated abnormalities which carry a poor prognosis. It also depends on the timing of the diagnosis as most patients will opt for a termination of pregnancy if the diagnosis is made before 24 weeks gestation. A review of the literature reveals that, excluding terminations, fetuses with isolated ventriculomegaly have an 80% chance of survival and a 50% chance of normal development.

The facial profile in the diagnosis of fetal abnormalities

In order to assess the significance of fetal facial anomalies detected by ultrasound, a 4 year review was made of all detailed antenatal scans performed in our department. Anomalies were detected in 24 fetuses. All findings were subsequently confirmed. Micrognathia was the most common finding, 38% of these had an abnormal karyotype, and 45% had a recognized skeletal dysplasia. Facial clefting was also commonly seen, both in isolation and associated with other abnormalities. When associated with other abnormalities, 40% of cases with facial clefting had a chromosomal abnormality indicating a need for karyotype analysis in these patients. Other anomalies detected included cebocephaly, hypotelorism, frontal bossing, exophthalmos and hypertelorism. We feel that visualization of the fetal face is an essential part of the assessment of intracranial abnormalities and is valuable in any situation where a chromosomal abnormality or a skeletal dysplasia is suspected.

The ultrasound markers of chromosomal disease: a retrospective study

Over a 3 year period 37 pregnancies were complicated by a chromosomal abnormality. In the two cases of trisomy 13, holoprosencephaly, facial clefting, polydactyly and growth retardation were seen. In the seven cases of trisomy 18, abnormalities of the extremities, face and heart were common. Growth retardation and diaphragmatic hernia were also demonstrated. In the 21 cases of Down's syndrome the main abnormalities were cardiac, duodenal atresia and subtle digital anomalies. The two fetuses with triploidy showed a large hydropic placenta and holoprosencephaly respectively, and all five cases of Turner's syndrome demonstrated a cystic hygroma two of which were associated with hydrops. From the antenatal scans major anomalies were detected in 18 fetuses, however, chromosomal disease was suspected in only 15 cases. This was in part owing to a high false negative rate for cardiac anomalies (14 cases) in both routine and detailed scans. Owing to the diversity of anomalies present in chromosomal disease full assessment of the fetus is recommended with particular attention to the fetal heart, face, hands and feet. Specific anomalies are suggested for karyotype.

The Dandy-Walker syndrome: the value of antenatal diagnosis

The Dandy-Walker syndrome can be accurately diagnosed in utero by sonographic demonstration of characteristic morphologic changes in the fetal posterior fossa. Three cases of Dandy-Walker syndrome are described. The associated intracranial and extracranial anomalies are reviewed, and the value of antenatal diagnosis is discussed.

Is a short femur length a useful ultrasound marker for Down's syndrome?

To assess the significance of a short femur in the antenatal diagnosis of Down's syndrome a retrospective analysis was made of all Down's syndrome fetuses diagnosed over a 3 year period. 11 fetuses were found to have had a biparietal diameter and femur length measurement taken between 15 and 24 weeks gestation. Normal graphs were plotted for femur length against gestational age, femur length against biparietal diameter and biparietal diameter/femur length against gestational age. When the Down's syndrome measurements were plotted on the normal graphs there were four abnormal measurements. These four measurements, however, represented two fetuses both of which demonstrated other abnormalities, one cystic hygroma and one duodenal atresia with choroid plexus cysts. We do not feel that the femur length measurement is useful in the antenatal diagnosis of Down's syndrome.

Case report: in utero diagnosis of a vein of Galen aneurysm using colour flow Doppler

We report the ante-natal diagnosis of a vein of Galen aneurysm using colour flow Doppler at 33 weeks gestation. Ultrasound demonstrated a midline, tubular, echo-free structure superior to the thalamus extending posteriorly. Venous flow was demonstrated within the structure using colour flow Doppler. The diagnosis was confirmed by post-natal sonography. We believe this to be the first ante-natal diagnosis of this condition using colour flow Doppler.

Case report: antenatal diagnosis of congenital glioblastoma

We report a case of congenital cerebral glioblastoma. The initial antenatal ultrasound scan showed a peripheral area of high reflectivity within the right cerebral hemisphere. A subsequent scan showed that the area of high reflectivity had increased in size to completely fill the hemisphere, with shift of the falx and contralateral ventriculomegaly. Glioblastoma is one of the least common congenital brain tumours and has the poorest prognosis with no recorded cases surviving beyond one year.

