Prevalence of food insecurity among caregivers of young children during the COVID-19 pandemic in Ireland

Our objectives were to explore the prevalence of food insecurity in primary caregivers of young children in Ireland and to compare two tools for measuring food insecurity during the COVID-19 crisis. A cross-sectional online survey was conducted among caregivers of children aged <2 years in Ireland in May/June 2020. Relevant survey questions were closed-ended using two established tools for measuring food poverty/insecurity; the Irish Food Poverty Indicator and the Food Insecurity Experience Scale, developed by the Food and Agriculture Organization. Descriptive statistics were used to calculate the prevalence of food poverty/insecurity. To explore agreement in the classification of food insecurity by the Food Poverty Indicator and the Food Insecurity Experience Scale, Cohen's κ was used. Analyses are based on 716 participants; most had a 3rd-level education and were married or in a partnership. Per the food poverty index, Ireland's national measure of food poverty, 3.9% (n = 28) of our sample were experiencing food poverty. This rose to 10.5% (n = 75) experiencing food insecurity when using the Food Insecurity Experience Scale, which also measures worry/anxiety around access to food. There was low agreement between the tools, with 11.3% of the sample classified as food secure by one tool and food insecure by the other. Our current measure of food poverty in Ireland may not be sufficient to describe the food-access struggles or worry/anxiety about food access, experienced by the population, particularly during an emergency like COVID-19.

Temporal effects on death by suicide: empirical evidence and possible molecular correlates

Popular culture and medical lore have long postulated a connection between full moon and exacerbations of psychiatric disorders. We wanted to empirically analyze the hypothesis that suicides are increased during the period around full moons. We analyzed pre-COVID suicides from the Marion County Coroner's Office (n = 776), and show that deaths by suicide are significantly increased during the week of the full moon (p = 0.037), with older individuals (age ≥ 55) showing a stronger effect (p = 0.019). We also examined in our dataset which hour of the day (3-4 pm, p = 0.035), and which month of the year (September, p = 0.09) show the most deaths by suicide. We had blood samples on a subset of the subjects (n = 45), which enabled us to look at possible molecular mechanisms. We tested a list of top blood biomarkers for suicidality (n = 154) from previous studies of ours 7, to assess which of them are predictive. The biomarkers for suicidality that are predictive of death by suicide during full moon, peak hour of day, and peak month of year, respectively, compared to outside of those periods, appear to be enriched in circadian clock genes. For full moon it is AHCYL2, ACSM3, AK2, and RBM3. For peak hour it is GSK3B, AK2, and PRKCB. For peak month it is TBL1XR1 and PRKCI. Half of these genes are modulated in expression by lithium and by valproate in opposite direction to suicidality, and all of them are modulated by depression and alcohol in the same direction as suicidality. These data suggest that there are temporal effects on suicidality, possibly mediated by biological clocks, pointing to changes in ambient light (timing and intensity) as a therapeutically addressable target to decrease suicidality, that can be coupled with psychiatric pharmacological and addiction treatment preventive interventions.

Age related progression of clinical measures and gait in ambulant children and youth with bilateral cerebral palsy without a history of surgical intervention

BACKGROUND

Age related progression needs to be considered when assessing current status and treatment outcomes in cerebral palsy (CP).

RESEARCH QUESTION

What is the association between age, gait kinematics and clinical measures in children with bilateral CP?

METHOD

A retrospective database review was conducted. Subjects with bilateral CP with baseline and follow-up 3D gait analyses, but no history of intervening surgery were identified. Clinical and summary kinematic measures were examined for age related change using repeat measures correlation. Interactions with GMFCS classification and whether surgery was recommended were examined using robust linear regression. Timeseries kinematic data for baseline and most recent follow-up analyses were analysed using statistical parametric mapping.

RESULTS

180 subjects were included. 75% of participants were classified as GMFCS I or II at baseline. Mean time to follow-up was 4.89 (2.8) years (range 1-15.9 years) with a mean age of 6.4 (2.4) at baseline and 11.3 (3.4) at final follow-up. 15.5% of subjects demonstrated an improvement in GMFCS classification while GDI remained stable. Age related progression was noted across many clinical measures with moderate correlations (r ≥ 0.5) noted for reduced popliteal angle, long lever hip abduction and internal hip rotation range. In gait, there was reduced hip extension in late stance (p < 0.001), increased knee flexion in mid-stance (p < 0.001), reduced peak knee flexion in swing (p < 0.001) and increased ankle dorsiflexion in stance (p < 0.001). In the coronal plane, there was reduced hip abduction in swing (p < 0.001). In the transverse plane, increased external rotation of the knee (p < 0.001) and reduced external ankle rotation were noted in early stance and through swing (p < 0.001). There were no changes in foot progression or hip rotation.

SIGNIFICANCE

Individuals with CP show age related progression of clinical and kinematic variables. Treatment can only be deemed successful if outcomes exceed or match these age-related changes.

Persisting Symptomatic Severe Secondary Mitral Regurgitation in Heart Failure Patients

Aims We aimed to assess the rate of persisting severe symptomatic secondary mitral regurgitation (MR) in a newly diagnosed heart failure (HF) population following optimisation of guideline directed medical therapy (GDMT), cardiac resynchronisation therapy (CRT) and revascularisation. Methods We assessed all new patients referred to our hospital group’s HF clinics. We retrospectively reviewed these patients at HF clinic enrolment, HF programme completion, as well as most recent follow up. Results Of the 242 new patients referred to our HF clinics, there were 10 patients (4.1%) who had either persisting symptomatic severe secondary MR at HF programme completion, or had undergone mitral valve surgery. There were no percutaneous mitral valve repairs at the time of these patients’ referrals. The rates of ACE/ARB/ARNI, BB and MRA use were 87.8%, 94.1%, and 49.8% in those with mid ranged, or reduced ejection fraction. The rates of ICD and CRT therapy were 15.1% and 4.4% at follow up. Patients with severe MR had higher time adjusted rates of death or hospitalization for heart failure. Conclusion In a well-treated newly diagnosed HF population, repeat assessment at HF programme completion suggests 4.1% of patients have a persisting indication for percutaneous mitral valve repair based on persisting severe symptomatic secondary MR.

