'Smart' BLE wearables for digital contact tracing in care homes during the COVID-19 pandemic-a process evaluation of the CONTACT feasibility study

BACKGROUND

Rapid and mass transmission of the SARS-CoV-2 virus amongst vulnerable people led to devastating effects from COVID-19 in care homes. The CONTACT intervention introduced Bluetooth Low Energy 'smart' wearable devices (BLE wearables) as a basis for automated contact tracing in, and feedback on infection risks and patterns to, care homes to try and improve infection prevention and control (IPC). We planned a cluster randomised controlled trial (RCT) of CONTACT. To be feasible, homes had to adopt CONTACT's technology and new ways of working. This paper reports on the process evaluation conducted alongside CONTACT's feasibility study and explains why it lacked the feasibility and acceptability for a definitive RCT.

METHODS

This mixed method process evaluation used Normalisation Process Theory (NPT) qualitative (interviews, field notes, study case report forms and documents, and observation) and quantitative (survey instruments, counts of activity) data to plan, implement, and analyse the mechanisms, effects, and contextual factors that shaped the feasibility and acceptability of the CONTACT intervention.

RESULTS

Thirteen themes within four core NPT constructs explained CONTACT's lack of feasibility. Coherence: the home's varied in the scale and extent of commitment and understanding of the technology and study procedures. Leadership credibility was important but compromised by competing priorities. Management and direct care staff saw CONTACT differently. Work to promote (cognitive participation) and enact (collective action) CONTACT was burdensome and failed to be prioritised over competing COVID-19-related demands on time and scarce human and cognitive resources. Ultimately, staff appraisal of the value of CONTACT-generated information and study procedures (reflexivity) was that any utility for IPC was insufficient to outweigh the perceived burden and complexity involved.

CONCLUSIONS

Despite implementation failure, dismissing BLE wearables' potential for contact tracing is premature. In non-pandemic conditions, with more time, better co-design and integration of theory-driven implementation strategies tailored to care homes' unique contexts, researchers could enhance normalisation in readiness for future pandemic challenges.

TRIAL REGISTRATION

ISRCTN registration: 11,204,126 registered 17/02/2021.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

First Direct Detection Constraints on Planck-Scale Mass Dark Matter with Multiple-Scatter Signatures Using the DEAP-3600 Detector

Dark matter with Planck-scale mass (≃10^{19}  GeV/c^{2}) arises in well-motivated theories and could be produced by several cosmological mechanisms. A search for multiscatter signals from supermassive dark matter was performed with a blind analysis of data collected over a 813 d live time with DEAP-3600, a 3.3 t single-phase liquid argon-based detector at SNOLAB. No candidate signals were observed, leading to the first direct detection constraints on Planck-scale mass dark matter. Leading limits constrain dark matter masses between 8.3×10^{6} and 1.2×10^{19}  GeV/c^{2}, and ^{40}Ar-scattering cross sections between 1.0×10^{-23} and 2.4×10^{-18}  cm^{2}. These results are interpreted as constraints on composite dark matter models with two different nucleon-to-nuclear cross section scalings.

Predictors of the outcome of physiotherapy following a meniscus tear: A systematic review

BACKGROUND

Physiotherapy is indicated for treatment of a painful degenerative knee meniscus tear. Predicting the outcome remains uncertain.

OBJECTIVE

The purpose of this systematic review was to identify which predictive factors are associated with the outcome of physiotherapy for degenerative knee meniscus tear.

METHODS

A systematic electronic literature search was undertaken of PubMed, CINAHL, Medline with AMED and EMBASE via Ovid from inception to July 2021. Studies of adults receiving physiotherapy which presented data on the association of baseline variables and the treatment outcome were included. Study quality was assessed using CASP (Critical Appraisal Skills Programme) tools. Data were narratively analysed.

RESULTS

1051 titles were retrieved and screened for eligibility. Fifteen studies met the inclusion criteria. Nine studies investigated just degenerative tears. The evidence-base was of low/moderate quality. Across all studies, seven and five studies (100%) reported no association between mechanical symptoms or gender respectively (p > 0.05). There was no association with osteoarthritis in 80%, age in 71%, or body mass index in 60% of studies (p > 0.05). Four studies (80%) reported that higher baseline pain was associated with cross-over to surgery, greater improvement with surgery or less improvement in pain score (p > 0.05).

CONCLUSION

Patient demographic characteristics provide minimal association with outcome following physiotherapy for degenerative meniscus tear. The evidence-base is limited in size and quality. A large adequately powered prospective cohort study investigating a broad range of predictive factors is warranted to develop a predictive model to better stratify those most likely to benefit from physiotherapy.

