Healthcare Ltd Research Articles

190. Meta-analysis of Impact of Follow-up Blood Cultures on Mortality in Patients with Gram-negative Bacteremia

Abstract Background It is not clear if follow-up blood cultures are beneficial in patients with Gram-negative bacteremia. It may improve clinical outcomes but have some drawbacks such as the possibility of inaccurate positive findings and extending the length of hospital stay and duration of antibiotic therapy. The aim of this meta-analysis was to evaluate the impact of follow-up blood cultures on mortality in patients with Gram-negative bacteremia. Methods PubMed and EMBASE databases were searched from inception to Jan 2023 for randomized controlled trials or observational studies comparing the mortality in patients with Gram-negative bacteremia who had follow-up blood cultures obtained versus those without these cultures. We estimated odds ratios (ORs) with 95% confidence intervals (CIs) using random-effects models and assessed for heterogeneity (I2). Results A total of six observational studies were included, while no randomized controlled trials were identified. The total number of patients was 4,631. One study used 28-day mortality, two studies used 30-day mortality, and three studies used in-hospital mortality. Follow-up blood cultures were associated with significantly lower odds of mortality ((OR, 0.6; 95%CI, 0.5-0.7; I2, 0%). No publication bias or heterogeneity was observed. Conclusion The use of follow-up blood cultures in patients with Gram-negative bacteremia was associated with lower mortality. Randomized controlled trials are needed. Currently, follow-up blood cultures should be obtained for at least the high-risk patients with Gram-negative bacteremia. Disclosures Khalid Eljaaly, PharmD, MS, BCPS, BCIDP, FCCP, Reckitt Benckiser Healthcare International Ltd, UK: Member of the Global Respiratory Infection Partnership, supported by unrestricted educational grant from Reckitt Benckiser Healthcare Ltd

Iodometric determination of quinine sulfate in tablets using N-oxidation with diperoxysebacic acid

Using diperoxysebacic acid as an example, it was shown the interaction of diperoxycarboxylic acids with quinine alkaloid in an aqueous medium by kinetics method. The reaction proceeds quantitatively by the mechanism of nucleophilic substitution of β-peroxide oxygen atom in diperoxycarboxylic acid with the formation of the corresponding N-oxide, and the kinetics of the process is a subject to general rules of specific acid-base catalysis. New iodometric methods were developed, and the possibility of quinine sulfate quantification in pure form ‘Quinine sulfate’, as well as in the combined dosage form ‘Limpar® N 200 mg’ (Cassella Med GmbH, Germany) and in ‘Quinine sulfate 200 mg Tablets’ (Accord Healthcare Ltd, UK) by the reaction of oxidation with diperoxycarboxylic acid. They are characterized by high selectivity, and rate, simplicity of performing, and good accuracy. No toxic reagents or special conditions required. RSD ≤1.6% (δ =+0.40..+0.72%), LOQ=0.01 mg.