104 COMPARING THE OTTAWA 3DY AND 6CIT IN DETECTING COGNITIVE IMPAIRMENT IN OLDER PATIENTS SEEN BY AN EMERGENCY DEPARTMENT THERAPY TEAM

Background

Recognising cognitive impairment in the Emergency Department (ED) is important in order to optimise outcomes for patients and to carry out a holistic assessment.

Currently the team screen routinely for delirium using the 4AT. Since 2016 the 03DY was used to screen for mild cognitive impairment however it was not being completed frequently in practice.

In a busy ED setting where time and resources are limited, one brief tool is preferable. The purpose of this investigation is to determine the most accurate cognitive screening tool to identify cognitive impairment in older adults in ED.

Methods

A literature review was completed comparing recent articles which examined the O3DY and 6CIT. The search criteria for journal articles were:

● Published within the last 10 years.

● Published in English.

● Full text only.

● Database: CINAHL.

Results

Our investigation identified that the O3DY offered the greatest sensitivity to rule out cognitive impairment.

The O3DY is quick to administer, requires no additional equipment or training, and can be completed at the patient’s bedside (BGS, 2020) which is particularly important within the ED. The 6CIT was shown to have poorer sensitivity for MCI diagnosis (Abdel-Aziz and Larner, 2014) and has a mathematical component which studies noted may not be appropriate for use in a busy clinical setting.

Conclusion

From this literature review, the O3DY has been identified as the most appropriate cognitive screening tool for our team to detect MCI in the ED. It is important to note that many of the articles reviewed highlighted that a single cognitive screen should not be used in isolation for the identification of cognitive impairment. It is unlikely that completing more than one cognitive screen is achievable in the ED however by implementing the most sensitive screening tool we can identify potential MCI and refer onwards.

SAT0609-HPR DELPHI CONSENSUS FOR THE OPTIMAL TREATMENT & MANAGEMENT OF COMPLEX RHEUMATOID ARTHRITIS (RA) PATIENTS

Background:

A significant proportion of patients with rheumatoid arthritis (RA) have additional considerations that must be taken into account for managing their disease.1These include; co-morbidities, extra-articular manifestations and poor prognostic factors.2-5Tailored management could reduce the burden on patients, the health system and wider society.

The ‘complex’ RA patient group is ill-defined and no specific recommendations exist for their optimal management and treatment.

Objectives:

A group of UK Rheumatology experts aimed to provide a set of recommendations to support consistent and high quality management, grounded in current evidence, expert opinion and best practice.

Methods:

A steering group meeting identified priority topics associated with complex RA.

Table 1.

Topics for consensus

TopicNo. of statementsDefinition of ‘complex’ RA from a medical perspective19Definition of patient factors that may contribute to ‘complex’ RA3Outcomes for RA patients with co-morbidities and/or extra articular manifestations5Prescribing options for ‘complex’ RA8Evidence vs. best practice requirements4Burden of ‘complex’ RA4TOTAL NUMBER OF STATEMENTS43

For each topic, the group defined statements they all agreed with. Delphi methodology was used to ratify these statements with rheumatology peers.

High levels of agreement (over 70%) were achieved in the first round, the group proceeded to formulate the recommendations.

Figure 1.

Responses received (n=163)

Figure 2.

Consensus Plot (total responses n=163)

Conclusion:

These recommendations are offered:

References:

[1]Uhlig T, Moe RH, Kvien TK. The burden of disease in rheumatoid arthritis. Pharmacoeconomics 2014;32:841–51

[2]Dougados M, et al. Ann Rheum Dis 2014;73:62–68.

[3]Parodi M et al,Rheumatism, 2005, 57(3): 154-60.

[4]Young A & Koduri G. Best Pract Res Clin Rheumatol. 2007 Oct;21(5):907-27.

[5]Holroyd CR, et al. Rheumatology 2019;58:e3-e42

Acknowledgments:

Support for medical writing/editorial assistance, provided by Tim Warren at Triducive was funded by Roche Products Ltd. & Chugai Pharma Ltd. in accordance with Good Publication Practice (GPP3) guidelines (http://www.ismpp.org/gpp3).

Disclosure of Interests:

