Impact of an e-learning module on personal protective equipment knowledge in student paramedics: a randomized controlled trial

BACKGROUND

Prehospital professionals such as emergency physicians or paramedics must be able to choose and adequately don and doff personal protective equipment (PPE) in order to avoid COVID-19 infection. Our aim was to evaluate the impact of a gamified e-learning module on adequacy of PPE in student paramedics.

METHODS

This was a web-based, randomized 1:1, parallel-group, triple-blind controlled trial. Student paramedics from three Swiss schools were invited to participate. They were informed they would be presented with both an e-learning module and an abridged version of the current regional prehospital COVID-19 guidelines, albeit not in which order. After a set of 22 questions designed to assess baseline knowledge, the control group was shown the guidelines before answering a set of 14 post-intervention questions. The e-learning group was shown the gamified e-learning module right after the guidelines, and before answering post-intervention questions. The primary outcome was the difference in the percentage of adequate choices of PPE before and after the intervention.

RESULTS

The participation rate was of 71% (98/138). A total of 90 answer sets was analyzed. Adequate choice of PPE increased significantly both in the control (50% [33;83] vs 25% [25;50], P = .013) and in the e-learning group (67% [50;83] vs 25% [25;50], P = .001) following the intervention. Though the median of the difference was higher in the e-learning group, there was no statistically significant superiority over the control (33% [0;58] vs 17% [- 17;42], P = .087). The e-learning module was of greatest benefit in the subgroup of student paramedics who were actively working in an ambulance company (42% [8;58] vs 25% [- 17;42], P = 0.021). There was no significant effect in student paramedics who were not actively working in an ambulance service (0% [- 25;33] vs 17% [- 8;50], P = .584).

CONCLUSIONS

The use of a gamified e-learning module increases the rate of adequate choice of PPE only among student paramedics actively working in an ambulance service. In this subgroup, combining this teaching modality with other interventions might help spare PPE and efficiently protect against COVID-19 infection.

Listeria myopericarditis associated with right atrial mural thrombus: a case report

Background 

Pericarditis is a common cardiology presentation, most often due to a viral or idiopathic cause. Listeria as a cause of pericarditis is rare. Listeria is an infection that is readily treatable with antibiotics following accurate identification. Without adequate treatment, Listeria infection has a high mortality rate.

Case summary 

In this case, a fit and well 59-year-old man complained of headaches and fever to the emergency department (ED). He was provisionally diagnosed with giant cell arteritis (GCA) and commenced on management pathways for GCA. He represented to the ED with chest pain and electrocardiogram (ECG) changes suggestive of a clinical presentation of pericarditis. He received treatment for idiopathic pericarditis with no clinical resolution. Cardiac magnetic resonance imaging (MRI) showed myopericardial inflammation associated with a right atrial mural thrombus. After 2 weeks of poor treatment response, peripheral blood cultures grew Listeria monocytogenes and the patient responded well to antibiotic treatment. Repeat cardiac MRI after an extended course of antibiotics showed resolution of MRI signs.

Discussion 

This is a case of Listeria myopericarditis. Physicians should consider rarer causes of myopericarditis in treatment resistance cases. Cardiac MRI has utility in atypical or treatment resistant patients to assess myopericardial inflammation and response to treatment.

Effect of an E-Learning Module on Personal Protective Equipment Proficiency Among Prehospital Personnel: Web-Based Randomized Controlled Trial

Background

To avoid misuse of personal protective equipment (PPE), ensure health care workers’ safety, and avoid shortages, effective communication of up-to-date infection control guidelines is essential. As prehospital teams are particularly at risk of contamination given their challenging work environment, a specific gamified electronic learning (e-learning) module targeting this audience might provide significant advantages as it requires neither the presence of learners nor the repetitive use of equipment for demonstration.

Objective

The aim of this study was to evaluate whether a gamified e-learning module could improve the rate of adequate PPE choice by prehospital personnel in the context of the coronavirus disease (COVID-19) pandemic.

Methods

This was an individual-level randomized, controlled, quadruple-blind (investigators, participants, outcome assessors, and data analysts) closed web-based trial. All emergency prehospital personnel working in Geneva, Switzerland, were eligible for inclusion, and were invited to participate by email in April 2020. Participants were informed that the study aim was to assess their knowledge regarding PPE, and that they would be presented with both the guidelines and the e-learning module, though they were unaware that there were two different study paths. All participants first answered a preintervention quiz designed to establish their profile and baseline knowledge. The control group then accessed the guidelines before answering a second set of questions, and were then granted access to the e-learning module. The e-learning group was shown the e-learning module right after the guidelines and before answering the second set of questions.

