A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies

The objective of this guideline is to provide healthcare professionals with clear, up-to-date and practical guidance on the management of thrombotic thrombocytopenic purpura (TTP) and related thrombotic microangiopathies (TMAs), including complement-mediated haemolytic uraemic syndrome (CM HUS); these are defined by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and small vessel thrombosis. Within England, all TTP cases should be managed within designated regional centres as per NHSE commissioning for highly specialised services.

Accidental lipid overdose in a preterm infant: A case report

BACKGROUND

Intravenous lipid emulsions (ILEs) provide essential fatty acids during parenteral nutrition (PN). Serious adverse events including death can occur from overdose. We report an accidental overdose in a preterm infant.

METHOD

On Day 2 of life, a 29-week gestational age (GA) twin was accidentally given 47.5 mL of Intralipid20% (≈3x daily amount) in 50-minutes.

RESULTS

No apparent clinical deterioration occurred, although blood samples were lipaemic. Outcomes at 2 years corrected GA were similar to that of his twin. Service changes were made to infusion packaging and administration to avoid similar errors.

CONCLUSIONS

Medication errors in neonates are unfortunately common. Published articles usually focus on poor outcomes, which can increase the distress for parents of children where errors have occurred. Publishing the full spectrum of outcomes instead allows parents and professionals to be aware of all possibilities and lessons learnt, even if serious harm was avoided.

Measurements of Argon-39 from locations near historic underground nuclear explosions

Measurement of radioactive gas seepage from an underground nuclear explosion is one of the primary methods to confirm whether an event was nuclear in nature. Radioactive noble gas indicators that are commonly targeted by such measurements (e.g. ¹³³Xe, ³⁷Ar) have half-lives of 35 days or less. Argon-39, an activation product similar to ³⁷Ar, is produced by the interaction between neutrons and potassium in the surrounding geology and has a half-life of 269 years. Measurements taken at three sites near three historic underground nuclear test locations at the Nevada National Security Site have all shown highly elevated levels of ³⁹Ar in soil gas decades after the test events. Elevated levels of ³⁹Ar were also detected in atmospheric air collected near two of these sites, and outside the entrance of the one tunnel site. These measurements demonstrate that ³⁹Ar has the potential to be a long-term signature of an underground nuclear event which can be reliably detected at the surface or in the shallow subsurface. This radionuclide detection of an underground nuclear event decades after the event takes place is in contrast to the commonly held assumption that detecting underground nuclear events via radionuclides at the surface needs to be done in a matter of months. Depending upon what further studies show about the robustness of this signature in a variety of geological settings, it may in fact be easy to detect underground nuclear events at the surface for a very long time post-detonation.

Evidence review of physical distancing and partition screens to reduce healthcare acquired SARS-CoV-2

We review the evidence base for two newly introduced Infection prevention and control strategies within UK hospitals. The new standard infection control precaution of 2 metres physical distancing and the use of partition screens as a means of source control of infection for SARS-CoV-2. Following review of Ovid-MEDLINE and governmental SAGE outputs there is limited evidence to support the use of 2 metres physical distancing and partition screens within healthcare.

Distinct adaptation patterns between grip dynamics and arm kinematics when the body is upside-down

