Helicobacter pylori Found Guilty of Obstructive Jaundice: A Pediatric Case Report

Pediatric Helicobacter pylori infection represents a small proportion of disease that is otherwise decreasing in the developed world. Typical presentations have been well-described in the literature. We report a 15-year-old male who presented with jaundice, anemia, dark urine, and poorly characterized abdominal pain and was found to have obstructive jaundice secondary to a duodenal ulcer resulting from H. pylori infection. Obstructive jaundice is a seldom reported complication of duodenal ulcer, particularly in children. This report reviews H. pylori infection, outlines complications of peptic ulcer disease, and illustrates the rarity of obstructive jaundice as a presenting sign of duodenal ulcer in children.

COVID-19 in Vietnam and Its Impact on Road Trauma: Retrospective Study Based on National Data

BACKGROUND

Despite significant improvement in the last decade, road trauma remains a substantial contributor to deaths in Vietnam. The COVID-19 pandemic necessitated public health measures that had an unforeseen benefit on road trauma in high-income countries. We investigate if this reduction was also seen in a low- to middle-income country like Vietnam.

OBJECTIVE

Our aim was to investigate how the COVID-19 pandemic and the government policies implemented in response to it impacted road trauma fatalities in Vietnam. We also compared this impact to other government policies related to road trauma implemented in the preceding 14 years (2007-2020).

METHODS

COVID-19 data were extracted from the Vietnamese Ministry of Health database. Road traffic deaths from 2007 to 2021 were derived from the Vietnamese General Statistical Office. We used Stata software (version 17; StataCorp) for statistical analysis. Poisson regression modeling was used to estimate trends in road fatality rates based on annual national mortality data for the 2007-2021 period. The actual change in road traffic mortality in 2021 was compared with calculated figures to demonstrate the effect of COVID-19 on road trauma fatalities. We also compared this impact to other government policies that aimed to reduce traffic-related fatalities from 2007 to 2020.

RESULTS

Between 2007 and 2020, the number of annual road traffic deaths decreased by more than 50%, from 15.3 to 7 per 100,000 population, resulting in an average reduction of 5.4% per annum. We estimated that the road traffic mortality rate declined by 12.1% (95% CI 8.9-15.3%) in 2021 relative to this trend. The actual number of road trauma deaths fell by 16.4%. This reduction was largely seen from August to October 2021 when lockdown and social distancing measures were in force.

CONCLUSIONS

In 2021, the road traffic-related death reduction in Vietnam was 3 times greater than the trend seen in the preceding 14 years. The public health response to the COVID-19 pandemic in Vietnam was associated with a third of this reduction. It can thus be concluded that government policies implemented to address the COVID-19 pandemic resulted in a 4.3% decrease in road traffic deaths in 2021. This has been observed in high-income countries, but we have demonstrated this for the first time in a low- and middle-income country.

Incentivising public transport use for physical activity gain: process evaluation of the COVID-19 disrupted trips4health randomised controlled trial

BACKGROUND

Partnering with a public transport (PT) provider, state government, and local government, the single-blinded randomised controlled trial, trips4health, investigated the impact of PT use incentives on transport-related physical activity (PA) in Tasmania, Australia. The intervention involved 16-weeks of incentives (bus trip credits) for achieving weekly PT use targets, supported by weekly text messages. This study objective was to conduct a process evaluation of the COVID-19 disrupted trips4health study.

METHODS

The Medical Research Council UK's framework for complex public health interventions guided the process evaluation. Participant reach, acceptability, fidelity and feasibility were evaluated. Administrative and post-intervention survey data were analysed descriptively. Semi-structured interviews with intervention participants (n = 7) and PT provider staff (n = 4) were analysed thematically.

RESULTS

Due to COVID-19, trips4health was placed on hold (March 2020) then stopped (May 2020) as social restrictions impacted PT use. At study cessation, 116 participants (approximately one third of target sample) had completed baseline measures, 110 were randomised, and 64 (n = 29 in the intervention group; n = 35 in the control group) completed post-intervention measures. Participants were 18 - 80 years (average 44.5 years) with females (69%) and those with tertiary education (55%) over-represented. The intervention was delivered with high fidelity with 96% of bus trip credits and 99% of behavioural text messages sent as intended. Interviewed PT staff said implementation was highly feasible. Intervention participant acceptability was high with 90% reporting bus trip incentives were helpful and 59% reporting the incentives motivated them to use PT more. From a total of 666 possible bus trip targets, 56% were met with 38% of intervention participants agreeing and 41% disagreeing that 'Meeting the bus trip targets was easy'. Interviews and open-ended survey responses from intervention participants revealed incentives motivated bus use but social (e.g., household member commitments) and systemic (e.g., bus availability) factors made meeting bus trip targets challenging.

CONCLUSIONS

trips4health demonstrated good acceptability and strong fidelity and feasibility. Future intervention studies incentivising PT use will need to ensure a broader demographic is reached and include more supports to meet PT targets.

TRIAL REGISTRATION

ACTRN12619001136190 .

Quantifying forensic investigations involving bloodstain pattern analysis within the UK

Research informed by practice is more likely to have a greater impact on society. However, forensic cases are confidential and thus, real-life data regarding the details of violent crime is usually withheld from the public and academia. Through a partnership between the authors institution and a UK police service, casefiles from 78 criminal investigations from 2012 to 2020 involving Bloodstain Pattern Analysis (BPA) were examined and quantified. The most common methods of assault and weapons used were identified as well as the frequency of different bloodstain pattern classifications. The results of this study will help inform researchers and supply forensic training providers with data derived from forensic practice. Despite a significant body of literature exploring impact patterns and software for calculating the Area of Origin (AO), impact pattern was classified at only 22% of scenes, with sharp-force trauma being the most prevalent form of assault. This paper recommends a review of the BPA terminology, to include additional commonly encountered patterns that are not defined by the current standard.

