Analytical validation of the PROphet test for treatment decision-making guidance in metastatic non-small cell lung cancer

The blood proteome, consisting of thousands of proteins engaged in various biological processes, acts as a valuable source of potential biomarkers for various medical applications. PROphet is a plasma proteomics-based test that serves as a decision-support tool for non-small cell lung cancer (NSCLC) patients, combining proteomic profiling using SomaScan technology and subsequent computational algorithm. PROphet was implemented as a laboratory developed test (LDT). Under the Clinical Laboratory Improvement Amendments (CLIA) and Commission on Office Laboratory Accreditation (COLA) regulations, prior to releasing patient test results, a clinical laboratory located in the United States employing an LDT must examine its performance characteristics with regard to analytical validity. This study describes the experimental and computational analytical validity of the PROphet test, as required by CLIA/COLA regulations. Experimental precision analysis displayed a median coefficient of variation (CV) of 3.9 % and 4.7 % for intra-plate and inter-plate examination, respectively, and the median accuracy rate between sites was 88 %. Computational precision exhibited a high accuracy rate, with 93 % of samples displaying complete concordance in results. A cross-platform comparison between SomaScan and other proteomics platforms yielded a median Spearman's rank correlation coefficient of 0.51, affirming the consistency and reliability of the SomaScan platform as used under the PROphet test. Our study presents a robust framework for evaluating the analytical validity of a platform that combines an experimental assay with subsequent computational algorithms. When applied to the PROphet test, strong analytical performance of the test was demonstrated.

Red-faced lies: a qualitative analysis of online misinformation and conspiracy theories in rosacea

Rosacea is a common chronic inflammatory skin disease with a complex aetiology and major psychological impact, rendering patients susceptible to misinformation. We aimed to assess the content of rosacea-related misinformation online. A formal review of PubMed was performed, using the terms 'rosacea' AND 'misinformation' OR 'disinformation' OR 'conspiracy theory', along with informal Google searches using combinations of these terms, and further targeted searches on Twitter, Facebook, Instagram and TikTok. Key areas of misinformation identified in the search included mislabelling of rosacea as adult acne; falsehoods about rosacea only occurring in older adults or in individuals with lightly pigmented skin; incorrect causes of rosacea such as makeup or diet; and misleading 'cures', some of which may lead to exacerbation of the underlying rosacea. Dermatologists must be aware of the large amount of rosacea misinformation trending online and be prepared to counteract them with evidence to optimize patient care.

STAR-0215 is a Novel, Long-Acting Monoclonal Antibody Inhibitor of Plasma Kallikrein for the Potential Treatment of Hereditary Angioedema

Hereditary angioedema (HAE) is a rare autosomal dominant disorder caused by a deficiency in functional C1 esterase inhibitor, a serpin family protein that blocks the activity of plasma kallikrein. Insufficient inhibition of plasma kallikrein results in the overproduction of bradykinin, a vasoactive inflammatory mediator that produces both pain and unpredictable swelling during HAE attacks, with potentially life-threatening consequences. We describe the generation of STAR-0215, a humanized IgG1 antibody with a long circulating half-life (t1/2) that potently inhibits plasma kallikrein activity, with a >1000-fold lower affinity for prekallikrein and no measurable inhibitory activity against other serine proteases. The high specificity and inhibitory effect of STAR-0215 is demonstrated through a unique allosteric mechanism involving N-terminal catalytic domain binding, destabilization of the activation domain, and reversion of the active site to the inactive zymogen state. The YTE (M252Y/S254T/T256E) modified fragment crystallizable (Fc) domain of STAR-0215 enhances pH-dependent neonatal Fc receptor binding, resulting in a prolonged t1/2 in vivo (∼34 days in cynomolgus monkeys) compared with antibodies without this modification. A single subcutaneous dose of STAR-0215 (≥100 mg) was predicted to be active in patients for 3 months or longer, based on simulations using a minimal physiologically based pharmacokinetic model. These data indicate that STAR-0215, a highly potent and specific antibody against plasma kallikrein with extended t1/2, is a potential agent for long-term preventative HAE therapy administered every 3 months or less frequently. SIGNIFICANCE STATEMENT: STAR-0215 is a YTE-modified immunoglobulin G1 monoclonal antibody with a novel binding mechanism that specifically and potently inhibits the enzymatic activity of plasma kallikrein and prevents the generation of bradykinin. It has been designed to be a long-lasting prophylactic treatment to prevent attacks of HAE and to decrease the burden of disease and the burden of treatment for people with HAE.

