Analysing cause of death during follow-up for non-muscle-invasive bladder cancer: is there a role for watchful waiting?

INTRODUCTION

Non-muscle-invasive bladder cancer (NMIBC) patients often require multiple invasive procedures during follow-up. Surveillance guidelines do not adjust for increasing frailty or competing comorbidity. We aim to evaluate the influence of these factors on the natural history of NMIBC and whether this may have implications for appropriate follow-up schedules.

METHODS

NMIBC patients who died in a 3-year period while on cystoscopic surveillance were identified. Frailty was assessed using the Rockwood Clinical Frailty Scale (CFS): 1-3, no frailty; 4, vulnerable; 5-9, mild/severe frailty. Similarly, three-tier categorisations were performed for comorbidity (Charlson Comorbidity Index) and for anaesthetic risk (American Society of Anesthesiologists' [ASA] score).

RESULTS

Of the 69 patients, 26 were categorised as no frailty, 20 as vulnerable and 13 as frail. There was no difference in the proportions of those with higher risk NMIBC between the categories. Increasing frailty was associated with reduced overall survival (median 59, 29 and 13 months; p < 0.05) but not recurrence-free survival (p = 0.98) or progression-free survival (p = 0.58). Similar results were obtained using the Charlson Comorbidity Index or ASA score. No frail patients with low/intermediate-risk NMIBC had clinically significant disease progression prior to death. Frail patients with CFS ≥ 4 were found to have similar complications due to bladder cancer itself (p = 0.48) yet almost three times as many complications following cystoscopic procedures during follow-up (p < 0.05).

CONCLUSIONS

For frail patients with low risk of progression, protocol-driven cystoscopic surveillance may not improve survival and watchful waiting may be more appropriate. Further investigation is required to determine the feasibility of this approach.

Fremantle protocol: Multicenter clinical outcomes for a pragmatic protocol for intravesical bacillus Calmette-Guerin

OBJECTIVES

To examine the utility and efficacy of a multifaceted protocol for the administration of intravesical bacillus Calmette-Guerin (BCG) for non-muscle-invasive bladder cancer (NMIBC).

SUBJECTS AND METHODS

A multicenter retrospective review was conducted among 83 patients undergoing Fremantle protocol intravesical BCG for NMIBC within 4 major hospitals in Western Australia between January 2016 and December 2018. The Fremantle protocol consists of weekly BCG instillations for 6 weeks during the induction phase, followed by monthly BCG instillations for 10 months during the maintenance phase with integrated clearance-to-proceed algorithms for urine MSU checks, flexible cystoscopies performed at 3 monthly intervals during maintenance BCG, and repeat GA cystoscopies with four quadrant bladder biopsies routinely obtained following the completion of induction and maintenance treatment.

RESULTS

For patients undergoing Fremantle protocol BCG, 98.8% (82/83) and 75.9% (63/83) of patients completed their induction and maintenance courses of BCG, respectively. Induction BCG was delivered over a median duration of 35 days (range 34-84 days), and maintenance BCG was delivered over a median duration of 266 days (range 1-682 days). The tumor recurrence rate was 10.8% (9/83) at the time of post-induction biopsies, 2.4% (2/83) during maintenance treatment, 0% (0/60) at the time of post-maintenance biopsies, and 8.8% (5/57) after a median further follow-up of 16 months (range 0-51 months).

CONCLUSION

The Fremantle protocol appears to be a safe and effective BCG regimen with several advantages over other BCG protocols, including high completion rates, low recurrence rates, and being highly pragmatic.

The unique COVID-19 experience in Western Australia: lessons learnt

BACKGROUND

Western Australia (WA) was in a unique position to experience coronavirus disease 2019 (COVID-19) in a highly vaccinated and geographically isolated population.

AIM

To describe the COVID-19 Omicron experience at the only quaternary hospital in WA following border opening from 3 March to 11 May 2022.

PARTICIPANTS

A total of 158 adults with microbiologically confirmed COVID-19 were admitted to the respiratory or intensive care unit (ICU).

OUTCOMES

Admission numbers, disease severity, prevalence of COVID-19 deterioration risk factors, immunisation status, severity of infection, immunosuppression and treatment regimen.

RESULTS

One hundred fifty-eight COVID-19-positive patients were admitted to the respiratory ward (n = 123) and the ICU (n = 35) during the study period. COVID-19 infection was the primary admission reason in 32.9% of patients, 51.3% were male and the median age was 62 years. Aboriginal or Torres Strait Islanders (ATSI) were overrepresented (13.3%). Care was predominantly ward based (77.2%). Nearly half of the patients had mild COVID-19 (49.4%). Dexamethasone was the most common treatment provided to patients (58.2%). The median length of stay was 5.8 days (interquartile range, 5-15). Eight patients died during the study period (5.1%), with three of those deaths attributable to COVID-19.

CONCLUSIONS

COVID-19 case numbers following WA state border opening were of lower care acuity and disease severity than predicted. Two-thirds of admissions were for other primary diagnoses, with incidental COVID detection. Hospital admissions were overrepresented by partially or unvaccinated patients and by ATSI Australians. An increase in social support along with general and geriatric medicine speciality input were required to treat hospitalised COVID-19 cases in the WA Omicron wave.