Results

Of the 291 randomized participants, 176 (60.5%) completed the trial. There was no significant difference in baseline knowledge between groups. Though the baseline proportion of adequate PPE choice was high (75%, IQR 50%-75%), participants’ description of the donning sequence was in most cases incorrect. After either intervention, adequate choice of PPE increased significantly in both groups (P<.001). Though the median of the difference in the proportion of correct answers was slightly higher in the e-learning group (17%, IQR 8%-33% versus 8%, IQR 8%-33%), the difference was not statistically significant (P=.27). Confidence in the ability to use PPE was maintained in the e-learning group (P=.27) but significantly decreased in the control group (P=.04).

Conclusions

Among prehospital personnel with an already relatively high knowledge of and experience with PPE use, both web-based study paths increased the rate of adequate choice of PPE. There was no major added value of the gamified e-learning module apart from preserving participants' confidence in their ability to correctly use PPE.

Risk of SARS-CoV-2 transmission by aerosols, the rational use of masks, and protection of healthcare workers from COVID-19

OBJECTIVES

To determine the risk of SARS-CoV-2 transmission by aerosols, to provide evidence on the rational use of masks, and to discuss additional measures important for the protection of healthcare workers from COVID-19.

METHODS

Literature review and expert opinion.

SHORT CONCLUSION

SARS-CoV-2, the pathogen causing COVID-19, is considered to be transmitted via droplets rather than aerosols, but droplets with strong directional airflow support may spread further than 2 m. High rates of COVID-19 infections in healthcare-workers (HCWs) have been reported from several countries. Respirators such as filtering face piece (FFP) 2 masks were designed to protect HCWs, while surgical masks were originally intended to protect patients (e.g., during surgery). Nevertheless, high quality standard surgical masks (type II/IIR according to European Norm EN 14683) appear to be as effective as FFP2 masks in preventing droplet-associated viral infections of HCWs as reported from influenza or SARS. So far, no head-to-head trials with these masks have been published for COVID-19. Neither mask type completely prevents transmission, which may be due to inappropriate handling and alternative transmission pathways. Therefore, compliance with a bundle of infection control measures including thorough hand hygiene is key. During high-risk procedures, both droplets and aerosols may be produced, reason why respirators are indicated for these interventions.

Risk of SARS-CoV-2 transmission by aerosols, the rational use of masks, and protection of healthcare workers from COVID-19

OBJECTIVES

To determine the risk of SARS-CoV-2 transmission by aerosols, to provide evidence on the rational use of masks, and to discuss additional measures important for the protection of healthcare workers from COVID-19.

METHODS

Literature review and expert opinion.

SHORT CONCLUSION

SARS-CoV-2, the pathogen causing COVID-19, is considered to be transmitted via droplets rather than aerosols, but droplets with strong directional airflow support may spread further than 2 m. High rates of COVID-19 infections in healthcare-workers (HCWs) have been reported from several countries. Respirators such as filtering face piece (FFP) 2 masks were designed to protect HCWs, while surgical masks were originally intended to protect patients (e.g., during surgery). Nevertheless, high quality standard surgical masks (type II/IIR according to European Norm EN 14683) appear to be as effective as FFP2 masks in preventing droplet-associated viral infections of HCWs as reported from influenza or SARS. So far, no head-to-head trials with these masks have been published for COVID-19. Neither mask type completely prevents transmission, which may be due to inappropriate handling and alternative transmission pathways. Therefore, compliance with a bundle of infection control measures including thorough hand hygiene is key. During high-risk procedures, both droplets and aerosols may be produced, reason why respirators are indicated for these interventions.

Contribution of neural networks in the diagnosis and treatment of cardiac arrhythmia

Arrhythmia is a dangerous disease in which the heart rhythm varies and it may be very fast or very slow. Rapid heartbeats can lead to shortness of breath, chest pain, and sudden weakness, whereas slow heartbeats can lead to dizziness, problems with concentration, and constant stress. Finding an effective treatment for arrhythmia has become a very important endeavor for researchers and clinicians. In this article, we review the latest methodologies used in arrhythmia diagnosis and treatment. They include the application of five different types of artificial neural networks trained by machine learning and powered by artificial intelligence: convolutional, recurrent, feedforward, radial basis function, and modular neural network. Some of these methodologies are merged to enhance accuracy and efficacy. This review suggests that more research needs to be carried out in merging neural network types for their application in electrocardiogram (ECG).

Qualitative theoretical modeling to study the possibility of detecting multi-virus in blood flow using Nano-quartz crystal microbalance

Methods for testing the presence of a virus in the blood are of interest to researchers and doctors because they determine how rapidly a virus is detected. In general, virus detection is a major scientific problem due to the serious effects of viruses on the human body. At present, only one virus can be detected in a single test. This potentially costs the medical establishment more time and money that could be saved if blood testing was more efficient. This study presents a qualitative method to enable doctors and researchers to detect more than one virus simultaneously. This was performed using quartz nanoparticles. Using polymer thin films of polydimethylsiloxane (PDMS), each chip emits a different frequency for each specific type of virus on the chip. The multiplicity of these chips allows for the detection of a number of viruses with the same number of nanoscale chips simultaneously. Blood flow around quartz nanoparticles was modelled. In this model, several conventional Quartz Crystal Microbalance (QCM) with nanostructures (Nano-QCM) particles are inserted into the three main types of blood vessels. The results showed that the best location for the Nano-QCM is the large artery and that it is possible to test for a number of viruses in all types of blood vessels.