In humans, practically all movements are learnt and performed in a constant gravitational field. Yet, studies on arm movements and object manipulation in parabolic flight have highlighted very fast sensorimotor adaptations to altered gravity environments. Here, we wondered if the motor adjustments observed in those altered gravity environments could also be observed on Earth in a situation where the body is upside-down. To address this question, we asked participants to perform rhythmic arm movements in two different body postures (right-side-up and upside-down) while holding an object in precision grip. Analyses of grip-load force coordination and of movement kinematics revealed distinct adaptation patterns between grip and arm control. Grip force and load force were tightly synchronized from the first movements performed in upside-down posture, reflecting a malleable allocentric grip control. In contrast, velocity profiles showed a more progressive adaptation to the upside-down posture and reflected an egocentric planning of arm kinematics. In addition to suggesting distinct mechanisms between grip dynamics and arm kinematics for adaptation to novel contexts, these results also suggest the existence of general mechanisms underlying gravity-dependent motor adaptation that can be used for fast sensorimotor coordination across different postures on Earth and, incidentally, across different gravitational conditions in parabolic flights, in human centrifuges, or in Space.NEW & NOTEWORTHY During rhythmic arm movements performed in an upside-down posture, grip control adapted very quickly, but kinematics adaptation was more progressive. Our results suggest that grip control and movement kinematics planning might operate in different reference frames. Moreover, by comparing our results with previous results from parabolic flight studies, we propose that a common mechanism underlies adaptation to unfamiliar body postures and adaptation to altered gravity.

First Measurement of Near-Threshold J/ψ Exclusive Photoproduction off the Proton

We report on the measurement of the γp→J/ψp cross section from E_{γ}=11.8  GeV down to the threshold at 8.2 GeV using a tagged photon beam with the GlueX experiment. We find that the total cross section falls toward the threshold less steeply than expected from two-gluon exchange models. The differential cross section dσ/dt has an exponential slope of 1.67±0.39  GeV^{-2} at 10.7 GeV average energy. The LHCb pentaquark candidates P_{c}^{+} can be produced in the s channel of this reaction. We see no evidence for them and set model-dependent upper limits on their branching fractions B(P_{c}^{+}→J/ψp) and cross sections σ(γp→P_{c}^{+})×B(P_{c}^{+}→J/ψp).

Validation of a national hand hygiene proxy measure in NHS Scotland

The Scottish national hand hygiene proxy measure uses the volume of alcohol-based hand rub (ABHR) purchased by NHS Scotland boards as an indicator of the number of hand hygiene moments being performed per patient-bed-day. The proxy measure calculation is based on the assumption that 3 mL of ABHR is used per hand hygiene moment. This study aimed to validate the volume of ABHR being used per hand hygiene moment. It found that the median volume of ABHR being used in practice is approximately 1 mL per hand hygiene moment, and that using this validated volume in the calculation substantially increases the proxy measure of hand hygiene compliance.

Preliminary Results of USA-European Field Trial on the Use of Patient-reported Measures in a Mobile Application and Potential Uses in Refugee Populations

Introduction

The use of patient-reported outcome measures in psychiatric practices in the United States is still in its beginning phases. More research is need to determine the usefulness of such measures and the optimal methods to present them to patients and practitioners in routine care settings.

Objectives

This presentation will describe the research plan for testing a group of patient-reported outcome measures using digital applications. Potential opportunities for use in underserved refugee populations will be presented.

Methods

The outcome measures were selected from those recommended in DSM-5 Section III, including cross-cutting symptom and disability measures. A user-friendly digital application was developed for data collection, synthesis, and presentation. The research plan has three phases: focus groups with patients and clinicians, piloting of methods, and the main study, a pragmatic trial comparing treatment outcomes using outcome measurement versus usual care.

Results

Results of the focus group sessions will be presented, along with changes made to the measures and the digital application in response to these results. Current status of the research project will be discussed.

Conclusions

The results of this research project will bring greater clarity to questions on the role of outcome measurements in improving quality of care and patient outcomes. With ever greater use of smart phones, tablets, and personal computers, digital technology has the potential to facilitate psychiatric assessment and treatment for underserved, difficult-to-reach populations such as refugees.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Physiological mechanisms for stabilizing the limb when acting against physical constraints