Gurdeep Dulay Grant/research support from: Educational grants to attend congress meetings/conferences from Roche, Chugai, UCB, Internis, Pfizer, Lilly, Sandoz, Consultant of: Honoraria for advisory board services from Roche, Chugai, Novartis, Speakers bureau: Speaker fees from Roche, Chugai, Novartis, Amgen, Lilly, Sandoz, Ernest Choy Grant/research support from: Amgen, Bio-Cancer, Chugai Pharma, Ferring Pharmaceuticals, Novimmune, Pfizer, Roche, UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Chelsea Therapeutics, Chugai Pharma, Daiichi Sankyo, Eli Lilly, Ferring Pharmaceuticals, GlaxoSmithKline, Hospita, Ionis, Janssen, Jazz Pharmaceuticals, MedImmune, Merck Sharp & Dohme, Merrimack Pharmaceutical, Napp, Novartis, Novimmune, ObsEva, Pfizer, R-Pharm, Regeneron Pharmaceuticals, Inc., Roche, SynAct Pharma, Sanofi Genzyme, Tonix, UCB, Speakers bureau: Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Chugai Pharma, Eli Lilly, Hospira, Merck Sharp & Dohme, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Sanofi-Aventis, UCB, Theresa Barnes Consultant of: Ad boards for Roche, Actelion and Abbvie, Speakers bureau: Speaker for MSD, UCB, Pfizer, Abbvie, Actelion, Roche and BMS, Debbie Chagadama Consultant of: Roche, Chugai, BI, Speakers bureau: Roche, Chugai, BI, Zoe Cole Consultant of: Consultancy work for Roche, Lilly, Gilead, Abbvie, Pfizer, UCB, Speakers bureau: Lilly, BMS, Abbvie, Pfizer, UCB, Janssen, Anshuman Malaviya Consultant of: Roche, Chugai, MSD, Pfizer, Novartis, Lily, BMS, Speakers bureau: Roche, BMS, Pfizer, MSD, Sandra Robinson Consultant of: Eli Lilly for Education Nurse Meeting, David Walker Grant/research support from: Gilead, Consultant of: Gilead, Lilly, Pfizer, Roche, Speakers bureau: Lilly, Pfizer, Roche, Chris Daly Employee of: Roche, Nicola Savill Employee of: Roche, Tim Warren Consultant of: Roche, Employee of: AstraZeneca, Nick Williams Shareholder of: MSD, Consultant of: Roche, Employee of: MSD

Primary surgical management of anterior pelvic organ prolapse: a systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

Anterior compartment prolapse is the most common pelvic organ prolapse (POP) with a range of surgical treatment options available.

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of surgical treatments for the repair of anterior POP.

METHODS

We conducted a systematic review of randomised controlled trials comparing surgical treatments for women with POP. Network meta-analysis was possible for anterior POP, same-site recurrence outcome. A Markov model was used to compare the cost-utility of surgical treatments for the primary repair of anterior POP from a UK National Health Service perspective.

MAIN RESULTS

We identified 27 eligible trials for the network meta-analysis involving eight surgical treatments tested on 3194 women. Synthetic mesh was the most effective in preventing recurrence at the same site. There was no evidence to suggest a difference between synthetic non-absorbable mesh, synthetic partially absorbable mesh, and biological mesh. The cost-utility analysis, which incorporated effectiveness, complications and cost data, found non-mesh repair to have the highest probability of being cost-effective. The conclusions were robust to model inputs including effectiveness, costs and utility values.

CONCLUSIONS

Anterior colporrhaphy augmented with mesh appeared to be cost-ineffective in women requiring primary repair of anterior POP. There is a need for further research on long-term effectiveness and the safety of mesh products to establish their relative cost-effectiveness with a greater certainty.

TWEETABLE ABSTRACT

New study finds mesh cost-ineffective in women with anterior pelvic organ prolapse.

Infective endocarditis: a retrospective cohort study

BACKGROUND

Infective endocarditis (IE) is a potentially life-threatening infection of the heart's endocardial surface. Despite advances in the diagnosis and management of IE, morbidity and mortality remain high.

AIM

To characterize the demographics, bacteriology and outcomes of IE cases presenting to an Irish tertiary referral centre.

DESIGN

Retrospective cohort study.

METHODS

Patients were identified using Hospital Inpatient Enquiry and Clinical Microbiology inpatient consult data, from January 2005 to January 2014. Patients were diagnosed with IE using Modified Duke Criteria. Standard Bayesian statistics were employed for analysis and cases were compared to contemporary international registries.

RESULTS

Two hundred and two patients were diagnosed with IE during this period. Mean age 54 years. Of these, 136 (67%) were native valve endocarditis (NVE), 50 (25%) were prosthetic valve endocarditis (PVE) and 22 (11%) were cardiovascular implantable electronic device-associated endocarditis. Culprit organism was identified in 176 (87.1%) cases and Staphylococcal species were the most common (57.5%). Fifty-nine per cent of NVE required surgery compared to 66% of PVE. Mean mortality rate was 17.3%, with NVE being the lowest (12.5%) and PVE the highest (32%). Increasing age was also associated with increased mortality. Fifty-three (26.2%) patients had embolic complications.

CONCLUSIONS

This Irish cohort exhibited first-world demographic patterns comparable to those published in contemporary international literature. PVE required surgery more often and was associated with higher rates of mortality than NVE. Embolic complications were relatively common and represent important sequelae, especially in the intravenous drug user population. It is also pertinent to aggressively treat older cohorts as they were associated with increased mortality.

Assessing the pathogenicity of RYR1 variants in malignant hyperthermia

Background

. Missense variants in the ryanodine receptor 1 gene ( RYR1 ) are associated with malignant hyperthermia but only a minority of these have met the criteria for use in predictive DNA diagnosis. We examined the utility of a simplified method of segregation analysis and a functional assay for determining the pathogenicity of recurrent RYR1 variants associated with malignant hyperthermia.

Methods

. We identified previously uncharacterised RYR1 variants found in four or more malignant hyperthermia families and conducted simplified segregation analyses. An efficient cloning and mutagenesis strategy was used to express ryanodine receptor protein containing one of six RYR1 variants in HEK293 cells. Caffeine-induced calcium release, measured using a fluorescent calcium indicator, was compared in cells expressing each variant to that in cells expressing wild type ryanodine receptor protein.

Results.