A rotating white dwarf shows different compositions on its opposite faces

White dwarfs, the extremely dense remnants left behind by most stars after their death, are characterized by a mass comparable to that of the Sun compressed into the size of an Earth-like planet. In the resulting strong gravity, heavy elements sink towards the centre and the upper layer of the atmosphere contains only the lightest element present, usually hydrogen or helium^1,2. Several mechanisms compete with gravitational settling to change a white dwarf's surface composition as it cools³, and the fraction of white dwarfs with helium atmospheres is known to increase by a factor of about 2.5 below a temperature of about 30,000 kelvin^4-8; therefore, some white dwarfs that appear to have hydrogen-dominated atmospheres above 30,000 kelvin are bound to transition to be helium-dominated as they cool below it. Here we report observations of ZTF J203349.8+322901.1, a transitioning white dwarf with two faces: one side of its atmosphere is dominated by hydrogen and the other one by helium. This peculiar nature is probably caused by the presence of a small magnetic field, which creates an inhomogeneity in temperature, pressure or mixing strength over the surface^9-11. ZTF J203349.8+322901.1 might be the most extreme member of a class of magnetic, transitioning white dwarfs-together with GD 323 (ref. ¹²), a white dwarf that shows similar but much more subtle variations. This class of white dwarfs could help shed light on the physical mechanisms behind the spectral evolution of white dwarfs.

Group size and mating system predict sex differences in vocal fundamental frequency in anthropoid primates

Vocalizations differ substantially between the sexes in many primates, and low-frequency male vocalizations may be favored by sexual selection because they intimidate rivals and/or attract mates. Sexual dimorphism in fundamental frequency may be more pronounced in species with more intense male mating competition and in those with large group size, where social knowledge is limited and efficient judgment of potential mates and competitors is crucial. These non-mutually exclusive explanations have not been tested simultaneously across primate species. In a sample of vocalizations (n = 1914 recordings) across 37 anthropoid species, we investigated whether fundamental frequency dimorphism evolved in association with increased intensity of mating competition (H1), large group size (H2), multilevel social organization (H3), a trade-off against the intensity of sperm competition (H4), and/or poor acoustic habitats (H5), controlling for phylogeny and body size dimorphism. We show that fundamental frequency dimorphism increased in evolutionary transitions towards larger group size and polygyny. Findings suggest that low-frequency male vocalizations in primates may have been driven by selection to win mating opportunities by avoiding costly fights and may be more important in larger groups, where limited social knowledge affords advantages to rapid assessment of status and threat potential via conspicuous secondary sexual characteristics.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Lessons Learned from CDC's Global COVID-19 Early Warning and Response Surveillance System

Early warning and response surveillance (EWARS) systems were widely used during the early COVID-19 response. Evaluating the effectiveness of EWARS systems is critical to ensuring global health security. We describe the Centers for Disease Control and Prevention (CDC) global COVID-19 EWARS (CDC EWARS) system and the resources CDC used to gather, manage, and analyze publicly available data during the prepandemic period. We evaluated data quality and validity by measuring reporting completeness and compared these with data from Johns Hopkins University, the European Centre for Disease Prevention and Control, and indicator-based data from the World Health Organization. CDC EWARS was integral in guiding CDC's early COVID-19 response but was labor-intensive and became less informative as case-level data decreased and the pandemic evolved. However, CDC EWARS data were similar to those reported by other organizations, confirming the validity of each system and suggesting collaboration could improve EWARS systems during future pandemics.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The economic case for hospital discharge services for people experiencing homelessness in England: An in-depth analysis with different service configurations providing specialist care