Teaching Adequate Prehospital Use of Personal Protective Equipment During the COVID-19 Pandemic: Development of a Gamified e-Learning Module

BACKGROUND

The coronavirus disease (COVID-19) pandemic has led to increased use of personal protective equipment (PPE). Adequate use of this equipment is more critical than ever because the risk of shortages must be balanced against the need to effectively protect health care workers, including prehospital personnel. Specific training is therefore necessary; however, the need for social distancing has markedly disrupted the delivery of continuing education courses. Electronic learning (e-learning) may provide significant advantages because it requires neither the physical presence of learners nor the repetitive use of equipment for demonstration.

OBJECTIVE

Inclusion of game mechanics, or "gamification," has been shown to increase knowledge and skill acquisition. The objective of this research was to develop a gamified e-learning module to interactively deliver concepts and information regarding the correct choice and handling of PPE.

METHODS

The SERES framework was used to define and describe the development process, including scientific and design foundations. After we defined the target audience and learning objectives by interviewing the stakeholders, we searched the scientific literature to establish relevant theoretical bases. The learning contents were validated by infection control and prehospital experts. Learning mechanics were then determined according to the learning objectives, and the content that could benefit from the inclusion of game mechanics was identified.

RESULTS

The literature search resulted in the selection and inclusion of 12 articles. In addition to gamification, pretesting, feedback, avoiding content skipping, and demonstrations using embedded videos were used as learning mechanics. Gamification was used to enhance the interactivity of the PPE donning and doffing sequences, which presented the greatest learning challenges. The module was developed with Articulate Storyline 3 to ensure that it would be compatible with a wide array of devices, as this software generates HTML5-compatible output that can be accessed on smartphones, tablets, and regular computers as long as a recent browser is available.

CONCLUSIONS

A gamified e-learning module designed to promote better knowledge and understanding of PPE use among prehospital health care workers was created by following the SERES framework. The impact of this module should now be assessed by means of a randomized controlled trial.

P425Single procedure pace and ablate. evaluation of efficacy and safety comparing three different vascular routes

Funding Acknowledgements

No financial support for this study

Introduction

Permanent pacemaker implantation combined with AVN ablation is a well-established treatment for rate control in patients with atrial fibrillation refractory to medical therapy. At the same sitting, this has been achieved in a single procedure via the subclavian vein (SCV) for both pacemaker implantation and AVN ablation, by pacemaker implantation via the SCV with femoral access for AVN ablation or by using the femoral vein (FV) for leadless pacemaker implantation and AVN ablation with a coaxial single-puncture technique.

We evaluated all combined procedures (pacemaker implantation and AVN ablation at the same sitting) performed in a single centre over 9 years comparing clinical outcomes, complications rates and procedure times.

Statistical methods: 

Continuous variables are described as mean ± standard deviation (SD), and statistical differences between groups were evaluated by one-way ANOVA. A X2 test was used for categorical variables, with Fisher’s exact test for any field where the expected frequency was ≤5 with pvalue &lt; 0.05 considered as statistically significant. The statistical analysis was performed using SPSS software package. 

Results

 

141 patients underwent AVN ablation at our institution as part of a ‘pace and ablate’ single procedure strategy between 14/2/11 and 10/6/19. 61 patients had a combined procedure via the SCV, 66 patients had pacemaker implanted via the SCV and AVN ablation via the FV in the same sitting and 14 patients had leadless pacemaker (Micra) implantation and AVN ablation via the FV. Our findings suggest that the fluoroscopy time as well as the total catheter laboratory time were much less in the Micra group compared to the other groups. In the conventional pacemaker groups (group 1 and 2), the fluoroscopy time was not statistically different between the two. There was a trend towards acute procedural failure, switching to another access as well as a higher complication rate in the SCV group, however this has not reached statistical significance. 

Conclusion

 

Our early data suggests that pacemaker implantation and AVN ablation with a coaxial single femoral vein puncture technique is safe and takes less fluoroscopy time as well as total laboratory time.

Procedural outcomes All (n = 141) Group 1: SCV (n = 61) Group 2: FV (n = 66) Group 3: Micra (n = 14) P-value Total cath-lab time (mins) 113.1 ± 40.4 106.2 ± 37.2 125.7 ± 42.5 86.9 ± 23.1 0.001 Total fluoroscopy time (mins) 8.8 ± 7.6 11 ± 7.8 7.7 ± 7.6 4.5 ± 3 0.0001 Acute procedural failure, n (%) 9 (6.4) 7 (11.5) 2 (3) 0 (0) **0.6 Complications, n (%) 7 (4.9) 5 (8.2) 2 (3) 0 (0) **0.62 **Fisher"s exact test applied to analysis of Micra VS Other methods

P1705ARE DIRECT-ACTING ANTI-VIRAL DRUGS ACCUSED OF INCREASED INCIDENCE OF HEPATOCELLULAR CARCINOMA IN ENDEMIC AREA: A PILOT STUDY

Background and Aims

Great progression in treating hepatitis C infection has been made with the new Interferon-free regimens. Reports about developing hepatocellular carcinoma after DAAs have been spotlighted. Kidney transplantation and hemodialysis are considered risk factors for developing malignancies. Here we are evaluating the prevalence of HCC after DAAs treatment in high risk population.