ICARUS at the Fermilab Short-Baseline Neutrino program: initial operation

The ICARUS collaboration employed the 760-ton T600 detector in a successful 3-year physics run at the underground LNGS laboratory, performing a sensitive search for LSND-like anomalous ν e appearance in the CERN Neutrino to Gran Sasso beam, which contributed to the constraints on the allowed neutrino oscillation parameters to a narrow region around 1 eV2 . After a significant overhaul at CERN, the T600 detector has been installed at Fermilab. In 2020 the cryogenic commissioning began with detector cool down, liquid argon filling and recirculation. ICARUS then started its operations collecting the first neutrino events from the booster neutrino beam (BNB) and the Neutrinos at the Main Injector (NuMI) beam off-axis, which were used to test the ICARUS event selection, reconstruction and analysis algorithms. ICARUS successfully completed its commissioning phase in June 2022. The first goal of the ICARUS data taking will be a study to either confirm or refute the claim by Neutrino-4 short-baseline reactor experiment. ICARUS will also perform measurement of neutrino cross sections with the NuMI beam and several Beyond Standard Model searches. After the first year of operations, ICARUS will search for evidence of sterile neutrinos jointly with the Short-Baseline Near Detector, within the Short-Baseline Neutrino program. In this paper, the main activities carried out during the overhauling and installation phases are highlighted. Preliminary technical results from the ICARUS commissioning data with the BNB and NuMI beams are presented both in terms of performance of all ICARUS subsystems and of capability to select and reconstruct neutrino events.

COVID-19 ethnic inequalities in mental health and multimorbidities: protocol for the COVEIMM study

PURPOSE

The COVID-19 pandemic may have exacerbated ethnic health inequalities, particularly in people with multiple long-term health conditions, the interplay with mental health is unclear. This study investigates the impact of the pandemic on the association of ethnicity and multimorbidity with mortality/service use among adults, in people living with severe mental illnesses (SMI).

METHODS

This study will utilise secondary mental healthcare records via the Clinical Record Interactive Search (CRIS) and nationally representative primary care records through the Clinical Practice Interactive Research Database (CPRD). Quasi-experimental designs will be employed to quantify the impact of COVID-19 on mental health service use and excess mortality by ethnicity, in people living with severe mental health conditions. Up to 50 qualitative interviews will also be conducted, co-produced with peer researchers; findings will be synthesised with quantitative insights to provide in-depth understanding of observed associations.

RESULTS

81,483 people in CRIS with schizophrenia spectrum, bipolar or affective disorder diagnoses, were alive from 1st January 2019. Psychiatric multimorbidities in the CRIS sample were comorbid somatoform disorders (30%), substance use disorders (14%) and personality disorders (12%). In CPRD, of 678,842 individuals with a prior probable diagnosis of COVID-19, 1.1% (N = 7493) had an SMI diagnosis. People in the SMI group were more likely to die (9% versus 2% in the non-SMI sample) and were more likely to have mental and physical multimorbidities.

CONCLUSION

The effect of COVID-19 on people from minority ethnic backgrounds with SMI and multimorbidities remains under-studied. The present mixed methods study aims to address this gap.

Urethral fistula and perineal collection during intravesical treatment for non-muscle invasive bladder cancer – A rare complication

Intravesical Bacillus Calmette-Guérin (BCG) immunotherapy for non-muscle invasive bladder cancer (NMIBC) has been used as a treatment since 1976. It is effective in reducing disease recurrence and progression, with mostly self-limiting or mild side effects. Serious complications are rare and thought to be either related to systemic BCG infection (BCG-osis) or a systemic inflammatory response, and often require systemic anti-tuberculous therapy. We report a rare case of urethral fistulation leading to perineal BCG-abscess during intravesical BCG immunotherapy for high grade bladder cancer. This ultimately required systemic anti-tuberculous therapy and cessation of intravesical BCG treatment.

A clinical and in vitro assessment of outpatient parenteral benzylpenicillin and ceftriaxone combination therapy for enterococcal endovascular infections

Background

Amoxicillin plus ceftriaxone combination therapy is now standard of care for enterococcal endocarditis. Due to amoxicillin instability in infusion devices, benzylpenicillin plus ceftriaxone may be substituted to facilitate outpatient parenteral antimicrobial therapy (OPAT) delivery, despite lack of guideline endorsement.

Objectives

To assess the clinical efficacy of benzylpenicillin plus ceftriaxone for the management of enterococcal endovascular infections, in addition to assessing this combination’s in vitro synergy.

Patients and methods

Retrospective cohort study assessing unplanned readmissions, relapses and mortality for 20 patients with endovascular Enterococcus faecalis infections treated with benzylpenicillin plus ceftriaxone delivered via OPAT. For a subset of isolates, synergism for both amoxicillin and benzylpenicillin in combination with ceftriaxone was calculated using a chequerboard method.

Results

Patients had endovascular infections of native cardiac valves (n = 11), mechanical or bioprosthetic cardiac valves (n = 7), pacemaker leads (n = 1) or left ventricular assistant devices (n = 1). The median duration of OPAT was 22 days, and the most frequent antimicrobial regimen was benzylpenicillin 14 g/day via continuous infusion and ceftriaxone 4 g once daily via short infusion. Rates of unplanned readmissions were high (30%), although rates of relapsed bacteraemia (5%) and 1 year mortality (15%) were comparable to the published literature. Benzylpenicillin less frequently displayed a synergistic interaction with ceftriaxone when compared with amoxicillin (3 versus 4 out of 6 isolates).

Conclusions

Lower rates of synergistic antimicrobial interaction and a significant proportion of unplanned readmissions suggest clinicians should exercise caution when treating enterococcal endovascular infection utilizing a combination of benzylpenicillin and ceftriaxone via OPAT.

Risk factors for catheter related thrombosis during outpatient parenteral antimicrobial therapy

BACKGROUND

Outpatient parenteral antimicrobial therapy (OPAT) delivery using peripherally inserted central catheters is associated with a risk of catheter related thrombosis (CRT). Individualised preventative interventions may reduce this occurrence, however patient selection is hampered by a lack of understanding of risk factors. We aimed to identify patient, infection or treatment related risk factors for CRT in the OPAT setting.

METHODS

Retrospective case control study (1:3 matching) within OPAT services at two tertiary hospitals within Australia.

RESULTS

Over a 2 year period, encompassing OPAT delivery to 1803 patients, there were 19 cases of CRT, giving a prevalence of 1.1% and incidence of 0.58/1000 catheter days. Amongst the cases of CRT, there were nine (47%) unplanned readmissions and two (11%) pulmonary emboli. Compared to controls, cases had a higher frequency of malposition of the catheter tip (4/19 (21%) vs 0/57 (0%), p = 0.003) and complicated catheter insertion (3/19 (16%) vs 1/57 (2%), p = 0.046).

CONCLUSIONS

Although CRTs during OPAT are infrequent, they often have clinically significant sequelae. Identification of modifiable vascular access related predictors of CRT should assist with patient risk stratification and guide risk reduction strategies.

Multi-route antifungal administration in the management of urinary Candida glabrata bezoar

A 65-year-old lady was admitted with urosepsis and imaging suggesting right sided hydronephrosis secondary to a filling defect consistent with a fungal bezoar. An indwelling urinary catheter and a right percutaneous nephrostomy tube were inserted. Candida glabrata cultured from urine was resistant to fluconazole. Amphotericin B was instilled into the renal pelvis via the nephrostomy tube while intravenous liposomal amphotericin was administered daily along with oral flucytosine. This multi-modal antifungal administration was continued for 14 days. Clinical and biochemical improvement was achieved and repeat imaging showed complete resolution of the filling defects and hydronephrosis.

Antibiotic allergy labels and optimal antimicrobial stewardship

BACKGROUND

Although common, antimicrobial allergy labels (AAL) rarely reflect immunologically-mediated hypersensitivity and can lead to poorer outcomes from alternative antimicrobial agents. Antimicrobial stewardship programs are ideally placed to assess AAL early as a means of improving antimicrobial use.

OBJECTIVES

To quantify the prevalence of AAL in patients referred for antimicrobial stewardship review and assess their impact on antibiotic prescribing, patient mortality, hospital length of stay, readmission, and rates of multidrug-resistant infections.

METHODS

We conducted a retrospective analysis of adult patients referred for inpatient antimicrobial prospective audit and feedback rounds (PAFR) via an electronic referral system (eReferrals) over a 12-month period in 2015. Outcome data was collected for a period of 36 months following the initial review.

RESULTS

Of the 639 patient records reviewed, 630 met inclusion criteria; 103 (16%) had an AAL, of which 82 (13%) had reported allergies to β-lactam antibiotics. Those with AAL were significantly less likely to be receiving guideline-recommended antimicrobial therapy (50% versus 64%, p=0.0311), however there were no significant difference in mortality, hospital length of stay, readmission or increased incidence of multidrug-resistant infections.

CONCLUSIONS

Our cohort demonstrated that AAL was associated with reduced adherence to antibiotic guidelines. The lack of association with adverse outcomes may reflect limitations within the study including retrospective cohort study numbers and observational nature, further skewed by high rates of poor documentation. A clear opportunity exists for antimicrobial stewardship programs to incorporate allergy assessment, delabelling, challenge and referral into these rounds. This article is protected by copyright. All rights reserved.

Seasonal and regional patterns of lower leg cellulitis in Western Australia

BACKGROUND

Lower leg cellulitis (LLC) is a common infection that is usually caused by Streptococcus pyogenes or other beta-haemolytic streptococci. We hypothesised that in Western Australia (WA), LLC is a summer disease and would be more common in the northern, tropical regions.

METHODS

We conducted a statewide data linkage of adult patients presenting to WA hospitals with a first ever diagnosis of LLC, from January 2002 through December 2013 according to the region and season.

RESULTS

A total of 36 276 cases presented with a primary episode of LLC. The northern regions of the Kimberley (2.26 (2.13-2.39), P < 0.001) and midwest (1.13 (1.06-1.20), P < 0.001) had higher incidence rates than the Perth metropolitan region, while the southern regions of Southwest, Great Southern and Goldfields had lower incidence rates (0.89 (0.85-0.93), P < 0.001; 0.81 (0.75-0.88), P < 0.001; and 0.77 (0.71-0.83), P < 0.001, respectively). The total number of primary cases was higher in summer (10 570 (29.1%, 95% confidence interval 28.7-29.6), P < 0.0001) and autumn (9306 (25.7%, 95% confidence interval 25.2-26.1), P = 0.004). Seasonality of LLC was observed in all WA regions except those in the Kimberley, Pilbara and Great Southern regions.

CONCLUSION

In most non-tropical regions of WA, LLC is a summer disease, while in the warmer tropical regions of WA where year-round temperatures are higher, no seasonality was observed, but overall incidence of LLC presentations were higher. These findings may have important implications for public health messaging and research around prevention of LLC.