Uncovering the effects of gender affirming hormone therapy on skeletal muscle and epigenetics: protocol for a prospective matched cohort study in transgender individuals (the GAME study)

INTRODUCTION

Gender affirming hormone therapy (GAHT) is increasingly used by transgender individuals and leads to shifts in sex hormone levels. Skeletal muscle is highly responsive to hormone activity, with limited data on the effects of GAHT on different human tissues. Here, we present the protocol for the GAME study (the effects of Gender Affirming hormone therapy on skeletal Muscle training and Epigenetics), which aims to uncover the effects of GAHT on skeletal muscle 'omic' profiles (methylomics, transcriptomics, proteomics, metabolomics) and markers of skeletal muscle health and fitness.

METHODS AND ANALYSIS

This study is a prospective age-matched cohort study in transgender adults commencing GAHT (n=80) and age-matched individuals not commencing GAHT (n=80), conducted at Austin Health and Victoria University in Victoria, Australia. Assessments will take place prior to beginning GAHT and 6 and 12 months into therapies in adults commencing GAHT. Age-matched individuals will be assessed at the same time points. Assessments will be divided over three examination days, involving (1) aerobic fitness tests, (2) muscle strength assessments and (3) collection of blood and muscle samples, as well as body composition measurements. Standardised diets, fitness watches and questionnaires will be used to control for key confounders in analyses. Primary outcomes are changes in aerobic fitness and muscle strength, as well as changes in skeletal muscle DNA methylation and gene expression profiles. Secondary outcomes include changes in skeletal muscle characteristics, proteomics, body composition and blood markers. Linear mixed models will be used to assess changes in outcomes, while accounting for repeated measures within participants and adjusting for known confounders.

ETHICS AND DISSEMINATION

The Austin Health Human Research Ethics Committee (HREC) and Victoria University HREC granted approval for this study (HREC/77146/Austin-2021). Findings from this project will be published in open-access, peer-reviewed journals and presented to scientific and public audiences.

TRIAL REGISTRATION NUMBER

ACTRN12621001415897; Pre-results.

Trauma Care Training in Vietnam: Narrative Scoping Review

BACKGROUND

The model of trauma in Vietnam has changed significantly over the last decade and requires reforming medical education to deal with new circumstances. Our aim is to evaluate this transition regarding the new target by analyzing trauma and the medical training system as a whole.

OBJECTIVE

This study aimed to establish if medical training in the developing country of Vietnam has adapted to the new disease pattern of road trauma emerging in its economy.

METHODS

A review was performed of Vietnamese medical school, Ministry of Health, and Ministry of Education and Training literature on trauma education. The review process and final review paper were prepared following the guidelines on scoping reviews and using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart.

RESULTS

The current trauma training at the undergraduate level is minimal and involves less than 5% of the total credit. At the postgraduate level, only the specialties of surgery and anesthesia have a significant and increasing trauma training component ranging from 8% to 22% in the content. Trauma training, which focuses on practical skills, accounts for 31% and 32% of the training time of orientation courses for young doctors in "basic surgery" and "basic anesthesia," respectively. Other relevant short course trainings, such as continuing medical education, in trauma are available, but they vary in topics, facilitators, participants, and formats.

CONCLUSIONS

Medical training in Vietnam has not adapted to the new emerging disease pattern of road trauma. In the interim, the implementation of short courses, such as basic trauma life support and primary trauma care, can be considered as an appropriate method to compensate for the insufficient competency-related trauma care among health care workers while waiting for the effectiveness of medical training reformation.

Is greater public transport use associated with higher levels of physical activity in a regional setting? Findings from a pilot study

BACKGROUND

Public transport users often accumulate more physical activity than motor vehicle users, but most studies have been conducted in large metropolitan areas with multiple public transport options with limited knowledge of the relationship in regional and rural areas. In a regional city, this pilot study aimed to (1) test the feasibility of preliminary hypotheses to inform future research, (2) test the utility of survey items, and (3) establish stakeholder engagement.

METHODS

Data were collected via a cross-sectional online survey of 743 Tasmanian adults. Physical activity outcomes were walking (min/week), total moderate- to vigorous-intensity physical activity (min/week) and attainment of physical activity guidelines (yes/no). Transport variables were frequency of public and private transport use per week. Truncated and log binomial regression examined associations between public/private transport use and physical activity.

RESULTS

Neither frequency of public nor private transport use was associated with minutes of walking (public transport: B - 24.4, 95% CI: - 110.7, 61.9; private transport: B - 1.1, 95% CI: - 72.4, 70.1), minutes of total physical activity (public transport: B - 90.8, 95% CI: - 310.0, 128.5; private transport: B 0.4, 95% CI: - 134.0, 134.9) or not meeting physical activity guidelines (public transport: RR 1.02, 95%CI: 0.95, 1.09; private transport: RR 1.02, 95%CI: 0.96, 1.08).

CONCLUSIONS

The hypothesis that public transport users would be more physically active than private transport users was not supported in this pilot study. Stakeholders were engaged and involved in various phases of the research including development of research questions, participant recruitment, and interpretation of findings. Further studies using representative samples and refined measures are warranted to confirm or refute findings.

102Assessing the characteristics of health state utilities among people living with multiple sclerosis

Background

While many studies have examined the impacts of multiple sclerosis (MS) on health-related quality-of-life (HRQoL), none have used the SF-6D multi-attribute utility instrument in a large international cohort (>2,000 subjects) of people with MS. Our objective was to derive SF-6D health state utilities (HSUs) for participants of the HOLISM international cohort and to describe the distribution and determinants thereof.

Methods

HSUs were generated using the SF-6D for the Version-1 United States SF-36 for participants with sufficient SF-36 data (n = 2,185/2,466 (88.6%)). Determinants of HSU were evaluated by linear regression, adjusted for age, sex, MS type, disability (Patient-Determined MS Severity Scale), fatigue (Fatigue Severity Scale), and prescription antidepressant use.