Smooth physical interaction with our environment, such as when working with tools, requires adaptability to unpredictable perturbations that can be achieved through impedance control of multi-joint limbs. Modulation of arm stiffness can be achieved either increasing co-contraction of antagonistic muscles or by increasing the gain of spinal reflex loops. According to the "automatic gain scaling" principle, the spinal reflex gain, as measured via the H-reflex, scales with muscle activation. A previous experiment from our labs suggested, however, that reflex gains might instead be scaled to the force exerted by the limb, perhaps as a means to counteract destabilizing external forces. The goal of our experiment was to test whether force output, rather than the muscular activity per se, could be the critical factor determining reflex gain. Five subjects generated different levels of force at the wrist with or without assistance to dissociate applied force from agonist muscular activity. We recorded contact force, EMG and H-reflex response from a wrist flexor. We did not find a strict relationship between reflex gain and contact force but nor did we observe consistent modulation of reflex gain simply as a function of agonist muscle activity. These results are discussed in relation to the stability of the task constraints.

"Cerebellar contribution to visuo-attentional alpha rhythm: insights from weightlessness"

Human brain adaptation in weightlessness follows the necessity to reshape the dynamic integration of the neural information acquired in the new environment. This basic aspect was here studied by the electroencephalogram (EEG) dynamics where oscillatory modulations were measured during a visuo-attentional state preceding a visuo-motor docking task. Astronauts in microgravity conducted the experiment in free-floating aboard the International Space Station, before the space flight and afterwards. We observed stronger power decrease (~ERD: event related desynchronization) of the ~10 Hz oscillation from the occipital-parietal (alpha ERD) to the central areas (mu ERD). Inverse source modelling of the stronger alpha ERD revealed a shift from the posterior cingulate cortex (BA31, from the default mode network) on Earth to the precentral cortex (BA4, primary motor cortex) in weightlessness. We also observed significant contribution of the vestibular network (BA40, BA32, and BA39) and cerebellum (lobule V, VI). We suggest that due to the high demands for the continuous readjustment of an appropriate body posture in free-floating, this visuo-attentional state required more contribution from the motor cortex. The cerebellum and the vestibular network involvement in weightlessness might support the correction signals processing necessary for postural stabilization, and the increased demand to integrate incongruent vestibular information.

The effect of augmenting early nutritional energy delivery on quality of life and employment status one year after ICU admission

Augmenting energy delivery during the acute phase of critical illness may reduce mortality and improve functional outcomes. The objective of this sub-study was to evaluate the effect of early augmented enteral nutrition (EN) during critical illness, on outcomes one year later. We performed prospective longitudinal evaluation of study participants, initially enrolled in The Augmented versus Routine approach to Giving Energy Trial (TARGET), a feasibility study that randomised critically ill patients to 1.5 kcal/ml (augmented) or 1.0 kcal/ml (routine) EN administered at the same rate for up to ten days, who were alive at one year. One year after randomisation Short Form-36 version 2 (SF-36v2) and EuroQol-5D-5L quality of life surveys, and employment status were assessed via telephone survey. At one year there were 71 survivors (1.5 kcal/ml 38 versus 1.0 kcal/ml 33; P=0.55). Thirty-nine (55%) patients consented to this follow-up study and completed the surveys (n = 23 and 16, respectively). The SF-36v2 physical and mental component summary scores were below normal population means but were similar in 1.5 kcal/ml and 1.0 kcal/ml groups (P=0.90 and P=0.71). EuroQol-5D-5L data were also comparable between groups (P=0.70). However, at one-year follow-up, more patients who received 1.5 kcal/ml were employed (7 versus 2; P=0.022). The delivery of 1.5 kcal/ml for a maximum of ten days did not affect self-rated quality of life one year later.

