Unwarranted variation and the goal of net zero for the NHS in England: exploring the link between efficiency working, patient outcomes and carbon footprint

In 2020 the NHS in England set a target of reaching net zero carbon emissions by 2040. Progress has already been made towards this goal, with substantial reductions in the use of environmentally harmful anaesthetic gases, such as desflurane, in recent years. Where an effective replacement already exists, changing practice to use low carbon alternatives is relatively easy to achieve, but much greater challenges lie ahead. The Getting It Right First Time (GIRFT) programme is a clinically-led, data-driven clinical improvement initiative with a focus on reducing unwarranted variation in clinical practice and patient outcomes. Reducing unwarranted variation can improve patient care and service efficiency, and can also support the drive to net zero. In this article we set out what the GIRFT programme is doing to support sustainable healthcare in England, why it is uniquely positioned to support this goal and what the future challenges, barriers, enablers and opportunities are likely to be in the drive to net zero.

The provision of a time-critical elective surgical service during the COVID-19 Crisis: a UK experience

INTRODUCTION

With the emergence of the COVID-19 pandemic, all elective surgery was temporarily suspended in the UK, allowing for diversion of resource to manage the anticipated surge of critically unwell patients. Continuing to deliver time-critical surgical care is important to avoid excess morbidity and mortality from pathologies unrelated to COVID-19. We describe the implementation and short-term surgical outcomes from a system to deliver time-critical elective surgical care to patients during the COVID-19 pandemic.

MATERIALS AND METHODS

A protocol for the prioritisation and safe delivery of time-critical surgery at a COVID-19 'clean' site was implemented at the Nuffield Health Exeter Hospital, an independent sector hospital in the southwest of England. Outcomes to 30 days postoperatively were recorded, including unplanned admissions after daycase surgery, readmissions and complications, as well as the incidence of perioperative COVID-19 infection in patients and staff.

RESULTS

A total of 128 surgical procedures were performed during a 31-day period by a range of specialties including breast, plastics, urology, gynaecology, vascular and cardiology. There was one unplanned admission and and two readmissions. Six complications were identified, and all were Clavien-Dindo grade 1 or 2. All 128 patients had preoperative COVID-19 swabs, one of which was positive and the patient had their surgery delayed. Ten patients were tested for COVID-19 postoperatively, with none testing positive.

CONCLUSION

This study has demonstrated the implementation of a safe system for delivery of time-critical elective surgical care at a COVID-19 clean site. Other healthcare providers may benefit from implementation of similar methodology as hospitals plan to restart elective surgery.

Intracardiac thrombi in pediatric patients: presentation profiles and clinical outcomes

We document the presentation profiles, treatment strategies, and clinical outcomes in a relatively large cohort of pediatric patients with intracardiac thrombi (ICT). We performed a retrospective review of patients diagnosed with ICT by echocardiography at a tertiary pediatric hospital during a 10-year period. These patients received medical therapy or thrombectomy. We provided echocardiographic descriptions of the ICT-size, chamber location, and mobility/morphology. The outcome measures were ICT (persistence, resolution, or embolization), effectiveness of therapy, and patient morbidity and mortality. There were 40 ICT diagnosed in 31 patients (22 males and 9 females). Mean age at diagnosis was 8.8 years (range, 15 days to 18 years). Overall mortality was 12/31 patients (39%); only one death was attributed to ICT embolization. Embolic events occurred in 4/31 patients (13%). The most common initial therapies included heparin infusion (n = 15), warfarin (n = 7), and aspirin (n = 7). The ICT resolved with medical therapy alone in 19/30 patients (63%). One patient required surgical thrombectomy. The cohort was divided into group 1 (dilated cardiomyopathy), group 2 (status post Fontan operation), and group 3 (other diagnoses). In group 1 (n = 11), there were 8 deaths. Embolization occurred in 2/5 large ICT, resulting in cerebral infarction and death (n = 1) and renal infarction (n = 1). The most common ICT location was the left ventricle (n = 10). Severe ventricular systolic dysfunction was present in 10/11 patients (91%). In group 2 (n = 9), there was 1 death. Embolization occurred in 1/7 large ICT, resulting in seizures and temporary paresis. All ICT were located in the Fontan pathway. Severe ventricular systolic dysfunction was present in 2/9 patients (22%). In group 3 (n = 11), there were 3 deaths. Embolization occurred in 1/9 small ICT, resulting in coronary emboli. ICT are most commonly diagnosed in pediatric patients with dilated cardiomyopathy or patients status post Fontan operation. The majority of ICT resolve with medical therapy. Larger ICT tend to embolize more frequently, and the morbidity secondary to embolization is significant. Rarely is mortality due to ICT embolization. The prognosis is poor for patients with left ventricular ICT or ICT in the presence of ventricular systolic dysfunction.