Castor patatin-like phospholipase A IIIβ facilitates removal of hydroxy fatty acids from phosphatidylcholine in transgenic Arabidopsis seeds

Castor patatin-like phospholipase A IIIβ facilitates the exclusion of hydroxy fatty acids from phosphatidylcholine in developing transgenic Arabidopsis seeds. Hydroxy fatty acids (HFAs) are industrial useful, but their major natural source castor contains toxic components. Although expressing a castor OLEATE 12-HYDROXYLASE in Arabidopsis thaliana leads to the synthesis of HFAs in seeds, a high proportion of the HFAs are retained in phosphatidylcholine (PC). Thus, the liberation of HFA from PC seems to be critical for obtaining HFA-enriched seed oils. Plant phospholipase A (PLA) catalyzes the hydrolysis of PC to release fatty acyl chains that can be subsequently channeled into triacylglycerol (TAG) synthesis or other metabolic pathways. To further our knowledge regarding the function of PLAs from HFA-producing plant species, two class III patatin-like PLA cDNAs (pPLAIIIβ or pPLAIIIδ) from castor or Physaria fendleri were overexpressed in a transgenic line of A. thaliana producing C18-HFA, respectively. Only the overexpression of RcpPLAIIIβ resulted in a significant reduction in seed HFA content with concomitant changes in fatty acid composition. Reductions in HFA content occurred in both PC and TAG indicating that HFAs released from PC were not incorporated into TAG. These results suggest that RcpPLAIIIβ may catalyze the removal of HFAs from PC in the developing seeds synthesizing these unusual fatty acids.

Pharmacokinetics of flucloxacillin during prolonged intermittent renal replacement therapy in a 76-year-old man

Prolonged intermittent renal replacement therapy (PIRRT) use has been increasing in critically ill patients with kidney dysfunction. PIRRT can affect the pharmacokinetics of many drugs, although no data is available to guide flucloxacillin dosing in this clinical scenario. Herein, we describe the pharmacokinetics of flucloxacillin, given at 1 g every 4 h during PIRRT, in a 76-year-old, critically ill patient with a methicillin-susceptible Staphylococcus aureus (MSSA) prosthetic joint infection complicated by bacteraemia. Blood samples were taken over 2 days including during a 9-h PIRRT session. A two-compartment model was developed to describe differences in clearance of flucloxacillin during PIRRT and off-PIRRT (9.45 vs. 6.89 L/h). A flucloxacillin dose of 1 g every 4 h during PIRRT therapy appeared to attain adequate exposures for MSSA sepsis in this patient, however higher doses may be required for infection sites with poor drug penetration.

Pharmacokinetics of Benzylpenicillin (Penicillin G) during Prolonged Intermittent Renal Replacement Therapy

Prolonged intermittent renal replacement therapy (PIRRT) is an increasingly adopted method of renal replacement in critically ill patients. Like continuous renal replacement therapy, PIRRT can alter the pharmacokinetics (PK) of many drugs. In this setting, dosing data for antibiotics like benzylpenicillin are lacking. In order to enable clinicians to prescribe benzylpenicillin safely and effectively, knowledge of the effects of PIRRT on the plasma PK of benzylpenicillin is required. Herein, we describe the PK of benzylpenicillin in 2 critically ill patients on PIRRT for the treatment of penicillin-susceptible Staphylococcus aureus bacteremia complicated by infective endocarditis. Blood samples were taken for each patient taken over dosing periods during PIRRT and off PIRRT. Two-compartment PK models described significant differences in the mean clearance of benzylpenicillin with and without PIRRT (6.61 vs. 3.04 L/h respectively). We would suggest a benzylpenicillin dose of 1,800 mg (3 million units) every 6-h during PIRRT therapy as sufficient to attain PK/pharmacodynamic target.

Ertapenem for osteoarticular infections in obese patients: a pharmacokinetic study of plasma and bone concentrations

PURPOSE

Ertapenem is used off-label to treat osteoarticular infections but there are few pharmacokinetic (PK) data to guide optimal dosing strategies in patients who may be obese with multiple co-morbidities including diabetes and peripheral vascular disease.

METHODS

Participants undergoing lower limb amputation or elective joint arthroplasty received a dose of intravenous ertapenem prior to surgery. Eight plasma samples were collected over 24 h, together with at least one bone sample per patient. Ertapenem concentrations in plasma and bone were measured using liquid-chromatography/mass-spectroscopy and analysed using non-linear mixed effects PK modelling.

RESULTS

Plasma and bone concentrations were obtained from 10 participants. The final population PK model showed that a fat free body mass was the most appropriate body size adjustment. Ertapenem diffused rapidly into bone but concentrations throughout the 24 h dosing period were on average 40-fold higher in plasma, corresponding to a bone to plasma ratio of 0.025, and highly variable between individuals. Simulations demonstrated a high probability of target attainment (PTA) for free plasma concentrations when the minimum inhibitory concentrations (MIC) were ≤ 0.25 mg/L. By contrast, at MICs of 0.5 mg/L and ≥ 1 mg/L, the fractions of patients attaining this target was ~ 80% and 40%, respectively. In bone, the PTA was ≤ 45% when the MIC was ≥ 0.25 mg/L.

CONCLUSION

Local bone and free plasma concentrations appear adequate for osteoarticular infections where Enterobacteriaceae are the main causative pathogens, but for Staphylococcus aureus and other bacteria, conventional dosing may lead to inadequate PTA.

Pharmacokinetics of Ceftolozane-Tazobactam during Prolonged Intermittent Renal Replacement Therapy

BACKGROUND

Prolonged intermittent renal replacement therapy (PIRRT) eliminates many drugs, and without dosing data, for new antibiotics like ceftolozane/tazobactam, suboptimal concentrations and treatment failure are likely.

