A Profile of the SAIL Databank on the UK Secure Research Platform

BACKGROUND

The Secure Anonymised Information Linkage (SAIL) Databank is a national data safe haven of de identified datasets principally about the population of Wales, made available in anonymised form to researchers across the world. It was established to enable the vast arrays of data collected about individuals in the course of health and other public service delivery to be made available to answer important questions that could not otherwise be addressed without prohibitive effort. The SAIL Databank is the bedrock of other funded centres relying on the data for research.

APPROACH

SAIL is a data repository surrounded by a suite of physical, technical and procedural control measures embodying a proportionate privacy-by-design governance model, informed by public engagement, to safeguard the data and facilitate data utility. SAIL operates on the UK Secure Research Platform (SeRP), which is a customisable technology and analysis platform. Researchers access anonymised data via this secure research environment, from which results can be released following scrutiny for disclosure risk. SAIL data are being used in multiple research areas to evaluate the impact of health and social exposures and policy interventions.

DISCUSSION

Lessons learned and their applications include: managing evolving legislative and regulatory requirements; employing multiple, tiered security mechanisms; working hard to increase analytical capacity efficiency; and developing a multi-faceted programme of public engagement. Further work includes: incorporating new data types; enabling alternative means of data access; and developing further efficiencies across our operations.

CONCLUSION

SAIL represents an ongoing programme of work to develop and maintain an extensive, whole population data resource for research. Its privacy-by-design model and UK SeRP technology have received international acclaim, and we continually endeavour to demonstrate trustworthiness to support data provider assurance and public acceptability in data use. We strive for further improvement and continue a mutual learning process with our contemporaries in this rapidly developing field.

Evaluation of the BAX® System for Detection of Salmonella in Selected Foods: Collaborative Study

A multilaboratory study was conducted to compare the automated BAX® System to the standard cultural methods for detection of Salmonella in selected foods. Five food types—frankfurters, raw ground beef, mozzarella cheese, raw frozen tilapia fish, and orange juice—at 3 inoculation levels, were analyzed by each method. A sixth food type, raw ground chicken, was tested using 3 naturally contaminated lots. A total of 16 laboratories representing government and industry participated. In this study, 1386 samples were analyzed, of which 1188 were paired samples and 198 were unpaired samples. Of the 1188 paired samples, 461 were positive by both methods and 404 were negative by both methods. Thirty-seven samples were positive by the BAX System but negative by the standard reference method, and 11 samples were positive by standard cultural method and negative by the BAX System. Of the 198 unpaired samples, 106 were positive by the BAX System and 60 were positive by the standard cultural method. A Chi square analysis of each of the 6 food types, at the 3 inoculation levels tested, was performed. For all foods, the BAX System demonstrated results comparable to those of the standard reference methods based on the Chi square results.

Modulation and study of photoblinking behavior in dye doped silver-silica core-shell nanoparticles for localization super-resolution microscopy

Blinking of fluorescent nanoparticles is a compelling phenomenon with widely debated mechanisms. The ability to inhibit or control blinking is important for applications in the field of optical, semiconductor and fluorescent imaging. Self-blinking nanomaterials are also attractive labels for localization-based super-resolution microscopy. In this work, we have synthesized silver core silica nanoparticles (Ag@SiO2) doped with Rhodamine 110 and studied the parameters that affect blinking. We found that under nitrogen rich conditions the nanoparticles shifted towards higher duty cycles. Also, it was found that hydrated nanoparticles showed a less drastic response to nitrogen rich conditions as compared to dried nanoparticles, indicating that surrounding matrix played a role in the response of nanoparticles to molecular oxygen. Further, the blinking is not a multi-body phenomena, super-resolution localization combined with intensity histogram analysis confirmed that single particles are emitting.