There are long-standing concerns that people experiencing homelessness may not recover well if left unsupported after a hospital stay. This study reports on a study investigating the cost-effectiveness of three different 'in patient care coordination and discharge planning' configurations for adults experiencing homelessness who are discharged from hospitals in England. The first configuration provided a clinical and housing in-reach service during acute care and discharge coordination but with no 'step-down' care. The second configuration provided clinical and housing in-reach, discharge coordination and 'step-down' intermediate care. The third configuration consisted of housing support workers providing in-reach and discharge coordination as well as step-down care. These three configurations were each compared with 'standard care' (control, defined as one visit by the homelessness health nurse before discharge during which patients received an information leaflet on local services). Multiple sources of data and multi-outcome measures were adopted to assess the cost utility of hospital discharge service delivery for the NHS and broader public perspective. Details of 354 participants were collated on service delivery costs (salary, on-costs, capital, overheads and 'hotel' costs, advertising and other indirect costs), the economic consequences for different public services (e.g. NHS, social care, criminal justice, housing, etc.) and health utilities (quality-adjusted-life-years, QALYs). Findings were complex across the configurations, but, on the whole, there was promising evidence suggesting that, with delivery costs similar to those reported for bed-based intermediate care, step-down care secured better health outcomes and improved cost-effectiveness (compared with usual care) within NICE cost-effectiveness recommendations.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Abstract LB029: Comprehensive structure-function evaluation of the SHOC2 holophosphatase reveals disease mechanisms and therapeutic opportunities

Receptor tyrosine kinase (RTK)-RAS signaling through the downstream mitogen activated protein kinase (MAPK) cascade regulate cell proliferation and survival. The SHOC2 holophosphatase functions as a key regulator of RTK-RAS signaling by removing an inhibitory phosphorylation on RAF family proteins to potentiate MAPK signaling. SHOC2 forms a ternary complex with MRAS and PP1C, and human germline gain-of-function mutations of this complex result in congenital RASopathy syndromes. However, the structure and the assembly of this complex are poorly understood. Here, we use cryogenic electron microscopy (cryo-EM) to resolve the structure of the SHOC2-PP1C-MRAS holophosphatase to 2.9Å resolution. Furthermore, we define the biophysical principles of SHOC2 holoenzyme interactions, elucidate the assembly order of the complex, and systematically interrogate the functional consequences of nearly all possible missense variants of SHOC2 through deep mutational scanning. We demonstrate that SHOC2 binds PP1C and MRAS through a concave surface created by the leucine-rich repeat region and further engages PP1C through the N-terminal disordered region containing a degenerate RVxF motif. Initial complex formation is mediated by SHOC2-PP1C interactions and is stabilized by binding of GTP-loaded MRAS. These observations define how clinical mutants in Noonan-like syndrome and cancer stabilize interactions of complex members to enhance holophosphatase activity. Together, this integrative structure-function model comprehensively defines key binding interactions within the SHOC2 holophosphatase, informing therapeutic development.

Citation Format: Jason Kwon, Behnoush Hajian, Yuemin Bian, Alvaro Amor, James Fuller, Cara Fraley, Laura Baker, Jonathan So, David Mayhew, Abbey Sykes, Nicole Persky, Xiaoping Yang, David Root, Charles Perry, Christopher Lemke, William Hahn, Andrew Aguirre. Comprehensive structure-function evaluation of the SHOC2 holophosphatase reveals disease mechanisms and therapeutic opportunities [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr LB029.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Improving care transfers for homeless patients after hospital discharge: a realist evaluation

Background

In 2013, 70% of people who were homeless on admission to hospital were discharged back to the street without having their care and support needs addressed. In response, the UK government provided funding for 52 new specialist homeless hospital discharge schemes. This study employed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines between September 2015 and 2019 to undertake a realist evaluation to establish what worked, for whom, under what circumstances and why. It was hypothesised that delivering outcomes linked to consistently safe, timely care transfers for homeless patients would depend on hospital discharge schemes implementing a series of high-impact changes (resource mechanisms). These changes encompassed multidisciplinary discharge co-ordination (delivered through clinically led homeless teams) and ‘step-down’ intermediate care. These facilitated time-limited care and support and alternative pathways out of hospital for people who could not go straight home.

Methods

The realist hypothesis was tested empirically and refined through three work packages. Work package 1 generated seven qualitative case studies, comparing sites with different types of specialist homeless hospital discharge schemes (n = 5) and those with no specialist discharge scheme (standard care) (n = 2). Methods of data collection included interviews with 77 practitioners and stakeholders and 70 people who were homeless on admission to hospital. A ‘data linkage’ process (work package 2) and an economic evaluation (work package 3) were also undertaken. The data linkage process resulted in data being collected on > 3882 patients from 17 discharge schemes across England. The study involved people with lived experience of homelessness in all stages.

