VA Home Based Primary Care Teams: Partnering with and Acting as Caregivers for Veterans

The U.S. Department of Veterans Affairs' Home-Based Primary Care (HBPC) Interdisciplinary Team (IDT) provides in-home, primary care for medically complex Veterans. This study explores how HBPC and Veterans' caregivers partner to provide care. Interviews, focus groups, and field observations were conducted during eight HBPC site visits. Qualitative thematic analysis was performed. Caregivers/IDT member partnerships are important to care. Effective partnerships include: ease of communication; caregiver-centered support; and when no caregiver is present, IDTs providing more monitoring/services to Veterans and connection to community services. As this model expands, understanding dynamics between IDT members and caregivers will optimize the success of HBPC programs.

The effect of advanced recovery room care on postoperative outcomes in moderate-risk surgical patients: a multicentre feasibility study

Postoperative complications are common and may be under-recognised. It has been suggested that enhanced postoperative care in the recovery room may reduce in-hospital complications in moderate- and high-risk surgical patients. We investigated the feasibility of providing advanced recovery room care for 12-18 h postoperatively in the post-anaesthesia care unit. The primary hypothesis was that a clinical trial of advanced recovery room care was feasible. The secondary hypothesis was that this model may have a sustained impact on postoperative in-hospital and post-discharge events. This was a multicentre, prospective, feasibility before-and-after trial of moderate-risk patients (predicted 30-day mortality of 1-4%) undergoing non-cardiac surgery and who were scheduled for postoperative ward care. Patients were managed using defined assessment checklists and goals of care in an advanced recovery room care setting in the immediate postoperative period. This utilised existing post-anaesthesia care unit infrastructure and staffing, but extended care until the morning of the first postoperative day. The advanced recovery room care trial was deemed feasible, as defined by the recruitment and per protocol management of > 120 patients. However, in a specialised cancer centre, recruitment was slow due to low rates of eligibility according to narrow inclusion criteria. At a rural site, advanced recovery room care could not be commenced due to logistical issues in establishing a new model of care. A definitive randomised controlled trial of advanced recovery room care appears feasible and, based on the indicative data on outcomes, we believe this is warranted.

2020 European guideline on the management of genital molluscum contagiosum

Molluscum contagiosum is a benign viral epidermal infection associated with high risk of transmission. The guideline is focused on the sexually transmitted molluscum contagiosum. The diagnosis is clinical with characteristic individual lesions, termed 'mollusca', seen as dome-shaped, smooth-surfaced, pearly, firm, skin-coloured, pink, yellow or white papules, 2 - 5 mm in diameter with central umbilication. Dermoscopy may facilitate diagnosis. Therapeutic options are numerous, including physical treatments (cautery, curettage and cryotherapy), topical chemical treatments (e.g. podophyllotoxin and imiquimod) or waiting for spontaneous resolution in immunocompetent patients. In pregnancy, it is safe to use physical procedures (e.g. cryotherapy). Immunosuppressed patients develop severe and recalcitrant molluscum lesions that may require treatment with cidofovir, imiquimod or interferon. Patients with molluscum contagiosum infection should be offered to be screened for other sexually transmitted infections.

Erratum: Evolution of π^{0} Suppression in Au+Au Collisions from sqrt[s_{NN}]=39 to 200 GeV [Phys. Rev. Lett. 109, 152301 (2012)]

This corrects the article DOI: 10.1103/PhysRevLett.109.152301.

AB0115 SECUKINUMAB THERAPY DOES NOT AFFECT NEUTROPHIL HOST DEFENCE IN PSORIATIC ARTHRITIS

Background:

Biologic therapies have revolutionised therapy in inflammatory diseases such as psoriatic arthritis (PsA), driving major improvements in outcomes. Th17 cells appear to play a key role in the pathogenesis of PsA, and IL-17 can trigger the release of chemoattractants such as CXCL8 and CCL20, leading to the further infiltration of other immune cells including neutrophils. Infiltrating activated neutrophils can themselves generate a range of chemoattractants which may amplify and sustain the inflammatory response. Therapeutic targeting of IL-17 with biologics such as secukinumab offers great benefit in PsA by blocking this inflammatory cycle: however the interaction of this agent with neutrophils, key components of host defence as well as potential mediators of this disease, is not known.