Results

Mean HSU for the sample was 0.67 (SD = 0.13) and diminished with increasing MS-related disability. These findings were robust to adjustment, supporting the SF-6D’s discriminatory power in people with MS. Severe disability and clinically significant fatigue were each associated with 11%-lower HSU (95%CI=-0.13,-0.10 & -0.12,-0.10), and depression risk (Patient Health Questionnaire-2) with 10%-lower HSU (95%CI=-0.11,-0.08). Employment, higher socioeconomic and married/partnered statuses, larger social-network size, greater physical activity, vitamin D and omega-3 supplementations were associated with significantly higher HSU, and overweight/obese BMI and tobacco smoking with lower HSU. Age, sex, and education were not associated.

Conclusions

The SF-6D revealed significant discriminatory power for the HOLISM international cohort. Modifiable lifestyle factors including diet, physical activity and supplement use for the international cohort were robustly associated with increased HSU and thus HRQoL. Confirmatory longitudinal HSU evidence could provide further support to our baseline findings using the SF-6D.

Key messages

Health state utilities in this sample of people living with MS were moderate and were significantly lower among those with greater disability, fatigue, and depression, while some lifestyle factors like physical activity and supplement use were associated with higher utility scores.

Too little, too late: Palliation and end-stage liver disease

BACKGROUND AND AIM

End-stage liver disease is a leading cause of mortality. Fewer than 60% of patients with decompensated cirrhosis survive after 2 years, with patients often experiencing distressing symptoms impairing quality of life. Early advanced care planning and timely palliative care referral can improve quality of life and the end of life experience. We aimed to determine palliative care referral rates and patterns for patients admitted with decompensated cirrhosis, and to identify the factors associated with referral.

METHODS

This was a retrospective, single-center study undertaken at a metropolitan tertiary referral hospital. Patients admitted between the 1 June 2016 and 31 January 2019 with a Child-Pugh score of B or C, and a model for end-stage liver disease score ≥ 15 were included. We assessed survival and compared those referred and not referred to palliative care, adjusting for lag-time to referral (Kaplan-Meier analysis).

RESULTS

One-hundred and sixteen admissions met eligibility criteria for referral. The median age at admission was 59 years, with 76% male participants. Only a fifth of eligible patients (25/116) were referred to palliative care. The median survival (from referral) for those referred to palliative care was 20 days, versus 148 days for those not referred.

CONCLUSIONS

Despite benefits from timely referral, less than one quarter of palliative care eligible patients was referred. Referral appears reserved for those facing imminent death-surviving just under 3 weeks postreferral, yet mortality in nonreferred patients remained high (148-day median). Low rates and late referral are a missed opportunity to improve the end of life care for patients with end-stage liver disease.

Public LC-Orbitrap Tandem Mass Spectral Library for Metabolite Identification

Liquid chromatography-mass spectrometry (LC-MS)-based untargeted metabolomics studies require high-quality spectral libraries for reliable metabolite identification. We have constructed EMBL-MCF (European Molecular Biology Laboratory-Metabolomics Core Facility), an open LC-MS/MS spectral library that currently contains over 1600 fragmentation spectra from 435 authentic standards of endogenous metabolites and lipids. The unique features of the library include the presence of chromatographic profiles acquired with different LC-MS methods and coverage of different adduct ions. The library covers many biologically important metabolites with some unique metabolites and lipids as compared with other public libraries. The EMBL-MCF spectral library is created and shared using an in-house-developed web application at https://curatr.mcf.embl.de/. The library is freely available online and also integrated with other mass spectral repositories.

Spatial segmentation and metabolite annotation involved in sperm maturation in the rat epididymis by MALDI imaging mass spectrometry

Spermatozoa acquire their fertilizing capacity during a complex maturation process that occurs in the epididymis. This process involves a substantial molecular remodeling at the surface of the gamete. Epididymis is divided into three regions (the caput, corpus, and cauda) or into 19 intraregional segments based on histology. Most studies carried out on epididymal maturation have been performed on sperm samples or tissue extracts. Here, we used MALDI imaging mass spectrometry in the positive and negative ion modes combined with spatial segmentation and automated metabolite annotation to study the precise localization of metabolites directly in the rat epididymis. The spatial segmentation revealed that the rat epididymis could be divided into several molecular clusters different from the 19 intraregional segments. The discriminative m/z values that contributed the most to each molecular cluster were then annotated and corresponded mainly to phosphatidylcholines, sphingolipids, glycerophosphates, triacylglycerols, plasmalogens, phosphatidylethanolamines, and lysophosphatidylcholines. A substantial remodeling of lipid composition during epididymal maturation was observed. It was characterized in particular by an increase in the number of sphingolipids and plasmalogens and a decrease in the proportion of triacylglycerols annotated from caput to cauda. Ion images reveal that molecules belonging to the same family can have very different localizations along the epididymis. For some of them, annotation was confirmed by on-tissue MS/MS experiments. A 3D model of the epididymis head was reconstructed from 61 sections analyzed with a lateral resolution of 50 μm and can be used to obtain information on the localization of a given analyte in the whole volume of the tissue.

Test evaluation trials present different challenges for trial managers compared to intervention trials

Introduction

Test evaluation trials present different challenges for trial managers compared to intervention trials. There has been very little research on the management of test evaluation trials and how this impacts on trial success, in comparison with intervention trials. Evaluations of medical tests present specific challenges, because they are a pivot point bridging the complexities of pathways prompting testing with treatment decision-making. We systematically explored key differences in the trial design and management of test evaluation trials compared to intervention trials at the different stages of study design and delivery. We identified challenges in test evaluation trials that were more pronounced than in intervention trials, based on experience from 10 test evaluation trials.

Methods

We formed a focus group of 7 trial managers and a statistician who had been involved in the day-to-day management of both test evaluation trials and intervention trials. We used discussion and content analysis to group challenges from 10 trials into a structured thematic format. The trials covered a range of medical conditions, diagnostic tests, clinical pathways and conditions including chronic kidney disease, chronic pelvic pain, colitis, detrusor over-activity, group B streptococcal colonisation, tuberculosis and colorectal, lung, ovarian and thyroid cancers.

Results

We identified 10 common themes underlying challenges that are more pronounced in test evaluation compared to intervention trials. We illustrate these themes with examples from 10 trials, including with 31 specific challenges we experienced. The themes were ethics/governance; accessing patient populations; recruitment; patient preference; test processes, clinical pathways and samples storage; uncertainty of diagnostic results; verifying diagnosis (reference standard); follow-up; adverse effects; and diagnostic impact.