Breaking taboos for whole-person care

British Journal of Cardiac NursingVol. 18, No. 6 EditorialBreaking taboos for whole-person careAysha MendesAysha MendesCorrespondence to: Aysha Mendes; E-mail Address: [email protected]British Journal of Cardiac Nursing, MA Healthcare Ltd, London, UKSearch for more papers by this authorAysha MendesPublished Online:23 Jun 2023https://doi.org/10.12968/bjca.2023.0060AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References British Heart Foundation. How to start a conversation about sex. 2023a. https://www.bhf.org.uk/informationsupport/heart-matters-magazine/wellbeing/sex-when-you-have-a-heart-condition/how-to-start-a-conversation-about-sex (accessed 20 June 2023) Google ScholarBritish Heart Foundation. Dealing with sex after a heart condition. 2023b. https://www.bhf.org.uk/informationsupport/heart-matters-magazine/wellbeing/sex-when-you-have-a-heart-condition (accessed 20 June 2023) Google ScholarBritish Heart Foundation. ‘How my heart condition has ended my sex life – and why I wish doctors would talk about it.’ 2023c. https://www.bhf.org.uk/informationsupport/heart-matters-magazine/wellbeing/sex-when-you-have-a-heart-condition/roger-fox (accessed 20 June 2023) Google ScholarInternational Longevity Centre UK. The last taboo: a guide to dementia, sexuality, intimacy and sexual behaviour in care home.s 2011. https://ilcuk.org.uk/the-last-taboo-a-guide-to-dementia-sexuality-intimacy-and-sexual-behaviour-in-care-homes/ (accessed 20 June 2023) Google ScholarMcLeod S. Maslow's hierarchy of needs. 2023. https://www.simplypsychology.org/maslow.html (accessed 20 June 2023) Google Scholar FiguresReferencesRelatedDetails 2 June 2023Volume 18Issue 6ISSN (online): 2052-2207 Metrics History Published online 23 June 2023 Published in print 2 June 2023 Information© MA Healthcare LimitedPDF download

0451 Dronabinol Plus Acetazolamide for the Treatment of Obstructive Sleep Apnoea: A Proof of Concept and Mechanistic Exploration Study

Abstract Introduction Current treatments for obstructive sleep apnoea (OSA) typically target the anatomical pathophysiological endotype and are either not tolerated or effective in a significant proportion of patients. Pharmaceuticals may provide an alternative therapeutic option and may address some or all of the remaining endotypes (loop gain, muscle compensation and arousal threshold). This randomised, double-blind, placebo-controlled, cross-over study examined the effect of combination acetazolamide and dronabinol (IHL-42X) at low, medium and high doses on OSA severity and the OSA endotypes. Methods Participants with OSA (apnoea-hypopnoea index; AHI≥15events/hr) received 1-week of IHL-42X at each of the 3 doses and 1-week of placebo, each separated by 1-week washout. The change from baseline in AHI, oxygen desaturation index (ODI), Epworth sleepiness score (ESS), and mood (profile of mood states) on the final night of each treatment arm relative to placebo were the major endpoints. Adverse events (AEs) were monitored throughout. Exploratory analyses examined the change in OSA endotypes determined from polysomnography from baseline values. Results Ten of 11 participants (mean baseline AHI 40.7events/hr) completed the final night of at least one treatment arm. All doses of IHL-42X demonstrated a significant reduction in AHI from baseline when compared with placebo (low, -19.7±27.1; medium, -17.5±23.3; high, -16.4±23.8 versus placebo, -2.8±21.0events/hr; all p< 0.05). The change from baseline in ODI3% at the low, medium and high doses of IHL-42X (-15.2±24.8; -15.4±19.0 and -8.3±13.2events/hr, respectively) were not significantly different from placebo (-2.8±21.0events/hr). IHL-42X did not significantly alter ESS or mood. No serious AEs occurred. However, 31 mild-moderate possibly, probably or treatment related AEs occurred during IHL-42X dosing (4 at the low dose) and 4 occurred during placebo. Relative to baseline, loop gain decreased by 15, 21 and 20% (Cohen’s d all ≥0.59) at the low, medium and high doses, respectively, and collapsibility improved by 12.5% (d=1.06) at the low dose only. Conclusion One week of nightly IHL-42X at all doses was well tolerated, safe and associated with significant reductions in OSA severity. IHL-42X may act to reduce OSA severity by decreasing loop gain and upper airway collapsibility, particularly at the low dose. Support (if any) Incannex Healthcare Ltd supported this study.

