Outcome of a screening programme for the prevention of neonatal invasive early-onset group B Streptococcus infection in a UK maternity unit: an observational study

BACKGROUND

Against a background of failure to prevent neonatal invasive early-onset group B Streptococcus infections (GBS) in our maternity unit using risk-based approach for intrapartum antibiotic prophylaxis, we introduced an antenatal GBS carriage screening programme to identify additional women to target for prophylaxis.

OBJECTIVES

To describe the implementation and outcome of an antepartum screening programme for prevention of invasive early-onset GBS infection in a UK maternity unit.

DESIGN

Observational study of outcome of screening programme (intervention) with comparison to historical controls (preintervention).

SETTING

Hospital and community-based maternity services provided by Northwick Park and Central Middlesex Hospitals in North West London.

PARTICIPANTS

Women who gave birth between March 2014 and December 2015 at Northwick Park Hospital.

METHODS

Women were screened for GBS at 35-37 weeks and carriers offered intrapartum antibiotic prophylaxis. Screening programme was first introduced in hospital (March 2014) and then in community (August 2014). Compliance was audited by review of randomly selected case records. Invasive early-onset GBS infections were defined through GBS being cultured from neonatal blood, cerebrospinal fluid or sterile fluids within 0-6 days of birth.

MAIN OUTCOME

Incidence of early-onset GBS infections.

RESULTS

6309 (69%) of the 9098 eligible women were tested. Screening rate improved progressively from 42% in 2014 to 75% in 2015. Audit showed that 98% of women accepted the offer of screening. Recto-vaginal GBS carriage rate was 29.4% (1822/6193). All strains were susceptible to penicillin but 11.3% (206/1822) were resistant to clindamycin. Early onset GBS rate fell from 0.99/1000 live births (25/25276) in the prescreening period to 0.33/1000 in the screening period (Rate Ratio=0.33; p=0.08). In the subset of mothers actually screened, the rate was 0.16/1000 live births (1/6309), (Rate Ratio=0.16; p<0.05).

CONCLUSIONS

Our findings confirm that an antenatal screening programme for prevention of early-onset GBS infection can be implemented in a UK maternity setting and is associated with a fall in infection rates.

The in vitro effect of xylitol on chronic rhinosinusitis biofilms

INTRODUCTION

Biofilms have been implicated in chronic rhinosinusitis (CRS) and may explain the limited efficacy of antibiotics. There is a need to find more effective, non-antibiotic based therapies for CRS. This study examines the effects of xylitol on CRS biofilms and planktonic bacteria.

METHODS

Crystal violet assay and spectrophotometry were used to quantify the effects of xylitol (5% and 10% solutions) against Staphylococcus epidermidis, Pseudomonas aeruginosa, and Staphylococcus aureus. The disruption of established biofilms, inhibition of biofilm formation and effects on planktonic bacteria growth were investigated and compared to saline and no treatment.

RESULTS

Xylitol 5% and 10% significantly reduced biofilm biomass (S. epidermidis), inhibited biofilm formation (S. aureus and P. aeruginosa) and reduced growth of planktonic bacteria (S. epidermidis, S. aureus, and P. aeruginosa). Xylitol 5% inhibited formation of S. epidermidis biofilms more effectively than xylitol 10%. Xylitol 10% reduced S. epidermidis planktonic bacteria more effectively than xylitol 5%. Saline, xylitol 5% and 10% disrupted established biofilms of S. aureus when compared with no treatment. No solution was effective against established P. aeruginosa biofilm.

CONCLUSIONS

Xylitol has variable activity against biofilms and planktonic bacteria in vitro and may have therapeutic efficacy in the management of CRS.

Abstract OT3-04-01: BRE12-158: A phase II randomized controlled trial of genomically directed therapy after preoperative chemotherapy in patients with triple negative breast cancer (TNBC)

Background: About 1/3 of patients with TNBC who receive preoperative therapy will experience a pathological complete response (pCR). Patients with residual disease have a markedly inferior overall survival (OS) compared to those who experience pCR. Recently, the CREATE-X trial demonstrated an improvement in disease free survival (DFS) and OS for post-neoadjuvant capecitebine; although the addition of capecitebine to standard therapy has not previously improved outcome across other non-selected adjuvant or neo-adjuvant trials. Prior data have also demonstrated that the residual tumors are genomically diverse and that these genetic changes are reflected at time of relapse.

Trial Design: This trial is a randomized phase II trial to determine whether a genomically guided therapy in the setting of incomplete response to standard neoadjuvant therapy will improve outcomes compared to standard of care. DNA from archived tumor samples collected at the time of surgery will be extracted and sequenced. The sequencing data will be interrogated for known genomic drivers of sensitivity or resistance to existing FDA approved agents. A cancer genomic tumor board (CGTB) will consider the genomic data along with the patient's prior treatment history, toxicities, and comorbidities and select the optimal therapy. Participants with a CGTB recommendation will be randomized to Experimental Arm A (genomically directed monotherapy) or Control Arm B (standard of care). Participants may have no CGTB recommendation either because sequencing did not identify a matched drug or because the drug was contraindicated and will be assigned to Control Arm B.

Eligibility criteria: Patients must have histologically confirmed TNBC with completion of all definitive local therapy and no evidence of metastatic disease. There must be significant residual disease characterized by &gt;2cm primary tumor, or lymph node positivity or RCB classification II or III. An FFPE tumor block with tumor cellularity &gt;20% is required. All patients must have completed preoperative chemotherapy including a taxane or anthracycline or both.

Specific aims: The Primary Aim is to compare 2-year DFS with a genomically directed therapy vs. standard of care. Secondary Aims include 1-year DFS, 5-year OS, collection of archival specimens for correlative studies, and to describe toxicities. Exploratory Aims are to describe the evolution of genomically directed therapies during the course of the study and to evaluate the drug specific effect on efficacy and toxicity.

Statistical methods: In order to detect an improvement in the fraction of patients free from disease at 2-year from 40% in the control Arm B to 63.2% in the genomically directed Experimental Arm A (corresponding to an HR=0.5), 136 participants will have 80% power to detect a difference in DFS using a two-side log-rank test with 0.05 level of significance.

Present accrual/target accrual: 38 accrued of 136 to be randomized.

Citation Format: Schneider B, Miller KD, Badve S, O'Neil B, Helft P, Chitambar C, Falkson C, Nanda R, McCormick M, Danso M, Blaya M, Langdon R, Lippman M, Paplomata E, Walling R, Thompson M, Robin E, Aggarwal L, Shalaby I, Canfield V, Adesunloye B, Lee T, Daily K, Ma C, Erban J, Radhakrishnan N, Bruetman D, Graham M, Reddy NA, Lynce FC, Radovich M. BRE12-158: A phase II randomized controlled trial of genomically directed therapy after preoperative chemotherapy in patients with triple negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-04-01.

Personality disorder: still the patients psychiatrists dislike?

Aims and method In 1988, Lewis and Appleby demonstrated that psychiatrists hold negative attitudes towards patients with personality disorder. We assessed the attitudes of psychiatry trainees towards patients with borderline personality disorder and depression, expecting an improvement. 166 trainees were block randomised to receive one of four case vignettes that varied by diagnosis and ethnic group. We used Lewis and Appleby's original questionnaire and the Attitudes to Personality Disorder Questionnaire (APDQ). Results We received 76 responses. Lewis and Appleby's questionnaire showed more negative attitudes towards personality disorder than depression, with no significant patient ethnic group effects, and the APDQ also showed a (weak) trend towards more negative attitudes to personality disorder. In subgroup analysis, only in the White British patient group were there significantly more negative attitudes to personality disorder. Factor analysis showed significantly less sense of purpose when working with personality disorder. Clinical implications The perceived greater lack of purpose in working with personality disorder should be the target of clinical training and intervention. Targeted interventions that include training in managing personality disorder, supervision and practice in non-specialist, general psychiatry settings are important.

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Uyar M, Shirazy M, Fayed A, Gupta S, Kaushal A, Dewan S, Varma A, Ghosh E, Yang L, Eshelman L, Lord B, Carlson E, Helme E, Broderick R, Hadfield S, Loveridge R, Ramos J, Forte D, Yang F, Hou P, Dudziak J, Feeney J, Wilkinson K, Bauchmuller K, Shuker K, Faulds M, Raithatha A, Bryden D, England L, Bolton N, Tridente A, Bauchmuller K, Shuker K, Tridente A, Faulds M, Matheson A, Gaynor J, Bryden D, ᅟ SSYHRC, Ramos J, Peroni B, Daglius-Dias R, Miranda L, Cohen C, Carvalho C, Velasco I, Forte D, Kelly JM, Neill A, Rubenfeld G, Masson N, Min A, Boezeman E, Hofhuis J, Hovingh A, De Vries R, Spronk P, Cabral-Campello G, Aragão I, Cardoso T, Van Mol M, Nijkamp M, Kompanje E, Ostrowski P, Omar A, Kiss K, Köves B, Csernus V, Molnár Z, Hoydonckx Y, Vanwing S, Stessel B, Van Assche A, Jamaer L, Dubois J, Medo V, Galvez R, Miranda JP, Stone C, Wigmore T, Arunan Y, Wheeler A, Bauchmuller K, Bryden D, Wong Y, Poi C, Gu C, Molmy P, Van Grunderbeeck N, Nigeon O, Lemyze M, Thevenin D, Mallat J, Ramos J, Correa M, Carvalho RT, Forte D, Fernandez A, McBride C, Koonthalloor E, Walsh C, Webber A, Ashe M, Smith K, Jeanrenaud P, Marudi A, Baroni S, Ragusa F, Bertellini E, Volakli EA, Chochliourou E, Dimitriadou M, Violaki A, Mantzafleri P, Samkinidou E, Vrani O, Arbouti A, Varsami T, Sdougka M, Bollen JA, Van Smaalen TC, De Jongh WC, Ten Hoopen MM, Ysebaert D, Van Heurn LW, Van Mook WN, Sim K, Fuller A, Roze des Ordons A, Couillard P, Doig C, Van Keer RV, Deschepper RD, Francke AF, Huyghens LH, Bilsen JB, Nyamaizi B, Dalrymple C, Molokhia A, Dobru A, Marrinan E, Ankuli A, Molokhia A, McPeake J, Struthers R, Crawford R, Devine H, Mactavish P, Quasim T, Morelli P, Degiovanangelo M, Lemos F, MArtinez V, Verga F, Cabrera J, Burghi G, Rutten A, Van Ieperen S, De Geer S, Van Vugt M, Der Kinderen E, Giannini A, Miccinesi G, Marchesi T, Prandi E. Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

A new top-loading venous bag provides vacuum-assisted venous drainage

A new venous bag has been developed, prototyped, and tested. The new bag has its inlet, outlet purge, and infusion tubes extending upward from the top of the bag, and are threaded through, bonded to, and sealed within a flat rigid top plate. This design allows the bag to be hung from its top plate by its tubes. It also allows the bag to be: 1) dropped into or removed from its holder, as is done with existing hard-shell reservoirs so that its weight pulls it into the holder without the need for eyelets and hooks and 2) placed closer to the floor so that gravity drainage is facilitated. The V-Bag® (VB) is easily sealed within an accompanying rigid housing. Once sealed, vacuum applied to the housing is transmitted across the flexible walls of the bag to the venous blood. Thus, vacuum-assisted venous drainage (VAVD) is obtained as it is with a hard-shell reservoir, but without any contact of air with the blood. Bench tests, using a circuit that simulated the venous side of the cardiopulmonary bypass (CPB) circuit, showed that applying suction to the housing increased venous flow, and the fractional increase in flow was not a function of the venous cannula, but of the level of vacuum applied. In the gravity drainage mode, the bubble counts at the outlet of the V-Bag compared to two other bags were lower at any pumping condition. When used in the VAVD mode, bubble counts were two orders of magnitude lower than when using kinetically assisted venous drainage (KAVD) with a centrifugal pump. Results obtained with the VB suggest its clinical usefulness.

Treatment Strategy for Persistent Sciatic Artery and Novel Classification Reflecting Anatomic Status

BACKGROUND

Persistent sciatic artery (PSA) is a relatively rare congenital variant of the lower limb vasculature and can have highly variable clinical presentations. The purpose of this study was to analyze the relationship between PSA anatomy and clinical presentation, and to suggest an optimal management strategy.

METHODS

Between 2001 and 2014, 24 PSAs in 19 patients were diagnosed by computed tomography and referred to the vascular surgery department. Patient demographics, types of PSA and femoral artery, aneurysmal changes, symptoms, and treatment methods were assessed. Additionally, all English literature from 1964 to 2014 was reviewed and compared using the PubMed database (224 PSAs in 171 patients).