Objectives:

This study aimed to measure key aspects of neutrophil function to determine: a) changes in the functions of circulating neutrophils in PsA patients pre-therapy, compared to age- and sex-matched healthy controls and b) if these functions changed in PsA patients 12-weeks post-secukinumab therapy.

Methods:

Neutrophils were isolated from venous blood of 16 PsA patients and 10 healthy controls. Key neutrophil functions were measured at baseline and 12 weeks: reactive oxygen species (ROS) production, apoptosis (+/- TNF and GM-CSF), phagocytosis, receptor expression and chemotaxis. Changes in gene expression pre- and 12-weeks post-therapy (n=5 PsA) were measured using RNAseq.

Results:

PsARC response was observed in 70.6% of participants on secukinumab therapy at 12 weeks. There were no significant differences in ROS production, phagocytosis or chemotaxis in PsA patients at baseline (compared to healthy controls) or during therapy. Chemotaxis towards IL-8 in PsA patients at baseline was decreased compared to that of healthy controls, but this difference did not reach statistical significance. Surface levels of activation markers CD11b/CD18 and CD63 were increased in PsA patients at 12-weeks compared to baseline, while surface levels of CD16 decreased. RNA-seq analysis indicated down-regulation of pathways mediated by IL-17A, oncostatin M, TWEAK (TNFSF12) and CCL2 during therapy, but up-regulated expression of pathways involvingde novoprotein biosynthesis.

Conclusion:

Therapy with secukimumab in PsA did not significantly affect neutrophil host defence functions. The changes that were seen in circulating neutrophils indicate selective up- and down-regulation of functions that may reflect potential alterations in local or systemic cytokines, and/or an increase in the circulating pool of activated neutrophils that are no longer recruited into sites of inflammation because of the down-regulation of the local IL-17/CXCL8 signalling network.

Disclosure of Interests:

Andrew Cross: None declared, Jennifer Hawkes: None declared, Helen Frankland: None declared, Ayren Mediana: None declared, Helen Wright Grant/research support from: Novartis supporting this study, Nicola Goodson Grant/research support from: Novartis supporting this research, Steven Edwards Grant/research support from: Novartis supporting this work, Robert Moots Grant/research support from: Novartis supporting this work, Consultant of: a variety of companies including Novartis, Speakers bureau: a variety of companies including Novartis

Short Communication: effect of positive handling of sows on litter performance and pre-weaning piglet mortality

Fear and environmental stressors may negatively affect the welfare of farm animals such as pigs. The present study investigated the effects of music and positive handling on reproductive performance of sows (n = 1014; parity 1 to 8) from a commercial pig farm practicing a batch farrowing system. Every 2 weeks, 56 sows were moved from the gestation unit to conventional-crated farrowing houses 1 week prior to expected farrowing. Treated (T; n = 299) and control (C; n = 715) sows were included in the study. In the farrowing houses, auditory enrichment (music from a radio) was provided to sows of T groups daily from 0600 to 1800 h until the end of lactation. Until the day of farrowing, T sows were additionally subjected, for 15 s per day per sow, to continuous back scratching by one member of farm staff. Litter performance and piglet mortality were recorded and analysed between T and C sows using linear mixed regression models. The number of liveborn piglets (C 13.85 v. T 13.26) and liveborn corrected for fostering (C 13.85 v. T 13.43) was significantly higher (P < 0.05) in C groups compared to the T groups. The number of stillborn piglets was 0.60 and 0.72 in T and C groups, respectively (P > 0.05). With regard to piglet mortality, a linear mixed regression model showed a significant overall effect of treatment in reducing piglet mortality (P < 0.01). Yet, the effect of treatment varied according to litter size (number of liveborn piglets) with a diminishing treatment effect in sows with a high litter size (P < 0.01). Pre-weaning survival was improved in the current study by the combined effect of daily back scratching of sows prior to farrowing and providing music to sows and piglets during lactation. Further research is needed to assess the separate effects of both interventions.

Bone marrow lesions in knee osteoarthritis: regional differences in tibial subchondral bone microstructure and their association with cartilage degeneration

OBJECTIVE

The aim of this study was to investigate how bone microstructure within bone marrow lesions (BMLs) relates to the bone and cartilage across the whole human tibial plateau.

DESIGN

Thirty-two tibial plateaus from patients with osteoarthritis (OA) at total knee arthroplasty and eleven age-matched non-OA controls, were scanned ex vivo by MRI to identify BMLs and by micro CT to quantitate the subchondral (plate and trabecular) bone microstructure. For cartilage evaluation, specimens were processed histologically.