Results

There was strong evidence to support our realist hypothesis. Specialist homeless hospital discharge schemes employing multidisciplinary discharge co-ordination and ‘step-down’ intermediate care were more effective and cost-effective than standard care. Specialist care was shown to reduce delayed transfers of care. Accident and emergency visits were also 18% lower among homeless patients discharged at a site with a step-down service than at those without. However, there was an impact on the effectiveness of the schemes when they were underfunded or when there was a shortage of permanent supportive housing and longer-term care and support. In these contexts, it remained (tacitly) accepted practice (across both standard and specialist care sites) to discharge homeless patients to the streets, rather than delay their transfer. We found little evidence that discharge schemes fired a change in reasoning with regard to the cultural distance that positions ‘homeless patients’ as somehow less vulnerable than other groups of patients. We refined our hypothesis to reflect that high-impact changes need to be underpinned by robust adult safeguarding.

Strengths and limitations

To our knowledge, this is the largest study of the outcomes of homeless patients discharged from hospital in the UK. Owing to issues with the comparator group, the effectiveness analysis undertaken for the data linkage was limited to comparisons of different types of specialist discharge scheme (rather than specialist vs. standard care).

Future work

There is a need to consider approaches that align with those for value or alliance-based commissioning where the evaluative gaze is shifted from discrete interventions to understanding how the system is working as a whole to deliver outcomes for a defined patient population.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 17. See the NIHR Journals Library website for further project information.

Hospital readmission among people experiencing homelessness in England: a cohort study of 2772 matched homeless and housed inpatients

BACKGROUND

Inpatients experiencing homelessness are often discharged to unstable accommodation or the street, which may increase the risk of readmission.

METHODS

We conducted a cohort study of 2772 homeless patients discharged after an emergency admission at 78 hospitals across England between November 2013 and November 2016. For each individual, we selected a housed patient who lived in a socioeconomically deprived area, matched on age, sex, hospital, and year of discharge. Counts of emergency readmissions, planned readmissions, and Accident and Emergency (A&E) visits post-discharge were derived from national hospital databases, with a median of 2.8 years of follow-up. We estimated the cumulative incidence of readmission over 12 months, and used negative binomial regression to estimate rate ratios.

RESULTS

After adjusting for health measured at the index admission, homeless patients had 2.49 (95% CI 2.29 to 2.70) times the rate of emergency readmission, 0.60 (95% CI 0.53 to 0.68) times the rate of planned readmission and 2.57 (95% CI 2.41 to 2.73) times the rate of A&E visits compared with housed patients. The 12-month risk of emergency readmission was higher for homeless patients (61%, 95% CI 59% to 64%) than housed patients (33%, 95% CI 30% to 36%); and the risk of planned readmission was lower for homeless patients (17%, 95% CI 14% to 19%) than for housed patients (30%, 95% CI 28% to 32%). While the risk of emergency readmission varied with the reason for admission for housed patients, for example being higher for admissions due to cancers than for those due to accidents, the risk was high across all causes for homeless patients.

CONCLUSIONS

Hospital patients experiencing homelessness have high rates of emergency readmission that are not explained by health. This highlights the need for discharge arrangements that address their health, housing and social care needs.

Investigating multiple sources of data for smart infusion pump and electronic health record interoperability

PURPOSE

Infusion pump data, which describe compliance to dose-error reduction software among other metrics, are retrievable from infusion pump vendor software, electronic health record (EHR) systems, and regional and national data repositories such as the Regenstrief National Center for Medical Device Informatics (REMEDI). Smart infusion pump and EHR interoperability has added to the granularity and complexity of data collected, and clinicians are challenged with efficiently comprehending and interpreting the data and reports available.

SUMMARY

Collaborative partnerships between the Indianapolis Coalition for Patient Safety and the Regenstrief Center for Healthcare Engineering allowed for clinicians, informaticists, researchers, and engineers to compare the information gained and strengths of using smart infusion pumps, EHR, and REMEDI to assess hospital medication safety in a setting of interoperability. Seven reporting capabilities were used to compare available reports, and 2 hypothetical scenarios were developed to highlight these processes. Infusion pump vendor-provided software and reports were found to provide the most usable information for detailed infusion reporting, while the EHR was strongly usable for interoperability compliance and REMEDI excelled in benchmarking capabilities.

CONCLUSION

While infusion analytics needs may differ across health systems, a better understanding of the strengths of infusion pump data and EHR data may help provide structure and direction in the infusion analytics process. Infusion data repositories such as REMEDI are useful tools to obtain information in a way not delivered by smart pump data.