Feasibility of Home-Based Neurologic Music Therapy for Behavioral and Psychological Symptoms of Dementia: A Pilot Study

Family caregivers often feel ill-equipped to handle bothersome behavioral and psychological symptoms of dementia, such as agitation, apathy, and sleep disturbances, leading to increased caregiver distress and nursing home placement for people with dementia. Therapies for such symptoms are currently limited and non-pharmacological options are preferred, given potential side effects of medications. Neurologic music therapy (NMT) could provide an additional treatment option for managing behavioral and psychological symptoms for community-dwelling people with dementia and their caregivers. This pilot study sought to evaluate the feasibility, acceptability, and effectiveness of home-based NMT for behavioral and psychological symptoms of dementia. Eighteen persons with dementia-caregiver dyads were enrolled to receive one-hour weekly sessions of home-based NMT for 6 weeks. Demographic, quality of life, neuropsychiatric symptom, and caregiver burden and self-efficacy information was collected at baseline, 6 weeks, and 12 weeks. Seven dyads (38.9%) withdrew from therapy before completing all sessions; these participants had higher Neuropsychiatric Inventory scores and were of older age at baseline. For those who completed therapy, neuropsychiatric symptom scores improved at 6 weeks, an effect that was sustained at 12 weeks. No other outcome measures changed significantly after therapy. Initiating NMT too late in the course of dementia, when behavioral symptoms are already present, may be impractical for people with dementia and increase caregiver stress, even when provided within the home. Introducing and incorporating the principles of NMT earlier in the course of dementia could allow for increased comfort and benefit for people with dementia and their caregivers.

TM3-4 The effect of acetazolamide on intracranial pressure: primary study with prolonged continuous intracranial pressure monitoring

Objectives

Acetazolamide has frequently been used as a first-line treatment for idiopathic Intracranial Hypertension (IIH) and other disorders which lead to a non-acute rise in intracranial pressure (ICP). The effect of acetazolamide has been observed through lumbar puncture, however the effect of acetazolamide on ICP has not been studied in continuous ICP measurement.

Design

A retrospective study of a prospectively built ICP database

Subjects

All patients with continuous ICP monitoring demonstrating 24 hours on and 24 hours off acetazolamide were included in the study.

Methods

Patients median ICP and median pulse amplitude over 24 hour monitoring period on and off Diamox was assessed.

Results

12 patients (9F, 3M) underwent ICP monitoring with data collected during the same admission. 8 patients had IIH, 1 Chiari Malformation, 3 new diagnostic ICP procedures. 10 patients saw a reduction in ICP while on acetazolamide. Overall, patients experienced a Median reduction of 1.14 mmHg (Mean 1.16 mmHg, Range 4.24 to −4.445 mmHg). Patients (n9) who were on ≥1 g of acetazolamide per day experienced a median reduction in ICP of 1.595 mmHg (Mean 1.91 mmHg, Range 4.24–0.5 mmHg).

Conclusions

Our data suggests acetazolamide can reduce ICP quickly following commencement, however this reduction was relatively small. The effect seems greater with a higher dose. Larger numbers of patients are required to gain a greater understanding into the significance of acetazolamide on ICP, particularly the affect at larger doses.

P102 Shunting slit ventricles: a comparison of the parieto-occipital vs frontal approach

Objectives

Slit ventricles can be a challenging target during shunt catheter insertion. Traditionally, the frontal approach has been considered optimal. At this centre, routine use of electromagnetic (EM) stereotatic guidance (StealthTM, Medtronic) has enabled a parieto-occipital burr hole approach to the frontal horns. We compare shunt placement and revisions required for patients with slit ventricles who had shunts inserted via a parieto-occipital (P-O) approach vs. frontal shunt.

Design

Retrospective cohort.

Subjects

Patients with slit ventricles and a ventricular shunt inserted using EM guidance between 2012–2018.

Methods

Slit ventricles were defined as <3 mm (widest). Outcome measures included placement accuary and survival using Kaplan-Meier curve.

Results

82 patients (77F:5M) aged 34.9±10.8 years (mean ±SD) had shunts inserted for IIH (n=63), chiari/syrinx (n=8), congenital hydrocephalus (n=10), pseudomeningocoele (n=1). 35 had primary P-O shunts and 46 had frontal shunts. Overall, 94% of cases had the catheter tip sitting in the frontal horn. The P-O approach was just as accurate as the frontal approach. Eight P-O shunts and 9 frontal shunts required revision over a 60 month periods. There was no significant different in shunt survival between the two approaches (p=0.99).

Conclusions

EM guided placement has enabled the P-O approach to be as safe and with equivalent survival to frontal approach. The accuracy of shunt placement between the two approaches was equivocal.