RESULTS

BMLs were detected in 75% of the OA samples (OA-BML), located predominantly in the anterior-medial (AM) region. In contrast to non-OA control and OA-no BML, in OA-BML differences in microstructure were significantly more evident between subregions. In OA-BML, the AM region contained the most prominent structural alterations. Between-group comparisons showed that the AM region of the OA-BML group had significantly higher histological degeneration (OARSI grade) (P < .0001, P < .05), thicker subchondral plate (P < .05, P < .05), trabeculae that are more anisotropic (P < .0001, P < .05), well connected (P < .05, P = n.s), and more plate-like (P < 0.05, P < 0.05), compared to controls and OA-no BML at this site. Compared to controls, OA-no BML had significantly higher OARSI grade (P < .0001), and lower trabecular number (P < .05).

CONCLUSION

In established knee OA, both the extent of cartilage damage and microstructural degeneration of the subchondral bone were dependent on the presence of a BML. In OA-no BML, bone microstructural alterations are consistent with a bone attrition phase of the disease. Thus, the use of BMLs as MRI image-based biomarkers appear to inform on the degenerative state within the osteochondral unit.

Impact of dealing with bereaved clients on the psychological wellbeing of veterinarians

BACKGROUND

Research has identified that members of the veterinary profession are at high risk of occupational stress, burnout, poor psychological wellbeing and an elevated rate of suicide. Although scholarly interest in veterinarians has increased in recent years, relatively few studies have specifically examined the emotional work in veterinary interactions and what effect dealing with companion animal owners' grief has on the wellbeing of veterinarians. The purpose of this study was to determine if dealing with bereaved clients affected the psychological wellbeing of veterinarians. The concept of compassion fatigue was explored, including whether veterinarians believed that their training had equipped them for communicating with grieving clients.

METHODS

Veterinary surgeons registered in South Australia in 2015 were invited to complete an online survey, with 105 participants responding.

RESULTS

Many participants, particularly female and younger veterinarians, were experiencing mild to severe psychological distress and nearly half of the sample was experiencing high to very high levels of compassion fatigue. No participants reported seeking psychological or other professional mental health support and the majority had not referred a grieving client to a psychologist or other mental health professional. A significant proportion of veterinarians felt their own mental health was affected by dealing with clients grieving the loss of a companion animal.

DISCUSSION

The findings are discussed in terms of increasing the wellbeing of veterinarians through improved curriculum training and workplace health promotion, particularly considering the high suicide rate reported for the profession.

Beam Energy and Centrality Dependence of Direct-Photon Emission from Ultrarelativistic Heavy-Ion Collisions

The PHENIX collaboration presents first measurements of low-momentum (0.4<p_{T}<3  GeV/c) direct-photon yields from Au+Au collisions at sqrt[s_{NN}]=39 and 62.4 GeV. For both beam energies the direct-photon yields are substantially enhanced with respect to expectations from prompt processes, similar to the yields observed in Au+Au collisions at sqrt[s_{NN}]=200. Analyzing the photon yield as a function of the experimental observable dN_{ch}/dη reveals that the low-momentum (>1  GeV/c) direct-photon yield dN_{γ}^{dir}/dη is a smooth function of dN_{ch}/dη and can be well described as proportional to (dN_{ch}/dη)^{α} with α≈1.25. This scaling behavior holds for a wide range of beam energies at the Relativistic Heavy Ion Collider and the Large Hadron Collider, for centrality selected samples, as well as for different A+A collision systems. At a given beam energy, the scaling also holds for high p_{T} (>5  GeV/c), but when results from different collision energies are compared, an additional sqrt[s_{NN}]-dependent multiplicative factor is needed to describe the integrated-direct-photon yield.