We identified 43 malignant hyperthermia families carrying one of the six RYR1 variants. There was segregation of genotype with the malignant hyperthermia susceptibility phenotype in families carrying the p.E3104K and p.D3986E variants, but the number of informative meioses limited the statistical significance of the associations. HEK293 functional assays demonstrated an increased sensitivity of RyR1 channels containing the p.R2336H, p.R2355W, p.E3104K, p.G3990V and p.V4849I compared with wild type, but cells expressing p.D3986E had a similar caffeine sensitivity to cells expressing wild type RyR1.

Conclusions

. Segregation analysis is of limited value in assessing pathogenicity of RYR1 variants in malignant hyperthermia. Functional analyses in HEK293 cells provided evidence to support the use of p.R2336H, p.R2355W, p.E3104K, p.G3990V and p.V4849I for diagnostic purposes but not p.D3986E.

Improving the Quality of Outcomes of Complex Cancer Surgery Through National Standards: Lessons From Canada

Background and context: Evidence shows there is wide variability in cancer care service delivery and patient outcomes. Outcomes of complex surgery can be improved by following standards that outline optimal ways to plan, organize and deliver surgical care. While some cancer surgeries are associated with a high risk of adverse outcomes, they also offer the best option for a cure. To ensure optimal patient outcomes, deliberate approaches are needed to standardize the organization of complex care surgeries. Aim: Leverage the expertise of specialty-based and multidisciplinary communities to develop pan-Canadian standards of practice as a means to elevate the delivery of oncologic surgery in Canada. Strategy/Tactics: A phased, multimodal qualitative and quantitative approach was undertaken to develop evidence-based consensus standards for best practice in complex surgery, through the analysis of administrative data to examine access and outcomes of complex, advanced-care surgery and discussion with public representatives to explore trade-offs for reorganizing cancer surgery. Results informed a literature review to identify best practices in complex surgery. Expert panels were convened with disease specific specialty surgeons to inform the development of evidence-informed consensus standards. Draft standards were finalized after targeted review and validation by a wider community of healthcare professionals. Program/Policy process: The standards were endorsed by national professional organizations. An audit was conducted with all surgical programs in Canada to assess pan-Canadian compliance with the standards. Barriers to compliance were tracked to identify areas where local, regional or national activity could support quality initiatives. Outcomes: National standards were developed and highlighted: surgeon criteria, practice settings, and quality improvement. These comprehensive standards provide actionable recommendations that can be tailored to meet local needs. The standards will help organize care in way that maximizes patient outcomes while maintaining reasonable access to care. This work reflects a Canadian approach to a global problem around appropriate delivery of cancer surgical services and facilitates international conversations to mobilize effective knowledge transfer and best practices. What was learned: • Development of national standards is an iterative process that requires upfront buy-in from surgeons, multidisciplinary communities and national associations. Lessons learned from this initiative can support development of international demonstration projects and can help model a process that others could use. • Mechanisms to enhance knowledge of the optimal organization of complex surgery services requires multifaceted and sustained attention. Thoughtful exploration of how surgical care interfaces with other treatment modalities is paramount to ensure a seamless patient journey.

Is Helmet and Faceguard Modification Common in Hurling and Camogie and Why Is It Done?

Aims Despite no previous research, it is anecdotally reported that hurling and camogie players modify their helmet and faceguard, which is against GAA regulations and can potentially increase injury risk. This study aimed to establish the prevalence and rationale behind modifications in hurling and camogie. Methods An online questionnaire was completed by 304 players aged over 18 (62% hurlers, 38% camogie players) which consisted of 27 questions. Results Appearance (43%) was the primary reasons for helmet brand choice, with just 1.6% citing safety as a main reason for choice. Surprisingly, 8% of helmets were already modified when purchased and 31% of participants made further modifications, primarily switching faceguards and removal of bars. Restricted vision, comfort and perceived poor quality of the helmet/faceguard were the most common reasons for modification. Players predominantly (75.8%) agreed that further education on modifications is required. Conclusion Future research on the relationship between helmet/faceguard modification and injury risk is required.

Uptake of Cancer Screening Tests Among Recipients of Solid Organ Transplantation

Population-based cancer screening recommendations are also suggested for solid organ transplant recipients (SOTR); however, recommendation adherence is unknown. In a population-based cohort of SOTR in Ontario between 1997 and 2010, we determined the uptake of breast, cervical, and colorectal cancer screening tests and identified factors associated with up-to-date screening using recurrent event analysis. We identified 4436 SOTR eligible for colorectal, 2252 for cervical, and 1551 for breast cancer screening. Of those, 3437 (77.5%), 1572 (69.8%), and 1417 (91.4%), respectively, were not up-to-date for cancer screening tests during the observation period. However, these rates are likely an overestimate due to the inability to differentiate between tests done for screening or for diagnosis. SOTR with fewer comorbidities had higher rates of becoming screen up-to-date. Assessment by a primary care provider (PCP) was associated with becoming up-to-date with cancer screening (breast relative risk [RR] = 1.40, 95% confidence interval [CI]: 1.12-1.76, cervical RR = 1.29, 95% CI: 1.06-1.57, colorectal RR = 1.30, 95% CI: 1.15-1.48). Similar results were observed for continuity of care by transplant specialist at a transplant center. In conclusion, cancer screening for most SOTR does not adhere to standard recommendations. Involvement of PCPs in posttransplant care and continuity of care at a transplant center may improve the uptake of screening.

Early and mid-term outcomes after transcatheter aortic valve implantation (TAVI) in Ireland

BACKGROUND

TAVI is a percutaneous approach to aortic valve replacement in high surgical risk patients deemed inoperable.