Conclusion

We present 10 common themes, including 31 challenges, in test evaluation trials that will be helpful to others designing and managing future test evaluation trials. Proactive identification of potential challenges at the design and planning stages of test evaluation trials will enable strategies to improve trial design and management that may be different from standard strategies used for intervention trials. Future work could extend this topic to include challenges for other trial stakeholders including participants, clinicians, statisticians and funders.

Trial registration

All trials reviewed in this project were registered and are provided in Table 1.

Quorum Sensing Behavior in the Model Unicellular Eukaryote Chlamydomonas reinhardtii

Microbial communities display behavioral changes in response to variable environmental conditions. In some bacteria, motility increases as a function of cell density, allowing for population dispersal before the onset of nutrient scarcity. Utilizing automated particle tracking, we now report on a population-dependent increase in the swimming speeds of the photosynthetic unicellular eukaryotes Chlamydomonas reinhardtii and C. moewussi. Our findings confirm that this acceleration in swimming speed arises as a function of culture density, rather than with age and/or nutrient availability. Furthermore, this phenomenon depends on the synthesis and detection of a low-molecular-weight compound which can be transferred between cultures and stimulates comparable effects across both species, supporting the existence of a conserved phenomenon, not unlike bacterial quorum sensing, among members of this genus. The potential expansion of density-dependent phenomena to a new group of unicellular eukaryotes provides important insight into how microbial populations evolve and regulate "social" behaviors.

Health care, overconsumption and uneconomic growth: A conceptual framework

Concerns have grown in recent decades that economic growth in many rich countries may, in fact, be uneconomic. Uneconomic growth occurs when expansion in economic activity causes environmental and social costs that are greater than the benefits of that additional activity. Health care has enjoyed a close historical relationship with economic growth, with health care spending consistently growing faster than GDP over the long term. This paper explores the possible relationship between health care and uneconomic growth. It summarises the rapidly growing evidence on the harms caused by poor quality health care and by the overuse of health care, and on the environmental harms caused by health care systems. Further, it develops a conceptual framework for considering the overconsumption of health care and the joint harms to human health and the natural environment that ensue. This framework illustrates how health-damaging overconsumption in the wider economy combines with unnecessary or low-quality health care to create a cycle of "failure demand" and defensive expenditure on health care services. Health care therefore provides important sectoral insights on the phenomenon of uneconomic growth. There are rich opportunities for interdisciplinary research to quantify the joint harms of overconsumption in health and health care, and to estimate the optimal scale of the health sector from novel perspectives that prioritise human and planetary health and well-being over GDP and profit.

Gastrointestinal Bleeding in a Pancreas Transplant Recipient: A Case to Remember

Patient: Male, 51-year-old

Final Diagnosis: Ectopic varix

Symptoms: Bleeding • portal hypertension

Medication:—

Clinical Procedure: —

Specialty: Transplantology

Computer-Assisted Tracking of Chlamydomonas Species

The green algae Chlamydomonas reinhardtii is a model system for motility in unicellular organisms. Photo-, gravi-, and chemotaxis have previously been associated with C. reinhardtii, and observing the extent of these responses within a population of cells is crucial for refining our understanding of how this organism responds to changing environmental conditions. However, manually tracking and modeling a statistically viable number of samples of these microorganisms is an unreasonable task. We hypothesized that automated particle tracking systems are now sufficiently advanced to effectively characterize such populations. Here, we present an automated method to observe C. reinhardtii motility that allows us to identify individual cells as well as global information on direction, speed, and size. Nutrient availability effects on wild-type C. reinhardtii swimming speeds, as well as changes in speed and directionality in response to light, were characterized using this method. We also provide for the first time the swimming speeds of several motility-deficient mutant lines. While our present effort is focused around the unicellular green algae, C. reinhardtii, we confirm the general utility of this approach using Chlamydomonas moewusii, another member of this genus which contains over 300 species. Our work provides new tools for evaluating and modeling motility in this model organism and establishes the methodology for conducting similar experiments on other unicellular microorganisms.

Analyzing Learned Molecular Representations for Property Prediction

Advancements in neural machinery have led to a wide range of algorithmic solutions for molecular property prediction. Two classes of models in particular have yielded promising results: neural networks applied to computed molecular fingerprints or expert-crafted descriptors and graph convolutional neural networks that construct a learned molecular representation by operating on the graph structure of the molecule. However, recent literature has yet to clearly determine which of these two methods is superior when generalizing to new chemical space. Furthermore, prior research has rarely examined these new models in industry research settings in comparison to existing employed models. In this paper, we benchmark models extensively on 19 public and 16 proprietary industrial data sets spanning a wide variety of chemical end points. In addition, we introduce a graph convolutional model that consistently matches or outperforms models using fixed molecular descriptors as well as previous graph neural architectures on both public and proprietary data sets. Our empirical findings indicate that while approaches based on these representations have yet to reach the level of experimental reproducibility, our proposed model nevertheless offers significant improvements over models currently used in industrial workflows.

Early or delayed anterior cruciate ligament reconstruction: Is one superior? A systematic review and meta-analysis

Background

Anterior cruciate ligament (ACL) reconstruction is a rapidly developing orthopaedic field and an area of notable clinical equipoise. The optimal timing of surgery in an acute (< 3 weeks) or delayed (≥ 3 weeks) time frame remains unresolved with a 2010 meta-analysis concluding no difference between these two groups across multiple outcomes. In an era of evidence-based medicine, surgeons are still basing their decisions on when to operate on little more than anecdotal evidence and personal preference. Clear guidance is required to determine whether the timing of surgery can optimise outcomes in this largely young and active patient cohort.