Prevention requires putting people over profits

British Journal of Cardiac NursingVol. 18, No. 5 EditorialPrevention requires putting people over profitsAysha MendesAysha MendesCorrespondence to: Aysha Mendes; E-mail Address: [email protected]British Journal of Cardiac Nursing, MA Healthcare Ltd, London, UKSearch for more papers by this authorAysha MendesPublished Online:31 May 2023AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article FiguresReferencesRelatedDetails 2 May 2023Volume 18Issue 5ISSN (online): 2052-2207 Metrics History Published online 31 May 2023 Published in print 2 May 2023 Information© MA Healthcare LimitedPDF download

Effects of an asymmetrical high flow nasal cannula interface in hypoxemic patients

BackgroundOptimal noninvasive respiratory support for patients with hypoxemic respiratory failure should minimize work of breathing without increasing the transpulmonary pressure. Recently, an asymmetrical high flow nasal cannula (HFNC) interface (Duet, Fisher & Paykel Healthcare Ltd), in which the caliber of each nasal prong is different, was approved for clinical use. This system might reduce work of breathing by lowering minute ventilation and improving respiratory mechanics.MethodsWe enrolled 10 patients ≥ 18 years of age who were admitted to the Ospedale Maggiore Policlinico ICU in Milan, Italy, and had a PaO2/FiO2 < 300 mmHg during HFNC support with a conventional cannula. We investigated whether the asymmetrical interface, compared to a conventional high flow nasal cannula, reduces minute ventilation and work of breathing. Each patient underwent support with the asymmetrical interface and the conventional interface, applied in a randomized sequence. Each interface was provided at a flow rate of 40 l/min followed by 60 l/min. Patients were continuously monitored with esophageal manometry and electrical impedance tomography.ResultsApplication of the asymmetrical interface resulted in a −13.5 [−19.4 to (−4.5)] % change in minute ventilation at a flow rate of 40 l/min, p = 0.006 and a −19.6 [−28.0 to (−7.5)] % change at 60 l/min, p = 0.002, that occurred despite no change in PaCO2 (35 [33–42] versus 35 [33–43] mmHg at 40 l/min and 35 [32–41] versus 36 [32–43] mmHg at 60 l/min). Correspondingly, the asymmetrical interface lowered the inspiratory esophageal pressure–time product from 163 [118–210] to 140 [84–159] (cmH2O*s)/min at a flow rate of 40 l/min, p = 0.02 and from 142 [123–178] to 117 [90–137] (cmH2O*s)/min at a flow rate of 60 l/min, p = 0.04.The asymmetrical cannula did not have any impact on oxygenation, the dorsal fraction of ventilation, dynamic lung compliance, or end-expiratory lung impedance, suggesting no major effect on PEEP, lung mechanics, or alveolar recruitment.ConclusionsAn asymmetrical HFNC interface reduces minute ventilation and work of breathing in patients with mild-to-moderate hypoxemic respiratory failure supported with a conventional interface. This appears to be primarily driven by increased ventilatory efficiency due to enhanced CO2 clearance from the upper airway.

Hepatitis E-associated neuralgic amyotrophy: a rare respiratory presentation.

Hepatitis E-associated neuralgic amyotrophy: a rare respiratory presentation.

Psychological wellbeing inside and outside NHS mental health services

British Journal of Healthcare ManagementVol. 29, No. 3 EditorialPsychological wellbeing inside and outside NHS mental health servicesIsobel CloughIsobel CloughCorrespondence to: Isobel Clough; E-mail Address: [email protected]British Journal of Healthcare Management, MA Healthcare Ltd, London, UKSearch for more papers by this authorIsobel CloughPublished Online:6 Mar 2023https://doi.org/10.12968/bjhc.2023.0021AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Mind. Mental health facts and statistics. 2020. https://tinyurl.com/5abh4pnd (accessed 23 February 2023) Google ScholarRimmer A. Mental health: staff shortages are causing distressingly long waits for treatment, college warns. BMJ. 2021;375:n2439. https://doi.org/10.1136/bmj.n2439 Crossref, Google ScholarRoyal College of Psychiatrists. Two-fifths of patients waiting for mental health treatment forced to resort to emergency or crisis services. 2020. https://tinyurl.com/3w6y8vrx (accessed 23 February 2023) Google ScholarSutherland R. Tackling the root causes of suicide. 2018. https://tinyurl.com/ybf4da2j (accessed 23 February 2023) Google Scholar FiguresReferencesRelatedDetails 2 March 2023Volume 29Issue 3ISSN (print): 1358-0574ISSN (online): 1759-7382 Metrics History Published online 6 March 2023 Published in print 2 March 2023 Information© MA Healthcare LimitedPDF download