OBJECTIVES

Herein, we describe the effect of PIRRT on the plasma pharmacokinetics of ceftolozane/tazobactam ad-ministered in a critically ill 55-year-old patient with a polymicrobial sternal wound osteomyelitis, including a multiresistant Pseudomonas aeruginosa.

METHOD

Blood samples were taken over 4 days where the patient received a 7.5-h PIRRT treatment. One- and 2-compartment models were tested for ceftolozane and tazobactam separately, and the log-likelihood ratio and goodness-of-fit plots were used to select the final model.

RESULTS

Two-compartment models were developed for ceftolozane and tazobactam separately and described significant differences in clearance of ceftolozane and tazobactam with and without PIRRT (8.273 vs. 0.393 and 8.020 vs. 0.767 L/h, respectively).

CONCLUSIONS

A ceftolozane/tazobactam dose of 500 mg/250 mg appears to be sufficient to attain pharmacokinetic/pharmacodynamic targets during PIRRT while the manufacturer's recommended dosing of 100 mg/50 mg every 8 h was sufficient during non-PIRRT periods.

Content of First Prenatal Visits

Objective The purpose of this study was to examine the content of the first prenatal visit within an academic medical center clinic and to compare the topics discussed to 2014 American College of Obstetrics and Gynecologists guidelines for the initial prenatal visit. Methods Clinical interactions were audio recorded and transcribed (n = 30). A content analysis was used to identify topics discussed during the initial prenatal visit. Topics discussed were then compared to the 2014 ACOG guidelines for adherence. Coded data was queried though the qualitative software and reviewed for accuracy and content. Results First prenatal visits included a physician, nurse practitioner, nurse midwife, medical assistant, medical students, or a combination of these providers. In general, topics that were covered in most visits and closely adhered to ACOG guidelines included vitamin supplementation, laboratory testing, flu vaccinations, and cervical cancer screening. Topics discussed less often included many components of the physical examination, education about pregnancy, and screening for an identification of psychosocial risk. Least number of topics covered included prenatal screening. Conclusions for Practice While the ACOG guidelines may include many components that are traditional in addition to those based on evidence, the guidelines were not closely followed in this study. Identifying new ways to disseminate information during the time constrained initial prenatal visit are needed to ensure improved patient outcomes.

Severe lower limb cellulitis: defining the epidemiology and risk factors for primary episodes in a population-based case-control study

OBJECTIVE

To describe the epidemiology and risk factors for primary episodes of severe lower leg cellulitis (LLC).

METHODS

This was a longitudinal cohort study using state-wide data linkage of adults presenting to Western Australian (WA) hospitals with a first ever LLC from January 2002 to December 2013. The study aimed at determining risk factors, medical records from the index patient, together with comparable data from controls matched by age, sex, postcode, and month of admission.

RESULTS

During the period, 36 276 patients presented with their first episode of LLC. The incidence increased by 4.7% per annum, reaching 204.8 (95% CI 198.6-211.1) per 100 000 population by December 2013. Analysis of 29 062 case-control pairs showed several conditions with lower limb pathology were independently associated with LLC, including varicose veins (AOR 2.95, 95% CI 2.50-3.48, p < 0.001), lymphoedema (AOR 2.65, 95% CI 1.71-4.10, p < 0.001), tinea pedis (AOR 3.05, 95% CI 1.45-6.42, p 0.003), and saphenous vein harvest during coronary artery bypass grafting (AOR 1.74, 95% CI 1.32-2.30, p < 0.001). Also associated with LLC was obesity (AOR 2.05, 95% CI 1.82-2.31, p < 0.001), renal disease (AOR 1.28, 95% CI 1.14-1.44, p < 0.001), rheumatologic conditions (AOR 2.12, 95% CI 1.72-2.60, p < 0.001), hemiplegia/paraplegia (AOR 1.31, 95% CI 1.13-1.52, p < 0.001), and liver disease (AOR 1.77, 95% CI 1.51-2.06, p < 0.001).

CONCLUSIONS

LLC presents a major burden to the health sector and is increasing with an ageing population. Given the high rates of recurrence, long-term morbidity, and economic impact, efforts to reduce primary episodes should be incorporated into the infectious diseases and healthy ageing research agenda.

Epidemiology and risk factors for recurrent severe lower limb cellulitis: a longitudinal cohort study

OBJECTIVE

To describe the epidemiology and risk factors for recurrence of severe lower leg cellulitis (LLC).

METHODS

A longitudinal cohort study using state-wide data of adults presenting with recurrent LLC following a primary episode occurring between January 2002 and December 2013. The incidence of recurrent LLC was estimated using the cumulative incidence function, accounting for mortality. Independent risk factors for recurrence were identified using Fine-Gray sub-distribution and Cox proportional hazards models.

RESULTS

Of 36 276 patients presenting with their first episode of LLC, 4598 had at least one recurrence during the follow-up period. The cumulative incidence of first, second, and third recurrences at 12 months since previous infection was 6.3% (95% CI 6.0-6.5), 17.2% (95% CI 16.1-18.4), and 29.4% (95% CI 26.8-31.9), respectively, and at 5 years was 13.9% (95% CI 13.5-14.3), 35.9% (95% CI 34.2-37.5), and 52.9% (95% CI 49.5-56.2), respectively. The length of hospitalization increased from 3 days for the primary episode to 4 and 5 days for first and all subsequent recurrences, respectively. Independent risk factors for recurrent LLC included age, ethnicity (Indigenous Australian), local factors relating to lower leg pathology, conditions that commonly result in peripheral oedema, and systemic conditions that may be associated with increased leg size.

