Presence and identity of Babesia microti in Ireland

Babesia microti is a tick-transmitted protozoan parasite of wildlife that can also cause serious disease in humans. It is now well established that B. microti represents an assemblage of different strains or species, only some of which are important zoonotic pathogens. Therefore, in order to assess the potential public health risk associated with B. microti in any given location, it is important to determine the strains that are present. This is the first study on the presence and identity of B. microti in Ireland. Overall, 314 wood mice (Apodemus sylvaticus), 243 bank voles (Myodes glareolus) and 634 questing Ixodes ricinus nymphs collected in various locations across Ireland were screened for the presence of B. microti by metabarcoding and nested PCR, respectively. Overall 8 rodent spleen samples (1.4%) were positive for B. microti, while all tick samples tested negative. Rodent isolates were identified as the 'Munich' strain which rarely causes human disease and is chiefly transmitted by the mouse tick, Ixodes trianguliceps. Together with reports from the UK these results suggest that B. microti does not represent a significant public health risk in Britain or Ireland.

Polygenic contributions to performance on the Balloon Analogue Risk Task

Risky decision-making is a common, heritable endophenotype seen across many psychiatric disorders. Its underlying genetic architecture is incompletely explored. We examined behavior in the Balloon Analogue Risk Task (BART), which tests risky decision-making, in two independent samples of European ancestry. One sample (n = 1138) comprised healthy participants and some psychiatric patients (53 schizophrenia, 42 bipolar disorder, 47 ADHD); the other (n = 911) excluded for recent treatment of various psychiatric disorders but not ADHD. Participants provided DNA and performed the BART, indexed by mean adjusted pumps. We constructed a polygenic risk score (PRS) for discovery in each dataset and tested it in the other as replication. