The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Plasmon-enhanced multi-photon excited photoluminescence of Au, Ag, and Pt nanoclusters

In this work, we have studied the multi-photon excited photoluminescence from metal nanoclusters (NCs) of Au, Ag and Pt embedded in Al2O3matrix by ion implantation. The thermal annealing process allows to obtain a system composed of larger plasmonic metal nanoparticles (NPs) surrounded by photoluminescent ultra-small metal NCs. By exciting at 1064 nm, visible emission, ranging from 450 to 800 nm, was detected. The second and fourth-order nature of the multiphoton process was verified in a power-dependent study measured for each sample below the damage threshold. Experiments show that Au and Ag NCs exhibit a four-fold enhanced multiphoton excited photoluminescence with respect to that observed for Pt NCs, which can be explained as a result of a plasmon-mediated near-field process that is of less intensity for Pt NPs. These findings provide new opportunities to combine plasmonic nanoparticles and photoluminescent nanoclusters inside a robust inorganic matrix to improve their optical properties. Plasmon-enhanced multiphoton excited photoluminescence from metal nanoclusters may find potential application as ultrasmall fluorophores in multiphoton sensing, and in the development of solar cells with highly efficient energy conversion modules.

In vitro activity of cefiderocol and other newly approved antimicrobials against multi-drug resistant Gram-negative pathogens recovered in intensive care units in Spain and Portugal

OBJECTIVE

The antimicrobial resistance is a significant public health threat, particularly for healthcare-associated infections caused by carbapenem-resistant Gram-negative pathogens which are increasingly reported worldwide. The aim of this study was to provide data on the in vitro antimicrobial activity of cefiderocol and that of commercially available comparator antibiotics against a defined collection of recent clinical multi-drug resistant (MDR) microorganisms, including carbapenem resistant Gram-negative bacteria collected from different regions in Spain and Portugal.

METHODS

A total of 477 clinical isolates of Enterobacterales, Pseudomonas aeruginosa, Acinetobacter baumannii and Stenotrophomonas maltophilia were prospectively (n=265) and retrospectively (n=212) included (2016-2019). Susceptibility testing was performed using standard broad microdilution and results were interpreted using CLSI-2021 and EUCAST-2021 criteria.

RESULTS

Overall, cefiderocol showed a good activity against Enterobacterales isolates, being 99.5% susceptible by CLSI and 94.5% by EUCAST criteria. It also demonstrated excellent activity against P. aeruginosa and S. maltophilia isolates, all being susceptible to this compound considering CLSI breakpoints. Regarding A. baumannii (n=64), only one isolate was resistant to cefiderocol.

CONCLUSIONS

Our results are in agreement with other studies performed outside Spain and Portugal highlighting its excellent activity against MDR gram-negative bacteria. Cefiderocol is a therapeutic alternative to those available for the treatment of infections caused by these MDR bacteria.

Tuning the aspect ratio of silver nanospheroids embedded in silica: erratum

We present a corrigendum to our Letter [Opt. Lett.35, 703 (2010)10.1364/OL.35.000703]. In the original Letter we inadvertently included in Fig. 2(a) a TEM micrograph corresponding to a different, but very similar, sample. This corrigendum replaces Fig. 2(a) with a correct version. Since the main results are rather based in optical absorption measurements, and their modeling by using the T-matrix method, this correction does not affect the results and conclusions of the original Letter.

Déterminants de l’adhésion vaccinale contre la COVID-19 chez les femmes enceintes et en post-partum pendant la troisième vague de la pandémie : une étude transversale multinationale européenne

Introduction

La vaccination contre le coronavirus (COVID-19) est recommandée chez les femmes enceintes, car elles courent un risque plus élevé de développer une forme sévère de la maladie. Cependant, malgré les preuves croissantes de l’intérêt de la vaccination anti-COVID-19 et de sa sécurité pendant la grossesse, l’hésitation vaccinale demeure élevée dans la population obstétricale – 48,6 % selon une méta-analyse de 46 études publiées jusqu’en février 2022. Ainsi, notre objectif était d’évaluer le statut vaccinal et/ou la volonté de se faire vacciner contre la COVID-19 chez les femmes enceintes et en post-partum dans cinq pays européens et d’en rechercher les facteurs associés.