AIM

To evaluate the early and mid-term outcomes for an Irish TAVI cohort over a six-year period at St James's Hospital and Blackrock Clinic, Dublin, Ireland.

RESULTS

In total 147 patients, 56% male with an average age of 82 underwent TAVI between December 2008 and December 2014. Thirty day, one year and two year survival was 90.5%, 83% and 71% respectively. Major vascular complications and renal failure were the biggest predictors of mortality at 30 days (p = 0.02). We observed a pacing rate of 13.5%, the majority in patients who had Medtronic Corevalve implants (p < 0.05). With increasing procedural experience there was a reduction in length of stay from 10 days to 7.5 days.

CONCLUSION

This review, the first of its kind in Ireland showed favorable rates of 30 day and one year and two year survival post TAVI with procedural success and complication rates similar to international registry data.

Attention, Vigilance and Visuospatial Functioning in Hospitalised Elderly Medical Inpatients – Relationship to Delirium Syndromal Status and Motor Subtype Profile

Objective

The early and efficacious detection of neurocognitive disorders poses a key diagnostic challenge. We examined how bedside cognitive tests perform across the spectrum of delirium and motor subtypes.

Methods

The performance on a battery of bedside cognitive tests were compared in elderly medical inpatients with DSM-IV delirium, subsyndromal delirium, and no neuro cognitive disorder and in motor subtypes.

Results

One hundred and ninety-eight patients (mean age 79.14 ± 8.26) were assessed with no delirium (n = 43), subsyndromal delirium (n = 45), and full syndromal delirium (n = 110). The ability to meaningfully engage with the tests varied from 59% for vigilance B test to 85% for Spatial Span forward test and was found to be least in the full syndromal delirium group. The no delirium group was distinguished from the delirium groups for all the tests and from the full syndromal delirium group for the vigilance B test and global visuospatial function test. The subsyndromal delirium group differed from the full syndromal delirium group in respect of global visuospatial function test, spatial span backwards and vigilance A tests. Patients with full syndromal delirium were best identified using the interlocking pentagons test and clock drawing test whereas those with subsyndromal delirium were best identified using interlocking pentagons test and months backwards test. Those with subsyndromal delirium were significantly better in their ability to engage than those with full syndromal delirium.

Conclusions

Simple bedside tests of attention, vigilance, and visuospatial ability are useful to help to distinguish neurocognitive disorders namely subsyndromal delirium from other presentations.

Disclosure of interest

The author haS not supplied his/her declaration of competing interest.

Attention, vigilance and visuospatial function in hospitalized elderly medical patients–relationship to delirium syndromal status and motor subtype profile

Objective

The early and efficacious detection of neurocognitive disorders poses a key diagnostic challenge. We examined how nine bedside cognitive tests perform across the spectrum of delirium and motor subtypes.

Methods

The performance on a battery of nine bedside cognitive tests were compared in elderly medical inpatients with DSM-IV delirium, subsyndromal delirium, and no neurocognitive disorder and in different motor subtypes of patients with delirium.

Results

One hundred and ninety-eight patients (mean age 79.14 ± 8.26) were assessed with no delirium (n = 43), subsyndromal delirium (n = 45), and full syndromal delirium (n = 110). The ability to meaningfully engage with the tests varied from 59% for vigilance B test to 85% for Spatial Span forward test and was found to be least in the full syndromal delirium group. The no delirium group was distinguished from the delirium groups for all the tests and from the full syndromal delirium group for the vigilance B test and global visuospatial function test. The subsyndromal delirium group differed from the full syndromal delirium group in respect of global visuospatial function test, spatial span backwards and vigilance A tests. Patients with full syndromal delirium were best identified using the interlocking pentagons test and clock drawing test. The ability to engage with testing was higher for those in the no subtype group.

Conclusions

Simple bedside tests of attention, vigilance, and visuospatial ability are useful to help to distinguish neurocognitive disorders namely subsyndromal delirium from other presentations.

Disclosure of interest

The author has not supplied his/her declaration of competing interest.

Cancer Screening Recommendations for Solid Organ Transplant Recipients: A Systematic Review of Clinical Practice Guidelines

Solid organ transplant recipients (SOTRs) are at increased risk of developing and dying from cancer. However, controversies exist around cancer screening in this population owing to reduced life expectancy and competing causes of death. This systematic review assesses the availability, quality and consistency of cancer screening recommendations in clinical practice guidelines (CPGs). We systematically searched bibliographic databases and gray literature to identify CPGs and assessed their quality using AGREE II. Recommendations were extracted along with their supporting evidence. Thirteen guidelines were included in the review. CPGs for kidney recipients were the most frequent source of screening recommendations, and recommendations for skin cancer screening were most frequently presented. Some screening recommendations differed from those for the general population, based on literature demonstrating higher cancer incidence among SOTRs versus direct evidence of screening effectiveness. Relevant stakeholders such as oncology specialists, primary care providers and public health experts were not involved in the formulation of the screening recommendations. In conclusion, although several guidelines make recommendations for cancer screening in SOTRs, the availability of cancer screening recommendations varied considerably by transplanted organ. More studies are required to inform cancer screening recommendations in SOTRs, and guideline development should involve transplant patients, oncologists and cancer screening specialists.

An Audit to Improve Prescription Writing on Inpatient Medication Cards

Background

The most common intervention performed by physicians is the writing of a prescription. All elements in the complex process of prescribing and administering drugs are susceptible to error.

Aims

To measure the extent to which information recorded on prescription cards conforms to basic standards of prescription writing.

To improve prescribing, recording and staff knowledge.

To identify common prescribing errors and focus on the same to improve our standard of practice.

Methods

An audit tool was designed to collect data and standard was set 100%.