Inertial torque during reaching directly impacts grip-force adaptation to weightless objects

A hallmark of movement control expressed by healthy humans is the ability to gradually improve motor performance through learning. In the context of object manipulation, previous work has shown that the presence of a torque load has a direct impact on grip-force control, characterized by a significantly slower grip-force adjustment across lifting movements. The origin of this slower adaptation rate remains unclear. On the one hand, information about tangential constraints during stationary holding may be difficult to extract in the presence of a torque. On the other hand, inertial torque experienced during movement may also potentially disrupt the grip-force adjustments, as the dynamical constraints clearly differ from the situation when no torque load is present. To address the influence of inertial torque loads, we instructed healthy adults to perform visually guided reaching movements in weightlessness while holding an unbalanced object relative to the grip axis. Weightlessness offered the possibility to remove gravitational constraints and isolate the effect of movement-related feedback on grip force adjustments. Grip-force adaptation rates were compared with a control group who manipulated a balanced object without any torque load and also in weightlessness. Our results clearly show that grip-force adaptation in the presence of a torque load is significantly slower, which suggests that the presence of torque loads experienced during movement may alter our internal estimates of how much force is required to hold an unbalanced object stable. This observation may explain why grasping objects around the expected location of the center of mass is such an important component of planning and control of manipulation tasks.

Hair and bone as predictors of tissular mercury concentration in the western Alaska red fox, Vulpes vulpes

We evaluated if total mercury (THg) concentrations of keratin-based and bone-based tissues can predict THg concentrations in skeletal muscle, renal medulla, renal cortex, and liver. The THg concentration in matched tissues of 65 red foxes, Vulpes vulpes, from western Alaska was determined. Hair THg concentration had a significant positive correlation with liver, renal medulla, renal cortex, and muscle. The THg concentration for males and females is moderately predictive of THg concentration in the renal cortex and liver for these foxes based on R(2) values (R(2)=0.61 and 0.63, respectively). Bone is weakly predictive of THg concentration in muscle (R(2)=0.40), but not a reliable tissue to predict THg concentration in liver (R(2)=0.24), renal cortex (R(2)=0.35), or renal medulla (R(2)=0.25). These results confirm the potential use of trapped animals, specifically foxes, as useful Arctic sentinel species to inform researchers about patterns in THg levels over time as industrialization of the Arctic continues.

Timing of antenatal care and ART initiation in HIV-infected pregnant women before and after introduction of NIMART

In this review of routinely collected data from five community health centres in the Johannesburg Health District, we assess timing of antenatal care and antiretroviral therapy (ART) initiation in HIV-infected pregnant women before and after the introduction of nurse-initiated management of ART in antenatal clinics. There are important lessons to be learnt as we reflect on the South African prevention of mother-to-child transmission of HIV programme.

Gravity-dependent estimates of object mass underlie the generation of motor commands for horizontal limb movements

Moving requires handling gravitational and inertial constraints pulling on our body and on the objects that we manipulate. Although previous work emphasized that the brain uses internal models of each type of mechanical load, little is known about their interaction during motor planning and execution. In this report, we examine visually guided reaching movements in the horizontal plane performed by naive participants exposed to changes in gravity during parabolic flight. This approach allowed us to isolate the effect of gravity because the environmental dynamics along the horizontal axis remained unchanged. We show that gravity has a direct effect on movement kinematics, with faster movements observed after transitions from normal gravity to hypergravity (1.8g), followed by significant movement slowing after the transition from hypergravity to zero gravity. We recorded finger forces applied on an object held in precision grip and found that the coupling between grip force and inertial loads displayed a similar effect, with an increase in grip force modulation gain under hypergravity followed by a reduction of modulation gain after entering the zero-gravity environment. We present a computational model to illustrate that these effects are compatible with the hypothesis that participants partially attribute changes in weight to changes in mass and scale incorrectly their motor commands with changes in gravity. These results highlight a rather direct internal mapping between the force generated during stationary holding against gravity and the estimation of inertial loads that limb and hand motor commands must overcome.

‘Feedback: Where data finally get thrilling’ – tools for facility managers to use data for improved health outcomes in the prevention of mother-to-child transmission of HIV and antiretroviral therapy

Data use and data quality continue to be a challenge for government sector health facilities and districts across South Africa. Led by the National Department of Health, key stakeholders, such as the Anova Health Institute and district health management teams, are aligning efforts to address these gaps. Coverage and correct implementation of existing tools – including TIER.net, routine data collection forms and the South African District Health Information System – must be ensured. This conference report provides an overview of such tools and summarises suggestions for quality improvement, data use and systematic evaluation of data-related interventions.