Methods

A systematic literature search was performed in January 2018 of Embase, Medline and OpenGrey in accordance with (PRISMA) guidelines. A total of 658 articles were retrieved, with 6 suitable for inclusion, covering 576 ACL reconstructions. Four meta-analyses were performed assessing subjective measures of Tegner activity scale and Lysholm score, and objective measures of arthroscopically identified meniscal and chondral injury. Additional relevant outcome measures underwent narrative review. Study bias was assessed and reported using the Downs and Black checklist.

Results

A statistically significant difference of 0.39 points was found on the Tegner activity scale in favour of early surgery within 3 weeks (RR 0.39, CI 0.10, 0.67, p = 0.008). No statistically difference was found between groups for the patient-reported Lysholm score (RR − 0.18, CI − 2.40, 2.05, p = 0.17). There was no statistically significant difference between groups for intra-operative findings of meniscal lesions (RR 0.84, CI 0.66, 1.08, p = 0.17). A trend towards significance was observed for the incidence of chondral lesions in the early surgery group (RR 0.56, CI 0.31, 1.02, p = 0.06). All the studies were rated either fair or good on the Downs and Black checklist with no study excluded due to bias.

Conclusions

Although there was a statistically significant result for the Tegner activity scale in favour of early surgery, the magnitude of the effect is unlikely to translate into any clinically meaningful difference. At present, there remains no clear evidence to determine superiority of acute/early or delayed reconstruction of a ruptured anterior cruciate ligament. Further research through methodologically robust randomised controlled trials or through the UK National Ligament Registry  may help to provide clearer guidance.

The impact of hip fracture on health-related quality of life and activities of daily living: the SPARE-HIP prospective cohort study

PURPOSE

The medical morbidity and mortality associated with neck of femur fractures is well-documented, whereas there is limited data for patient-reported outcomes. The aim of this study was to characterize the impact of neck of femur fractures on activities of daily living and patient-reported health-related quality of life.

METHODS

Design and participants: Multicentric prospective cohort study. Consecutive sample patients with fragility hip fracture over 50 years old admitted in 48 hospitals in Spain.

OUTCOMES

daily living activity function (Barthel Index) and health-related quality of life (EQ-5D) pre-fracture, admission to hospital and at 1- and 4-month follow-up post-fracture.

STATISTICS

Barthel and EQ-5D over time are described as mean (SD) and median (interquartile range).

RESULTS

A total of 997 patients were recruited at baseline with 4-month outcomes available for, and 856 patients (89.5%). Barthel Index fell from 78.77 (23.75) at baseline to 43.62 (19.86) on admission to hospital with the fracture. Scores partially recovered to 54.89 (25.40) and 64.09 (21.35) at 1- and 4-month post-fracture, respectively. EQ-5D fell from a median of 0.75 (0.47-0.91) to - 0.01 (- 0.03 to 0.51) on admission. Partial recovery was observed again to (0.51 (- 0.06 to 0.67)) and (0.60 (0.10 to 0.80)) at 1- and 4-month post-fracture, respectively.

CONCLUSIONS

Hip fracture results in a large decline in the ability to perform activities of daily living and patient-reported health-related quality of life with only partial recovery amongst survivors 4-month post-fracture.

Comparison of learning outcomes for teaching focused cardiac ultrasound to physicians: A supervised human model course versus an eLearning guided self- directed simulator course

PURPOSE

Focused cardiac ultrasound (FCU) training in critical care is restricted by availability of instructors. Supervised training may be substituted by self-directed learning with an ultrasound simulator guided by automated electronic learning, enabling scalability.

MATERIALS AND METHODS

We prospectively compared learning outcomes in novice critical care physicians after completion of a supervised one-and-a-half-day workshop model with a self-guided course utilizing a simulator over four weeks. Both groups had identical pre-workshop on-line learning (20h). Image quality scores were compared using FCU performed on humans without pathology. Interpretive knowledge was compared using 20MCQ tests.

RESULTS

Of 161 eligible, 145 participants consented. Total Image quality scores were higher in the Simulator group (95.2% vs. 66.0%, P < .001) and also higher for each view (all P < .001). Interpretive knowledge was not different before (78.6% vs. 79.0%) and after practical training (74.7% vs. 76.1%) and at 3 months (81.0% vs. 77.0%, all P > .1). Including purchase of the simulator and ultrasound equipment, the simulator course required lower direct costs (AUD$796 vs. $1724 per participant) and instructor time (0.5 vs.1.5 days) but similar participant time (2.8 vs. 3.0 days).

CONCLUSIONS

Self-directed learning with ultrasound simulators may be a scalable alternative to conventional supervised teaching with human models.

Data-Driven Rescoring of Metabolite Annotations Significantly Improves Sensitivity

When analyzing mass spectrometry imaging data sets, assigning a molecule to each of the thousands of generated images is a very complex task. Recent efforts have taken lessons from (tandem) mass spectrometry proteomics and applied them to imaging mass spectrometry metabolomics, with good results. Our goal is to go a step further in this direction and apply a well established, data-driven method to improve the results obtained from an annotation engine. By using a data-driven rescoring strategy, we are able to consistently improve the sensitivity of the annotation engine while maintaining control of statistics like estimated rate of false discoveries. All the code necessary to run a search and extract the additional features can be found at https://github.com/anasilviacs/sm-engine and to rescore the results from a search in https://github.com/anasilviacs/rescore-metabolites .

Procedural sedation of elderly patients by emergency physicians: a safety analysis of 740 patients

BACKGROUND

The elderly are perceived as a high-risk group for procedural sedation. Concern exists regarding the safety of sedation of this patient group by emergency physicians, particularly when using propofol.

METHODS

We analysed prospectively collected data on patients aged 75 yr or older undergoing sedation between October 2006 and March 2017 in the emergency department of a single centre. We used the World Society of Intravenous Anaesthesia International Sedation Task Force adverse event tool, stratifying identified adverse events according to consensus agreement.

RESULTS

Of 740 consecutive patients (median age 84 yr), 571 patients received propofol, 142 morphine and midazolam, and 27 other agents. We identified 19 sentinel events: 2 cases of hypoxia, 10 of apnoea (without hypoxaemia), 5 of hypotension, and 2 of both hypoxaemia and hypotension. We also identified 30 moderate, 41 minor, and 7 minimal risk adverse events. There were no adverse outcomes.