Stronger Together

British Journal of Cardiac NursingVol. 18, No. 3 EditorialStronger TogetherAysha MendesAysha MendesCorrespondence to: Aysha Mendes; E-mail Address: [email protected]British Journal of Cardiac Nursing, MA Healthcare Ltd, London, UKSearch for more papers by this authorAysha MendesPublished Online:6 Apr 2023https://doi.org/10.12968/bjca.2023.0027AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article FiguresReferencesRelatedDetails 2 March 2023Volume 18Issue 3ISSN (online): 2052-2207 Metrics History Published online 6 April 2023 Published in print 2 March 2023 Information© MA Healthcare LimitedPDF download

Mind Over Matter

British Journal of Cardiac NursingVol. 18, No. 2 EditorialMind Over MatterAysha MendesAysha MendesCorrespondence to: Aysha Mendes; E-mail Address: [email protected]British Journal of Cardiac Nursing, MA Healthcare Ltd, London, UKSearch for more papers by this authorAysha MendesPublished Online:27 Feb 2023https://doi.org/10.12968/bjca.2023.0017AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Balban MY, Neri E, Kogon MM et al.. Brief structured respiration practices enhance mood and reduce physiological arousal. Cell Rep Med. 2023;4(1):100895. https://doi.org/10.1016/j.xcrm.2022.100895 Crossref, Google ScholarCowan H. Nurtured by nature: finding your anchor. British Journal of Cardiac Nursing. 2022;17(6):1–2. https://doi.org/10.12968/bjca.2022.0029 Abstract, Google ScholarHowarth M, Lister C. Social prescribing in cardiology: rediscovering the nature within us. British Journal of Cardiac Nursing. 2019;14(8):1–9. https://doi.org/10.12968/bjca.2019.0036 Link, Google ScholarNeff MA. Up and down regulation: how to regulate your nervous system. 2023. https://neurodivergentinsights.com/blog/up-and-down-regulation (accessed 20 February 2023) Google Scholar FiguresReferencesRelatedDetails 2 February 2023Volume 18Issue 2ISSN (online): 2052-2207 Metrics History Published online 27 February 2023 Published in print 2 February 2023 Information© MA Healthcare LimitedPDF download

THRIVE to the rescue.