CONCLUSIONS

LLC recurrences are frequent, and each episode increases the likelihood of subsequent recurrence and length of hospitalization. These data provide context and scope to develop workable and effective strategies to prevent secondary episodes for all cases of primary LLC.

Case Report: Chorioamnionitis and Premature Delivery due to Burkholderia pseudomallei Infection in Pregnancy

We report a case of placental infection leading to preterm delivery in a mother diagnosed with septicemia and pneumonia due to Burkholderia pseudomallei in pregnancy. Placental infection occurred despite prolonged ceftazidime therapy.

Should old age psychiatry develop memory clinics? A comparison with domiciliary work

Aims and Method

Memory clinics have become very popular in old age psychiatry and there is some pressure for them to be developed in old age services. However, there is little evidence to suggest that they are more advantageous over the traditional domiciliary visits or who should be seen in clinic. This was a naturalistic comparison of 76 consecutive new referrals to a memory clinic, with 74 consecutive new domiciliary requests within the same service over the same period of time. A retrospective case note review collected the clinical features and an 18-month prospective follow-up examined the subsequent clinical management.

Clinical Implications

The two groups were characterised more by their similarities than their differences. However, the domiciliary group had greater behavioural and psychological complications. The memory clinic patients were less likely to receive psychotropic medication and here more likely to be followed up.

Results

We conclude that memory clinics might be less suitable for patients with prominent psychiatric complications. Memory clinics could complement the domiciliary model by providing early psychosocial/neuropsychiatric approaches, although this is likely to lead to an increased clinical case-load.

Optimizing adherence to advice from antimicrobial stewardship audit and feedback rounds

We examined adherence to antimicrobial stewardship prospective audit and feedback rounds in a rehabilitation service compared with the remainder of the acute hospital, and explored the reasons for this. Between October 2014 and December 2015, we retrospectively assessed the rate of non-adherence to advice from antimicrobial stewardship prospective audit and feedback rounds between the rehabilitation service and the acute hospital, along with the source of the patient referral. Compared with the rehabilitation service, acute hospital medical staff were almost twice as likely to not adhere to advice provided on antimicrobial stewardship prospective audit and feedback rounds (13.8% vs. 7.6%, p < 0.0001, relative risk 1.8 [95% confidence interval 1.3, 2.5]). In the rehabilitation service, referrals were more likely to come from medical staff (61.9% vs. 16.3%, p < 0.0001). These findings may be explained by regular, direct engagement of the antimicrobial stewardship team with the rehabilitation service clinical team, a model potentially applicable to other settings.

Effect of a Mediterranean Type Diet on Inflammatory and Cartilage Degradation Biomarkers in Patients with Osteoarthritis

OBJECTIVES

To investigate the effects of a Mediterranean type diet on patients with osteoarthritis (OA).

PARTICIPANTS

Ninety-nine volunteers with OA (aged 31 - 90 years) completed the study (83% female).

SETTING

Southeast of England, UK.

DESIGN

Participants were randomly allocated to the dietary intervention (DIET, n = 50) or control (CON, n = 49). The DIET group were asked to follow a Mediterranean type diet for 16 weeks whereas the CON group were asked to follow their normal diet.

MEASUREMENTS

All participants completed an Arthritis Impact Measurement Scale (AIMS2) pre-, mid- and post- study period. A subset of participants attended a clinic at the start and end of the study for assessment of joint range of motion, ROM (DIET = 33, CON = 28), and to provide blood samples (DIET = 29, CON = 25) for biomarker analysis (including serum cartilage oligomeric matrix protein (sCOMP) (a marker of cartilage degradation) and a panel of other relevant biomarkers including pro- and anti-inflammatory cytokines).

RESULTS

There were no differences between groups in the response of any AIMS2 components and most biomarkers (p > 0.05), except the pro-inflammatory cytokine IL-1α, which decreased in the DIET group (~47%, p = 0.010). sCOMP decreased in the DIET group by 1 U/L (~8%, p = 0.014). There was a significant improvement in knee flexion and hip rotation ROM in the DIET group (p < 0.05).

CONCLUSIONS

The average reduction in sCOMP in the DIET group (1 U/L) represents a meaningful change, but the longer term effects require further study.

An inexpensive satellite-download GPS receiver for wildlife: field trial on black swans

Context Knowledge of the movements and space-use patterns of wildlife is crucial for implementation of effective conservation and management actions. Such information can be difficult to obtain, especially from hard-to-capture or far-ranging taxa. Global-positioning-system (GPS) receivers that have remote data-acquisition capability via satellite-communication networks offer an effective means of tracking highly mobile animals; however, often the equipment and operational costs of these devices are prohibitive. Aim To evaluate the operational performance and potential of an inexpensive, commercially available satellite-download GPS receiver that can be easily modified for use on wildlife, and to demonstrate its utility for revealing novel information on individual animal movements in an important wildlife management context. Methods We added external batteries and supplementary waterproofing to ‘off-the-shelf’ SPOT Trace® GPS receivers (~$120 USD; Spot LLC, Covington, LA) that transmit recorded location data to users through the Globalstar satellite network. We then deployed these devices on eight wild black swans (Cygnus atratus) inhabiting a large inland marine harbor adjacent to Auckland International Airport and assessed the GPS units’ operational performance and overall cost effectiveness. Key results During field trials with the tracking devices lasting up to 25 days we were able to collect thousands of precision location observations from the swans without the need for recapture. Cost-per-fix was only ~$0.04 USD – up to an order of magnitude lower than some satellite-download GPS receivers manufactured specifically for wildlife. We provide novel information about the swans’ patterns of activity, movement, space-use, habitat preferences and responses to actions taken by airport staff to scare problem individuals from threat zones. Conclusions User-modified satellite-download GPS devices can be a highly cost-effective means of tracking the movements of animals. Implications Knowledge of where and when swans present the greatest likely threat to air traffic and how they respond to displacement from restricted areas near the airport will be useful in devising threat-management plans. The ready availability of affordable remote-download GPS receivers will provide many new opportunities to study the movement and/or space-use patterns of wildlife and incorporate such information into a broad range of research and management programs.