CONCLUSIONS

We observed safe sedation practice in this high-risk group of patients in this department. A sentinel adverse event rate of 2.6% including a hypoxaemia rate of 0.5%, with no adverse outcomes sets a benchmark for elderly sedation. We recommend quality pre-oxygenation, an initial propofol bolus of no more than 0.5 mg kg^-1, and a robust training and governance framework.

Uptake of and Expenditure on Direct-Acting Antiviral Agents for Hepatitis C Treatment in Australia

BACKGROUND

Direct-acting antiviral agents (DAAs) have revolutionised treatment for the hepatitis C virus (HCV). Currently, treatment costs between 20,000 and 80,000 Australian dollars ($A) per patient. The Australian Federal Government provided $A1 billion over 5 years to subsidise these drugs.

OBJECTIVE

The aim of this paper was to evaluate the uptake and financial impact of DAA prescribing in Australia.

METHODS

We undertook a retrospective analysis of Medicare prescription and expenditure data for March 2016 to August 2017. Prescription numbers and expenditure data were extracted from the Medicare Statistical Reports website. Numbers of prescriptions were converted to per capita rates. HCV prevalence measures were used to provide context to prescription rates. All costs were reported in $A, year 2017 values.

RESULTS

Nationally, 211,184 DAA prescriptions were reimbursed. Whilst $A3.6 billion was expended through the Pharmaceutical Benefits Scheme, confidential pricing agreements precluded calculation of the precise cost. In 18 months, estimated expenditure greatly exceeded the $A1 billion in funding for 5 years. Nationally, the rate of prescriptions was 872/100,000 individuals. Prescription rates were highest in the Australian Capital Territory (1087/100,000) and lowest in Western Australia (625/100,000) despite HCV prevalence being comparable to the national rate in both regions.

CONCLUSIONS

Uptake of DAAs has been enthusiastic in the first 18 months of this funding agreement. However, the lack of transparency due to the confidential special pricing agreements means actual government expenditure is unknown. Post-marketing review by the Pharmaceutical Benefits Advisory Committee may enable renegotiation of DAA prices with the sponsors.

Comparative enteric viruses and coliphage removal during wastewater treatment processes in a sub-tropical environment

Microbiological safety of reclaimed water is one of the most important issues in managing potential health risks related to wastewater recycling. Presence and removal of human adenovirus (HAdV), human polyomavirus (HPyV), human torque teno virus (HTtV) and somatic coliphage family Microviridae in three wastewater treatment plants (WWTP) in sub-tropical Brisbane, Australia was investigated. All three WWTPs employ activated sludge process with added on Bardenpho process for nutrient removal. HPyV, HAdV, HTtV and Microviridae were consistently detected in the influent (10⁵ to 10⁶ Genomic copies (GC) L^-1) and secondary treated effluent (10² to 10³GCL^-1). The results of this study suggest that, under appropriate conditions, WWTPs with activated sludge process in sub-tropical climate could be an effective treatment barrier with >3 log₁₀ removal of enteric virus. The geometric mean of pooled data for each virus from all sites showed the highest removal for HPyV (3.65 log₁₀) and lowest for HAdV (2.79 log₁₀) which was statistically significant (p=0.00001). Whereas, the removal rate of HTtV and Microviridae was identical (2.81 log₁₀). A poor correlation between the presence of enteric virus in influent or effluent with routinely monitored physicochemical parameters suggests limited use of physicochemical parameters as predictors of enteric virus presence. High prevalence of HAdV in influent and effluent combined with comparatively low removal suggest that it could be used as a model microorganism for determining enteric virus removal efficacy. Additional tertiary treatment may be required prior to effluent reuse for non-potable purposes or discharge into the recreational waters to prevent exposure of people to health hazards.

Transport and potential attenuation of nitrogen in shallow groundwaters in the lower Rangitikei catchment, New Zealand

Intensive agricultural activities are generally associated with nitrogen leaching from agricultural soils, and this nitrogen has the potential to percolate and contaminate groundwater and surface waters. We assessed surface water and groundwater interactions, and nitrogen leaching and its potential attenuation in shallow groundwater in the lower Rangitikei River catchment (832km²), New Zealand. We combined regional- and local-scale field surveys and experiments, nutrient budget modelling, and hydraulic and geochemical methods, to gain an insight into leaching, transformation and transport of nitrogen via groundwaters to the river in the study area. Concurrent river flow gaugings (in January 2015) and a piezometric map, developed from measured depths to groundwater in 110 bores (in October 2014), suggest groundwater discharges to the Rangitikei River in the upper parts of the study area, while there is groundwater recharge near the coast. The groundwater redox characterisation, based on sampling and analysis of 15 mostly shallow bores (<30m below ground level (bgl)), suggests groundwater across the lower Rangitikei catchment in general is under anoxic/reduced conditions. The groundwater typically has low dissolved oxygen (DO) concentrations (<1mg/L), suggesting the subsurface environment is conducive to potential attenuation by 'denitrification' of NO₃-N in groundwater. We further measured NO₃-N attenuation in shallow groundwater piezometers (3-6mbgl) using single-well push-pull tests. We found generally low levels (<0.5mg/L) of NO₃-N in shallow groundwater piezometers (>5mbgl), despite being installed under intensive land uses, such as dairying and cropping. Our in-field push-pull tests showed NO₃-N reduction at four shallow groundwater piezometers, with the rates of reduction varying from 0.04mgNL^-1h^-1 to 1.57mgNL^-1h^-1. This highlights the importance of a sound understanding of not only the sources, but also transport and transformation, or fate, of nutrients leached from farms, to mitigate the likely impacts of land use on water quality and ecosystem health in agricultural catchments.