Pulse-shape discrimination against low-energy Ar-39 beta decays in liquid argon with 4.5 tonne-years of DEAP-3600 data

The DEAP-3600 detector searches for the scintillation signal from dark matter particles scattering on a 3.3 tonne liquid argon target. The largest background comes from 39 Ar beta decays and is suppressed using pulse-shape discrimination (PSD). We use two types of PSD estimator: the prompt-fraction, which considers the fraction of the scintillation signal in a narrow and a wide time window around the event peak, and the log-likelihood-ratio, which compares the observed photon arrival times to a signal and a background model. We furthermore use two algorithms to determine the number of photons detected at a given time: (1) simply dividing the charge of each PMT pulse by the mean single-photoelectron charge, and (2) a likelihood analysis that considers the probability to detect a certain number of photons at a given time, based on a model for the scintillation pulse shape and for afterpulsing in the light detectors. The prompt-fraction performs approximately as well as the log-likelihood-ratio PSD algorithm if the photon detection times are not biased by detector effects. We explain this result using a model for the information carried by scintillation photons as a function of the time when they are detected.

The effect of ambient sounds on decision-making and heart rate variability in autism

LAY ABSTRACT

Many autistic people report difficulties making decisions during everyday tasks, such as shopping. To examine the effect of sounds on decision-making, we developed a supermarket task where people watched a film shown from the shopper's perspective and were asked to make decisions between different products. The task was divided into three sections and participants completed each section in a different auditory environment: (1) no sounds, (2) non-social sounds (e.g. fridges humming) and (3) social sounds (e.g. people talking). Thirty-eight autistic and 37 neurotypical adults took part. We measured decision-making by examining how long it took to make a decision and how consistent people were with their decisions. We also measured heart rate variability because this biological response provides a measure of anxiety. After the supermarket shopping task, participants told us in their own words about their experiences. Autistic participants said that they found the non-social and social sound conditions more difficult than the no sound condition, and autistic participants found the social sound condition more negative than neurotypical participants. However, decision-making and heart rate variability were similar for autistic and neurotypical participants across the sound conditions, suggesting that these measures may not have been sensitive enough to reflect the experiences the autistic participants reported. Further research should consider alternative measures to explore the experiences reported by autistic people to help us understand which specific aspects of the environment autistic people are sensitive to. This, in turn, may enable more specific and evidence-based autism-friendly changes to be made.

Enhancements in laser-generated hot-electron production via focusing cone targets at short pulse and high contrast

We report on the increase in the accelerated electron number and energy using compound parabolic concentrator (CPC) targets from a short-pulse (∼150 fs), high-intensity (>10^{18} W/cm^{2}), and high-contrast (∼10^{8}) laser-solid interaction. We report on experimental measurements using CPC targets where the hot-electron temperature is enhanced up to ∼9 times when compared to planar targets. The temperature measured from the CPC target is 〈T_{e}〉=4.4±1.3 MeV. Using hydrodynamic and particle in cell simulations, we identify the primary source of this temperature enhancement is the intensity increase caused by the CPC geometry that focuses the laser, reducing the focal spot and therefore increasing the intensity of the laser-solid interaction, which is also consistent with analytic expectations for the geometrical focusing.

The potential impact of the COVID-19 pandemic on global antimicrobial and biocide resistance: an AMR Insights global perspective

The COVID-19 pandemic presents a serious public health challenge in all countries. However, repercussions of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections on future global health are still being investigated, including the pandemic’s potential effect on the emergence and spread of global antimicrobial resistance (AMR). Critically ill COVID-19 patients may develop severe complications, which may predispose patients to infection with nosocomial bacterial and/or fungal pathogens, requiring the extensive use of antibiotics. However, antibiotics may also be inappropriately used in milder cases of COVID-19 infection. Further, concerns such as increased biocide use, antimicrobial stewardship/infection control, AMR awareness, the need for diagnostics (including rapid and point-of-care diagnostics) and the usefulness of vaccination could all be components shaping the influence of the COVID-19 pandemic. In this publication, the authors present a brief overview of the COVID-19 pandemic and associated issues that could influence the pandemic’s effect on global AMR.

Improving mental health literacy in year 9 high school children across Wales: a protocol for a randomised control treatment trial (RCT) of a mental health literacy programme across an entire country

Background

Adolescence is a crucial period for developing and maintaining good habits for mental health and well-being. This is important for future mental health, as most mental health problems manifest during adolescence. Mental health literacy is the foundation for mental health prevention, stigma reduction, and increased help-seeking efficacy particularly among adolescents. The mental health literacy programme “The Guide”, which was developed in Canada, has shown success in increasing mental health literacy in North American 16–17 year olds. “The Guide Cymru” is an adaptation of The Guide designed for a younger age group (13–14 year olds) and for the Welsh culture and context and is being offered to all state schools in Wales.

Methods

This two-armed cluster randomised control trial (RCT) will evaluate the effectiveness of The Guide Cymru. All 205 secondary schools in Wales will be invited to take part, involving up to 30,000 year 9 pupils. Schools will be randomised to either the immediate implementation of The Guide Cymru or to a wait-list control. The wait-list control will receive The Guide Cymru around 12 weeks later. Measures of mental health literacy (assessed via the Knowledge and Attitudes to Mental Health scale) and mental health problems (via the PedsQL and Strengths and Difficulties Questionnaire) will be taken at baseline (pre-intervention), 12 weeks later (after the active group has received The Guide Cymru), and 24 weeks later (after the wait-list control has received The Guide Cymru).