Development and analysis of a highly flexible multi-gene expression system for metabolic engineering in Arabidopsis seeds and other plant tissues

Production of novel value-added compounds in transgenic crops has become an increasingly viable approach in recent years. However, in many cases, product yield still falls short of the levels necessary for optimal profitability. Determination of the limiting factors is thus of supreme importance for the long-term viability of this approach. A significant challenge to most metabolic engineering projects is the need for strong coordinated co-expression of multiple transgenes. Strong constitutive promoters have been well-characterized during the >30 years since plant transformation techniques were developed. However, organ- or tissue-specific promoters are poorly characterized in many cases. Oilseeds are one such example. Reports spanning at least 20 years have described the use of certain seed-specific promoters to drive expression of individual transgenes. Multi-gene engineering strategies are often hampered by sub-optimal expression levels or improper tissue-specificity of particular promoters, or rely on the use of multiple copies of the same promoter, which can result in DNA instability or transgene silencing. We describe here a flexible system of plasmids that allows for expression of 1-7 genes per binary plasmid, and up to 18 genes altogether after multiple rounds of transformation or sexual crosses. This vector system includes six seed-specific promoters and two constitutive promoters. Effective constitutive and seed-specific RNA interference gene-suppression cloning vectors were also constructed for silencing of endogenous genes. Taken together, this molecular toolkit allows combinatorial cloning for multiple transgene expression in seeds, vegetative organs, or both simultaneously, while also providing the means to coordinately overexpress some genes while silencing others.

Maggots as a wound debridement agent for chronic venous leg ulcers under graduated compression bandages: A randomised controlled trial

Objectives

Slough in chronic venous leg ulcers may be associated with delayed healing. The purpose of this study was to assess larval debridement in chronic venous leg ulcers and to assess subsequent effect on healing.

Methods

All patients with chronic leg ulcers presenting to the leg ulcer service were evaluated for the study. Exclusion criteria were: ankle brachial pressure indices <0.85 or >1.25, no venous reflux on duplex and <20% of ulcer surface covered with slough. Participants were randomly allocated to either 4-layer compression bandaging alone or 4-layer compression bandaging + larvae. Surface areas of ulcer and slough were assessed on day 4; 4-layer compression bandaging was then continued and ulcer size was measured every 2 weeks for up to 12 weeks.

Results

A total of 601 patients with chronic leg ulcers were screened between November 2008 and July 2012. Of these, 20 were randomised to 4-layer compression bandaging and 20 to 4-layer compression bandaging + larvae. Median (range) ulcer size was 10.8 (3–21.3) cm2 and 8.1 (4.3–13.5) cm2 in the 4-layer compression bandaging and 4-layer compression bandaging + larvae groups, respectively (Mann–Whitney U test, P = 0.184). On day 4, median reduction in slough area was 3.7 cm2 in the 4-layer compression bandaging group ( P < 0.05) and 4.2 cm2 ( P < 0.001) in the 4-layer compression bandaging + larvae group. Median percentage area reduction of slough was 50% in the 4-layer compression bandaging group and 84% in the 4-layer compression bandaging + larvae group (Mann–Whitney U test, P < 0.05). The 12-week healing rate was 73% and 68% in the 4-layer compression bandaging and 4-layer compression bandaging + larvae groups, respectively (Kaplan–Meier analysis, P = 0.664).

Conclusions

Larval debridement therapy improves wound debridement in chronic venous leg ulcers treated with multilayer compression bandages. However, no subsequent improvement in ulcer healing was demonstrated.

Continuous infusions of meropenem in ambulatory care: clinical efficacy, safety and stability

OBJECTIVES

Concerns regarding the clinical impact of meropenem instability in continuous infusion (CI) devices may contribute to inconsistent uptake of this method of administration across outpatient parenteral antimicrobial therapy (OPAT) services.

METHODS

We retrospectively reviewed the clinical efficacy and safety of CIs of meropenem in two Australian tertiary hospitals and assessed its stability under simulated OPAT conditions including in elastomeric infusion devices containing 1% (2.4 g) or 2% (4.8 g) concentrations at either 'room temperature' or 'cooled' conditions. Infusate aliquots were assayed at different time-points over 24 hours.

RESULTS

Forty-one (82%) of 50 patients had clinical improvement or were cured. Adverse patient outcomes including hemato-, hepato- and nephrotoxicity were infrequent. Cooled infusers with 1% meropenem had a mean 24-hour recovery of 90.3%. Recoveries of 1% and 2% meropenem at room temperature and 2% under cooled conditions were 88%, 83% and 87%, respectively. Patients receiving 1% meropenem are likely to receive >95% of the maximum deliverable dose (MDD) over a 24-hour period whilst patients receiving 2% meropenem should receive 93% and 87% of the MDD under cooled and room temperature conditions, respectively.

CONCLUSIONS

Meropenem infusers are likely to deliver ∼95% MDD and maintain effective plasma concentrations throughout the dosing period. These data reflect our local favourable clinical experience with meropenem CIs.