Keep your head on straight: facilitating sensori-motor transformations for eye-hand coordination

In many day-to-day situations humans manifest a marked tendency to hold the head vertical while performing sensori-motor actions. For instance, when performing coordinated whole-body motor tasks, such as skiing, gymnastics or simply walking, and even when driving a car, human subjects will strive to keep the head aligned with the gravito-inertial vector. Until now, this phenomenon has been thought of as a means to limit variations of sensory signals emanating from the eyes and inner ears. Recent theories suggest that for the task of aligning the hand to a target, the CNS compares target and hand concurrently in both visual and kinesthetic domains, rather than combining sensory data into a single, multimodal reference frame. This implies that when sensory information is lacking in one modality, it must be 'reconstructed' based on information from the other. Here we asked subjects to reach to a visual target with the unseen hand. In this situation, the CNS might reconstruct the orientation of the target in kinesthetic space or reconstruct the orientation of the hand in visual space, or both. By having subjects tilt the head during target acquisition or during movement execution, we show a greater propensity to perform the sensory reconstruction that can be achieved when the head is held upright. These results suggest that the reason humans tend to keep their head upright may also have to do with how the brain manipulates and stores spatial information between reference frames and between sensory modalities, rather than only being tied to the specific problem of stabilizing visual and vestibular inputs.

The provision of critical care in emergency departments at Canada

Introduction:

Critically ill patients are common in emergency medicine, and require expert care to maximize patient outcomes. However, little data is available on the provision of critical care in the ED. The goal of this study is to describe the management of critically ill patients in the ED via a survey of Canadian emergency physicians.

Materials and Methods:

A survey of attending physician members of CAEP was conducted by email. The survey was developed by the authors and internal validity was established prior to survey deployment. Data on physician demographics, hospital resources, use of invasive procedures, vasopressor/inotropic medications, length of stay in the ED and patient responsibility were assessed.

Results:

The survey response rate was 22.9%, with the majority of respondents possessing speciality training in EM (73.5%). Respondents indicated that critically ill patients were commonly managed in the ED, with 68.5% reporting >6 critically ill patients per month, and 12.4% indicating > 20 patients per month. Respondents indicated that the majority of critically ill patients remained in the ED for 1-4 hours (70%) after resuscitation, yet 18% remained in the ED for >5 hours. Patients with a “respiratory” etiology were the most common critically ill patient population reported, followed by “cardiovascular”, “infectious” and “traumatic illness”. Direct laryngoscopy was frequently performed (66.9%> 11 in the year prior to the survey) in the year prior to the survey, while other invasive procedures and vasopressor/inotropic medications were utilized less often. EM physicians were responsible for the management of critically ill patients in the ED, even after consultation to an inpatient service, and were often required to provided acute care to critically ill patients admitted to an ICU, yet remaining in the ED prior to transfer (20% reported > 50% of the time).

Conclusion:

Our survey demonstrates that critically ill patients are common in Canadian ED's, and that EMP's are often responsible to provide care for prolonged period of time. In addition, the use of invasive procedures other then direct laryngoscopy was variable. Further research is warranted to determine the impact of delayed transfer and ED physician management of critically ill patients in the ED.

Tuberculosis in HIV programmes in lower-income countries: practices and risk factors

BACKGROUND

Tuberculosis (TB) is a common diagnosis in human immunodeficiency virus (HIV) infected patients on antiretroviral treatment (ART).

OBJECTIVE

To describe TB-related practices in ART programmes in lower-income countries and identify risk factors for TB in the first year of ART.

METHODS

Programme characteristics were assessed using standardised electronic questionnaire. Patient data from 2003 to 2008 were analysed and incidence rate ratios (IRRs) calculated using Poisson regression models.