Results

In the initial audit, there was significant deficiency in prescription writing, which was presented at the internal teaching to all doctors and recommendations were made. This audit was repeated after a month, which showed improvement in prescription writing and recording.

Recommendations

Write all drugs in CAPITALS ensuring correct spelling, dose, route of administration and frequency.

Complete all fields on front of the prescription card legibly.

Document any change in prescription card in clinical notes.

All doctors to go through their current clients medication cards and ensure any gaps filled and errors corrected.

Audit report will be kept in audit folder as a reference for any rotating doctor to repeat the audit every six months in the services.

Conclusion

Doctors should continue to improve prescription writing and reduce any adverse events or errors.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Clinically significant extra-cardiac findings in asymptomatic HIV-positive men undergoing cardiac magnetic resonance imaging

Increased research-based imaging has led to an increase in clinically significant extra-cardiac findings. HIV patients are at increased risk of having polypathology at a younger age; therefore, it may be hypothesised that they would have more incidental findings on imaging. We reviewed the magnetic resonance imaging results of 169 HIV-positive and 40 HIV-negative, clinically well volunteers undergoing cardiac magnetic resonance imaging scanning to assess the prevalence of subclinical cardiac pathology. This sub-study assessed the prevalence of clinically significant extra-cardiac findings. Associated risk factors were assessed and clinical follow-up and outcome were ascertained. Of the HIV-positive study group, 12/169 (7.1%) vs. 1/40 (2.5%) control patients had a clinically significant extra-cardiac finding which warranted further radiological or clinical intervention (p = 0.28). A total of three out of 169 (1.1%) were highly clinically significant findings. On logistic regression analysis, age was the only significant contributing factor (p = 0.049); no HIV-associated factors were found to be significant. The prevalence of clinically significant extra-cardiac findings of 7.1% in this HIV-positive cohort is comparable to the prevalence found in previous studies carried out on an older, sicker general population. This highlights the need for planning for unexpected outcomes and also the high rate of clinically significant findings in a seemingly well HIV-positive population.

Safety comes first: are doctors attentive enough to their initial clinical assessment notes?

Accurate hospital admission/initial history and physical examination [H&P] notes are vital to support patient care. We aimed to assess the quality of H&P notes and to compare medical/surgical, and inpatient/outpatient H&P notes. A cross-sectional study examined 154 initial H&P notes for the adherence to a standard protocol in a tertiary referral hospital. 134 doctors (87.1%) adhered to the correct layout in accordance with the standard. Only 77 doctors (50%) recorded the names of the patient's medications. 106 (68.8%) documented the allergy status. Six doctors (3.9%) omitted an objective record of their own identity. Surgeons were superior at recording admission type (p = 0.0001) and past surgical history (p = 0.002) only. The data in this study show that the standard o completeness of the H&P documentation among doctors is suboptimal. We recommend the introduction of a standardised H&P template to reduce errors.

Food web structure in oil sands reclaimed wetlands

Boreal wetlands play an important role in global carbon balance. However, their ecosystem function is threatened by direct anthropogenic disturbance and climate change. Oil sands surface mining in the boreal regions of Western Canada denudes tracts of land of organic materials, leaves large areas in need of reclamation, and generates considerable quantities of extraction process-affected materials. Knowledge and validation of reclamation techniques that lead to self-sustaining wetlands has lagged behind development of protocols for reclaiming terrestrial systems. It is important to know whether wetlands reclaimed with oil sands process materials can be restored to levels equivalent to their original ecosystem function. We approached this question by assessing carbon flows and food web structure in naturally formed and oil sands-affected wetlands constructed in 1970-2004 in the postmining landscape. We evaluated whether a prescribed reclamation strategy, involving organic matter amendment, accelerated reclaimed wetland development, leading to wetlands that were more similar to their natural marsh counterparts than wetlands that were not supplemented with organic matter. We measured compartment standing stocks for bacterioplankton, microbial biofilm, macrophytes, detritus, and zoobenthos; concentrations of dissolved organic carbon and residual naphthenic acids; and microbial production, gas fluxes, and aquatic-terrestrial exports (i.e., aquatic insect emergence). The total biomass of several biotic compartments differed significantly between oil sands and reference wetlands. Submerged macrophyte biomass, macroinvertebrate trophic diversity, and predator biomass and richness were lower in oil sands-affected wetlands than in reference wetlands. There was insufficient evidence to conclude that wetland age and wetland amendment with peat-mineral mix mitigate effects of oil sands waste materials on the fully aquatic biota. Although high variability was observed within most compartments, our data show that 20-year-old wetlands containing oil sands material have not yet reached the same level of function as their reference counterparts.

Safety of therapeutic hypothermia in post VF/VT cardiac arrest patients

Therapeutic hypothermia (TH) is a process of cooling a patient post ventricular tachycardia/ventricular fibrillation (VT/VF) cardiac arrest to 32-34 degrees C for 24 hours. This improves neurological outcome and is part of current guidelines. Hypothermia prolongs QT interval, which can precipitate torsades de pointes (TdP). We performed a retrospective review of all patients who received TH in our hospital over a period of 2 years to assess the effect of TH on the corrected OT interval (QTc) and any possible pro-arrhythmia. A total of 13 patients received TH. QTc prolonged in all patients with an average of 80.3 + 57.2 ms., and up to 109.8 + 80.4 ms in patients who received Amiodarone concurrently. No TdP was seen in any patient. We conclude that TH is safe, though careful monitoring of the OTc interval is advisable especially with concurrent use of QT prolonging drugs.