Social Work Practice with Adults under the Rising Second Wave of Covid-19 in England: Frontline Experiences and the Use of Professional Judgement

The impacts on adult social work in England of the Covid-19 pandemic were sudden and are proving long-standing. In England, many social workers moved to home working and virtual contact with colleagues, managers, staff from other agencies and service users. A first national lockdown was followed by a lessening of restrictions, but a second wave started at the end of Summer 2020 and restrictions were re-introduced. This study draws on telephone interviews with a sample of twenty-two social workers working with adults in a wide range of roles and settings in ten local authorities and two National Health Service Hospital Trusts, interviewed August–October 2020. Following transcription, interview data were analysed thematically. Findings are reported under three emerging themes: using professional judgement, new and emerging case work and embedding change. These are compared with findings from studies of practice in children’s services and of surveys of social workers during the Covid-19 pandemic. Implications for practice, service users and research are explored.

The Plastics Industry: A Comparative Study of Research and Innovation

Plastics are already one of the world's main groups of industrial materials; in volume terms, world plastics consumption is now greater than that of all non-ferrous metals combined. The main point that emerges from international comparisons is West Germany's predominance in production and exports (and also in exports of plastics machinery). German production of plastic materials in 1961 was 19 kilograms per head, compared to 17½ in the United States and 12 in Britain. This is not due to lower costs. In material costs, Germany has been, if anything, at a disadvantage : she had only a small petro-chemicals industry in the early post-war years, and she has very little natural gas. In labour costs (which in any case are not very important in this industry) and in plant costs, again there is no evidence of any marked German advantage over her competitors. In general her quoted prices were not below those of other countries.

Stakeholder perceptions of smart infusion pumps and drug library updates: A multisite, interdisciplinary study

PURPOSE

Results of a questionnaire-based study to evaluate smart infusion pump end users' perceptions and understanding of the drug library update process are reported.

METHODS

The Indianapolis Coalition for Patient Safety, Inc., in partnership with the Regenstrief Center for Healthcare Engineering, conducted a 33-item electronic, cross-sectional survey across 5 Indiana health systems from May through November 2017. Interdisciplinary participants identified for survey distribution included nurses, pharmacists, biomedical engineers, administrators, and medication safety officers. The survey assessed the following domains: patient safety, the drug library update process, knowledge of drug libraries and the update process, and end-user perceptions.

RESULTS

A total of 778 submitted surveys were included in the data analysis, with a large majority of responses (90.2%) provided by nurses. The use of drug libraries for ensuring patient safety was deemed extremely important or important by 88% of respondents, but 36% indicated that they were unsure of whether drug libraries are updated on a routine basis in their health system. Approximately two-thirds agreed that the current update process improves quality of care (65.0%) and patient safety (68.1%). Moreover, 53.3% agreed that the current drug library update process was effective. However, less than 10% responded correctly when asked about the steps required to update the drug library. Furthermore, only 18% correctly indicated that when a pump is on it may not necessarily contain the most up-to-date version of the drug library.

CONCLUSION

A survey of 5 health systems in Indianapolis identified several end-user knowledge gaps related to smart pump drug library updates. The results suggest that these gaps were most likely due to a combination of the 2-step update process and the fact that the current drug library version is not easy to find and/or user-friendly and it is unclear when an update is pending.

Development of a standardized, citywide process for managing smart-pump drug libraries

PURPOSE

Development and implementation of an interprofessional consensus-driven process for review and optimization of smart-pump drug libraries and dosing limits are described.

SUMMARY

The Indianapolis Coalition for Patient Safety (ICPS), which represents 6 Indianapolis-area health systems, identified an opportunity to reduce clinically insignificant alerts that smart infusion pumps present to end users. Through a consensus-driven process, ICPS aimed to identify best practices to implement at individual hospitals in order to establish specific action items for smart-pump drug library optimization. A work group of pharmacists, nurses, and industrial engineers met to evaluate variability within and lack of scrutiny of smart-pump drug libraries. The work group used Lean Six Sigma methodologies to generate a list of key needs and barriers to be addressed in process standardization. The group reviewed targets for smart-pump drug library optimization, including dosing limits, types of alerts reviewed, policies, and safety best practices. The work group also analyzed existing processes at each site to develop a final consensus statement outlining a model process for reviewing alerts and managing smart-pump data. Analysis of the total number of alerts per device across ICPS-affiliated health systems over a 4-year period indicated a 50% decrease (from 7.2 to 3.6 alerts per device per month) after implementation of the model by ICPS member organizations.