Differential Effects of a Substituted Pyridazinone, BASF 13-338, on Pathways of Monogalactosyldiacylglycerol Synthesis in Arabidopsis

We have examined the effects of the substituted pyridazinone herbicide, 4-chloro-5-(dimethylamino)-2-phenyl-3(2H)pyridazinone (BASF 13-338, Sandoz 9785), on the desaturation of linoleic acid (18:2) on different molecular species of monogalactosyldiacylglycerol (MGDG) and phosphatidylcholine (PC) in leaf tissue of Arabidopsis thaliana (L.) Heynh. Specific changes in lipid composition allowed identification of different substrates for desaturation of 18:2 to linolenic acid (18:3). 18:2/16:2 MGDG was desaturated in the chloroplast to form 18:3/16:3 MGDG. Levels of 18:3/16:3 MGDG were reduced by treatment with BASF 13-338, suggesting that both the formation of 18:3 at the sn-1 position, and the formation of 16:3 at the sn-2 position of 18:2/16:2 MGDG were inhibited by this compound. Kinetic studies using exogenously incorporated [(14)C] 18:1 indicated that 18:2/18:3 MGDG originated from an 18:2/18:3 diglyceride precursor derived from PC. The formation of 18:3 at the sn-1 position of 18:2/18:3 MGDG was also inhibited by BASF 13-338. In contrast the desaturation of 18:2 proposed to occur at the sn-2 position of PC outside the chloroplast, was not affected.

Metabolism of Unsaturated Monogalactosyldiacylglycerol Molecular Species in Arabidopsis thaliana Reveals Different Sites and Substrates for Linolenic Acid Synthesis

Synthesis of unsaturated monogalactosyldiacylglycerol (MGDG) was examined in a mutant of Arabidopsis thaliana (L.) Heynh. containing reduced levels of hexadecatrienoic (16:3) and linolenic (18:3) acids in leaf lipids. Molecular species composition and labeling kinetics following the incorporation of exogenous [(14)C]fatty acids suggest that at least two pathways and multiple substrates are involved in desaturation of linoleic acid (18:2) to 18:3 for production of unsaturated galactolipids. A reduction in 18:3/16:3 MGDG and an increase in 18:2/16:2 MGDG, together with labeling kinetics of these molecular species following the incorporation of exogenous [(14)C]12:0 fatty acids, suggests that a chloroplastic pathway for production of 18:3 at the sn-1 position of MGDG utilizes 18:2/16:2 MGDG as a substrate. This chloroplastic (prokaryotic) pathway is deficient in the mutant. When exogenous [(14)C]18:1 was supplied, a eukaryotic (cytoplasmic) pathway involving the desaturation of 18:2 to 18:3 on phosphatidylcholine serves as the source of 18:3 for the sn-2 position of MGDG. This eucaryotic pathway predominates in the mutant.

Rhythmical changes in the sensitivity of cotton seedlings to herbicides

Cotton (Gossypium hirsutum L.) seedlings that were grown under a photoperiod of 12 hours darkness and 12 hours light showed oscillations in their sensitivity to the herbicides sodium 5-(2-chloro-4-trifluoromethyl)-phenoxy)-2-nitrobenzoate (acifluorfen), butyl 2-(4-((5-(trifluoromethyl)-2-pyridinyl)oxy)phenoxy)propanoate (fluazifop) and 3-isopropyl-1H-2,1,3-benzothiadiazin-4(3H)-one 2,2-dioxide (bentazon). Sensitivity was expressed in appearance of necrotic areas on the cotyledons and in decreased growth of the shoot. The seedlings were least sensitive in the beginning and middle of the light period, then the sensitivity increased and reached its maximum during the beginning and middle of the dark period and then declined. Seedlings grown from germination under continuous light exhibited very small or no oscillations in sensitivity. The oscillations in sensitivity were entrained by one cycle of darkness and light. A cycle of 12 hours darkness and 12 hours light triggered the greatest oscillations while either increasing or decreasing the duration of the dark period resulted in smaller oscillations. Apparently, these oscillations in sensitivity to herbicides were endogenously controlled since after entrainment they continued irrespective of the light conditions.