Dear Editor, “Transnasal humidified rapid insufflation ventilator exchange (THRIVE)” works on the principle of ventilation without ventilator movements. With THRIVE, ventilation occurs with a noninvasive nasal cannula, with high flow humidified oxygen at 30–60 L/min. These high flows create a distending alveolar pressure or positive end-expiratory pressure (PEEP) up to 7 cm of water, which prevents airway collapse and atelectasis.[1,2] We describe two cases in which the use of THRIVE helped prevent reintubation postoperatively. Case 1: A 61-year-old male was operated for robotic radical cystectomy under general anesthesia in lithotomy and Trendelenburg position for 8 h. After extubation within a few minutes, he started to desaturate. Blood gas showed pH-7.33/pCO2-46.5/pO2-47.2/sat-76.4%. Bilateral lung basal atelectasis secondary to the position during the procedure was the probable diagnosis. In view of persistent hypoxia and the possibility of worsening oxygenation, the choice was noninvasive ventilation (NIV) or reintubation. However, NIV was logistically not possible in the OT. THRIVE (OptiFlow THRIVE system by Fisher and Paykel Healthcare Ltd, Auckland, New Zealand), was started at 30 L/min. Within few minutes, the saturation picked to 100%. Blood gas done after 30 min of THRIVE showed pH-7.38, pCO2-35, pO2-107.9, satulation-97.5%. As the patient was breathing comfortably and hemodynamically stable, he was shifted to the intensive care unit (ICU) with facemask oxygen for transfer. THRIVE was continued in the ICU for another 2 h and finally weaned off to a nasal cannula of 2 L/min. Case 2: A 61-year-old lady was operated for breast microdocectomy under general anesthesia, post-operatively the patient was extubated after which her respiratory rate was 36–38 per min with oxygen saturation of 88%–90% on 10 L oxygen non rebreathing mask and blood pressure of 213/102 mm Hg. Chest auscultation revealed bilateral crepts. Suspecting it to be pulmonary edema, injection furosemide IV was administered, and nitroglycerine (NTG) infusion was started. Her blood gas showed pH- 6.99, pCO2- 116, pO2- 85, pHCO3- 19, oxygen saturation-90%. After the initiation of THRIVE at 40 L/min over the next 10 min, her saturation started picking up to 97%–98%, and her respiratory rate settled to 18–20 per mi. Eventually her THRIVE flow was reduced to 20 L/min. Her blood gas was pH- 7.32, pCO2- 50.6, PO2 -140, HCO3-26 and was shifted to the ICU. After 2 h of THRIVE in the ICU, her blood gas was pH-7.3, pCO2- 41, pO2- 138, pHCO3- 25. Thrive delivers gases at a flow rate that exceeds the patient’s peak inspiratory flow rate.[3] It helps to recruit the lungs. It washes out the upper airway dead space, creating an oxygen reservoir and increasing the tidal volume, probably explaining the mechanism for decreasing the PCO2.[4] By increasing the end-inspiratory lung volume, it decreases the work of breathing.[5] The warm and humidified inspired gases decrease airway inflammation and improve drainage of respiratory secretions.[4] THRIVE can be an important additional tool to provide oxygen in the post-operative period to prevent reintubation. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

On the precipice of change

British Journal of Cardiac NursingVol. 17, No. 12 EditorialOn the precipice of changeAysha MendesAysha MendesCorrespondence to: Aysha Mendes; E-mail Address: [email protected]British Journal of Cardiac Nursing, MA Healthcare Ltd, London, UKSearch for more papers by this authorAysha MendesPublished Online:3 Jan 2023https://doi.org/10.12968/bjca.2022.0139AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article FiguresReferencesRelatedDetails 2 December 2022Volume 17Issue 12ISSN (online): 2052-2207 Metrics History Published online 3 January 2023 Published in print 2 December 2022 Information© MA Healthcare LimitedPDF download

COP27 Climate Change Conference: urgent action needed for Africa and the world

<scp>COP27</scp> Climate Change Conference: urgent action needed for Africa and the world

COP27 Climate Change Conference: urgent action needed for Africa and the world

COP27 Climate Change Conference: urgent action needed for Africa and the world

Fighting for nurses

British Journal of Cardiac NursingVol. 17, No. 11 EditorialFighting for nursesAysha MendesAysha MendesCorrespondence to: Aysha Mendes; E-mail Address: [email protected]British Journal of Cardiac Nursing, MA Healthcare Ltd, London, UKSearch for more papers by this authorAysha MendesPublished Online:1 Dec 2022https://doi.org/10.12968/bjca.2022.0130AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article

Community Houses to Increase Access to Home Dialysis.

Community Houses to Increase Access to Home Dialysis.