Evidence for the presence of white spot syndrome virus (WSSV) and monodon baculovirus (MBV) in wild Penaeus monodon (Fabricius) broodstock, in the southeast coast of India

A survey on the presence of the viruses of two economically significant diseases, white spot syndrome virus (WSSV) and monodon baculovirus (MBV) in wild-collected Penaeus monodon broodstock, was conducted during different seasons of the year in two major coastal areas of southeast India. The broodstock were collected along the coast of Tamil Nadu and Andhra Pradesh during summer, premonsoon, monsoon and post-monsoon seasons for three consecutive years. A total of 7905 samples were collected and subjected to MBV screening, and 6709 samples that were screened as MBV negative were diagnosed for WSSV. MBV was detected using rapid malachite green staining and WSSV by nested polymerase chain reaction. Prevalence data of the viruses were analysed using the EpiCalc 2000 program at 95% confidence interval. Samples collected from the Andhra Pradesh coast displayed a slightly higher prevalence of WSSV and MBV infection than those collected from Tamil Nadu, although this difference was not statistically significant (P > 005). In addition, it was found that the prevalence of both WSSV and MBV infections fluctuated according to season. Data on prevalence of these viruses in broodstock would be useful to develop strategies for shrimp health management along the southeast coast of India.

Vascular access type and risk of mortality in a national prospective cohort of haemodialysis patients

BACKGROUND

Central venous catheters (CVC) are a potential source of bacteraemia and have been associated with increased mortality in haemodialysis patients. We aimed to investigate the relationships between haemodialysis vascular access, taking into account changes in vascular access type during patients' lives, and cause specific mortality risk in a national cohort of dialysis patients.

METHODS

Prospective cohort study including all patients receiving haemodialysis in Scotland at annual cross sectional surveys in 2009, 2010 and 2011. Data were collected through the Scottish Renal Registry and by a structured review of case records following death. Cox proportional hazards regression and multivariable logistic regression were used to model survival and risk of death from septicaemia respectively.

RESULTS

Of a cohort of 2666 patients, 873 (32%) died during follow-up. After case-mix adjustment, patients using only tunnelled CVC during follow-up had a higher risk of all cause mortality across all strata of prior renal replacement therapy exposure [adjusted hazard ratio (HR): 1.83-2.08]. Case-mix adjusted risks of cardiovascular death (adjusted HR: 2.20-2.95) and infection-related death (adjusted HR: 3.10-3.63) were also higher in this group. Patients using tunnelled CVCs during follow-up and prior to death had 6.9-fold higher odds of death from septicaemia compared with those using only arteriovenous fistulae or grafts.

CONCLUSION

Compared with an arteriovenous fistula or graft, sustained use of tunnelled CVCs for vascular access is associated with higher risks of all-cause, cardiovascular and infection-related mortality.

Use of ribozymes and antisense oligodeoxynucleotides to investigate mechanisms of drug resistance

Chemotherapy can cure a number of human cancers but resistance (either intrinsic or acquired) remains a significant problem in many patients and in many types of solid tumour. Combination chemotherapy (using drugs with different cellular targets/mechanisms) was introduced in order to kill cells which had developed resistance to a specific drug, and to allow delivery of a greater total dose of anti-cancer chemicals by combining drugs with different side-effects (Pratt et al., 1994). Nearly all anti-cancer drugs kill tumour cells by activating an endogenous bio-chemical pathway for cell suicide, known as programmed cell death or apoptosis.

Concomitant conjugal transfer of reduced-bacteriophage-sensitivity mechanisms with lactose- and sucrose-fermenting ability in lactic streptococci

Ten previously reported lactose-positive (Lac) transconjugants from Streptococcus lactis, S. cremoris, and S. lactis subsp. diacetylactis and one sucrose-positive (Suc) transconjugant from S. lactis were examined for their sensitivity to prolate- and small isometric-headed bacteriophages. Four of the Lac transconjugants showed a 10- to 100-fold reduction in the efficiency of plating (EOP) as well as a reduced plaque size for the prolate phage c2 and were insensitive to the small isometric phage 712. A fifth Lac transconjugant demonstrated a similar reduced sensitivity to phage c2; however, this transconjugant was able to plaque phage 712, but with a reduced plaque size and EOP. The other five Lac transconjugants were sensitive to both c2 and 712 phages. The Suc transconjugant plaqued phage 712 with a reduced plaque size and EOP, but no reduction in plaque size or EOP was observed for phage c2. The Lac and reduced bacteriophage sensitivity (Rbs) phenotypes were correlated with specific plasmids in the Lac transconjugants. As four of the Lac transconjugants exhibited a phenotypically indistinguishable Rbs, one (AB001) was selected for further study. The Rbs in AB001 for both small isometric- and prolate-headed phages was not related to adsorption, and the reduced EOP for phage c2 was not related to the presence of a restriction and modification system. The latent period for phage c2 was unchanged, but the burst size was reduced 80%. The presence of the plasmid coding for Rbs retarded the lysis of a mitomycin C-induced prophage-containing strain. The Rbs mechanism appears to be abortive phage infection. This study supports previous observations that Rbs and conjugal transfer ability are physically linked among some group N streptococci. The results presented have implications in the identification of plasmids coding for Rbs and may also aid in explaining the dissemination of Rbs genes among lactic streptococci.