Effects of 2,4-dinitrophenol on membrane lipids of roots

Previous work has shown that the undissociated form of 2,4-dinitrophenol (DNP) increases the permeability of barley (Hordeum vulgare var. trebi) roots to ions. The present studies were undertaken to determine whether the effects of undissociated DNP were directly on membrane lipids. Relative amounts of the principal fatty acids from the lipids of barley root membranes were assayed as a function of DNP concentration, pH, and time of treatment under conditions similar to the previous studies of DNP effects on permeability. Undissociated DNP increases the proportions of palmitic and oleic acids and decreases linoleic and linolenic acids with no changes in the amounts of total fatty acids. The effects are immediate, as are the effects on permeability. Only the undissociated DNP is effective. Anionic DNP has no effect, although it is the major species taken up by the roots both at pH 5 and pH 7. DNP has no effect on respiration at either pH, indicating that undissociated DNP effects are on the membranes and not a general metabolic effect. The close parallelism between the effects of DNP on the composition of membrane lipids and on permeability suggests that the increase in permeability produced by undissociated DNP is due to a direct effect on the root membranes.

Lipid composition of chloroplast membranes from weed biotypes differentially sensitive to triazine herbicides

Chloroplasts were isolated from triazine-sensitive and triazine-resistant biotypes of common groundsel (Senecio vulgaris L.), common lambsquarter (Chenopodium album L.), and redroot pigweed (Amaranthus retroflexus L.). Chloroplast lipids were extracted and analyzed for differences among sensitive and resistant biotypes. The distribution of lipid between major lipid classes differed in chloroplasts from resistant and susceptible biotypes. Chloroplasts from resistant biotypes contained higher proportions of monogalactosyl diglyceride and phosphatidyl ethanolamine and lower proportions of digalactosyl diglyceride and phosphatidyl choline than did chloroplasts from susceptible biotypes. Monogalactosyl diglyceride and phosphatidyl ethanolamine were also quantitatively higher in membranes of resistant versus susceptible biotypes. The major lipid classes of resistant chloroplast membranes contained lipids comparatively richer in unsaturated fatty acids with the exceptions of digalactosyl diglyceride from all three biotypes and phosphatidyl ethanolamine from common groundsel. Results correlated changes in triazine sensitivity with qualitative and quantitative differences in the lipid composition of chloroplast membranes.

Inhibition of linolenic Acid synthesis and modification of chilling resistance in cotton seedlings

The temperature at which cotton seeds (Gossypium hirsutum L.) germinated influenced the fatty acid composition of the polar lipids of developing root tips. Seeds were germinated at 15, 20, 25, and 30 C. As the temperature decreased the linolemic acid content of the polar lipid fraction increased. Sandoz 9785[4-chloro-5-(dimethylamino)-2-phenyl-3(2H)-pyridazinone] reduced the low temperature-induced increase in linolenic acid content of the polar lipids and reduced seedling ability to withstand 8 C chilling. The results are consistent with the conclusion that chilling resistance in cotton seedlings is related to the level of linolenic acid in the polar lipids in the developing root tips.

Manipulation of galactolipid Fatty Acid composition with substituted pyridazinones

The fatty acid composition of the major lipids of the chloroplast membranes, the mono- and digalactosyl diglycerides, can be definably altered with various substituted pyridazinones. Galactolipid fatty acid composition of wheat (Triticum aestivum L.) can be altered so that there is a decrease in linolenic acid accompanied by an increase in linoleic acid without a shift in the relative proportion of saturated to unsaturated fatty acids; the fatty acid composition can be shifted toward a higher proportion of saturated fatty acids; or the fatty acid composition of the monogalactosyl diglycerides can be altered in preference to the digalactosyl diglycerides. Also, the light-mediated parallel accumulation of chlorophyll and linolenic acid can be separated with a substituted pyridazinone. The substituted pyridazinones may be useful tools in clarifying the role the galactolipids and their component fatty acids play in the structure and function of chloroplast membranes in higher plants.