COP27 climate change conference: Urgent action needed for Africa and the world

COP27 climate change conference: Urgent action needed for Africa and the world

Beyond colour

British Journal of Cardiac NursingVol. 17, No. 10 EditorialBeyond colourAysha MendesAysha MendesCorrespondence to: Aysha Mendes; E-mail Address: [email protected]British Journal of Cardiac Nursing, MA Healthcare Ltd, London, UKSearch for more papers by this authorAysha MendesPublished Online:1 Nov 2022https://doi.org/10.12968/bjca.2022.0117AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article FiguresReferencesRelatedDetails 2 October 2022Volume 17Issue 10ISSN (online): 2052-2207 Metrics History Published online 1 November 2022 Published in print 2 October 2022 Information© MA Healthcare LimitedPDF download

Action, not words

British Journal of Cardiac NursingVol. 17, No. 9 EditorialAction, not wordsAysha MendesAysha MendesCorrespondence to: Aysha Mendes; E-mail Address: [email protected]British Journal of Cardiac Nursing, MA Healthcare Ltd, London, UKSearch for more papers by this authorAysha MendesPublished Online:30 Sep 2022https://doi.org/10.12968/bjca.2022.0105AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References The King's Fund. NHS waiting times: our position. 2022. https://www.kingsfund.org.uk/projects/positions/nhs-waiting-times?gclid=Cj0KCQjw0oyYBhDGARIsAMZEuMtzMgkcqfrNlO7PbNaNKd8pbsbm264AoFEjp9dxrGChr5DPKrJ4U8YaAkLGEALw_wcB (accessed 22 September 2022) Google ScholarUK Government. People living in deprived neighbourhoods. 2020. https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/demographics/people-living-in-deprived-neighbourhoods/latest (accessed 22 September 2022) Google Scholar FiguresReferencesRelatedDetails 2 September 2022Volume 17Issue 9ISSN (online): 2052-2207 Metrics History Published online 30 September 2022 Published in print 2 September 2022 Information© MA Healthcare LimitedPDF download

Caution against the new normal

British Journal of Cardiac NursingVol. 17, No. 8 EditorialCaution against the new normalAysha MendesAysha MendesCorrespondence to: Aysha Mendes; E-mail Address: [email protected]British Journal of Cardiac Nursing, MA Healthcare Ltd, London, UKSearch for more papers by this authorAysha MendesPublished Online:30 Aug 2022https://doi.org/10.12968/bjca.2022.0094AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Blake I. 12,000 fewer heart operations performed in England. 2021. https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2021/january/12000-fewer-heart-operations-in-england (accessed 22 August 2022) Google ScholarBlake I. Over 100,000 people now waiting over four months for time-sensitive care. 2022. https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2022/august/100000-waiting-over-four-months-for-heart-care (accessed 22 August 2022) Google ScholarBritish Heart Foundation. How the pandemic is taking its toll on people with heart and circulatory conditions. 2021. https://www.bhf.org.uk/informationsupport/heart-matters-magazine/news/coronavirus-and-your-health/pandemic-effect-on-heart-patients (accessed 22 August 2022) Google ScholarDepartment of Health and Social Care. The NHS improvement plan: putting people at the heart of public services. Norwich: The Stationary Office; 2004 Google ScholarDepartment of Health and Social Care. The NHS Long Term Plan. 2019. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf (accessed 22 August 2022) Google ScholarGallagher P. Thousands of heart patients ‘missed out on urgent care during first wave’ of Coronavirus. 2021. https://inews.co.uk/news/health/coronavirus-thousands-heart-patients-missed-out-urgent-care-first-wave-923678 (accessed 22 August 2022) Google ScholarHockaday J. Heart disease deaths up by 5,000 as pandemic takes toll on other patients. 2020. https://metro.co.uk/2020/11/14/heart-disease-deaths-up-by-5000-as-pandemic-takes-toll-on-other-patients-13595053/ (accessed 22 August 2022) Google Scholar FiguresReferencesRelatedDetails 2 August 2022Volume 17Issue 8ISSN (online): 2052-2207 Metrics History Published online 30 August 2022 Published in print 2 August 2022 Information© MA Healthcare LimitedPDF download