CONCLUSION

Through implementation of a standardized, consensus-driven process for smart-pump drug library optimization, ICPS member health systems reduced clinically insignificant smart-pump alerts.

Standardizing concentrations of adult drug infusions in Indiana

PURPOSE

A multidisciplinary, consensus-driven initiative to promote the use of standardized medication concentrations for adult drug infusions across the state of Indiana is described.

METHODS

To accomplish development of the Indiana Standard Concentrations of Adult Drug Infusions List ("the Indiana List"), several available lists of i.v. concentrations were compiled, consolidated, and compared. Lists of adult standardized i.v. concentrations were primarily drawn from Indiana regional patient safety coalitions, published literature, and publicly available lists of recommended i.v. concentrations. The standardization project, which expanded initial work completed by the Indianapolis Coalition for Patient Safety, was conducted in conjunction with Purdue University's Center for Medication Safety Advancement, the Indiana Hospital Association, and the 11 regional patient safety coalitions across the state.

RESULTS

After a review of 9 existing lists of standard i.v. concentrations, an initial list of 69 concentrations representing a total of 37 medications was derived; 34 of those concentrations were represented on at least 1 of the 3 evaluated Indiana regional patient safety coalition lists. A statewide interdisciplinary work group of representatives of regional patient safety coalitions and 9 health systems representing a total of 81 hospitals ranging from academic medical centers to critical access hospitals assembled to develop consensus on a final list of standard medication concentrations for adult i.v. infusions.

CONCLUSION

A final list of 28 concentrations of 26 medications was identified for the recommended Indiana List by an interdisciplinary work group. A checklist of considerations for implementation was also developed.

Causes of death among homeless people: a population-based cross-sectional study of linked hospitalisation and mortality data in England

Background: Homelessness has increased by 165% since 2010 in England, with evidence from many settings that those affected experience high levels of mortality. In this paper we examine the contribution of different causes of death to overall mortality in homeless people recently admitted to hospitals in England with specialist integrated homeless health and care (SIHHC) schemes.  Methods: We undertook an analysis of linked hospital admission records and mortality data for people attending any one of 17 SIHHC schemes between 1st November 2013 and 30th November 2016. Our primary outcome was death, which we analysed in subgroups of 10th version international classification of disease (ICD-10) specific deaths; and deaths from amenable causes. We compared our results to a sample of people living in areas of high social deprivation (IMD5 group). Results: We collected data on 3,882 individual homeless hospital admissions that were linked to 600 deaths. The median age of death was 51.6 years (interquartile range 42.7-60.2) for SIHHC and 71.5 for the IMD5 (60.67-79.0).  The top three underlying causes of death by ICD-10 chapter in the SIHHC group were external causes of death (21.7%; 130/600), cancer (19.0%; 114/600) and digestive disease (19.0%; 114/600).  The percentage of deaths due to an amenable cause after age and sex weighting was 30.2% in the homeless SIHHC group (181/600) compared to 23.0% in the IMD5 group (578/2,512). Conclusion: Nearly one in three homeless deaths were due to causes amenable to timely and effective health care. The high burden of amenable deaths highlights the extreme health harms of homelessness and the need for greater emphasis on prevention of homelessness and early healthcare interventions.

Hazara nairovirus elicits differential induction of apoptosis and nucleocapsid protein cleavage in mammalian and tick cells

The Nairoviridae family within the Bunyavirales order comprise tick-borne segmented negative-sense RNA viruses that cause serious disease in a broad range of mammals, yet cause a latent and lifelong infection in tick hosts. An important member of this family is Crimean-Congo haemorrhagic fever virus (CCHFV), which is responsible for serious human disease that results in case fatality rates of up to 30 %, and which exhibits the most geographically broad distribution of any tick-borne virus. Here, we explored differences in the cellular response of both mammalian and tick cells to nairovirus infection using Hazara virus (HAZV), which is a close relative of CCHFV within the CCHFV serogroup. We show that HAZV infection of human-derived SW13 cells led to induction of apoptosis, evidenced by activation of cellular caspases 3, 7 and 9. This was followed by cleavage of the classical apoptosis marker poly ADP-ribose polymerase, as well as cellular genome fragmentation. In addition, we show that the HAZV nucleocapsid (N) protein was abundantly cleaved by caspase 3 in these mammalian cells at a conserved DQVD motif exposed at the tip of its arm domain, and that cleaved HAZV-N was subsequently packaged into nascent virions. However, in stark contrast, we show for the first time that nairovirus infection of cells of the tick vector failed to induce apoptosis, as evidenced by undetectable levels of cleaved caspases and lack of cleaved HAZV-N. Our findings reveal that nairoviruses elicit diametrically opposed cellular responses in mammalian and tick cells, which may influence the infection outcome in the respective hosts.