Membrane-surfactant Interactions in Lipid Micelles Labeled with l-Anilino-8-naphthalenesulfonate

Sonicated lipid micelles, formed from phospholipids isolated from yolks of fresh hen eggs, were used as a model membrane system for studying the effects of several surfactants on membrane properties. The interactions of the surfactants with the model system were followed through the fluorescence of the hydrophobic probe l-anilino-8-naphthalenesulfonate. The surfactants investigated were polyoxyethylene sorbitan monolaurate (Tween 20), polyoxyethylene thioether (Sterox SK), mono-calcium salt of polymerized aryl alkyl sulfonic acids (Daxad 21), and alkylbenzyl quaternary ammonium halide (AHCO DD 50). All surfactants enhanced fluorescence of the membrane-bound probe, and the degree of this enhancement correlated with the previously established phytotoxicity of these substances. The results indicate that surfactants can produce distinct changes in artificial phospholipid membranes and suggest that this lipid interaction may account for altered membrane permeability characteristics in surfactant-treated plants. The effects are observable for surfactant concentrations as low as 0.0001% (w/v), representing an approximate 10-fold increase in sensitivity for detecting surfactant effects compared with previous results on permeability changes in isolated plant cells.

Interactions of lipoidal materials and a pyridazinone inhibitor of chloroplast development

Formation of chloroplast pigments was inhibited, and free fatty acids accumulated in mustard (Brassica juncea [L.] Coss.) cotyledons and in barley (Hordeum vulgare L.) first leaves developed after treatment with 4-chloro-5- (dimethylamino)-2- (alpha, alpha, alpha-trifluoro-m-tolyl) -3 (2H) -pyridazinone. The inhibitor reduced the amount of fatty acids found in polar lipids (galactolipids) of barley chloroplasts and increased the amount in nonpolar lipids while having little effect on total content of bound fatty acids. The inhibition of chlorophyll formation was circumvented by D-alpha-tocopherol acetate, phytol, farnesol, and squalene, and by unsaturated fatty acids and their methyl esters. The protective action can be explained partially by an interaction external to the plant whereby 4-chloro-5- (dimethylamino) -2- (alpha, alpha, alpha-trifluoro-m-tolyl) -3 (2H) -pyridazinone partitioned out of the aqueous phase and into the lipid phase, thus limiting availability of the inhibitor to plants. However, the amount of inhibitor reaching the cotyledons of tocopherol-protected mustard seedlngs was still in excess of the amount necessary to cause white foliage, but it failed to produce the effect. Tocopherol treatment did not prevent the 4-chloro-5- (dimethylamino) -2- (alpha, alpha, alpha-trifluoro-m-tolyl) -3 (2H) -pyridazinone-induced buildup of fatty acids in mustard cotyledons but did partially circumvent the effect in barley leaves. The amount of linolenic acid relative to linoleic acid was reduced in barley leaves and chloroplasts by 4-chloro-5- (dimethylamino) -2- (alpha, alpha, alpha-trifluoro-m-tolyl) -3 (2H) -pyridazinone action and this effect was circumvented by tocopherol.

Entero-Aggregative- Haemorrhagic Escherichia coli (EAHEC) Serotype O104:H4 -The Evolving "Superbug"

The rare, E.coli strain O104:H4 has been identified as the causative agent of one of the largest ever reported food-borneoutbreaks of gastroenteritis and Hemolytic-uremic syndrome (HUS) in Germany this year. This hypervirulent pathotype possess a unique combination of two pathogens: enterohemorrhagicE.coli (EHEC) and enteroaggregative E.coli (EAEC) strains. The serotype has rarely been described previously in humans and never associated with any earlier large scale EHEC outbreaks. It is now being referred to as the Entero-Aggregative-Haemorrhagic Escherichia coli (EAHEC).Advances in high-throughput sequencing technologies helped in rapid complete genome sequencing of the outbreak strains by different laboratories.Comparison of the genome sequence of the outbreak strain with other diarrhea-associated EAEC serotype O104:H4 indicate that the chromosome of the outbreak strain is most similar to that of an early isolated EAEC strain 55989 and has evolved to become more virulent by the acquisition of a Shiga toxin 2 encoding prophage, a plasmid encoding CTX-M beta-lactamases, and substituting the aggregative adherence fimbria III (AAF/III)with the rarer aggregative adherence fimbria I (AAF/I). The present article reviews the virulent traits ofthe outbreak strain, and also presents an update of the different intervention strategies that are being tested for the treatment of infections by such highly pathogenic strains. DOI: http://dx.doi.org/10.3329/bjms.v11i1.9815 BJMS 2012; 11(1): 4-11