Method

This cross-sectional study was held in Urology and Nephrology Center, Mansoura University, Egypt including. Total number of 165 patients received DAAs included in this study in 2 phases. The first phase included 50 patients (12 hemodialysis and 38 kidney transplant recipients). All patients completed DAAs course as treatment for hepatitis C infection (HCV) 24 months ago. Alfa feto protein and liver ultrasound (Use of both modalities combined yielded sensitivity (99.2%) and specificity (68.3%)) was used to screening of HCC for all patients. Triphasic CT liver with 86% to 94% sensitivity was done for all hemodialysis patients and KTRs with suspicious lesions or high alfa-feto protein.

Results

Our patients mean age was 52.32±3.2 years with male predominance. Mean Hemodialysis duration was 48.21±12.3 months and mean kidney transplantation duration was 36.21±6.7 months. Baseline laboratory investigations: ALT: 39.17±16.3 iu/l, Albumin: 3.6±1.32 g/dl, Bilirubin: 0.54±0.21, Hemoglobin: 10.57±1.9 g/dl, AFP: 5.3±2.4 ng/ml. Baseline liver US: normal (49%), enlarged (42%) and cirrhotic (9%) (No focal lesions). Fibro scan: F0 (26%), F1 (31%), F2 (32%) and F3 (11%). None of them experienced hepatic encephalopathy attacks or bleeding varices. All hemodialysis patients received Ombitasvir/Paritaprevir/Ritonavir (OMV/PTV/RTV) regimen (3 months). Only 2 KTRs received OMV/PTV/RTV regimen (3 months), the remaining 36 KTRs received Sofosbuvir/Daclatasvir regimen (6 months). Only 1 case reported relapse within 3 month after completing treatment. The rest achieved 12-week and 24-week SVR successfully. After 2 years from completing treatment, there was significant improvement in ALT levels. Four KTRs passed to graft failure due to accelerated immunologic response (rejection episodes) and 7 KTRs showed rise of serum creatinine (biopsy-proven rejection). Mean AFP rose up to 7.6±2.4 ng/ml with no statistical difference. Three hemodialysis patients and 4 KTRs showed rise in alfa-feto protein above normal values (10ng/dl). Four out of them exceeded 500ng/ml (1 HD and 3 KTRs). Abdominal US revealed: no change (39 patients), enlargement (6 patients) and cirrhosis (5 patients). Suspicious mass was found in 11 patients. Triphasic CT then was done for all hemodialysis patients and 9 KTRs. Regarding hemodialysis, 1 patient was diagnosed as HCC based on increased enhancement by Triphasic CT and alfa-fetoprotein was &gt;500 ng/ml. Regarding KTRs, HCC was diagnosed in 2 patients and liver metastasis secondary to lymphoma was diagnosed in 1 case. The other patients with suspicious lesions (5 patients) showed uniform enhancement by Triphasic CT suggesting benign lesions. So, we have 3 (6%) out of 50 patients has been diagnosed as HCC after DAAs. By retrieval of their data, HCV duration was over 10 years and the liver was cirrhotic or enlarged with cirrhotic changes by ultrasound. Baseline ALT was slightly high without significant improvement after treatment. Also, baseline alfa-feto protein was high. The 3 patients were F2 or F3.

Conclusion

Hepatocellular carcinoma incidence after Direct-acting anti-virals is related mostly to the poor condition of the patients at baseline not to the drug itself and HCC in such cases could be considered as a part of disease progression not a drug complication.

P1384EFFECT OF ANEMIA ON EFFICACY AND SAFETY OF CHRONIC HEPATITIS C TREATMENT AMONG RENAL PATIENTS USING DIRECT ACTING ANTI-VIRUS

Background and Aims

With the advance of new direct acting antiviral, treatment of HCV became safer and easier. Renal impairment makes treatment of HCV more difficult due to poor drug tolerability. Anemia is a common side effect occurring in renal patients. Effect of anemia on the efficacy and safety of these drugs in those particular populations is a point of interest.

Method

This is a single center cohort study was held in Urology and Nephrology Center, Mansoura, Egypt, including 235 renal patients who were divided into 2 groups according to presence/absence of anemia; hemoglobin below 10.5 g/dL is considered cut-off value: 70 chronic kidney disease patients (CKD) (42 anemic and 28 non-anemic), 40 hemodialysis patients (HD) (24 anemic and 16 non-anemic) and 125 kidney-transplant recipients (KTRs) (40 anemic and 85 non-anemic). Hemodialysis patients received ritonavir-boosted paritaprevir and ombitasvir±ribavirin (OMV/PTV/RTV), KTRs received sofosbuvir and daclatasvir. CKD with eGFR &gt;30 ml/min/1.73m2 received sofosbuvir and daclatasvir. CKD with eGFR &lt;30 ml/min/1.73m2 received OMV/PTV/RTV. All patients were followed-up for 6 months after completing HCV treatment.

Results: Demographics: Mean age was 49.17y for CKD, 43.2y for HD and 45.2y for KTRs. Most of them were males with body mass index around 23.8. Out of 235, 22 patients had been previously treated with interferon-IFN- (14 patients showed relapse after primary response on IFN and 8 patients could not tolerate IFN due to severe anemia, leucopenia and recurrent infection) and 7 patients had been co-infected with hepatitis B virus (all patients were cleared from the virus prior to HCV treatment).

Efficacy: Rapid virologic response was achieved in all groups. 12-week sustained viral response (SVR-12) among CKD patients was 92.86% in anemic group and 96.42% in no-anemic group (p=91%). SVR-24 was lower in both groups. There were 16 relapse cases among CKD patients (11 in anemic group and 5 in non-anemic group; p value=0.69). Relative Risk for relapse incidence among anemic CKD patients was 1.4 with 95% CI 3.58 to 8.58 (p value: 0.42). Among HD patients, there was only 1 relapse case and it was in anemic group. All KTRs achieved SVR-12 and SVR-24.

Safety: Deterioration of kidney function within 1 month from starting DAAs was the major side effect in both groups among CKD patients but it was more profound in anemic group (59.5%) (p value: 0.024). Deterioration of creatinine clearance was more obvious in anemic group (26.7±11.8mL/min, 21.28±12.97mL/min; p value: 0.014). More cases needed hemodialysis either temporary (3 cases) or permanently (13 cases) in anemic group (p value: 0.03 for temporary hemodialysis and 0.005 for permanent hemodialysis). Relative Risk for A/CKD incidence with anemia among CKD patients was 1.85 with 95% CI from 22.94 to 1.98 (p value: 0.04). Anemia was associated with rise of serum creatinine among kidney transplant recipient also. Graft impairment among anemia group was 30% (12 out of 40 patients) in comparison to 3.5% in no-anemia group (3 out of 85 patients); p value: 0.0002. Relative Risk for graft impairment with anemia among KTRs was 8.5 with 95% CI 6.95 to 2.64. Subsequently, drug interruption was more frequent among anemia group in both CKD and KTRS as treatment was suspended during AKI period.

Regarding hemodialysis patients, the only difference was that worsening of anemia was more frequent among no-anemia group (p value: 0.0002). Ribavirin resulted in this this difference as no-anemia group received ribavirin while the other group did not receive it.

Conclusion

Direct-acting anti viral drugs are considered advance in treatment of hepatitis C infection and it is well tolerated by kidney disease patients. However, this particular population needs special care. Correction of anemia before starting DAAs may improve the outcome. Hemoglobin levels below 10.5 g/dL prior to DAAs are associated with rise of serum creatinine among KTRs and CKD patients.

"In situ similis" Culturing of Plant Microbiota: A Novel Simulated Environmental Method Based on Plant Leaf Blades as Nutritional Pads

High-throughput cultivation methods have recently been developed to accelerate the recovery of microorganisms reluctant to cultivation. They simulate in situ environmental conditions for the isolation of environmental microbiota through the exchange of growth substrates during cultivation. Here, we introduce leaf-based culture media adopting the concept of the plant being the master architect of the composition of its microbial community. Pre-physical treatments of sunflower plant leaves, namely punching, freezing, and/or autoclavation, allowed the diffusion of electrolytes and other nutrients to configure the leaf surface as a natural pad, i.e., creating an “in situ similis” environment suitable for the growth of rarely isolated microbiota. We used surface inoculation and membrane-filtration methods to assess the culturability of endophytic bacteria from the sunflower phyllosphere and rhizosphere. Both methods supported excellent colony-forming unit (CFU) development when compared to standard R2A medium, with a special affinity to support better growth of epiphytic and endophytic populations of the phyllosphere compared with the rhizosphere. A 16S rRNA gene analysis of >122 representative isolates indicated the cultivation of a diverse set of microorganisms by application of the new methods. It indicated the predominance of 13 genera of >30 potential species, belonging to Firmicutes, Proteobacteria, and Actinobacteria, and especially genera not commonly reported for sunflower, e.g., Rhizobium, Aureimonas, Sphingomonas, Paracoccus, Stenotrophomonas, Pantoea, Kosakonia, and Erwinia. The strategy successfully extended diversity and richness in the endophyllosphere compared to the endorhizosphere, while CFUs grown on the standard R2A medium mainly pertain to Firmicutes, especially Bacillus spp. MALDI-TOF MS analysis clustered the isolates according to their niche and potential functions, where the majority of isolates of the endorhizosphere were clustered away from those of the endophyllosphere. Isolates identified as Gammaproteobacteria and Alphaproteobacteria were distinguishably sub-clustered, which was in contrast to the heterogeneous isolates of Firmicutes (Bacillus spp.). In conclusion, leaf in situ similis cultivation is an effective strategy to support the future application of culturomics of plant microbiota. This is an effort to access novel isolates that are more adapted and competitive in their natural environments, especially those subjected to abiotic stresses like those prevailing in arid/semi-arid zones, and, consequently, to support the application of agro-biotechnologies, among other technologies, to improving agriculture in such zones.

Experimental assessment of the performance of reinforced concrete beams strengthened with carbon fiber reinforced polymer laminates

In this study, experimental research is carried out to assess the flexural performance of RC beams strengthened with different amount of CFRP laminates at the tension face. Twelve rectangular RC beams were fabricated and three are un-strengthened and used as reference beams and the remaining nine are strengthened with different amount of CFRP varying from single to triple layers and all are tested to failure under three points bending test. The increase of ultimate strength provided by the bonded CFRP laminates is assessed and failure modes is identified and compared to the un-strengthened RC beams. The results indicated that the flexural capacity of the beams was significantly improved as the amount of the laminates increases that ranged from 20% to 52% increased for single to triple layers laminates. It is concluded that the attachment of CFRP laminates has substantial influence on the performance of CFRP strengthened RC beams. Based on the observed results, recommendations are made that externally application of CFRP laminates can be used for a significant enhancement of the strength deficient RC beams in increasing the ultimate load carrying capacity. Keywords: CPRP laminate, Reinforced concrete, ductility, index, epoxy resin, flexural strengthening

Validation of Nanoparticle Response to the Sound Pressure Effect during the Drug-Delivery Process

Intravenous delivery is the fastest conventional method of delivering drugs to their targets in seconds, whereas intramuscular and subcutaneous injections provide a slower continuous delivery of drugs. In recent years, nanoparticle-based drug-delivery systems have gained considerable attention. During the progression of nanoparticles into the blood, the sound waves generated by the particles create acoustic pressure that affects the movement of nanoparticles. To overcome this issue, the impact of sound pressure levels on the development of nanoparticles was studied herein. In addition, a composite nanostructure was developed using different types of nanoscale substances to overcome the effect of sound pressure levels in the drug-delivery process. The results demonstrate the efficacy of the proposed nanostructure based on a group of different nanoparticles. This study suggests five materials, namely, polyimide, acrylic plastic, Aluminum 3003-H18, Magnesium AZ31B, and polysilicon for the design of the proposed structure. The best results were obtained in the case of the movement of these molecules at lower frequencies. The performance of acrylic plastic is better than other materials; the sound pressure levels reached minimum values at frequencies of 1, 10, 20, and 60 nHz. Furthermore, an experimental setup was designed to validate the proposed idea using advanced biomedical imaging technologies. The experimental results demonstrate the possibilities of detecting, tracking, and evaluating the movement behaviors of nanoparticles. The experimental results also demonstrate that the lowest sound pressure levels were observed at lower frequency levels, thus proving the validity of the proposed computational model assumptions. The outcome of this study will pave the way to understand the interaction behaviors of nanoparticles with the surrounding biological environments, including the sound pressure effect, which could lead to the useof such an effect in facilitating directional and tactic movements of the micro- and nano-motors.

124 Ovarian follicular development and steroid secretion during oestrous cycle of Lohi sheep

Pakistan has 30.9 million heads of sheep; however, little information is available on their reproductive aspects. The objective of this study was to document ovarian physiology and endocrinology of Lohi ewes during the oestrous cycle. Nine Lohi ewes, synchronized by administering single prostaglandin F2α (PGF2a; Cyclomate, Star Laboratories), were monitored for ovarian follicular dynamics using transrectal ultrasonography (7.5MHz, HS-1500, Honda) for two consecutive oestrous cycles during the breeding season (September to November 2018). Changes in plasma progesterone and oestradiol-17β concentrations of ewes (n=9) were also determined during the oestrous cycle using radioimmunoassay. The interovulatory interval of Lohi ewes averaged 17.0±0.1 days, and the duration of follicular and luteal phases was 4.6±0.2 and 11.3±0.2 days, respectively. Follicles emerged in either 3- or 4-wave patterns, but the frequency of the 3-wave pattern was higher than that of the 4-wave (87 vs. 13%, respectively; P=0.05). Following ovulation (Day 0), follicles (=3mm) in 3-wave cycles (n=14) emerged on Days 0.7, 5.2, and 10.5, whereas in 4-wave cycles (n=2) follicles emerged on Days 0.1, 4, 8.5, and 11.5. The maximum diameter of preovulatory follicles and corpora lutea (CL) were 5.4±0.3 and 10.4±0.3mm, respectively. Regardless of the wave pattern, single ovulation occurred in each cycle. The CL was first detectable on Day 4±0.1, it reached maximum diameter on Day 9±0.1, and luteolysis began on Day 12.2±0.2 of the cycle. The peak plasma oestradiol-17β concentration (42.5±2.6 pgmL−1) was observed 48h before ovulation and correlated with the diameter of the preovulatory follicle during the follicular phase (r=0.84; P&lt;0.05). The peak plasma progesterone concentration (11.8±1.7ngmL−1) was observed on Day 9±0.1 and coincided with the diameter of CL throughout the oestrous cycle (r=0.93; P&lt;0.05). In conclusion, the majority of oestrous cycles in Lohi ewes had a 3-wave pattern and were mono-ovulatory in nature.

141 Effect of combined treatment of melatonin and equine chorionic gonadotrophin on fresh semen quality of Beetal bucks during the non-breeding season

In the subtropics, bucks show seasonal breeding patterns, and their semen quality decreases during the non-breeding season. Therefore, breeders tend to improve bucks’ semen quality before the breeding season for higher conception rates. In the current study, we hypothesised that simultaneous administration of equine chorionic gonadotrophin (ECG) and melatonin would improve fresh semen quality in bucks before the breeding season. Nine Beetal bucks were randomly assigned (n=3 per treatment) to three treatments: control, melatonin, and melatonin + ECG. Melatonin implants (18 mg; BTC Lab) were placed subcutaneously at the base of the ear. Bucks in the melatonin + ECG treatment were administered ECG (400 IU; Syncro-Part, Ceva Santé Animale) intramuscularly on every fourth day until the end of the experiment. Control bucks were administered normal saline (400 IU; Otuska Pakistan) intramuscularly on every fourth day. Semen was collected twice per week using an artificial vagina (42°C) and immediately evaluated for volume, color, pH, and contaminants. Sperm concentration, motility and kinematics (curvilinear velocity, straight-line velocity, average path velocity, and amplitude of lateral head displacement), viability, DNA, and acrosomal and mitochondrial integrity were monitored using a computer-assisted semen analyzer (AndroVision, Minitube). Weekly concentrations of plasma testosterone and melatonin of all bucks were analysed using radioimmunoassay (Immunotech, Beckman Coulter Ltd.) and enzyme-linked immunosorbent assay (450nm), respectively. Comparisons within and between treatments were made using generalised linear models (repeated-measures analysis of variance). Weekly single-point variance between the treatments was determined (analysis of variance) at P ≤ 0.05 (SPSS ver. 20.0; IBM Corp.). Semen quality (volume, pH, total motility (%), and concentration) improved after Week 4 in the melatonin + ECG treatment compared with the control and melatonin treatments (P&lt;0.05). Similarly, progressive motility (%), viability, DNA, acrosomal and mitochondrial integrity, and sperm kinematics (curvilinear velocity, straight-line velocity, average path velocity, and amplitude of lateral head displacement) improved (P&lt;0.05) after Week 4 in the melatonin + ECG treatment. Similarly, non-viability and ratio of abnormal spermatozoa decreased by Week 3 in the melatonin + ECG treatment (P&lt;0.05) compared with the control and melatonin treatments. Likewise, plasma testosterone concentration (ngmL−1) of bucks was higher (P&lt;0.05) at Week 3 in the melatonin + ECG treatment (4.2±0.2) than in the melatonin (0.8±0.1) and control (1.2±0.1) treatments. Within the melatonin + ECG treatment, plasma testosterone concentration was higher (P&lt;0.05) at Week 5 (4.9±0.2) and Week 9 (4.5±0.1) than at Week 3 (4.2±0.2). Plasma melatonin concentration (pgmL−1) increased (P&lt;0.05) from Week 5 onward in the melatonin + eCG (12.5±0.1) and melatonin (10.2±0.1) treatments compared with the control (2.65±0.1). In conclusion, the simultaneous administration of melatonin and ECG improved fresh semen quality in Beetal bucks.

Sonochemical engineering of highly efficient and robust Au nanoparticle-wrapped on Fe/ZrO2 nanorods and their controllable product selectivity in dimethyl oxalate hydrogenation

A facile sonochemical approach is adopted for the synthesis of Fe/ZrO₂ and Au decorated Fe/ZrO₂ NRs catalysts and their outstanding stability and catalytic performance for the synthesis of EtOH and MG from DMO hydrogenation were reported.

158 Optimal time of AI and changes in vaginal mucus characteristics relative to the onset of standing oestrus in Beetal goats

The aim of this study was to determine the optimum time of AI and its relationship with vaginal mucus characteristics relative to the onset of standing oestrus in Beetal goats. For this purpose, goats (n=257) were synchronised for oestrus by administering two doses of prostaglandin F2α (0.075mg intramuscularly, d+ cloprostenol, Dalmazin) 11 days apart during the breeding season (September-December, 2016-2018). The onset of standing oestrus was determined using apronised bucks. Intracervical inseminations were performed at 0 (n=28), 12 (n=84), 24 (n=101), and 36h (n=44) after the onset of standing oestrus using chilled semen (diluted in skim milk at 200×106 spermatozoa per 0.5-mL dose). Color (transparent=1, turbid=2, cheesy/whitish=3), consistency (thin=1, thick=2), and volume (excess=1, scant=2) of the vaginal mucus in goats were observed at the time of inseminations and graded to determine the cumulative mucus score. Resistive index of vaginal mucus (R-value) was monitored at the time of AI using a Draminski heat detector. The intervals to the onset of oestrus among different months of synchronisation, cumulative mucus score, and vaginal electrical resistance at different times of AI were compared using one-way analysis of variance. Pregnancy rates at different times of AI were compared using chi-square analysis, and the Pearson coefficient of correlation was used to correlate mucus color, consistency, and volume with the cumulative mucus score. Following the second prostaglandin F2α administration, the interval to the onset of standing oestrus was longer (P&lt;0.05) in goats synchronised in December than in those synchronised from September to November. The pregnancy rate was lower (P&lt;0.05) in goats inseminated at 0h (28.6%) compared with those inseminated at 12 (58.3%), 24 (56.4%), and 36h (54.5%). However, the pregnancy rates were similar in goats inseminated at 12, 24, and 36h (P&gt;0.05). Odds for pregnancy rate at 12h were 3.5, 1.08, and 1.16 times higher than those at 0, 24, and 36h, respectively. Relative to the time of AI, the cumulative mucus scores varied (P&lt;0.05), and changes in mucus colour and consistency were more highly correlated (r=0.832 and 0.793, respectively; P&lt;0.05) with cumulative mucus score than the mucus volume (r=0.588). Relative to the onset of standing oestrus, the R-value of the mucus was lower at 12h than at 0 and 36h (P&lt;0.05); however, there was no change in R-value of the mucus at 12 and 24h. In conclusion, the optimum time to inseminate Beetal does using chilled semen is 12h following the onset of oestrus, whereas cumulative mucus score and R-value can be used as alternatives if the time of the onset of oestrus is not known.

Changing perioperative prophylaxis during antibiotic therapy and iterative debridement for orthopedic infections?

Background

Perioperative antibiotic prophylaxis in non-infected orthopedic surgery is evident, in contrast to prophylaxis during surgery for infection. Epidemiological data are lacking for this particular situation.

Methods and findings

It is a single-center cohort on iterative surgical site infections (SSIs) in infected orthopedic patients. We included 2480 first episodes of orthopedic infections (median age 56 years and 833 immune-suppressed): implant-related infections (n = 648), osteoarticular infections (1153), and 1327 soft tissue infections. The median number of debridement was 1 (range, 1–15 interventions). Overall, 1617 infections (65%) were debrided once compared to 862 cases that were operated multiple times (35%). Upon iterative intraoperative tissue sampling, we detected pathogens in 507 cases (507/862; 59%), of which 241 (242/507; 48%) corresponded to the initial species at the first debridement. We witnessed 265 new SSIs (11% of the cohort) that were resistant to current antibiotic therapy in 174 cases (7% of the cohort). In multivariate analysis, iterative surgical debridements that were performed under current antibiotic administration were associated with new SSIs (odds ratio 1.6, 95%CI 1.2–2.2); mostly occurring after the 2^nd debridement. However, we failed to define an ideal hypothetic prophylaxis during antibiotic therapy to prevent further SSIs.

Conclusions

Selection of new pathogens resistant to ongoing antibiotic therapy occurs frequently during iterative debridement in orthopedic infections, especially after the 2^nd debridement. The new pathogens are however unpredictable. The prevention, if feasible, probably relies on surgical performance and wise indications for re-debridement instead of new maximal prophylactic antibiotic coverage in addition to current therapeutic regimens.

Missed vaccinations and critical care admission: all you may wish to know or rediscover-a narrative review

Most vaccines are so effective that they could lead to the control/elimination of the diseases they target and directly impact on intensive care admissions or complications. This is best illustrated by the use of vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, zoster, yellow fever, Ebola virus, influenza or measles-but also by third party strategies such as maternal, toddler and care-giver immunization. However, each of these vaccine-induced protection is threatened by insufficient vaccine uptake. Here, we briefly discuss how vaccine hesitancy has led to the resurgence of diseases that were considered as controlled and explore the effect of vaccine-hesitant healthcare workers on nosocomial infections. As intensive care physicians are in charge of polymorbid patients, we briefly summarize the current recommendations for vaccinations in high-risk patients. We finally give some perspective on ongoing research, and discuss how institutional policies and intensive care physicians could play a role in increasing the impact of vaccination, overall and in intensive care units.