Improving hospital discharge arrangements for people who are homeless: A realist synthesis of the intermediate care literature

This review presents a realist synthesis of "what works and why" in intermediate care for people who are homeless. The overall aim was to update an earlier synthesis of intermediate care by capturing new evidence from a recent UK government funding initiative (the "Homeless Hospital Discharge Fund"). The initiative made resources available to the charitable sector to enable partnership working with the National Health Service (NHS) in order to improve hospital discharge arrangements for people who are homeless. The synthesis adopted the RAMESES guidelines and reporting standards. Electronic searches were carried out for peer-reviewed articles published in English from 2000 to 2016. Local evaluations and the grey literature were also included. The inclusion criteria was that articles and reports should describe "interventions" that encompassed most of the key characteristics of intermediate care as previously defined in the academic literature. Searches yielded 47 articles and reports. Most of these originated in the UK or the USA and fell within the realist quality rating of "thick description". The synthesis involved using this new evidence to interrogate the utility of earlier programme theories. Overall, the results confirmed the importance of (i) collaborative care planning, (ii) reablement and (iii) integrated working as key to effective intermediate care delivery. However, the additional evidence drawn from the field of homelessness highlighted the potential for some theory refinements. First, that "psychologically informed" approaches to relationship building may be necessary to ensure that service users are meaningfully engaged in collaborative care planning and second, that integrated working could be managed differently so that people are not "handed over" at the point at which the intermediate care episode ends. This was theorised as key to ensuring that ongoing care arrangements do not break down and that gains are not lost to the person or the system vis-à-vis the prevention of readmission to hospital.

Outcomes of specialist discharge coordination and intermediate care schemes for patients who are homeless: analysis protocol for a population-based historical cohort

INTRODUCTION

People who are homeless often experience poor hospital discharge arrangements, reflecting ongoing care and housing needs. Specialist integrated homeless health and care provision (SIHHC) schemes have been developed and implemented to facilitate the safe and timely discharge of homeless patients from hospital. Our study aims to investigate the health outcomes of patients who were homeless and seen by a selection of SIHHC services.

METHODS AND ANALYSIS

Our study will employ a historical population-based cohort in England. We will examine health outcomes among three groups of adults: (1) homeless patients seen by specialist discharge schemes during their hospital admission; (2) homeless patients not seen by a specialist scheme and (3) admitted patients who live in deprived neighbourhoods and were not recorded as being homeless. Primary outcomes will be: time from discharge to next hospital inpatient admission; time from discharge to next accident and emergency attendance and 28-day emergency readmission. Outcome data will be generated through linkage to hospital admissions data (Hospital Episode Statistics) and mortality data for November 2013 to November 2016. Multivariable regression will be used to model the relationship between the study comparison groups and each of the outcomes.

ETHICS AND DISSEMINATION

Approval has been obtained from the National Health Service (NHS) Confidentiality Advisory Group (reference 16/CAG/0021) to undertake this work using unconsented identifiable data. Health Research Authority Research Ethics approval (REC 16/EE/0018) has been obtained in addition to local research and development approvals for data collection at NHS sites. We will feedback the results of our study to our advisory group of people who have lived experience of homelessness and seek their suggestions on ways to improve or take this work further for their benefit. We will disseminate our findings to SIHHC schemes through a series of regional workshops.

Classification and automatic transcription of primate calls

This paper reports on an automated and openly available tool for automatic acoustic analysis and transcription of primate calls, which takes raw field recordings and outputs call labels time-aligned with the audio. The system's output predicts a majority of the start times of calls accurately within 200 milliseconds. The tools do not require any manual acoustic analysis or selection of spectral features by the researcher.

Natural history of early first-trimester pregnancies implanted in Cesarean scars

OBJECTIVE

To describe the ultrasound findings and natural history of pregnancies implanted within or on Cesarean section scars in the first trimester of pregnancy.