Discussion

The trial aims to evaluate if The Guide Cymru increases mental health literacy, including reduced stigma to others and to the self, and increased levels of good mental health behaviours and help-seeking for mental health problems.

Trial registration

ISRCTN15462041. Registered 03/10/2019.

Production of relativistic electrons at subrelativistic laser intensities

Relativistic electron temperatures were measured from kilojoule, subrelativistic laser-plasma interactions. Experiments show an order of magnitude higher temperatures than expected from a ponderomotive scaling, where temperatures of up to 2.2 MeV were generated using an intensity of 1×10^{18}W/cm^{2}. Two-dimensional particle-in-cell simulations suggest that electrons gain superponderomotive energies by stochastic acceleration as they sample a large area of rapidly changing laser phase. We demonstrate that such high temperatures are possible from subrelativistic intensities by using lasers with long pulse durations and large spatial scales.

Plasma Collision in a Gas Atmosphere

We present a study on the impact of a gas atmosphere on the collision of two counterpropagating plasmas (gold and carbon). Imaging optical Thomson scattering data of the plasma collision with and without helium in between have been obtained at the Omega laser facility. Without gas, we observed large scale mixing of colliding gold and carbon ions. Once ambient helium is added, the two plasmas remain separated. The difference in ionic temperature is consistent with a reduction of the maximum Mach number of the flow from M=7 to M=4. It results in a reduction of a factor ∼10 of the counterstreaming ion-ion mean free path. By adding a low-density ambient gas, it is possible to control the collision of two high-velocity counterstreaming plasma, transitioning from an interpenetrating regime to a regime in agreement with a hydrodynamic description.

The causal web of foetal alcohol spectrum disorders: a review and causal diagram

Foetal alcohol spectrum disorders (FASDs) are a leading cause of developmental disability. Prenatal alcohol use is the sole necessary cause of FASD, but it is not always sufficient. Multiple factors influence a child's susceptibility to FASD following prenatal alcohol exposure. Much of the FASD risk factor literature has been limited to discussions of association, rather than causation. While knowledge of predictor variables is important for identifying who is most at risk of FASD and for targeting interventions, causal knowledge is important for identifying effective mechanisms for prevention and intervention programmes. We conducted a systematic search and narrative synthesis of the evidence and used this to create a causal diagram (directed acyclic graph; DAG) to describe the causal pathways to FASD. Our results show that the aetiology of FASD is multifaceted and complex. FASD risk is determined by a range of lifestyle, sociodemographic, maternal, social, gestational, and genetic factors. The causal diagram that we present in this review provides a comprehensive summary of causal risk factors for FASD and can be used as a tool to inform data collection and statistical modelling strategies to minimise bias in future studies of FASD.

Associations of depression-anxiety and dyslipidaemia with subclinical carotid arterial disease: Findings from the Whitehall II Study

AIMS

There is mixed evidence for an association between depression and/or anxiety and carotid intima-media thickness, and limited information on the related role of dyslipidaemia. Here we report associations between depression and/or anxiety and intima-media thickness in the Whitehall II cohort, considering the moderating effects of sex and dyslipidaemia.

METHODS

A total of 2822 men and 1112 women (61 ± 6 years) were studied during phase 7 (2002-2004) of the Whitehall II study. Intima-media thickness and lipid levels were assessed, and questionnaires (general health questionnaire and the Centre for Epidemiologic Studies depression scale) were completed. Linear regression was used to explore relationships between depression and/or anxiety and intima-media thickness and the moderating effects of sex and dyslipidaemia.

RESULTS

A total of 1461 participants were categorised with depression and/or anxiety. The association between depression and/or anxiety and intima-media thickness differed between men and women so analyses were undertaken separately by sex. In men, intima-media thickness was significantly associated with dyslipidaemia (P = 0.002) but not depression and/or anxiety (P = 0.29). In women, both dyslipidaemia and depression and/or anxiety were independently associated with intima-media thickness (P = 0.028 and P = 0.031). The greatest intima-media thickness was in women with both depression and/or anxiety and dyslipidaemia. These results were replicated when the general health questionnaire score was substituted for depression and/or anxiety and non-high-density lipoprotein cholesterol for dyslipidaemia.

CONCLUSIONS

Depression and/or anxiety is associated with increased intima-media thickness in women but not in men. Dyslipidaemia is associated with intima-media thickness in both men and women. Women with both depression and/or anxiety and dyslipidaemia are potentially at the greatest risk of cardiovascular disease.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Medication taking in people with hip and knee osteoarthritis: An analysis of the English Longitudinal Study of Ageing

OBJECTIVES

Osteoarthritis (OA) is a highly prevalent condition seen across primary care services. Although evidence-based guidelines have encouraged the prescription of medications, including analgesics, for this population, there remains uncertainty as to which types of individuals actually take prescribed or over-the-counter medications. The purpose of the present study was to determine whether there is a difference in characteristics between people who take medicines for OA compared with those who do not.