Relationship between residual feed intake and radiated heat loss using infrared thermography in young beef bulls

Residual feed intake (RFI) has been used to select metabolically efficient cattle in beef breeding programs, particularly for sire selection. Adoption of genetic selection using RFI has been limited due to the cost and difficulty of measuring individual feed intake. An alternative method of predicting RFI is to measure radiated heat loss using infrared thermography (IRT) as previous studies have shown promise using this technique to predict metabolic efficiency in mature cows, heifers, and growing bulls. The objective of this study was to explore use of IRT to predict RFI in growing beef bulls. Sixty bulls in each of two years were fed either a forage-based or a grain-based ration. Eye (Ey) and cheek (Ck) surface temperatures were measured using infrared images of the head collected on 16 and 14 sample days in Years 1 and 2, respectively, using a FLIR S60 camera. In Year 2, infrared images were collected continuously using a within-pen FLIR A310 camera system. Bulls were grouped into low, medium and high classes based on ± 0.5 standard deviations of backfat adjusted residual feed intake (RFI_Fat); RFI_Fat values ranged from - 2.27 to + 2.61 kg DM day^-1 (mean=0.0; SD=0.61). Sample day Ey and Ck temperatures were pooled and an average temperature was calculated for individual bulls. Average Ey and Ck temperatures measured using the FLIR S60 and the within-pen camera did not differ significantly across low, medium and high RFI groups (P > 0.05). Temperature deviations associated with extremes in ambient temperature (placing animals outside their thermoneutral zone) or underlying subclinical health problems could bias results in IRT measurements and RFI ranking. Standardization of IRT data and the conditions during measurement is necessary to more accurately assess its potential use to predict RFI.

Energy utilization in cattle with steady state and non-steady state methods: the importance of thermal neutrality

The efficiency by which animals utilize dietary energy is fundamental to the cost of production for protein of animal origin and to the carbon footprint an animal industry has. Hence, the development of cost effective methodology for determining these measurements of efficiency is important. The objective of the present study was to investigate the use of infrared thermography in a rapid, non-steady state method for measuring energy loss in cattle. Data from 241 yearling bulls and steers as well as heifers and mature cows are presented. Infrared images were collected following a 24h feed withdrawal period. The infrared thermal response in these animals was significantly ranked (P < 0.03) with conventional measurements of feed efficiency using residual feed intake values for animals demonstrated to be within a thermal neutral zone. When animals were not within a thermal neutral zone there was no significant ranking. The data suggests that the use of a non-steady state approach using infrared thermography for identifying metabolic efficiency in animals may be a more rapid and less expensive method for identifying differences in energy utilization. The data also demonstrates the importance of maintaining thermal neutrality when measuring metabolic efficiency irrespective of the methodology.

An Elemental Impurities Excipient Database: A Viable Tool for ICH Q3D Drug Product Risk Assessment

To support the practical implementation of the International Council for Harmonisation (ICH) Q3D guideline, which describes a risk-based approach to the control of elemental impurities in drug products, a consortium of pharmaceutical companies has established a database to collate the results of analytical studies of the levels of elemental impurities within pharmaceutical excipients. This database currently includes the results of 26,723 elemental determinations for 201 excipients and represents the largest known, and still rapidly expanding, collection of data of this type. Analysis of the database indicates good coverage of excipients relevant to real-world drug product formulations and tested element profiles consistent with ICH Q3D recommendations. The database includes the results from multiple analytical studies for an excipient and thus incorporates within it an indication of both excipient supplier and batch-to-batch variability as well as any variability associated with the different testing organizations and methods employed. The data confirm the findings of earlier smaller studies that elemental impurity concentrations in excipients are generally low and when used in typical proportions in formulated drug products are unlikely to pose a significant patient safety risk. The database is now in active use as one line of evidence in ICH Q3D risk assessments.