Fetal choroid plexus cysts: a prospective study and review of the literature

To determine the incidence and significance of fetal choroid plexus cysts, a prospective study was carried out at Queen's Medical Centre, Nottingham. The incidence of cysts was found to be 0.42% and the size of cysts varied from 3 to 13 mm with a mean diameter of 6.2 mm. Choroid plexus cysts were associated with other fetal abnormalities in three cases, two of which were subsequently found to have a chromosomal abnormality, one Trisomy 18 and one Trisomy 21. A review of the reported cases of choroid plexus cysts reveals an overall incidence of 5.8% for Trisomy 18. We therefore recommend that in patients with choroid plexus cysts a detailed scan should be carried out to look for the ultrasound markers of Trisomy 18. If there is an associated abnormality or cysts are large (13 mm or greater in diameter) and bilateral then a karyotyping should be carried out.

The prevalence of disc degeneration associated with neural arch defects of the lumbar spine assessed by magnetic resonance imaging

The morphology of the intervertebral discs in 40 patients with spondylolytic and mild spondylolisthetic defects of the lumbar spine were assessed using magnetic resonance imaging. The results were compared with an age- and sex-matched asymptomatic population, and the difference in prevalence of disc degeneration between the two groups was noted. Under the age of 25 years, degeneration was uncommon in both the disc associated with the neural arch defect and the comparable disc in the control population. However, after this age, the prevalence of the disc degeneration rose in both groups, but was more marked in the spondylytic group, and this difference was statistically significant (P = 0.025). The results suggest that a neural arch defect is associated with an increased prevalence of disc degeneration, which is greater than is seen in a normal aging population.

Diagnosis of lumbar disc protrusion. A comparison between magnetic resonance imaging and radiculography

Forty-two consecutive patients with suspected lumbar disc protrusions were studied prospectively to compare the diagnostic accuracy of low-field strength MRI with that of radiculography. Thirty patients subsequently underwent surgical exploration at 33 levels and the operative findings were compared to both methods of diagnostic imaging. All patients had MRI studies, whilst 29 patients also had radiculography. Both studies were evaluated without prior knowledge of the clinical signs, operative findings or the results of other imaging techniques. MRI predicted the correct diagnosis in 29 of the 33 levels explored, an accuracy of 88%. All discs proven to be abnormal demonstrated a reduced signal from the nucleus pulposus. There were two false positive results and two doubtful cases but no false negatives. Radiculography predicted the correct diagnosis in 24 of 32 levels explored, an accuracy of 75%. There were two false positive results, five doubtfuls and one false negative. The overall accuracy when both tests were considered rose to 94%. Of the remaining 12 patients all except one showed good correlation between the MRI and radiculographic findings. These results indicate that low field strength MRI is slightly better than radiculography in diagnosing lumbar disc protrusions.

The use of the pelvic radiograph alone to assess therapeutic response in bone metastases from breast cancer

This study examines the necessity for repeated full skeletal radiographic surveys to assess the response of bone metastases from breast cancer to systemic treatment. This method of evaluating response is compared with that achieved using sequential radiography of the pelvis alone. Sequential changes on pelvic radiographs were identical to those seen on a complete skeletal survey in 87% of the patients studied. In only 6% of the patients were the changes on the pelvic radiographs sufficiently at variance with those on the skeletal survey to suggest a difference in management. It is suggested that sequential radiography of pelvic bones alone is sufficient to assess response of bone metastases in breast cancer in the majority of patients.

The use of serum carcinoembryonic antigen to assess therapeutic response in locally advanced and metastatic breast cancer: a prospective study with external review

Serum carcinoembryonic antigen (CEA) has been measured throughout initial systemic endocrine treatment in 87 patients with stage III and 179 patients with stage IV breast cancer. Clinical response has been assessed after six months according to UICC criteria with external review of clinical and radiological data. Pretreatment CEA concentrations have been compared with those found in 55 'disease free' women attending a diagnostic breast clinic. A strong correlation exists between therapeutic response and alterations in CEA concentration (above 6 ng/ml) in patients presenting with stage IV disease. More than 50% of such patients either present with or develop CEA concentration greater than 6 ng/ml during the first six months of treatment.

Upper gastrointestinal barium studies in the elderly: follow-up in 101 patients

A A retrospective study of 101 elderly patients who were referred for upper gastrointestinal barium studies showed that this led to a change of management in 36 patients. The commonest management change was endoscopic referral (10 patients). However, in only on patient did this sequence lead to surgery and this was merely palliative. Dysphagia, vomiting and weight loss were shown to be the presenting features most likely to result in an abnormal barium study. The most frequently detected abnormalities were hiatus hernia, reflux, oesophageal stricture, peptic ulcer and gastric carcinoma.