METHODS

A cross-sectional analysis of the English Longitudinal Study of Ageing (ELSA) cohort was undertaken. Individuals who reported hip and/or knee OA pain were included. Data on medication taking were self-reported and collected as part of the ELSA data collection programme. Logistic regression analyses were undertaken to determine the relationship between potential predictors (demographic, pathology-specific, psychological, social and functional) and whether individuals took medications for their OA symptoms.

RESULTS

A total of 654 participants reported OA: 543 medicine takers and 111 nontakers. Individuals who had access to a car (odds ratio [OR]: 56.2; 95% confidence interval [CI]: 3.35 to 941.36), those with a greater duration of hip pain (OR: 5.79; 95% CI: 1.40 to 24.0) and those who achieved 10 chair raises at greater speed (OR: 1.08; 95% CI: 1.03 to 1.14) were more likely to take OA medicines.

CONCLUSIONS

The study identified predictors for medication taking in individuals with hip and/or knee OA. Strategies are now warranted to provide better support to these individuals, to improve health and well-being for this long-term, disabling condition.

First Results from the DEAP-3600 Dark Matter Search with Argon at SNOLAB

This Letter reports the first results of a direct dark matter search with the DEAP-3600 single-phase liquid argon (LAr) detector. The experiment was performed 2 km underground at SNOLAB (Sudbury, Canada) utilizing a large target mass, with the LAr target contained in a spherical acrylic vessel of 3600 kg capacity. The LAr is viewed by an array of PMTs, which would register scintillation light produced by rare nuclear recoil signals induced by dark matter particle scattering. An analysis of 4.44 live days (fiducial exposure of 9.87 ton day) of data taken during the initial filling phase demonstrates the best electronic recoil rejection using pulse-shape discrimination in argon, with leakage <1.2×10^{-7} (90% C.L.) between 15 and 31  keV_{ee}. No candidate signal events are observed, which results in the leading limit on weakly interacting massive particle (WIMP)-nucleon spin-independent cross section on argon, <1.2×10^{-44}  cm^{2} for a 100  GeV/c^{2} WIMP mass (90% C.L.).

Prevalence and determinants of antibiotic exposure in infants: A population-derived Australian birth cohort study

AIM

The aim of this study was to describe antibiotic exposure in Australian infants during the first year of life, focusing on antibiotic class, indication, risk factors associated with exposure and comparison with international counterparts.

METHODS

The Barwon Infant Study is a birth cohort study (n = 1074) with an unselected antenatal sampling frame from a large regional centre in Victoria, Australia. Longitudinal data on infection and medication were collected at 1, 3, 6, 9 and 12 months by parental questionnaire and from general practitioner and hospital records. Predictors of questionnaire non-completion were identified. A total of 660 infants with complete serial data were comprehensively examined. Antibiotic exposure was calculated as (i) antibiotic prescriptions and (ii) antibiotic days-exposed per person-year.

RESULTS

Mean antibiotic prescription rate was 0.92 prescriptions (95% confidence interval (CI), 0.83-1.02) per person-year, with the highest rates in those aged <1 month (1.50 (95% CI, 1.09-1.91) per person-year). A total of 50.0% of infants were exposed to at least one antibiotic in their first year of life. Increasing number of siblings was associated with increased antibiotic exposure. Penicillin with extended spectrum (365 of 661 antibiotic prescriptions, 52.6%) and cephalosporins (12.0%) were the most frequently prescribed antibiotics. One fifth of antibiotics were prescribed for respiratory tract infections and bronchiolitis.

CONCLUSION

Australian infants in this large population-based study are exposed to considerably more antibiotics than the majority of their international counterparts. Interventions aimed at addressing avoidable prescribing by medical practitioners and modifiable risk factors associated with antibiotic exposure may reduce antibiotic use.

Environmental and genetic determinants of two vitamin D metabolites in healthy Australian children

BACKGROUND

Vitamin D deficiency has been associated with adverse health outcomes. We examined genetic and environmental determinants of serum 25(OH)D3 and 1,25(OH)2D3 in childhood.

METHODS

The study sample consisted of 322 healthy Australian children (predominantly Caucasians) who provided a venous blood sample. A parental interview was conducted and skin phototype and anthropometry measures were assessed. Concentrations of 25(OH)D3 and 1,25(OH)2D3 were measured by selective solid-phase extraction-capillary liquid chromatography-tandem mass spectrometry. These concentrations were deseasonalised where relevant to remove the effect of month of sampling.

RESULTS

Deseasonalised log 25(OH)D3 and 1,25(OH)2D3 concentrations were only moderately correlated (r=0.42, p<0.001). The following predicted both 25(OH)D3 and 1,25(OH)2D3: UVR 6 weeks before the interview, natural skin and eye colour, height and vitamin D allelic metabolism score. The following predicted 25(OH)D3 only: lifetime sunburns and vitamin D allelic synthesis score. Overall, 43.5% and 25.6% of variation in 25(OH)D3 and 1,25(OH)2D3 could be explained. After accounting for 25(OH)D3 concentrations, higher UVR 6 weeks before the interview and vitamin D allelic metabolism score further predicted 1,25(OH)2D3 concentrations.

CONCLUSIONS

Environmental factors and genetic factors contributed to both vitamin D metabolite concentrations. The intriguing finding that the higher ambient UVR contributed to higher 1,25(OH)2D3 after accounting for 25(OH)D3 concentrations requires further evaluation.

Conjunctival Ultraviolet Autofluorescence as a Measure of Past Sun Exposure in Children

Background: Conjunctival ultraviolet autofluorescence (CUVAF) area detected from UVAF photographs is a recently developed potential marker for past sun exposure, but its relationship with sun-related factors has not been fully investigated.Methods: The study included 339 healthy children ages 5 to 15 years in Melbourne, Australia. Data were collected by questionnaire and examination at school. CUVAF area was measured using a computer program and analyzed as a continuous and dichotomous outcome (any/none).Results: Fifty-three children (15.6%) had detectable CUVAF, and the youngest age at which a child showed sun damage was 8 years. Compared with silicone skin cast score, there was good inter-grader agreement on CUVAF grading, with Cohen kappa 0.85 [95% confidence interval (CI), 0.65-1.00] for total CUVAF area using both eye photographs. Perfect intra-grader agreement was achieved. Fairer pigmentation, including medium/fair skin color [adjusted odds ratio (AOR), 3.42; 95% CI, 1.02-11.48 vs. dark/olive] and blue/gray eye color (AOR, 4.07; 95% CI, 1.73-9.55 vs. brown) was associated with increased odds of CUVAF. Increasing lifetime sunburn number (e.g., AOR, 2.89; 95% CI, 1.14-7.35 and 4.29; 1.04-17.76 for sunburns 2 to 4 and ≥ 5 times, respectively, vs. no sunburns, trend P = 0.004) and freckling by the end of last summer were associated with increased odds of CUVAF.Conclusions: CUVAF area can be an a priori objective measure of past sun exposure in pediatric populations for future research.Impact: To our knowledge, this is the first pediatric study that evaluated associations of sun-related risk factors with CUVAF. Cancer Epidemiol Biomarkers Prev; 26(7); 1146-53. ©2017 AACR.

Development and validation of a physical model to investigate the biomechanics of infant head impact

Head injury in childhood is the single most common cause of death or permanent disability from injury. However, despite its frequency and significance, there is little understanding of the response of a child's head to injurious loading. This is a significant limitation when making early diagnoses, informing clinical and/or forensic management or injury prevention strategies. With respect to impact vulnerability, current understanding is predominantly based on a few post-mortem-human-surrogate (PMHS) experiments. Researchers, out of experimental necessity, typically derive acceleration data, currently an established measure for head impact vulnerability, by calculation. Impact force is divided by the head mass, to produce a "global approximation", a single-generalised head response acceleration value. A need exists for a new experimental methodology, which can provide specific regional or localised response data. A surrogate infant head, was created from high resolution computer tomography scans with properties closely matched to tissue response data and validated against PMHS head impact acceleration data. The skull was 3D-printed from co-polymer materials. The brain, represented as a lumped mass, comprised of an injected gelatin/water mix. High-Speed Digital-Image-Correlation optically measured linear and angular velocities and accelerations, strains and strain rates. The "global approximation" was challenged by comparison with regional and local acceleration data. During impacts, perpendicular (at 90°) to a surface, regional and local accelerations were up to three times greater than the concomitant "global" accelerations. Differential acceleration patterns were very sensitive to impact location. Suture and fontanelle regions demonstrated ten times more strain (103%/s) than bone, resulting in skull deformations similar in magnitude to those observed during child birth, but at much higher rates. Surprisingly, perpendicular impacts produced significantly greater rotational velocities and accelerations, which are closer to current published injury thresholds than expected, seemingly as a result of deformational changes to the complex skull geometry. The methodology has proven a significant new step in characterising and understanding infant head injury mechanics.

Ultrafast probing of magnetic field growth inside a laser-driven solenoid

We report on the detection of the time-dependent B-field amplitude and topology in a laser-driven solenoid. The B-field inferred from both proton deflectometry and Faraday rotation ramps up linearly in time reaching 210 ± 35 T at the end of a 0.75-ns laser drive with 1 TW at 351 nm. A lumped-element circuit model agrees well with the linear rise and suggests that the blow-off plasma screens the field between the plates leading to an increased plate capacitance that converts the laser-generated hot-electron current into a voltage source that drives current through the solenoid. ALE3D modeling shows that target disassembly and current diffusion may limit the B-field increase for longer laser drive. Scaling of these experimental results to a National Ignition Facility (NIF) hohlraum target size (∼0.2cm^{3}) indicates that it is possible to achieve several tens of Tesla.

Zika virus disease: a public health emergency

No abstract available.

Selecting children for head CT following head injury

OBJECTIVE

Indicators for head CT scan defined by the 2007 National Institute for Health and Care Excellence (NICE) guidelines were analysed to identify CT uptake, influential variables and yield.

DESIGN

Cross-sectional study.

SETTING

Hospital inpatient units: England, Wales, Northern Ireland and the Channel Islands.