Comparison of the first whole genome sequence of 'Haemophilus quentini' with two new strains of 'Haemophilus quentini' and other species of Haemophilus

Comparison of the genome of the Gram negative human pathogen Haemophilus quentini MP1 with other species of Haemophilus revealed that, although it is more closely related to Haemophilus haemolyticus than Haemophilus influenzae, the pathogen is in fact genetically distinct, a finding confirmed by phylogenetic analysis using the H. influenzae multilocus sequence typing genes. Further comparison with two other H. quentini strains recently identified in Canada revealed that these three genomes are more closely related than any other species of Haemophilus; however, there is still some sequence variation. There was no evidence of acquired antimicrobial resistance within the H. quentini MP1 genome nor any mutations within the DNA gyrase or topoisomerase IV genes known to confer resistance to fluoroquinolones, which has been previously identified in other H. quentini isolates. We hope by presenting the annotation and genetic comparison of the H. quentini MP1 genome it will aid the future molecular detection of this potentially emerging pathogen via the identification of unique genes that differentiate it from other species of Haemophilus.

Business Process Modelling is an Essential Part of a Requirements Analysis

To perform a requirements analysis of the barriers to conducting research linking of primary care, genetic and cancer data.

We extended our initial data-centric approach to include socio-culturalandbusinessrequirements.Wecreatedreferencemodels of core data requirements common to most studies using unified modelling language (UML), dataflow diagrams (DFD) and business process modelling notation (BPMN). We conducted a stakeholder analysis and constructed DFD and UML diagrams for use cases based on simulated research studies. We used research output as a sensitivity analysis.

Differences between the reference model and use cases identified study specific data requirements. The stakeholder analysis identified: tensions, changes in specification, some indifference from data providers and enthusiastic informaticians urging inclusion of socio-cultural context. We identified requirements to collect information at three levels: microdata items, which need to be semantically interoperable, meso-the medical record and data extraction, and macro-the health system and socio-cultural issues. BPMN clarified complex business requirements among data providers and vendors; and additional geographical requirements for patients to be represented in both linked datasets. High quality research output was the norm for most repositories.

Reference models provide high-level schemata of the core data requirements. However, business requirements’ modelling identifies stakeholder issues and identifies what needs to be addressed to enable participation.

Genomic landscape of extended-spectrum β-lactamase resistance in Escherichia coli from an urban African setting

Objectives

Efforts to treat Escherichia coli infections are increasingly being compromised by the rapid, global spread of antimicrobial resistance (AMR). Whilst AMR in E. coli has been extensively investigated in resource-rich settings, in sub-Saharan Africa molecular patterns of AMR are not well described. In this study, we have begun to explore the population structure and molecular determinants of AMR amongst E. coli isolates from Malawi.

Methods

Ninety-four E. coli isolates from patients admitted to Queen's Hospital, Malawi, were whole-genome sequenced. The isolates were selected on the basis of diversity of phenotypic resistance profiles and clinical source of isolation (blood, CSF and rectal swab). Sequence data were analysed using comparative genomics and phylogenetics.

Results

Our results revealed the presence of five clades, which were strongly associated with E. coli phylogroups A, B1, B2, D and F. We identified 43 multilocus STs, of which ST131 (14.9%) and ST12 (9.6%) were the most common. We identified 25 AMR genes. The most common ESBL gene was bla CTX-M-15 and it was present in all five phylogroups and 11 STs, and most commonly detected in ST391 (4/4 isolates), ST648 (3/3 isolates) and ST131 [3/14 (21.4%) isolates].

Conclusions

This study has revealed a high diversity of lineages associated with AMR, including ESBL and fluoroquinolone resistance, in Malawi. The data highlight the value of longitudinal bacteraemia surveillance coupled with detailed molecular epidemiology in all settings, including low-income settings, in describing the global epidemiology of ESBL resistance.

Fumarase Deficiency: A Safe and Potentially Disease Modifying Effect of High Fat/Low Carbohydrate Diet

Fumarate hydratase deficiency (FHD) caused by biallelic alterations of the FH (fumarate hydratase) gene is a rare disorder of the tricarboxylic acid cycle, classically characterized by encephalopathy, profound psychomotor retardation, seizures, a spectrum of brain abnormalities and early death in childhood. Less common milder phenotypes with moderate cognitive impairment and long-term survival have been reported. In addition, heterozygous mutations of the FH gene are responsible for hereditary leiomyomatosis and renal cell cancer (HLRCC). There is currently no recommended disease modifying treatment for FHD and only isolated reports of unsuccessful dietary modifications. Herein, we describe the safe and possibly disease modifying effect of a high fat, low carbohydrate diet in a 14-year-old female with severe FHD.