METHODS

This was a prospective observational study of 10 women diagnosed with a pregnancy implanted in or on a Cesarean section scar in the first trimester, who declined medical intervention because of their desire to continue the pregnancy. The study population comprised women at < 12 weeks' gestation who were seen in our early pregnancy unit between January 2011 and September 2013. Nine women were followed up by serial ultrasound examinations and had detailed care plans for delivery at King's College Hospital (KCH). One woman was followed up and delivered at another teaching hospital. The first-trimester ultrasound findings were compared with the clinical outcome of the pregnancy.

RESULTS

The nine patients who were followed up at KCH developed ultrasound findings of morbidly adherent placenta (MAP) in the second and third trimesters. All 10 patients were diagnosed with MAP at the time of delivery by Cesarean section. The gestational age at delivery ranged from 26 to 38 weeks. The uterus was conserved in five patients, and Cesarean hysterectomy was performed in the remaining five. All three women with complete implantation of the gestational sac within the scar and two of three cases with placental lakes in the first trimester had hysterectomies. The two cases with bulging of the gestational sac out of the uterine contour had a preterm emergency hysterectomy due to placenta percreta. Histology confirmed placenta accreta in the five hysterectomy specimens. There were no fetal or neonatal complications.

CONCLUSIONS

Implantation of a pregnancy on or in a Cesarean section scar is a precursor of MAP; however, the degree of morbidity associated with this implantation is variable and difficult to predict based on first-trimester ultrasound findings only. The assessment of ongoing pregnancies implanted in Cesarean scars is most beneficial when performed between 7 and 9 weeks' gestation. Complete implantation within the myometrial defect, bulging of the trophoblast from the uterine contour and large placental lakes in the first trimester are ultrasound findings that may predict severe placenta accreta or percreta and consequently a poor outcome.

The geographic and demographic scope of shared sanitation: an analysis of national survey data from low- and middle-income countries

OBJECTIVE

A large and growing proportion of the world's population rely on shared sanitation facilities that have historically been excluded from international targets due to concerns about acceptability, hygiene and access. In connection with a proposed change in such policy, we undertook this study to describe the prevalence and scope of households that report relying on shared sanitation and to characterise them in terms of selected socio-economic and demographic covariates.

METHODS

We extracted data from the most recent national household surveys of 84 low- and middle-income countries from Demographic and Health Surveys and Multiple Indicator Cluster Surveys. We describe the prevalence of shared sanitation and explore associations between specified covariates and reliance on shared sanitation using log-binomial regression.

RESULTS

While household reliance on any type of shared sanitation is relatively rare in Europe (2.5%) and the Eastern Mediterranean (7.7%), it is not uncommon in the Americas (14.2%), Western Pacific (16.4%) and South-East Asia (31.3%), and it is most prevalent in Africa (44.6%) where many shared facilities do not meet the definition of 'improved' even if they were not shared (17.7%). Overall, shared sanitation is more common in urban (28.6%) than in rural settings (25.9%), even after adjusting for wealth. While results vary geographically, people who rely on shared sanitation tend to be poorer, reside in urban areas and live in households with more young children and headed by people with no formal education. Data from 21 countries suggest that most sharing is with neighbours and other acquaintances (82.0%) rather than the public.

CONCLUSIONS

The determinants of shared sanitation identified from these data suggest potential confounders that may explain the apparent increased health risk from sharing and should be considered in any policy recommendation. Both geographic and demographic heterogeneity indicate the need for further research to support a change in policies.

Successful lung transplant in a child with cystic fibrosis and persistent Blastobotrys rhaffinosifermentans infection

Fungal respiratory infections in patients with CF are a significant concern both pre- and post-lung transplantation (LTx). Fungal infection is associated with increased mortality post-LTx, and in the past decade, the prevalence of fungal colonization in Canadian pediatric patients with CF has increased. The emergence of novel fungal pathogens is particularly challenging to the transplant community, as little is known regarding their virulence and optimal management. We present a case of a successful double-lung transplant in a pediatric patient with CF who was infected pretransplantation with a novel yeast, Blastobotrys rhaffinosifermentans. This patient was treated successfully with aggressive antifungal therapy post-transplantation, followed by extended fungal prophylaxis. The significance of fungal colonization and infection in children with CF pre- and post-LTx is reviewed.