Méthodes

Il s’agissait d’une étude transversale, menée en Belgique, en Norvège, aux Pays-Bas, en Suisse et au Royaume-Uni entre juin et août 2021. Cette enquête en ligne faisait partie d’un projet de recherche international sur la COVID-19 visant à fournir des informations sur les expériences vécues par les femmes enceintes et les mères ayant accouché dans les 3 derniers mois, pendant la troisième vague de la pandémie.

Résultats

Parmi les 5210 femmes ayant participé à l’étude, nous avons exclu 216 femmes enceintes et 140 en post-partum qui n’avaient pas répondu à la question sur leur statut vaccinal. Chez les femmes enceintes (n = 3195), les proportions de femmes déjà vaccinées et/ou souhaitant être vaccinées étaient 80,5 % en Belgique, 78,5 % au Royaume-Uni, 62,6 % aux Pays-Bas, 32,1 %, en Suisse et 21,5 % en Norvège. Les caractéristiques associées à l’adhésion vaccinale contre la COVID-19 pendant la grossesse étaient l’activité professionnelle, une profession dans le secteur de la santé, un niveau d’éducation élevé, le premier trimestre de la grossesse, et la résidence en Belgique comparée à la Norvège, la Suisse et aux Pays-Bas.

Parmi les femmes en post-partum (n = 1659), les proportions de femmes déjà vaccinées et/ou souhaitant être vaccinées étaient 86,0 % au Royaume-Uni, 85,7 % en Belgique, 81 % en Norvège, 72,6 % aux Pays-Bas et 58,6 % en Suisse. Lors du post-partum, les caractéristiques associées à l’adhésion vaccinale contre la COVID-19 étaient l’âge maternel de « 36–40 ans », puis « 31–35 ans », suivi de « 25–30 ans » par rapport à la catégorie « 18–25 ans », une profession dans le domaine de la santé, l’absence d’antécédent d’infection au SARS-CoV-2, l’absence d’allaitement, et la résidence en Belgique par rapport à la Suisse ou aux Pays-Bas.

Conclusion

L’hésitation vaccinale dépend de nombreux facteurs démographiques et socio-culturels. La connaissance de ces notions est nécessaire afin de mieux l’appréhender, et d’encourager respectueusement l’adhésion à la vaccination.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

The Marsden Morbidity Index: the derivation and validation of a simple risk index scoring system using cardiopulmonary exercise testing variables to predict morbidity in high-risk patients having major cancer surgery

Background

Morbidity and mortality risk prediction tools are increasingly being used as part of preoperative assessment of patients presenting for major abdominal surgery. Cardiopulmonary exercise testing (CPET) can predict which patients undergoing major abdominal surgery are at risk of complications. The primary objective of this study was to identify preoperative variables including those derived from CPET, which were associated with inpatient morbidity in high-risk patients following major abdominal cancer surgery. The secondary objective was to use these variables to derive and validate a morbidity risk prediction tool.

Methods

We conducted a retrospective cohort analysis of consecutive adult patients who had CPET as part of their preoperative work-up for major abdominal cancer surgery. Morbidity was a composite outcome, defined by the Clavien-Dindo score and/or the postoperative morbidity survey (POMS) score which was assessed on postoperative day 7. A risk prediction tool was devised using variables from the first analysis which was then applied prospectively to a matched cohort of patients.

Results

A total of 1398 patients were included in the first phase of the analysis between June 2010 and May 2017. Of these, 540 patients (38.6%) experienced postoperative morbidity. CPET variables deemed significant (p < 0.01) were anaerobic threshold (AT), maximal oxygen consumption at maximal exercise capacity (VO2 max), and ventilatory equivalent for carbon dioxide at anaerobic threshold (AT VE/VCO2). In addition to the CPET findings and the type of surgery the patient underwent, eight preoperative variables that were associated with postoperative morbidity were identified. These include age, WHO category, body mass index (BMI), prior transient ischaemic attack (TIA) or stroke, chronic renal impairment, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and cancer stage. Both sets of variables were then combined to produce a validated morbidity risk prediction scoring tool called the Marsden Morbidity Index. In the second phase of the analysis, this tool was applied prospectively to 424 patients between June 2017 and December 2018. With an area under the curve (AUC) of 0.79, this new model had a sensitivity of 74.2%, specificity of 78.1%, a positive predictive value (PPV) of 79.7%, and a negative predictive value of (NPV) of 79%.

Conclusion

Our study showed that of the CPET variables, AT, VO2 max, and AT VE/VCO2 were shown to be associated with postoperative surgical morbidity following major abdominal oncological surgery. When combined with a number of preoperative comorbidities commonly associated with increased risk of postoperative morbidity, we created a useful institutional scoring system for predicting which patients will experience adverse events. However, this system needs further validation in other centres performing oncological surgery.

Recommendations for antibiotic selection for severe nosocomial infections

Severe infection and its evolution to sepsis are becoming more prevalent every day and are among the leading causes of critical illness and mortality. Proper management is crucial to improve prognosis. This document addresses three essential points that have a significant impact on this objective: a) early recognition of patients with sepsis criteria, b) identification of those patients who suffer from an infection and have a high risk of progressing to sepsis, and c) adequate selection and optimization of the initial antimicrobial treatment.

Access to health services for non-Covid-19 causes during the pandemic. A literature review

Background

Negative effects of the Covid-19 pandemic on access to care for other diseases are currently at debate.

Aim

To review existing literature on care access for non-Covid-19 conditions since the pandemic onset.

Methods

Scoping review using various databases (Medline, VHL, Web of Science, 2020/21). Terms used: ‘access', ‘health services', ‘Covid-19'. Out of 4,060 identified articles, 37 were selected after reviewing and assessing titles, abstracts and full text. Aday and Andersen's framework guided the analysis.

Results

Of selected articles, 21 analyse impact on health services use; 8 on performance; 8 on access barriers. Most analyse specific services during early pandemic stages through register review, showing an initial decline in use with inconsistent results on recovery. Some indicate increased complexity of treated patients and treatment delays. Studies surveying professionals analyse the impact on services performance or clinical practice, reporting a decrease in consultations/interventions for diverse pathologies and response implementation (e.g. telemedicine), but not how they affected access. Few studies focus on social inequalities in use, showing a greater reduction in low-income or ethnic minority users. Studies on unmet needs, access or barriers based on user surveys or qualitative methods are scarce, focused on a pathology or clinical area. Particularly in Spain, studies analyse impact on use of emergency, primary care and cancer diagnosis, and on emergency and cardiology services functioning. Studies based on user surveys are lacking: only a qualitative study analysed access difficulties for chronic patients in confinement. Methodological weaknesses are identified.

Conclusions

Although currently emerging, studies analysing the pandemic impact on equal access to care for non-Covid-19 conditions are scarce, limited in focus and methodology, especially in Spain. Comprehensive medium/long-term impact assessments, including analysis of causes, are needed.

Key messages

Research is lacking on the impact of the COVID-19 pandemic on healthcare access, particularly for vulnerable groups. Further evidence is needed to improve health systems resilience in the future.

Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso trial

OBJECTIVE

To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage.

DESIGN

Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS).

SETTING

Twenty-eight UK NHS early pregnancy units.

SAMPLE

A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage.

METHODS

Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets.

MAIN OUTCOME MEASURES

Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs).

RESULTS

For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management.

CONCLUSIONS

The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage.

TWEETABLE ABSTRACT

The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

Enhanced ultrafast optomagnetic effects in room-temperature ferromagnetic Pt nanoclusters embedded in silica by ion implantation

Ferromagnetic-like behavior at room temperature (300 K) was observed in Pt particles embedded in ion-implanted silica matrices. Results in samples integrated by ultra-small photoluminescent Pt clusters (<2 nm) were compared with samples containing exclusively larger plasmonic Pt nanoparticles (>3 nm). The ferromagnetic behavior coexists simultaneously with a diamagnetic response. Enhanced diamagnetic response of one order of magnitude was observed compared to typical diamagnetism in pure silica, and it is increased with the mean diameter of the Pt particles. Besides, a larger sensitivity to an external field was observed in the ferromagnetic response of the nanostructures with a characteristic saturation at 20 kOe. This ferromagnetic behavior was only observed in the samples with nucleated Pt particles. The magnitude of the saturation magnetization shows up to a fivefold increase in the samples with smaller particle size and larger particle density. Saturation magnetization was observed between 3-15 × 10^-4 emu g^-1, with remanent magnetization of 0.2-0.6 × 10^-4emu g^-1, measured at 300 K. Coercitive fields also decrease in samples with smaller size and particles density, with values of 114 and 300 Oe. At lower temperatures (5 K) the saturation magnetization increases, as it would be expected from a ferromagnetic state. Optomagnetic response was studied by inverse Faraday effects and induced photomagnetization with circular polarized picosecond pulsed light at 1064 nm wavelength. Results showed that samples with a stronger ferromagnetic response exhibit larger Faraday rotation up to 5.3 × 10³deg cm^-1 by light excitations with irradiances between 50 and 180 GW cm^-2. These findings have immediate applications in multifunctional solid-state magneto-optical devices such as optical isolators, high-data storage devices and ultrafast all-optical switching of magnetization.

Plasmon coupling interactions and inhibition of nonlinear absorption in a complex system with Ag and Pt nanoparticles in silica

The optical response exhibited by a complex hybrid system integrated by Pt ultrasmall fluorescent particles and plasmonic Ag nanoparticles is reported. The system was synthesized by coimplantation of Ag and Pt ions into a silica matrix followed by a proper thermal annealing. The energies and fluences were chosen in order to overlap the spatial regions of the Ag and Pt ion distributions below the silica surface. Optical absorption and emission spectroscopies show that the complex nanostructures exhibit an important plasmonic response, together with photoluminescence excited at 355 nm, which is enhanced when compared to the reference sample with only Pt particles. Off-resonance nonlinear transmission and Z-scan measurements were undertaken using ultrafast pulses. High-irradiance excitation at 1064 nm with picosecond pulses shows that the Pt or Ag nanoparticles exhibit a two-photon absorption effect, while the complex system shows the absence of any nonlinear absorption. Similar observations were made using femtosecond pulses at 800 nm wavelength. This inhibition of the two-photon absorption effect and enhancement in the emission of the complex hybrid samples by the synergic participation of Ag and Pt particles can be explained as a result of a plasmon coupling via the near-field interaction between plasmonic and emitting sources.

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

A systematic scoping review to approach the construct of gender discrimination

Key messages

The heterogeneity in the conception of gender discrimination has led to different ways of assessment and to a great heterogeneity around the analysis of GD perception. This operative gender discrimination construct could add order and precision to its measurement, increase response rates and reported GD.

Superlinear Photoluminescence by Ultrafast Laser Pulses in Dielectric Matrices with Metal Nanoclusters

An intense photoluminescence emission was observed from noble metal nanoclusters (Pt, Ag or Au) embedded in sapphire plates, nucleated by MeV ion-implantation and assisted by an annealing process. In particular, the spectral photoluminescence characteristics, such as range and peak emission, were compared to the behavior observed from Pt nanoclusters embedded in a silica matrix and excited by UV irradiation. Correlation between emission energy, nanoclusters size and metal composition were analyzed by using the scaling energy relation EFermi/N1/3 from the spherical Jellium model. The metal nanocluster luminescent spectra were numerically simulated and correctly fitted using the bulk Fermi energy for each metal and a Gaussian nanoclusters size distribution for the samples. Our results suggest protoplasmonics photoluminescence from metal nanoclusters free of surface state or strain effects at the nanoclusters-matrix interface that can influence over their optical properties. These metal nanoclusters present very promising optical features such as bright visible photoluminescence and photostability under strong picosecond laser excitations. Besides superlinear photoluminescence from metal nanoclusters were also observed under UV high power excitation showing a quadratic dependence on the pump power fluence.

Predictors of outcome in patients with severe sepsis or septic shock due to extended-spectrum β-lactamase-producing Enterobacteriaceae

PURPOSE

There are few data in the literature regarding sepsis or septic shock due to extended-spectrum β-lactamases (ESBL)-producing Enterobacteriaceae (E). The aim of this study was to assess predictors of outcome in septic patients with bloodstream infection (BSI) caused by ESBL-E.

METHODS

Patients with severe sepsis or septic shock and BSI due to ESBL-E were selected from the INCREMENT database. The primary endpoint of the study was the evaluation of predictors of outcome after 30 days from development of severe sepsis or septic shock due to ESBL-E infection. Three cohorts were created for analysis: global, empirical-therapy and targeted-therapy cohorts.

RESULTS

367 septic patients were analysed. Overall mortality was 43.9% at 30 days. Escherichia coli (62.4%) and Klebsiella pneumoniae (27.2%) were the most frequent isolates. β-lactam/β-lactamase inhibitor (BLBLI) combinations were the most empirically used drug (43.6%), followed by carbapenems (29.4%). Empirical therapy was active in vitro in 249 (67.8%) patients, and escalation of antibiotic therapy was reported in 287 (78.2%) patients. Cox regression analysis showed that age, Charlson Comorbidity Index, McCabe classification, Pitt bacteremia score, abdominal source of infection and escalation of antibiotic therapy were independently associated with 30-day mortality. No differences in survival were reported in patients treated with BLBLI combinations or carbapenems in empirical or definitive therapy.

CONCLUSIONS

BSI due to ESBL-E in patients who developed severe sepsis or septic shock was associated with high 30-day mortality. Comorbidities, severity scores, source of infection and antibiotic therapy escalation were important determinants of unfavorable outcome.

Plasma and Urinary Heparin Cofactor II Levels in Patients with Nephrotic Syndrome

Heparin cofactor II (HC II) levels were measured by electroimmunoassay in plasmas and urines from 68 patients with nephrotic syndrome. In addition, antithrombin III (AT III) and protein C (PC) activities and antigens were measured also in the same group of patients. Seven of these patients had histories of thrombosis. Plasma HC II levels (mean ± SD 105 ± 43) were not different from levels in healthy subjects (94 ± 17). Only 5 patients had low plasma levels of HC II. None of the patients with thrombosis had low HC II levels. Even though measurable amounts of HC II were found in 25 urines from 50 patients. There was a relationship in the urinary excretion between HC II and AT III and their urinary clearances were quite similar. However, no correlation was found between plasma HC II and AT III levels, and levels of AT III activity and antigen were significantly lower than in healthy subjects. Three patients with hystories of thrombosis had low AT III levels. Most patients (including those with thrombosis histories) had high plasma PC levels and increased urinary loss.

It is suggested that HC II does not play an important role in the pathogenesis of thrombosis in nephrotic syndrome.

A Stochastic Spiking Neural Network for Virtual Screening

Virtual screening (VS) has become a key computational tool in early drug design and screening performance is of high relevance due to the large volume of data that must be processed to identify molecules with the sought activity-related pattern. At the same time, the hardware implementations of spiking neural networks (SNNs) arise as an emerging computing technique that can be applied to parallelize processes that normally present a high cost in terms of computing time and power. Consequently, SNN represents an attractive alternative to perform time-consuming processing tasks, such as VS. In this brief, we present a smart stochastic spiking neural architecture that implements the ultrafast shape recognition (USR) algorithm achieving two order of magnitude of speed improvement with respect to USR software implementations. The neural system is implemented in hardware using field-programmable gate arrays allowing a highly parallelized USR implementation. The results show that, due to the high parallelization of the system, millions of compounds can be checked in reasonable times. From these results, we can state that the proposed architecture arises as a feasible methodology to efficiently enhance time-consuming data-mining processes such as 3-D molecular similarity search.

Trace element concentrations in patients on home enteral feeding: two cases of severe copper deficiency

Background: Enteral feeding is the fastest growing area of artificial nutrition, with the annual rate of growth being estimated at 20-25% a year. Previous studies have demonstrated trace element deficiencies in patients on long-term home enteral nutrition (HEN).

Methods: The trace elements zinc, selenium, copper and manganese were measured in blood samples from 37 patients on HEN using atomic absorption spectroscopy.

Results: Plasma zinc concentrations (range 7.4-14.4 µmol/L) were below the reference range (12.6-22.0 µmol/L) in 30 patients, plasma selenium concentrations (range 0.73-1.76 µmol/L) were below the reference range (0.8-2.0 µmol/L) in only one patient. Whole blood manganese (range 74-309 nmol/L) and plasma manganese (range 13-51 nmol/L) were above both respective reference ranges (73-210 nmol/L and 9-24 nmol/L) in four patients. Two patients showed severely low plasma copper concentrations of 2.4 µmol/L and 2.5 µmol/L, and responded to treatment with extra copper supplementation.

Conclusion: Although enteral feeds contain adequate concentrations of trace elements, problems with bioavailability may occur and patients receiving long-term enteral feeding should be monitored with regard to plasma trace element concentrations.

Bupropion and naltrexone for smoking cessation: A double-blind randomized placebo-controlled clinical trial

Combination of non-nicotine pharmacotherapies has been underexamined for cigarette smoking cessation. A randomized, double-blind, parallel-group double-dummy study evaluated two medications, bupropion (BUP) and naltrexone (NTX), in treatment-seeking cigarette smokers (N = 121) over a 7-week treatment intervention with 6-month follow-up. Smokers were randomized to either BUP (300 mg/day) + placebo (PBO) or BUP (300 mg/day) + NTX (50 mg/day). The primary outcome was biochemically verified (saliva cotinine, carbon monoxide) 7-day, point-prevalence abstinence. BUP + NTX was associated with significantly higher point-prevalence abstinence rates after 7-weeks of treatment (BUP + NTX, 54.1%; BUP + PBO, 33.3%), P = 0.0210, but not at 6-month follow-up (BUP + NTX, 27.9%; BUP + PBO, 15.0%), P = 0.09. Continuous abstinence rates did not differ, P = 0.0740 (BUP + NTX, 26.2%; BUP + PBO, 13.3%). Those receiving BUP + NTX reported reduced nicotine withdrawal, P = 0.0364. The BUP + NTX combination was associated with elevated rates of some side effects, but with no significant difference in retention between the groups.

Improved Automatic Detection of New T2 Lesions in Multiple Sclerosis Using Deformation Fields

BACKGROUND AND PURPOSE

Detection of disease activity, defined as new/enlarging T2 lesions on brain MR imaging, has been proposed as a biomarker in MS. However, detection of new/enlarging T2 lesions can be hindered by several factors that can be overcome with image subtraction. The purpose of this study was to improve automated detection of new T2 lesions and reduce user interaction to eliminate inter- and intraobserver variability.

MATERIALS AND METHODS

Multiparametric brain MR imaging was performed at 2 time points in 36 patients with new T2 lesions. Images were registered by using an affine transformation and the Demons algorithm to obtain a deformation field. After affine registration, images were subtracted and a threshold was applied to obtain a lesion mask, which was then refined by using the deformation field, intensity, and local information. This pipeline was compared with only applying a threshold, and with a state-of-the-art approach relying only on image intensities. To assess improvements, we compared the results of the different pipelines with the expert visual detection.

RESULTS

The multichannel pipeline based on the deformation field obtained a detection Dice similarity coefficient close to 0.70, with a false-positive detection of 17.8% and a true-positive detection of 70.9%. A statistically significant correlation (r = 0.81, P value = 2.2688e-09) was found between visual detection and automated detection by using our approach.

CONCLUSIONS

The deformation field-based approach proposed in this study for detecting new/enlarging T2 lesions resulted in significantly fewer false-positives while maintaining most true-positives and showed a good correlation with visual detection annotations. This approach could reduce user interaction and inter- and intraobserver variability.

Cohort study to test the predictability of the NHS Institute for Innovation and Improvement Paediatric Early Warning System

OBJECTIVE

To test the predictability of the National Health Service Institute for Innovation and Improvement (NHSIII) Paediatric Early Warning System (PEWS) score to identify children at risk of developing critical illness.

DESIGN

Cohort study.

SETTING

Admissions to all paediatric wards at the University Hospital of Wales between 1 December 2005 and 30 November 2006.

OUTCOME MEASURES

Unscheduled paediatric high dependency unit (PHDU) admission, paediatric intensive care unit (PICU) admission and death.

RESULTS

There were 9075 clinical observations from 1000 children. An NHSIII PEWS score of 2 or more, which triggers review, has a sensitivity of 73.2% (95% CI 62.2% to 82.4%), specificity of 75.2% (95% CI 74.3% to 76.1%), positive predictive value (PPV) of 2.6% (95% CI 2.0% to 3.4%), negative predictive value of 99.7% (95% CI 99.5% to 99.8%) and positive likelihood ratio of 3.0 (95% CI 2.6 to 3.4) for predicting PHDU admission, PICU admission or death. Six (37.5%) of the 16 children with an adverse outcome did not have an abnormal NHSIII PEWS score. The area under the receiver operating characteristic curve for the NHSIII PEWS score was 0.83 (95% CI 0.77 to 0.88).

CONCLUSIONS

The NHSIII PEWS has a low PPV and its full implementation would result in a large number of false positive triggers. The issue with PEWS scores or triggers is neither their sensitivity nor children with high scores which require clinical interventions who are not 'false positives'; but their low specificity and low PPV arising from the large number of children with low but raised scores.

Nonlinear optical response of platinum nanoparticles and platinum ions embedded in sapphire

We report on the fabrication of sapphire samples containing platinum nanoparticles (Pt-NPs) and platinum ions (Pt-ions) and the investigation of their third-order nonlinear (NL) optical properties. The presence of Pt-NPs was confirmed by electronic microscopy and by the linear absorption spectrum that shows a localized surface plasmon band centered at 290 nm. A sample without NPs but containing Pt-ions was also studied. The absorptive and refractive contributions to the nonlinearity were studied using the z-scan technique with 100 fs pulses at 800nm. The experiments revealed a NL refractive index, +3.8×10^-13 < n₂ < +1.3×10^-12cm²/W and NL absorption coefficient (β < 9.3 cm/GW). The results show enhancement of about five orders of magnitude with respect to the NL refractive index of sapphire.

Synthesis and summary of patient-reported outcome measures to inform the development of a core outcome set in colorectal cancer surgery

AIM

Patient-reported outcome (PRO) measures (PROMs) are standard measures in the assessment of colorectal cancer (CRC) treatment, but the range and complexity of available PROMs may be hindering the synthesis of evidence. This systematic review aimed to: (i) summarize PROMs in studies of CRC surgery and (ii) categorize PRO content to inform the future development of an agreed minimum 'core' outcome set to be measured in all trials.

METHOD

All PROMs were identified from a systematic review of prospective CRC surgical studies. The type and frequency of PROMs in each study were summarized, and the number of items documented. All items were extracted and independently categorized by content by two researchers into 'health domains', and discrepancies were discussed with a patient and expert. Domain popularity and the distribution of items were summarized.

RESULTS

Fifty-eight different PROMs were identified from the 104 included studies. There were 23 generic, four cancer-specific, 11 disease-specific and 16 symptom-specific questionnaires, and three ad hoc measures. The most frequently used PROM was the EORTC QLQ-C30 (50 studies), and most PROMs (n = 40, 69%) were used in only one study. Detailed examination of the 50 available measures identified 917 items, which were categorized into 51 domains. The domains comprising the most items were 'anxiety' (n = 85, 9.2%), 'fatigue' (n = 67, 7.3%) and 'physical function' (n = 63, 6.9%). No domains were included in all PROMs.

CONCLUSION

There is major heterogeneity of PRO measurement and a wide variation in content assessed in the PROMs available for CRC. A core outcome set will improve PRO outcome measurement and reporting in CRC trials.

Collective optical Kerr effect exhibited by an integrated configuration of silicon quantum dots and gold nanoparticles embedded in ion-implanted silica

The study of the third-order optical nonlinear response exhibited by a composite containing gold nanoparticles and silicon quantum dots nucleated by ion implantation in a high-purity silica matrix is presented. The nanocomposites were explored as an integrated configuration containing two different ion-implanted distributions. The time-resolved optical Kerr gate and z-scan techniques were conducted using 80 fs pulses at a 825 nm wavelength; while the nanosecond response was investigated by a vectorial two-wave mixing method at 532 nm with 1 ns pulses. An ultrafast purely electronic nonlinearity was associated to the optical Kerr effect for the femtosecond experiments, while a thermal effect was identified as the main mechanism responsible for the nonlinear optical refraction induced by nanosecond pulses. Comparative experimental tests for examining the contribution of the Au and Si distributions to the total third-order optical response were carried out. We consider that the additional defects generated by consecutive ion irradiations in the preparation of ion-implanted samples do not notably modify the off-resonance electronic optical nonlinearities; but they do result in an important change for near-resonant nanosecond third-order optical phenomena exhibited by the closely spaced nanoparticle distributions.

Evaluating the effects of white matter multiple sclerosis lesions on the volume estimation of 6 brain tissue segmentation methods

BACKGROUND AND PURPOSE

The accuracy of automatic tissue segmentation methods can be affected by the presence of hypointense white matter lesions during the tissue segmentation process. Our aim was to evaluate the impact of MS white matter lesions on the brain tissue measurements of 6 well-known segmentation techniques. These include straightforward techniques such as Artificial Neural Network and fuzzy C-means as well as more advanced techniques such as the Fuzzy And Noise Tolerant Adaptive Segmentation Method, fMRI of the Brain Automated Segmentation Tool, SPM5, and SPM8.

MATERIALS AND METHODS

Thirty T1-weighted images from patients with MS from 3 different scanners were segmented twice, first including white matter lesions and then masking the lesions before segmentation and relabeling as WM afterward. The differences in total tissue volume and tissue volume outside the lesion regions were computed between the images by using the 2 methodologies.

RESULTS

Total gray matter volume was overestimated by all methods when lesion volume increased. The tissue volume outside the lesion regions was also affected by white matter lesions with differences up to 20 cm(3) on images with a high lesion load (≈50 cm(3)). SPM8 and Fuzzy And Noise Tolerant Adaptive Segmentation Method were the methods less influenced by white matter lesions, whereas the effect of white matter lesions was more prominent on fuzzy C-means and the fMRI of the Brain Automated Segmentation Tool.

CONCLUSIONS

Although lesions were removed after segmentation to avoid their impact on tissue segmentation, the methods still overestimated GM tissue in most cases. This finding is especially relevant because on images with high lesion load, this bias will most likely distort actual tissue atrophy measurements.

Nanoparticle containing channel waveguides produced by a multi-energy masked ion-implantation process

We present the fabrication and characterization of channel waveguides based on composites containing silver nanoparticles. The substrate employed is silica and the nanoparticles were produced by a masked ion-implantation technique. Multiple implantation processes were made at different energies in order to produce waveguides with an appropriate width. We also present results for the characterization of the waveguiding properties of the devices produced.

A systematic review of outcome reporting in colorectal cancer surgery

AIM

Evaluation of surgery for colorectal cancer (CRC) is necessary to inform clinical decision-making and healthcare policy. The standards of outcome reporting after CRC surgery have not previously been considered.

METHOD

Systematic literature searches identified randomized and nonrandomized prospective studies reporting clinical outcomes of CRC surgery. Outcomes were listed verbatim, categorized into broad groups (outcome domains) and examined for a definition (an appropriate textual explanation or a supporting citation). Outcome reporting was considered inconsistent if results of the outcome specified in the methods were not reported. Outcome reporting was compared between randomized and nonrandomized studies.

RESULTS

Of 5644 abstracts, 194 articles (34 randomized and 160 nonrandomized studies) were included reporting 766 different clinical outcomes, categorized into seven domains. A mean of 14 ± 8 individual outcomes were reported per study. 'Anastomotic leak', 'overall survival' and 'wound infection' were the three most frequently reported outcomes in 72, 60 and 44 (37.1%, 30.9% and 22.7%) studies, respectively, and no single outcome was reported in every publication. Outcome definitions were significantly more often provided in randomized studies than in nonrandomized studies (19.0% vs 14.9%, P = 0.015). One-hundred and twenty-seven (65.5%) papers reported results of all outcomes specified in the methods (randomized studies, n = 21, 61.5%; nonrandomized studies, n = 106, 66.2%; P = 0.617).

CONCLUSION

Outcome reporting in CRC surgery lacks consistency and method. Improved standards of outcome measurement are recommended to permit data synthesis and transparent cross-study comparisons.

Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?

OBJECTIVE

To determine the use of paediatric early warning systems (PEWS) and rapid response teams (RRTs) in paediatric units in Great Britain.

DESIGN

Cross sectional survey.

SETTING

All hospitals with inpatient paediatric services in Great Britain.

OUTCOME MEASURES

Proportion of units using PEWS, origin of PEWS used, criterion included in PEWS, proportion of units with an RRT and membership of RRT.

RESULTS

The response rate was 95% (149/157). 85% of units were using PEWS and 18% had an RRT in place. Tertiary units were more likely than district general hospital to have implemented PEWS, 90% versus 83%, and an RRT, 52% versus 10%. A large number of PEWS were in use, the majority of which were unpublished and unvalidated systems.

CONCLUSIONS

Despite the inconclusive evidence of effectiveness, the use of PEWS has increased since 2005. The implementation has been inconsistent with large variation in the PEWS used, the activation criteria used, availability of an RRT and the membership of the RRT. There must be a coordinated national evaluation of the implementation, impact and effectiveness of a standardised PEWS programme in the various environments where acutely sick children are managed.