RESULTS

Fifteen ART programmes in 12 countries in Africa, South America and Asia were included. Chest X-ray, sputum microscopy and culture were available free of charge in respectively 13 (86.7%), 14 (93.3%) and eight (53.3%) programmes. Eight sites (53.3%) used directly observed treatment and five (33.3%) routinely administered isoniazid preventive treatment (IPT). A total of 19 413 patients aged ≥ 16 years contributed 13,227 person-years of follow-up; 1081 new TB events were diagnosed. Risk factors included CD4 cell count (>350 cells/μl vs. <25 cells/μl, adjusted IRR 0.46, 95%CI 0.33-0.64, P < 0.0001), sex (women vs. men, adjusted IRR 0.77, 95%CI 0.68-0.88, P = 0.0001) and use of IPT (IRR 0.24, 95%CI 0.19-0.31, P < 0.0001).

CONCLUSIONS

Diagnostic capacity and practices vary widely across ART programmes. IPT prevented TB, but was used in few programmes. More efforts are needed to reduce the burden of TB in HIV co-infected patients in lower income countries.

Probability of freezing in the freeze-avoiding beetle larvae Cucujus clavipes puniceus (Coleoptera: Cucujidae) from interior Alaska

Freeze-avoiding insects must resist freezing or die. A suite of adaptations to low temperatures, including the production of antifreeze proteins, colligative antifreezes (polyols), and dehydration allows most individuals to prevent freezing below the lowest ambient temperatures experienced in situ; however, there can be a wide variance in the minimum temperatures that individuals of freeze-avoiding species reach before freezing. We used logistic regression to explore factors that affect this variance and to estimate the probability of freezing in larvae of the freeze-avoiding beetle Cucujus clavipes puniceus. We hypothesized that water content ≤0.5 mg mg(-1) dry mass would lead to deep supercooling (avoidance of freezing below -58°C). We found a significant interaction between water content and ambient below-snow temperature and a significant difference between individuals collected from two locations in Alaska: Wiseman and Fairbanks. Individuals collected in Wiseman deep supercooled with greater water content and to a greater range of ambient temperatures than individuals collected in Fairbanks, leading to significantly different lethal water contents associated with 50% probability of freezing.

Prioritising prevention strategies for patients in antiretroviral treatment programmes in resource-limited settings

Expanded access to antiretroviral therapy (ART) offers opportunities to strengthen HIV prevention in resource-limited settings. We invited 27 ART programmes from urban settings in Africa, Asia and South America to participate in a survey, with the aim to examine what preventive services had been integrated in ART programmes. Twenty-two programmes participated; eight (36%) from South Africa, two from Brazil, two from Zambia and one each from Argentina, India, Thailand, Botswana, Ivory Coast, Malawi, Morocco, Uganda and Zimbabwe and one occupational programme of a brewery company included five countries (Nigeria, Republic of Congo, Democratic Republic of Congo, Rwanda and Burundi). Twenty-one sites (96%) provided health education and social support, and 18 (82%) provided HIV testing and counselling. All sites encouraged disclosure of HIV infection to spouses and partners, but only 11 (50%) had a protocol for partner notification. Twenty-one sites (96%) supplied male condoms, seven (32%) female condoms and 20 (91%) provided prophylactic ART for the prevention of mother-to child transmission. Seven sites (33%) regularly screened for sexually transmitted infections (STI). Twelve sites (55%) were involved in activities aimed at women or adolescents, and 10 sites (46%) in activities aimed at serodiscordant couples. Stigma and discrimination, gender roles and funding constraints were perceived as the main obstacles to effective prevention in ART programmes. We conclude that preventive services in ART programmes in lower income countries focus on health education and the provision of social support and male condoms. Strategies that might be equally or more important in this setting, including partner notification, prompt diagnosis and treatment of STI and reduction of stigma in the community, have not been implemented widely.