Arbuscular mycorrhizas are present on Spitsbergen

A previous study of 76 plant species on Spitsbergen in the High Arctic concluded that structures resembling arbuscular mycorrhizas were absent from roots. Here, we report a survey examining the roots of 13 grass and forb species collected from 12 sites on the island for arbuscular mycorrhizal (AM) colonisation. Of the 102 individuals collected, we recorded AM endophytes in the roots of 41 plants of 11 species (Alopecurus ovatus, Deschampsia alpina, Festuca rubra ssp. richardsonii, putative viviparous hybrids of Poa arctica and Poa pratensis, Poa arctica ssp. arctica, Trisetum spicatum, Coptidium spitsbergense, Ranunculus nivalis, Ranunculus pygmaeus, Ranunculus sulphureus and Taraxacum arcticum) sampled from 10 sites. Both coarse AM endophyte, with hyphae of 5-10 μm width, vesicles and occasional arbuscules, and fine endophyte, consisting of hyphae of 1-3 μm width and sparse arbuscules, were recorded in roots. Coarse AM hyphae, vesicles, arbuscules and fine endophyte hyphae occupied 1.0-30.7, 0.8-18.3, 0.7-11.9 and 0.7-12.8% of the root lengths of colonised plants, respectively. Principal component analysis indicated no associations between the abundances of AM structures in roots and edaphic factors. We conclude that the AM symbiosis is present in grass and forb roots on Spitsbergen.

Regulation of Chemokine Function: The Roles of GAG-Binding and Post-Translational Nitration

The primary function of chemokines is to direct the migration of leukocytes to the site of injury during inflammation. The effects of chemokines are modulated by several means, including binding to G-protein coupled receptors (GPCRs), binding to glycosaminoglycans (GAGs), and through post-translational modifications (PTMs). GAGs, present on cell surfaces, bind chemokines released in response to injury. Chemokines bind leukocytes via their GPCRs, which directs migration and contributes to local inflammation. Studies have shown that GAGs or GAG-binding peptides can be used to interfere with chemokine binding and reduce leukocyte recruitment. Post-translational modifications of chemokines, such as nitration, which occurs due to the production of reactive species during oxidative stress, can also alter their biological activity. This review describes the regulation of chemokine function by GAG-binding ability and by post-translational nitration. These are both aspects of chemokine biology that could be targeted if the therapeutic potential of chemokines, like CXCL8, to modulate inflammation is to be realised.

Sensory trait variation contributes to biased dispersal of threespine stickleback in flowing water

Gene flow is widely thought to homogenize spatially separate populations, eroding effects of divergent selection. The resulting theory of 'migration-selection balance' is predicated on a common assumption that all genotypes are equally prone to dispersal. If instead certain genotypes are disproportionately likely to disperse, then migration can actually promote population divergence. For example, previous work has shown that threespine stickleback (Gasterosteus aculeatus) differ in their propensity to move up- or downstream ('rheotactic response'), which may facilitate genetic divergence between adjoining lake and stream populations of stickleback. Here, we demonstrate that intraspecific variation in a sensory system (superficial neuromast lines) contributes to this variation in swimming behaviour in stickleback. First, we show that intact neuromasts are necessary for a typical rheotactic response. Next, we showed that there is heritable variation in the number of neuromasts and that stickleback with more neuromasts are more likely to move downstream. Variation in pectoral fin shape contributes to additional variation in rheotactic response. These results illustrate how within-population quantitative variation in sensory and locomotor traits can influence dispersal behaviour, thereby biasing dispersal between habitats and favouring population divergence.

COSMIC: High-Resolution Cancer Genetics Using the Catalogue of Somatic Mutations in Cancer

COSMIC (http://cancer.sanger.ac.uk) is an expert-curated database of somatic mutations in human cancer. Broad and comprehensive in scope, recent releases in 2016 describe over 4 million coding mutations across all human cancer disease types. Mutations are annotated across the entire genome, but expert curation is focused on over 400 key cancer genes. Now encompassing the majority of molecular mutation mechanisms in oncogenetics, COSMIC additionally describes 10 million non-coding mutations, 1 million copy-number aberrations, 9 million gene-expression variants, and almost 8 million differentially methylated CpGs. This information combines a consistent interpretation of the data from the major cancer genome consortia and cancer genome literature with exhaustive hand curation of over 22,000 gene-specific literature publications. This unit describes the graphical Web site in detail; alternative protocols overview other ways the entire database can be accessed, analyzed, and downloaded. © 2016 by John Wiley & Sons, Inc.