PATIENTS

Children (<15 years) admitted to hospital for more than 4 h following a head injury (September 2009 to February 2010).

INTERVENTIONS

CT scan.

MAIN OUTCOME MEASURES

Number of children who had CT, extent to which NICE guidelines were followed and diagnostic yield.

RESULTS

Data on 5700 children were returned by 90% of eligible hospitals, 84% of whom were admitted to a general hospital. CT scans were performed on 30.4% of children (1734), with a higher diagnostic yield in infants (56.5% (144/255)) than children aged 1 to 14 years (26.5% (391/1476)). Overall, only 40.4% (984 of 2437 children) fulfilling at least one of the four NICE criteria for CT actually underwent one. These children were much less likely to receive CT if admitted to a general hospital than to a specialist centre (OR 0.52 (95% CI 0.45 to 0.59)); there was considerable variation between healthcare regions. When indicated, children >3 years were much more likely to have CT than those <3 years (OR 2.35 (95% CI 2.08 to 2.65)).

CONCLUSION

Compliance with guidelines and diagnostic yield was variable across age groups, the type of hospital and region where children were admitted. With this pattern of clinical practice the risks of both missing intracranial injury and overuse of CT are considerable.

The Automatic Detection of Chronic Pain-Related Expression: Requirements, Challenges and the Multimodal EmoPain Dataset

Pain-related emotions are a major barrier to effective self rehabilitation in chronic pain. Automated coaching systems capable of detecting these emotions are a potential solution. This paper lays the foundation for the development of such systems by making three contributions. First, through literature reviews, an overview of how pain is expressed in chronic pain and the motivation for detecting it in physical rehabilitation is provided. Second, a fully labelled multimodal dataset (named 'EmoPain') containing high resolution multiple-view face videos, head mounted and room audio signals, full body 3D motion capture and electromyographic signals from back muscles is supplied. Natural unconstrained pain related facial expressions and body movement behaviours were elicited from people with chronic pain carrying out physical exercises. Both instructed and non-instructed exercises were considered to reflect traditional scenarios of physiotherapist directed therapy and home-based self-directed therapy. Two sets of labels were assigned: level of pain from facial expressions annotated by eight raters and the occurrence of six pain-related body behaviours segmented by four experts. Third, through exploratory experiments grounded in the data, the factors and challenges in the automated recognition of such expressions and behaviour are described, the paper concludes by discussing potential avenues in the context of these findings also highlighting differences for the two exercise scenarios addressed.

Epidemiology of children with head injury: a national overview

BACKGROUND

The National Confidential Enquiry describes the epidemiology of children admitted to hospital with head injury.

METHOD

Children (<15 years old) who died or were admitted for >4 h with head injury were identified from 216 UK hospitals (1 September 2009 to 28 February 2010). Data were collected using standard proformas and entered on to a database. A descriptive analysis of the causal mechanisms, child demographics, neurological impairment, CT findings, and outcome at 72 h are provided.

RESULTS

Details of 5700 children, median age 4 years (range 0-14.9 years), were analysed; 1093 (19.2%) were <1 year old, 3500 (61.4%) were boys. There was a significant association of head injury with social deprivation 39.7/100 000 (95% CI 37.0 to 42.6) in the least deprived first quintile vs. 55.1 (95% CI 52.1 to 58.2) in the most deprived fifth quintile (p<0.01). Twenty-four children died (0.4%). Most children were admitted for one night or less; 4522 (79%) had a Glasgow Coma Scale score of 15 or were Alert (on AVPU (Alert, Voice, Pain, Unresponsive)). The most common causes of head injury were falls (3537 (62.1%); children <5 years), sports-related incidents (783 (13.7%); median age 12.4 years), or motor vehicle accidents (MVAs) (401 (7.1%); primary-school-aged children). CT scans were performed in 1734 (30.4%) children; 536 (30.9%) were abnormal (skull fracture and/or intracranial injury or abnormality): 269 (7.6%) were falls, 82 (10.5%) sports related and 100 (25%). A total of 357 (6.2%) children were referred to social care because of child protection concerns (median age 9 months (range 0-14.9 years)).

CONCLUSIONS

The data described highlight priorities for targeted age-specific head injury prevention and have the potential to provide a baseline to evaluate the effects of regional trauma networks (2012) and National Institute of Health and Care Excellence (NICE) head injury guidelines (2014), which were revised after the study was completed.

Persistence to oral 5-aminosalicylate therapy for inflammatory bowel disease in Australia

Aminosalicylate (5-ASA) is effective treatment for inflammatory bowel diseases (IBDs) but requires continuous maintenance therapy. This study determines persistence of 5-ASA in IBD using national population-based data for Australia from 2002 to 2011 with follow up for 36 months. Non-persistence was defined as failing to fill a prescription for 3 months. Of 12,592 patients those initiated on non-sulphasalazine 5-ASA (2917) had significantly higher persistence (P < 0.001) than those on sulphasalazine (9675). Persistence for sulphasalazine and non-sulphasalazine 5-ASA initiation was 22.3% and 28.5% at 12-months, and 11.9% and 16.2% at 24-months. Sulphasalazine poor persistence continued despite intra-class switch to another 5-ASA. Patients receiving immunomodulator co-therapy had higher persistence (P < 0.001). National population-based data identified persistence to 5-ASA to be low but significantly lower when sulphasalazine is the initial drug. Physicians should stress the importance of long-term 5-ASA therapy as overall drug efficacy especially the 5-ASA chemo-prophylactic benefits may be reduced by non-persistence.