Mycophenolate mofetil therapy in immunoglobulin A nephropathy: histological changes after treatment

Background

Endocapillary hypercellularity independently predicts renal outcome in immunoglobulin A nephropathy (IgAN). Mycophenolate mofetil (MMF) treatment is offered to patients presenting to the Imperial College Renal and Transplant Centre with IgAN and histological evidence of endocapillary hypercellularity. Clinical trials of MMF in IgAN have been inconclusive and have been limited by a lack of specific histological inclusion and exclusion criteria when recruiting patients. Evidence of histological improvement following MMF treatment would support its therapeutic use. We therefore reviewed histological changes after MMF therapy in a cohort of IgAN patients.

Method

Eighteen IgAN patients with native renal biopsies before and after repeated MMF treatment were identified. Patients were excluded if they had received any other immunosuppressive therapy, including corticosteroids. On the basis of the Oxford Classification of IgAN, we reviewed histological changes after MMF treatment.

Results

Nine patients (50%) were male. At diagnostic renal biopsy, the median age was 35 years [interquartile range (IQR) 30-41], serum creatinine was 97 µmol/L (IQR 79-153) and urine protein creatinine ratio (UPCR) was 146 mg/mmol (IQR 98-212). The median time between biopsies was 24 months (range 9-41). Following MMF treatment, repeat biopsy demonstrated statistically significant improvement in the mean percentage of glomeruli showing endocapillary hypercellularity and cellular/fibrocellular crescents. There was no change in mesangial hypercellularity, segmental sclerosis or tubular atrophy scores. Mesangial IgA deposition was also significantly reduced. Histopathological improvement persisted after the cessation of MMF therapy, suggesting that 2 years of treatment is adequate for benefit. The median serum creatinine remained stable at 3 years follow-up at 104 µmol/L (IQR 79-147).

Conclusion

MMF treatment is associated with histopathological improvement in IgAN.

Diagnostic and prognostic value of delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) in early osteoarthritis of the hip

BACKGROUND

Delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) can detect glycosaminoglycan loss in the acetabular cartilage of asymptomatic individuals with cam morphology. The aims of this study were to explore the relationship between cam morphology and dGEMRIC values, and to explore whether baseline dGEMRIC can predict the development of radiographic hip osteoarthritis.

METHODS

Prospective cohort (SibKids) study with clinical, radiographic, and MRI assessment at baseline and five-year follow-up (n = 34). The dGEMRIC values of cartilage regions were correlated with measures of cam morphology. Receiver operating characteristic (ROC) analysis was applied to baseline variables to predict radiographic loss of joint space width.

RESULTS

Superolateral acetabular cartilage dGEMRIC values were significantly lower in participants with cam morphology (P < 0.001), defined as an alpha angle greater than 60°. There was a negative correlation between alpha angle and the dGEMRIC value of adjacent acetabular cartilage. This relationship was strongest superoanteriorly (r = -0.697 P < 0.001). There was a positive correlation between baseline dGEMRIC and the magnitude of joint space width narrowing (r = 0.398 P = 0.030). ROC analysis of combined baseline variables (positive impingement test, alpha angle, dGEMRIC ratio) gave an Area Under the Curve (AUC) of 0.75 for predicting joint space width narrowing greater than 0.5 mm within 5 years.

CONCLUSIONS

The size and position of cam morphology determines the severity and location of progressive cartilage damage, supporting the biomechanical aetiology of femoroacetabular impingement. Baseline dGEMRIC is able to predict the development of radiographic osteoarthritis. Compositional MRI offers the potential to identify patients who may benefit from early intervention to prevent the development of osteoarthritis.

Optimization of sampling strategy to determine pathogen removal efficacy of activated sludge treatment plant

Large-scale wastewater schemes rely on multi-barrier approach for the production of safe and sustainable recycled water. In multi-barrier wastewater reclamation systems, conventional activated sludge process (ASP) often constitutes a major initial treatment step. The main aim of this research was to determine most appropriate sampling approach to establish pathogen removal efficacy of ASP. The results suggest that ASP is capable of reducing human adenovirus (HAdV) and polyomavirus (HPyV) by up to 3 log₁₀. The virus removal data suggests that HAdV removal is comparable to somatic bacteriophage belonging to Microviridae family. Due to the high removal of Escherichia coli (>3 log₁₀) and very poor correlation with the enteric virus, it is not recommended that E. coli be used as a surrogate for enteric virus removal. The results also demonstrated no statistically significant differences (t test, P > 0.05) in calculated log removal values (LRVs) for HAdV, HPyV, and Microviridae from samples collected on hydraulic retention time (HRT) or simultaneous paired samples collected for influent and effluent. This indicates that a more practical approach of simultaneous sampling for influent and effluent could be used to determine pathogen removal efficiency of ASP. The results also suggest that a minimum of 10, preferably 20 samples, are required to fully capture variability in the removal of virus. In order to cover for the potential seasonal prevalence of viruses such as norovirus and rotavirus, sampling should be spread across all seasons.

Osseous impingement occurs early in flexion in cam-type femoroacetabular impingement

Aims

The aim of this study was to examine the real time in vivo kinematics of the hip in patients with cam-type femoroacetabular impingement (FAI).

Patients and Methods

A total of 50 patients (83 hips) underwent 4D dynamic CT scanning of the hip, producing real time osseous models of the pelvis and femur being moved through flexion, adduction, and internal rotation. The location and size of the cam deformity and its relationship to the angle of flexion of the hip and pelvic tilt, and the position of impingement were recorded.

Results

In these patients with cam-type FAI, there was significant correlation between the alpha angle and flexion to the point of impingement (mean 41.36°; 14.32° to 57.95°) (R = -0.5815 and p = < 0.001). Patients with a large cam deformity (alpha angle > 78°) had significantly less flexion to the point of impingement (mean 36.30°; 14.32° to 55.18°) than patients with a small cam deformity (alpha angle 60° to 78°) (mean 45.34°; 27.25° to 57.95°) (p = < 0.001).

Conclusion

This study has shown that cam-type impingement can occur early in flexion (40°), particularly in patients with large anterior deformities. These patients risk chondrolabral damage during routine activities such as walking, and going up stairs. These findings offer important insights into the cause of the symptoms, the mechanisms of screening and the forms of treatment available for these patients. Cite this article: Bone Joint J 2017;99-B(4 Supple B):41–8.