RESULTS

PSA was diagnosed in 10 men (52.6%) and nine women (47.4%). PSAs were bilateral in five patients (26.3%) and symptomatic in 12 patients, while in seven patients PSA was found incidentally. According to the Pillet-Gauffre classification, Type 2a was the most common variant (n = 15/24, 62.5%), with unclassifiable types in two limbs. Compared with cases in the literature, the PSA occlusion rate in this study was higher (n = 10/24, 41.7% vs. n = 54/224, 27.5%), but aneurysm incidence was higher in the literature cases (n = 5/24, 20.8% vs. n = 112/224; 50.7%). In this study, 16 limbs (66.6%) were treated conservatively, and six limbs were treated by open surgery, including four bypasses, one amputation, and one thrombo-embolectomy. Endovascular coil embolization was performed in one limb, and a hybrid procedure with stent graft was performed in one limb with PSA aneurysm. Based on the present series and the literature review, a new classification system and treatment option is proposed according to the anatomic status and the presence of aneurysm. According to the new classification, class III was the most common in both the present study (18/24; 75%) and the literature review, and the presence of aneurysm was the most important determinant of surgical treatment.

CONCLUSIONS

The new classification system is simple and provides guidance for management. Limb anatomy of the femoral artery system and the presence of PSA aneurysm should be considered when selecting the optimal treatment. The risk of embolism from the presence of aneurysm is an important factor for treatment, and bypass surgery is mostly required in classes III and IV.

Latrophilin receptors: novel bronchodilator targets in asthma

Background

Asthma affects 300 million people worldwide. In asthma, the major cause of morbidity and mortality is acute airway narrowing, due to airway smooth muscle (ASM) hypercontraction, associated with airway remodelling. However, little is known about the transcriptional differences between healthy and asthmatic ASM cells.

Objectives

To investigate the transcriptional differences between asthmatic and healthy airway smooth muscle cells (ASMC) in culture and investigate the identified targets using in vitro and ex vivo techniques.

Methods

Human asthmatic and healthy ASMC grown in culture were run on Affymetrix_Hugene_1.0_ST microarrays. Identified candidates were confirmed by PCR, and immunohistochemistry. Functional analysis was conducted using in vitro ASMC proliferation, attachment and contraction assays and ex vivo contraction of mouse airways.

Results

We suggest a novel role for latrophilin (LPHN) receptors, finding increased expression on ASMC from asthmatics, compared with non-asthmatics in vivo and in vitro, suggesting a role in mediating airway function. A single nucleotide polymorphism in LPHN1 was associated with asthma and with increased LPHN1 expression in lung tissue. When activated, LPHNs regulated ASMC adhesion and proliferation in vitro, and promoted contraction of mouse airways and ASMC.

Conclusions

Given the need for novel inhibitors of airway remodelling and bronchodilators in asthma, the LPHN family may represent promising novel targets for future dual therapeutic intervention.

Evaluating the safety and the effects on colonic compliance of neostigmine during motility testing in patients with chronic constipation

BACKGROUND

Neostigmine, an acetyl cholinesterase inhibitor, stimulates colonic motor activity and may induce vagally mediated cardiovascular effects. Our aim was to evaluate effects of i.v. neostigmine on colonic compliance and its safety in patients with chronic constipation.

METHODS

We retrospectively reviewed medical records of a selected group of 144 outpatients with chronic constipation who were refractory to treatment. These patients had undergone intracolonic motility and compliance measurements with an infinitely compliant balloon linked to a barostat. Data abstracted included barostat balloon mean volumes with increases in pressure (4 mmHg steps from 0 to 44 mmHg) before and after i.v. neostigmine. Vital signs and oxygen saturation before and after neostigmine were recorded.

KEY RESULTS

Of the 144 patients, 133 were female, mean age was 41.0 ± 15.4 years (SD), and duration of constipation was 12.9 ± 13.8 years. Among patients who had undergone colonic transit measurement by scintigraphy, the overall colonic transit at 24 h (geometric center, GC24 [n = 115]) was 1.5 ± 0.7 (normal >1.3), and at 48 h (GC48 [n = 75]) it was 2.3 ± 0.9 (normal >1.9). Neostigmine decreased colonic compliance at lower distension pressures (e.g., 12 and 20 mmHg [both p < 0.001]), but not at 40 mmHg. There were expected minor changes in vital signs in response to neostigmine in 144 patients; however, one patient developed unresponsiveness, significant bradycardia, hypotension, and muscular rigidity that responded to 400 mcg i.v. atropine.

CONCLUSIONS & INFERENCES

Neostigmine significantly decreases colonic compliance in patients with refractory chronic constipation. Symptomatic bradycardia in response to neostigmine should be promptly reversed with atropine.

Correction to 'Comparison of social structures within cities of very different sizes'

[This corrects the article DOI: 10.1098/rsos.150526.].