Identification of the Minimal Replicon of Lactococcus lactis subsp. lactis UC317 Plasmid pCI305

Replication functions of the stable, cryptic 8.7-kilobase (kb) plasmid pCI305 from multi-plasmid-containing Lactococcus lactis subsp. lactis UC317 were studied. Analysis of this replicon was facilitated by the construction of replication probe vectors that consisted of the pBR322 replication region, a pUC18-derived multiple cloning site, and either the cat gene of pC194 (pCI341; 3.1 kb) or the erm gene of pAMbeta1 (pCI3330; 4.0 kb). Plasmid pCI305 was introduced into plasmid-free L. lactis subsp. lactis MG1363Sm, a streptomycin-resistant derivative of MG1363, by a transformation procedure with the 75-kb lactose-proteinase plasmid pCI301 of UC317 as a marker plasmid. A combination of transposon Tn5 mutagenesis and subcloning in pCI341 and pCI3330 with individual Tn5 insertions around the replication region facilitated the identification of a 1.6-kb minimal replicon on pCI305. This region was separable into two domains: (i) a 1.3-kb region (repB) encoding a trans-acting function (in vitro transcription-translation studies suggested the involvement of a 48-kilodalton protein); and (ii) a 0.3-kb region (repA) sufficient to direct replication when provided with repB in trans and thus probably containing the origin of replication. Lactococcus-Escherichia coli shuttle vectors based on the pCI305 replication region were constructed.

Detailed characterization and comparison of four lactic streptococcal bacteriophages based on morphology, restriction mapping, DNA homology, and structural protein analysis

Bacteriophages uc1001 and uc1002, which are lytic for Streptococcus cremoris UC501 and UC502, respectively, were characterized in detail. Comparisons were made with a previously characterized phage, P008, which is lytic for Streptococcus lactis subsp. diacetylactis F7/2, and uc3001, which is a lytic phage for S. cremoris UC503. Phages uc1001 and uc1002 had small isometric heads (diameters, 52 and 50 nm, respectively) and noncontractile tails (lengths, 152 and 136 nm, respectively), and uc1002 also had a collar. Both had 30.1 +/- 0.6 kilobase pairs (kbp) of DNA with cross-complementary cohesive ends. Restriction endonuclease maps made with seven endonucleases showed no common fragments. Despite this there was a very high level of homology between uc1001 and uc1002, and results of cross-hybridization experiments showed that the organization of both phage genomes was similar. Heteroduplex analysis confirmed this and quantified the level of homology at 83%. The regions of nonhomology comprised 2.1-, 1.1-, and 1.0-kbp deletion loops and 13 smaller loops and bubbles. The sodium dodecyl sulfate-polyacrylamide gel electrophoretic structural protein profiles were related, with a major band of about 40,000 molecular weight and minor bands of 35,000 and 34,000 molecular weight in common. There were also differences, however, in that uc1001 had a second major band of 68,000 molecular weight and two extra minor bands. Except for the restriction maps, which were strain specific, phages uc1001, uc1002, and P008 were closely related by all the criteria listed above. Their DNAs also showed a very significant bias against the cleavage sites of 9 of 11 restriction endonucleases. Phage uc3001 was unrelated to uc1001, uc1002, or P008 in that it had a prolate head (53 by 39 nm) and a shorter tail (105 nm), contained approximately 22 kbp of DNA, had unrelated cohesive ends, showed no DNA homology with the isometric-headed phages, and displayed a very different structural protein profile.

Controlled Integration into the Lactococcus Chromosome of the pCI829-Encoded Abortive Infection Gene from Lactococcus lactis subsp. lactis UC811

The phage insensitivity gene of lactococcal plasmid pCI829 which encodes an abortive infection defense mechanism (Abi) was inserted into the Lactococcus lactis subsp. lactis CH919 chromosome by utilizing the integration plasmid pCI194, which contains 4.2 kb of homology with the conjugative transposon Tn919. Chloramphenicol-resistant transformants expressed phage insensitivity to the prolate-headed phage c2 and the small isometric-headed phage 712, and hybridization analysis indicated that transformants contained pCI194 integrated in single copy. The level of phage insensitivity expressed by the transformants was reduced from that observed when the abi gene was located on a replicating plasmid, as determined by plaque assay and burst size analysis. Amplification of the integrated structure after growth in increased concentrations of chloramphenicol resulted in an increase in the expression of phage insensitivity. Hybridization analysis revealed that while pCI194 was stably maintained in an integrated state over 100 generations in the absence of selective pressure, the ability to express phage insensitivity was lost. Hybridization analysis also revealed that DNA flanking the abi gene contains homology to the CH919 chromosome.

Development of High-Frequency Delivery System for Transposon Tn919 in Lactic Streptococci: Random Insertion in Streptococcus lactis subsp. diacetylactis 18-16

The conjugative transposon Tn919, originally isolated in Streptococcus sanguis FC1, is capable of low-frequency transfer (10 and 10 per recipient) on membrane filters to a wide number of streptococcal recipients including the industrially important lactic streptococci. The introduction of pMG600 (Lac Lax; a lactose plasmid capable of conjugative transfer at high frequencies and which, in certain hosts, confers an unusual clumping phenotype) into a Streptococcus lactis CH919 donor, generating S. lactis CH001, resulted in a significant improvement in the transfer frequency of Tn919 to S. lactis CK50 (1.25 x 10 per recipient). In addition, these matings could be performed on agar surfaces, allowing the recovery of a greater number of recipients than with filter matings. Tn919 also transferred at high frequency to S. lactis subsp. diacetylactis 18-16S but not to Streptococcus cremoris strains. Insertion in 18-16S transconjugants generated from filter matings with an S. lactis CH919 donor was random, occurring at different sites on the chromosome and also in plasmid DNA. Thus, the conditions necessary for the practical exploitation of Tn919 in the targeting and cloning of genes from a member of the lactic streptococci, namely, high-frequency delivery and random insertion in host DNA, were achieved.