Range Analysis and Terrain Preference of Adult Southern White Rhinoceros (Ceratotherium simum) in a South African Private Game Reserve: Insights into Carrying Capacity and Future Management

The Southern white rhinoceros (Ceratotherium simum) is a threatened species, central to the tourism appeal of private game reserves in South Africa. Privately owned reserves in South Africa tend to be smaller than government run reserves such as Kruger National Park. Because of their relatively small size and the often heterogeneous nature of the landscape private game reserve managers benefit from detailed knowledge of white rhinoceros terrain selection preferences, which can be assessed from their ranging behaviours. We collected adult and sub-adult white rhinoceros distribution data over a 15 month period, calculating individual range size using kernel density estimation analysis within a GIS. From this, terrain selectivity was calculated using 50% and 95% kernels to extract terrain composition values. Jacob’s correction of the Ivlev’s selectivity index was subsequently applied to the terrain composition of each individual to identify trends in selectivity. Results reveal that adult males hold exclusive territories considerably smaller than those found in previous work conducted in “open” or large reserves. Similarly, results for the size of male versus female territories were also not in keeping with those from previous field studies, with males, rather than females, having the larger territory requirement. Terrain selection for both genders and age classes (adult and sub-adult) showed a strong preference for open grassland and avoidance of hill slope and riparian terrains. This research reveals white rhinoceros terrain selection preferences and how they influence range requirements in small, closed reserves. We conclude that this knowledge will be valuable in future white rhinoceros conservation management in small private game reserves, particularly in decisions surrounding removal of surplus individuals or augmentation of existing populations, calculation of reserve carrying capacity and future private reserve acquisition.

Collaborative meta-analysis of individual participant data from observational studies of Lp-PLA2 and cardiovascular diseases

BACKGROUND

A large number of observational epidemiological studies have reported generally positive associations between circulating mass and activity levels of lipoprotein-associated phospholipase A2 (Lp-PLA2) and the risk of cardiovascular diseases. Few studies have been large enough to provide reliable estimates in different circumstances, such as in different subgroups (e.g., by age group, sex, or smoking status) or at different Lp-PLA2 levels. Moreover, most published studies have related disease risk only to baseline values of Lp-PLA2 markers (which can lead to substantial underestimation of any risk relationships because of within-person variability over time) and have used different approaches to adjustment for possible confounding factors.

OBJECTIVES

By combination of data from individual participants from all relevant observational studies in a systematic 'meta-analysis', with correction for regression dilution (using available data on serial measurements of Lp-PLA2), the Lp-PLA2 Studies Collaboration will aim to characterize more precisely than has previously been possible the strength and shape of the age and sex-specific associations of plasma Lp-PLA2 with coronary heart disease (and, where data are sufficient, with other vascular diseases, such as ischaemic stroke). It will also help to determine to what extent such associations are independent of possible confounding factors and to explore potential sources of heterogeneity among studies, such as those related to assay methods and study design. It is anticipated that the present collaboration will serve as a framework to investigate related questions on Lp-PLA2 and cardiovascular outcomes.

METHODS

A central database is being established containing data on circulating Lp-PLA2 values, sex and other potential confounding factors, age at baseline Lp-PLA2 measurement, age at event or at last follow-up, major vascular morbidity and cause-specific mortality. Information about any repeat measurements of Lp-PLA2 and potential confounding factors has been sought to allow adjustment for possible confounding and correction for regression dilution. The analyses will involve age-specific regression models. Synthesis of the available observational studies of Lp-PLA2 will yield information on a total of about 15 000 cardiovascular disease endpoints.

Psychosocial Issues in Heart Transplantation: A Review for Transplant Coordinators

The latest advances in medicine and technology are used to care for transplant recipients, yet many patients have psychosocial difficulties that technology alone cannot resolve. Although most healthcare professionals acknowledge the importance of the staff's role in working with patients to resolve psychosocial problems, little research has examined the nature of staff-patient relationships and the proven ability of good relationships to improve outcomes. The purposes of this paper are to profile psychosocial risk and its relationship to outcomes after heart transplantation, explore staff-patient interactions in dealing with psychosocial problems, and present a growth and development model that can be used as a theoretical base to establish a more therapeutic alliance with patients.