Abstract P1-13-16: Women commencing with anastrozole, letrozole or tamoxifen: The impact of comorbidity and demographics on initial choice

Background: Australian clinical guidelines recommend post-surgical endocrine therapy for all women with early, hormone-dependent breast cancer. Guidelines specify tamoxifen as first-line therapy for pre-menopausal women, and either tamoxifen or an aromatase inhibitor for post-menopausal women depending on their risk of recurrence which is based on tumour size and other prognostic indicators. Tamoxifen and the aromatase inhibitors have different side effect profiles and therefore comorbidity may also influence choice of therapy. We examined comorbidities, and the clinical and demographic characteristics of women initiated on different endocrine therapies for breast cancer in Australian practice.

Method: We identified the first dispensing of tamoxifen, anastrozole or letrozole for women diagnosed with invasive breast cancer in the 45 and Up Study between January 2003 and December 2009 (n = 1383). Unit-level pharmacy and medical service claims, hospital separations, and Cancer Registry records were linked to self-reported data to determine menopause status at diagnosis, tumour size, age, change in subsidy restrictions, and specified comorbidities which may affect choice of therapy (i.e. arthritis, endometrial cancer, osteoporosis, thromboembolism). Chi-square tests and multivariate generalised linear models were used to compare the characteristics of post-menopausal women initiated on different therapies.

Results: The majority of pre-menopausal women commenced therapy with tamoxifen (93%). Tamoxifen was the predominant therapy for post-menopausal women with tumours ≤1cm (54%), and anastrozole most common for those with larger tumours (49%). Post-menopausal women with osteoporosis were less likely to commence an aromatase inhibitor compared with tamoxifen (anastrozole RR = 0.7, 95%CI = 0.5-0.9, P = 0.019; letrozole RR = 0.6, 95%CI = 0.3-0.9, P = 0.033) and those with arthritis were 1.6-times more likely to commence with letrozole than anastrozole (95%CI = 1.6-2.3, P = 0.004). Tamoxifen was more likely to be initiated in women with large tumours who also had comorbid arthritis or were aged ≥75 years. Changes in subsidy restrictions were associated with significant increases in the proportion of post-menopausal women commencing an aromatase inhibitor rather than tamoxifen (anastrozole RR = 7.0; letrozole RR = 18.5).

Conclusions: The findings show clinical guidelines regarding endocrine therapies are being followed in Australian practice, particularly in relation to menopause status and tumour size as a recurrence risk factor. The findings also indicate there is interplay of comorbidity and choice of therapy for older women and those with arthritis or osteoporosis.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-13-16.

Rift valley Fever in Kruger national park: do buffalo play a role in the inter-epidemic circulation of virus?

Rift Valley fever (RVF) is a zoonotic mosquito-borne virus disease of livestock and wild ruminants that has been identified as a risk for international spread. Typically, the disease occurs in geographically limited outbreaks associated with high rainfall events and can cause massive losses of livestock. It is unclear how RVF virus persists during inter-epidemic periods but cryptic cycling of the virus in wildlife populations may play a role. We investigated the role that free-living African buffalo (Syncerus caffer caffer) might play in inter-epidemic circulation of the virus and looked for geographic, age and sex patterns of Rift Valley fever virus (RVFV) infection in African buffalo. Buffalo serum samples were collected (n = 1615) in Kruger National Park (KNP), South Africa, during a period of 1996-2007 and tested for antibodies to RVF. We found that older animals were more likely to be seropositive for anti-RVFV antibody than younger animals, but sex was not correlated with the likelihood of being anti-RVFV antibody positive. We also found geographic variation within KNP; herds in the south were more likely to have acquired anti-RVFV antibody than herds farther north - which could be driven by host or vector ecology. In all years of the study between 1996 and 2007, we found young buffalo (under 2 years of age) that were seropositive for anti-RVFV antibody, with prevalence ranging between 0 and 27% each year, indicating probable circulation. In addition, we also conducted a 4-year longitudinal study on 227 initially RVFV seronegative buffalo to look for evidence of seroconversion outside known RVF outbreaks within our study period (2008-2012). In the longitudinal study, we found five individuals that seroconverted from anti-RVFV antibody negative to anti-RVFV antibody positive, outside of any detected outbreak. Overall, our results provide evidence of long-term undetected circulation of RVFV in the buffalo population.

The impact of depression heterogeneity on cognitive control in major depressive disorder

OBJECTIVE

Depressed patients display a variety of deficits in neuropsychological function, and contradictory findings in the literature may be due to disorder heterogeneity. The aim of this study was to examine the impact of severity, subtype and symptoms on cognitive control.