How Consistent is the Relationship between Improved Glucose Control and Modelled Health Outcomes for People with Type 2 Diabetes Mellitus? a Systematic Review

BACKGROUND

There are an increasing number of studies using simulation models to conduct cost-effectiveness analyses for type 2 diabetes mellitus.

OBJECTIVE

To evaluate the relationship between improvements in glycosylated haemoglobin (HbA_1c) and simulated health outcomes in type 2 diabetes cost-effectiveness studies.

METHODS

A systematic review was conducted on MEDLINE and EMBASE to collect cost-effectiveness studies using type 2 diabetes simulation models that reported modelled health outcomes of blood glucose-related interventions in terms of quality-adjusted life-years (QALYs) or life expectancy (LE). The data extracted included information used to characterise the study cohort, the intervention's treatment effects on risk factors and model outcomes. Linear regressions were used to test the relationship between the difference in HbA_1c (∆HbA_1c) and incremental QALYs (∆QALYs) or LE (∆LE) of intervention and control groups. The ratio between the ∆QALYs and ∆LE was calculated and a scatterplot between the ratio and ∆HbA_1c was used to explore the relationship between these two.

RESULTS

Seventy-six studies were included in this research, contributing to 124 pair of comparators. The pooled regressions indicated that the marginal effect of a 1% HbA_1c decrease in intervention resulted in an increase in life-time QALYs and LE of 0.371 (95% confidence interval 0.286-0.456) and 0.642 (95% CI 0.494-0.790), respectively. No evidence of heterogeneity between models was found. An inverse exponential relationship was found and fitted between the ratio (∆QALY/∆LE) and ∆HbA_1c.

CONCLUSION

There is a consistent relationship between ∆HbA_1c and ∆QALYs or ∆LE in cost-effectiveness analyses using type 2 diabetes simulation models. This relationship can be used as a diagnostic tool for decision makers.

Seasonal Assessment of Opportunistic Premise Plumbing Pathogens in Roof-Harvested Rainwater Tanks

A seasonal study on the occurrence of six opportunistic premise plumbing pathogens (OPPPs) in 24 roof-harvested rainwater (RHRW) tanks repeatedly sampled over six monthly sampling events (n = 144) from August 2015 to March 2016 was conducted using quantitative qPCR. Fecal indicator bacteria (FIB) Escherichia coli (E. coli) and Enterococcus spp. were enumerated using culture-based methods. All tank water samples over the six events were positive for at least one OPPP (Legionella spp., Legionella pneumophila, Mycobacterium avium, Mycobacterium intracellulare, Pseudmonas aeruginosa, or Acanthamoeba spp.) during the entire course of the study. FIB were positively but weakly correlated with P. aeruginosa (E. coli vs P. aeruginosa τ = 0.090, p = 0.027; Enterococcus spp. vs P. aeruginosa τ = 0.126, p = 0.002), but not the other OPPPs. FIBs were more prevalent during the wet season than the dry season, and L. pneumophila was only observed during the wet season. However, concentrations of Legionella spp., M. intracellulare, Acanthamoeba spp., and M. avium peaked during the dry season. Correlations were assessed between FIB and OPPPs with meteorological variables, and it was determined that P. aeruginosa was the only OPPP positively associated with an increased antecedent dry period, suggesting stagnation time may play a role for the occurrence of this OPPP in tank water. Infection risks may exceed commonly cited benchmarks for uses reported in the rainwater usage survey such as pool top-up, and warrant further exploration through quantitative microbial risk assessment (QMRA).

Public health implications of Acanthamoeba and multiple potential opportunistic pathogens in roof-harvested rainwater tanks

A study of six potential opportunistic pathogens (Acanthamoeba spp., Legionella spp., Legionella longbeachae, Pseudomonas aeruginosa, Mycobacterium avium and Mycobacterium intracellulare) and an accidental human pathogen (Legionella pneumophila) in 134 roof-harvested rainwater (RHRW) tank samples was conducted using quantitative PCR (qPCR). All five opportunistic pathogens and accidental pathogen L. pneumophila were detected in rainwater tanks except Legionella longbeachae. Concentrations ranged up to 3.1×10(6) gene copies per L rainwater for Legionella spp., 9.6×10(5) gene copies per L for P. aeruginosa, 6.8×10(5) gene copies per L for M. intracellulare, 6.6×10(5) gene copies per L for Acanthamoeba spp., 1.1×10(5) gene copies per L for M. avium, and 9.8×10(3) gene copies per L for L. pneumophila. Among the organisms tested, Legionella spp. (99% tanks) were the most prevalent followed by M. intracellulare (78%). A survey of tank-owners provided data on rainwater end-uses. Fecal indicator bacteria (FIB) Escherichia coli and Enterococcus spp. were enumerated using culture-based methods, and assessed for correlations with opportunistic pathogens and L. pneumophila tested in this study. Opportunistic pathogens did not correlate well with FIB except E. coli vs. Legionella spp. (tau=0.151, P=0.009) and E. coli vs. M. intracellulare (tau=0.14, P=0.015). However, M. avium weakly correlated with both L. pneumophila (Kendall's tau=0.017, P=0.006) and M. intracellulare (tau=0.088, P=0.027), and Legionella spp. also weakly correlated with M. intracellulare (tau=0.128, P=0.028). The presence of these potential opportunistic pathogens in tank water may present health risks from both the potable and non-potable uses documented from the current survey data.

Role of Iron in Hydrogen Sulphide Removal from Hot Gas

Yields of SO2 formed during H2S removal from N2 + H2S mixture at 800°C in the presence of Fe2O3, Mn-nodule and red mud have been determined. The largest yields were observed for Fe2O3 followed by Mn-nodule, whereas no SO2 was detected in the presence of red mud. A mechanism for H2S reaction with Fe oxides has been proposed involving the use of the component distribution in the clean gas as well as the Fe sulphides formed during adsorption. X-ray diffraction and Mossbauer spectroscopy have been used to determine the forms of Fe in the solids at the end of adsorption. FeS was the main sulphide which was always accompanied by FeS2.