Pharmacokinetics and pharmacodynamics of pergolide mesylate after oral administration in horses with pituitary pars intermedia dysfunction

Published information on the pharmacokinetic and pharmacodynamic properties of pergolide is limited. The aim of this study was to investigate the pharmacokinetic and pharmacodynamic properties of oral pergolide in horses with pituitary pars intermedia dysfunction (PPID). The study design was a nonrandomized clinical trial. Six horses with PPID diagnosed by thyrotropin-releasing hormone (TRH) stimulation tests received pergolide at 4 μg/kg for 18 d. Plasma samples for determination of pergolide and ACTH concentration were collected 0.5 h before and 2 and 12 h after each administration of pergolide. Maximum plasma concentrations after the first oral dose of pergolide (0.104-0.684 ng/mL; median 0.261 ng/mL; interquartile range [IQR] 0.184-0.416 ng/mL) were not significantly different to the maximum steady-state concentration at day 18 (0.197-0.628 ng/mL; median 0.274; IQR 0.232-0.458 ng/mL). Chronic administration was not associated with drug accumulation (R = 1.09) and pergolide concentration reached steady state within 3 d. Throughout, concentrations of pergolide fluctuated considerably, with median plasma peak concentrations more than four times higher than median trough concentrations. Plasma ACTH concentration reduced significantly within 12 h of administration with further reductions occurring up to 10 d after the initiation of treatment. Although there were parallel fluctuations in the concentrations of pergolide and ACTH, timing of ACTH measurement in relation to the administration of pergolide did not have a significant effect. Alterations in the response to TRH were identified at 8 d with no further change being identified at 18 d. A small number of horses were studied. Oral pergolide results in significant suppression of pars intermedia activity within hours. Pergolide and ACTH concentrations fluctuated in tandem although correlation was poor. Fluctuations in pergolide concentration were consistent with a terminal elimination half-life of less than 12 h. To reduce the level of fluctuation of ACTH, twice-daily dosing of pergolide may be more appropriate.

A multidisciplinary perspective on the subcutaneous administration of trastuzumab in HER2-positive breast cancer

Trastuzumab is the standard treatment in Canada for patients with breast cancer positive for her2 (human epidermal growth factor receptor 2), dramatically improving outcomes in that patient group. However, its current intravenous (IV) administration is associated with long infusion times that place a significant burden on health care resources and patient quality of life. In an effort to provide a faster and easier administration method, a subcutaneous (sc) formulation of trastuzumab has been developed. Data from comparative trials demonstrate that the two formulations are comparable with respect to pharmacokinetics and efficacy. They also have similar safety profiles, with the exception of mild local and administration reactions with the sc formulation. Furthermore, the sc formulation is preferred by patients and health care professionals, and greatly reduces administration and chair time. Additional advantages include easier preparation and dosing, reduced drug wastage, and reduced discomfort at the injection site. By using well-thought-out administration procedures, the sc formulation can be given safely and effectively, potentially reducing the burden on health care resources and improving quality of life for patients.

Neptunium(iv)-hydroxamate complexes: their speciation, and kinetics and mechanism of hydrolysis

First time determination of rate parameters for hydrolysis of mono- and bis-acetohydroxamatoneptunium(iv) complexes under conditions relevant to nuclear reprocessing.

GSK2878175, a pan-genotypic non-nucleoside NS5B polymerase inhibitor, in healthy and treatment-naïve chronic hepatitis C subjects

GSK2878175 is a potent, pan-genotypic, non-nucleoside, nonstructural protein 5B palm polymerase inhibitor being developed for the treatment of chronic hepatitis C (CHC). A first-in-human, randomized, placebo-controlled, dose escalation study, evaluated the safety and pharmacokinetics of GSK2878175 administered as single and repeat oral doses (once daily for 14 days) to healthy volunteers. A separate proof-of-concept, placebo-controlled, repeat dose (once daily for 2 days) study evaluated the safety, pharmacokinetics and antiviral activity of GSK2878175 monotherapy in treatment-naïve, noncirrhotic, subjects with hepatitis C virus (HCV) genotype 1 [1a and 1b], 2, or 3. No deaths or SAEs were reported in either study, and treatment was well-tolerated. Across all the HCV genotypes, GSK2878175 monotherapy at doses of 10, 30 or 60 mg once daily for 2 days produced a statistically significant multilog reduction (P<.001) in plasma HCV RNA log₁₀ IU/mL from Baseline to 24, 48 and 72 hours after the first dose of GSK2878175 compared to placebo. The reduction in HCV RNA was sustained for a prolonged period across all of the active treatment groups, consistent with the long apparent half-life of GSK2878175 that was observed (mean t_1/2 range: 60-63 hours in the CHC subjects). In summary, GSK2878175, when administered to healthy subjects and subjects with CHC, did not reveal any safety concerns that would limit or preclude further clinical development. GSK2878175 monotherapy across a wide dose range produced substantial reduction in HCV RNA, irrespective of HCV genotype. The results from these studies support further evaluation of GSK2878175-based regimens.