METHODS

Neuropsychological function across a range of cognitive control tasks was examined in melancholic (n = 65) and non-melancholic depressed patients (n = 59) relative to controls (n = 124). The relationship between subtype (melancholia vs non-melancholia) and anxiety was also examined.

RESULTS

Melancholia was characterised by attention and working memory deficits typically associated with the dorsolateral prefrontal cortex, while non-melancholia was characterised by verbal memory recall deficits indicative of left frontal lobe and medial temporal lobe function. The severity of anxious arousal and psychomotor disturbance contributed to cognitive impairment more than the severity of depression symptoms and anxious apprehension.

CONCLUSIONS

Findings highlight a differential impact of depression subtype and severity, and suggest that anxious arousal and psychomotor disturbance may contribute to poorer performance on neuropsychological tasks associated with dorsolateral prefrontal cortex function.

Ebola virus outbreaks in Africa: past and present

Ebola haemorrhagic fever (EHF) is a zoonosis affecting both human and non-human primates (NHP). Outbreaks in Africa occur mainly in the Congo and Nile basins. The first outbreaks of EHF occurred nearly simultaneously in 1976 in the Democratic Republic of the Congo (DRC, former Zaire) and Sudan with very high case fatality rates of 88% and 53%, respectively. The two outbreaks were caused by two distinct species of Ebola virus named Zaire ebolavirus (ZEBOV) and Sudan ebolavirus (SEBOV). The source of transmission remains unknown. After a long period of silence (1980-1993), EHF outbreaks in Africa caused by the two species erupted with increased frequency and new species were discovered, namely Côte d'Ivoire ebolavirus (CIEBOV) in 1994 in the Ivory Coast and Bundibugyo ebolavirus (BEBOV) in 2007 in Uganda. The re-emergence of EHF outbreaks in Gabon and Republic of the Congo were concomitant with an increase in mortality amongst gorillas and chimpanzees infected with ZEBOV. The human outbreaks were related to multiple, unrelated index cases who had contact with dead gorillas or chimpanzees. However, in areas where NHP were rare or absent, as in Kikwit (DRC) in 1995, Mweka (DRC) in 2007, Gulu (Uganda) in 2000 and Yambio (Sudan) in 2004, the hunting and eating of fruit bats may have resulted in the primary transmission of Ebola virus to humans. Human-to-human transmission is associated with direct contact with body fluids or tissues from an infected subject or contaminated objects. Despite several, often heroic field studies, the epidemiology and ecology of Ebola virus, including identification of its natural reservoir hosts, remains a formidable challenge for public health and scientific communities.

Beware the lymphopenia: a case of severe combined immunodeficiency

We present a case of a 2-month-old boy with partially treated meningitis and suspected Pneumocystis carinii pneumonia. A full blood count revealed profound lymphopenia. The child was diagnosed with adenosine deaminase deficiency, a rare cause of severe combined immunodeficiency (SCID). SCID is an immunological emergency and must be considered in any lymphopaenic infant with opportunistic infection. We discuss adenosine deaminase-deficient SCID, which can involve multiple systems and in which other treatment options apart from bone marrow transplant are available.

Infant anthropometry, early life infection, and subsequent risk of type 1 diabetes mellitus: a prospective birth cohort study

BACKGROUND

Higher birthweight is associated with increased type 1 diabetes mellitus (T1DM) risk, but the contribution of higher adiposity or lean mass is unclear. In this Tasmanian infant cohort, early upper respiratory infection has been associated with higher asthma risk.

PATIENTS AND METHODS

Eligible infants represented one-fifth of live births in Tasmania, 1988-1995. Hospital interview data (day 6) were obtained on 96.3% (10 628/11 040), home (5 wk) visit data (38 d) on 92.9% (9876/10 628) of those, then a phone (12 wk) interview (87 d). Tricep and subscapular skinfold measures and upper arm circumference were recorded at the first two interviews. T1DM cases (n = 26) arising from the age of 16 or under in Tasmania from 1988 to 2006 were ascertained.

RESULTS

Higher birthweight [adjusted odds ratio (AOR) 2.82 (95% CI 1.31-6.09)], lean mid-upper arm circumference [AOR 1.76 (95% CI 1.16-2.66)], not skinfold measures, were associated with T1DM risk. Children with an early upper respiratory tract infection by 5-wk visit [AOR 2.74 (95% CI 1.19-6.32)] or ear infection by 12-wk interview [AOR 3.44 (95% CI 1.00-11.79)] were also at higher risk. Putative markers of altered microbial exposure such as resident density were not associated with T1DM risk but the effect of increasing birth order on T1DM risk differed for older (AOR 0.41, p = 0.02) than young mother (AOR 2.45, p = 0.01); difference in effect, p = 0.001.

CONCLUSION

In this cohort, early upper respiratory tract infection was associated with T1DM risk, as had been previously found for asthma, consistent with immunoinflammatory upregulation. Using the detailed anthropometric measures available, the link between higher birthweight and T1DM did not appear to reflect increased adiposity.