Incontinence after brain injury: prevalence, outcome and multidisciplinary management on a neurological rehabilitation unit

Objective: To investigate the prevalence, outcome and multidisciplinary management of incontinence in patients with acquired brain injury.

Design: Retrospective case notes review.

Setting: Regional neurological rehabilitation unit. Subjects: Two hundred and thirty-eight patients with acquired brain injury.

Main measures: Bladder and bowel subscores of the Barthel Index and Functional Independence Measure; number of multidisciplinary goals addressing bladder and bowel function.

Results: Fifty per cent of patients (n=112) had impaired bladder or bowel subscores on admission. Significant improvement was seen at discharge but 36% of patients (n=77) still had some degree of impairment. Over 90% of patients were set multidisciplinary goals addressing self-care (n=213) and mobility (n=205) but only 3.5% (n=8) were set multidisciplinary goals addressing bladder and bowel function.

Conclusions: Incontinence was common in patients with brain injury on a neurological rehabilitation unit. Significant improvement was seen following rehabilitation. Bladder and bowel management was not well incorporated into the multidisciplinary management process.

Failure of a trial evaluating the effect of venous surgery on healing and recurrence rates in venous ulcers? The USABLE trial: rationale, design and methodology, and reasons for failure

Objective: This Medical Research Council funded trial was set up to investigate whether venous surgery provided any additional benefit in the healing and recurrence rates of venous ulcers over compression bandaging alone.

Methods: Ulcer surgery as adjuvant to compression bandaging for leg ulcers (USABLE) was a multicentre, randomized controlled trial, which planned to recruit 1000 venous ulcer patients to receive either compression bandaging alone or compression bandaging plus venous surgery. Follow up recorded ulcer healing, recurrence and patient quality of life.

Results: Recruitment was slow, and involved screening a large number of patients (759) with only 75 randomized over an 18-month recruitment period.

Conclusions: The results would infer that surgery is unlikely to be a management option for the majority of patients presenting to a hospital with a gaiter area leg ulcer.

A Quality Improvement Project to Assess Timing of Initial Investigations in Stroke Medicine

There are several investigations that can be completed in the acute phase of admission for patients with suspected stroke.These include receiving a CT Head scan and also blood tests specific for stroke. The national guidelines regarding CT Head scans detail they should be completed within 12 hours of admission(1) and the trust guidelines, local to where this quality improvement project was based, advise a CT Head should be completed within four hours of admission.(2) The current national guidelines do not specify exact stroke blood tests, however trust guidelines give a specific set of blood tests that would be appropriate to be taken when a patient presents to A&E with a suspected stroke. These included FBC, U&E, blood glucose, ESR, cholesterol, TFTs, and coagulation screen.(2) The aim of this quality improvement project was to assess the timing of CT Head scans and blood tests and to implement a tool to ensure these are done in a timely fashion, within the emergency care setting. The project was completed through three PSDA cycles. The first was undertaken in an A&E department, which was soon to be closed and moved to a different site. The second cycle was then completed at the new site, to assess if there had been any change in timings of these interventions. In the previous site it was found that 97% of patients audited received a CT Head scan within four hours. At the new site it was found 94% patients received a CT Head within four hours, therefore both meeting trust targets on the whole. A full set of stroke blood tests were completed at the old site in 53% of patients and this decreased to 22% of patients at the new site. At this point it was decided an intervention should be implemented to ensure this did not continue. The intervention used was updating a stroke panel on the trust computer system (an easy to use, one-click button entitled "Stroke/TIA") with the correct blood tests and the use of this was promoted throughout the trust. A post-intervention audit was completed three months after the tool was promoted and patients receiving the correct blood tests whilst in the A&E department increased to 75%. The amount of patients receiving a CT Head scan within four hours was 100% therefore meeting both trust and national guidelines. In conclusion, the stroke blood panel appears to have improved the amount of patients receiving the correct blood tests when admitted with suspected stroke and will continue to stay in place at the trust.