Seroepidemiological study of outdoor recreationists' exposure to spotted fever group Rickettsia in Western Australia

Bushland activity has previously been linked to rickettsial exposure in eastern and central regions of Australia, whereas little is known about the risks in Western Australia. The isolation of Rickettsia gravesii sp. nov. from Amblyomma triguttatum ticks and anecdotal reports of low-grade illness among bush recreationists raised the possibility of rickettsial transmission in the State. This study investigated rickettsial seroprevalence and potential risk of exposure to the spotted fever group rickettsiae in rogainers. Our results showed that rogainers active in the bush had a significantly higher risk of seropositivity (immunofluorescence total antibody titer ≥ 128) for the spotted fever group Rickettsia (odds ratio [OR] = 14.02, 95% confidence interval [CI] = 1.38-142.07) compared with a reference population, the overall seroprevalence in the rogainer group being 23.1%.

Assessing participatory practices in community-based natural resource management: experiences in community engagement from southern Africa

The emphasis on participatory environmental management within international development has started to overcome critiques of traditional exclusionary environmental policy, aligning with shifts towards decentralisation and community empowerment. However, questions are raised regarding the extent to which participation in project design and implementation is meaningful and really engages communities in the process. Calls have been made for further local-level (project and community-scale) research to identify practices that can increase the likelihood of meaningful community engagement within externally initiated projects. This paper presents data from three community-based natural resource management (CBNRM) project case studies from southern Africa, which promote Joint Forest Management (JFM), tree planting for carbon and conservation agriculture. Data collection was carried out through semi-structured interviews with key stakeholders, community-level meetings, focus groups and interviews. We find that an important first step for a meaningful community engagement process is to define 'community' in an open and participatory manner. Two-way communication at all stages of the community engagement process is shown to be critical, and charismatic leadership based on mutual respect and clarity of roles and responsibilities is vital to improve the likelihood of participants developing understanding of project aims and philosophy. This can lead to successful project outcomes through community ownership of the project goals and empowerment in project implementation. Specific engagement methods are found to be less important than the contextual and environmental factors associated with each project, but consideration should be given to identifying appropriate methods to ensure community representation. Our findings extend current thinking on the evaluation of participation by making explicit links between the community engagement process and project outcomes, and by identifying further criteria that can be considered in process and outcome-based evaluations. We highlight good practices for future CBNRM projects which can be used by project designers and initiators to further the likelihood of successful project outcomes.

Characterization of the role of eIF4G in stimulating cap- and IRES-dependent translation in aplysia neurons

The rate-limiting step(s) of translation in the nervous system have not been clearly identified. We have been examining this question in the cell body of the Aplysia sensory neuron, where translational regulation is important for the regulation of synaptic strength. In the present study, we examined the role of the adaptor protein eIF4G. We cloned Aplysia eIF4G (Ap4G) and Ap4G contains all the standard metazoan eIF4G protein–protein interaction domains. Overexpressing Ap4G in Aplysia sensory neurons caused an increase in both cap-dependent and internal ribosome entry site (IRES)-dependent translation using a previously characterized bicistronic fluorescent reporter. Unexpectedly, measurement of overall translation using the methionine analog, L-azidohomoalanine, revealed that overexpression of Ap4G did not lead to an increase in overall translation rates. Indeed, the effect of Ap4G on the bicistronic reporter depended on the presence of an upstream open reading frame (uORF) in the 5’ UTR encoded by the vector. We have previously shown that Mnk strongly decreased cap-dependent translation and this depended on a putative 4G binding domain. Here we extend these results showing that even in the absence of the uORF, overexpression of Mnk strongly decreases cap-dependent translation and this depends on the Mnk binding site in eIF4G. Similarly, an increase in cap-dependent translation seen with overexpression of elongation factor 2 kinase did not depend on the uORF. Overall, we show that eIF4G is rate limiting for translation of an mRNA encoding an uORF, but is not generally a rate-limiting step for translation.

Hospital Episode Statistics data analysis of postoperative venous thromboembolus in patients undergoing urological surgery: a review of 126,891 cases

Introduction

Current guidelines on venous thromboembolism (VTE) prevention do not reflect the potential varying risk for patients undergoing different urological procedures. Our study aimed to establish the procedure specific rate of postoperative VTE in patients undergoing urological surgery.

Methods

Hospital Episode Statistics were obtained for all patients undergoing common urological procedures between April 2009 and April 2010. This cohort was followed up to identify all patients reattending with either deep vein thrombosis (DVT) or pulmonary embolism (PE) within 12 months.

Results

A total of 126,891 individuals underwent urological surgery during the study period. This included 89,628 men (70.6%) and 37,236 women (29.3%) with a mean age of 65.2 years. At the 12-month follow-up, 839 patients (0.66%) were readmitted with VTE. Of these, 373 (0.29%) were admitted with DVT and 466 (0.37%) with PE. The procedure-specific rate of VTE varied significantly between 2.86% following cystectomy and 0.23% following urethral dilatation. Procedures performed in the lithotomy position carried a significantly lower risk of VTE than those performed in the supine position (0.60% vs 1.28%, p<0.0001). Furthermore, of all procedures performed in the lithotomy position, those performed on benign conditions carried a significantly lower risk than those performed on malignant disease (0.52% vs 0.79%, p<0.0001).

Conclusions

Procedure specific rates of postoperative VTE vary widely among patients undergoing urological procedures. These findings suggest the potential benefit of prolonging the use of thromboprophylaxis in high-risk patients but also exploring the apparent lack of need for routine thromboprophylaxis in patients undergoing low-risk procedures.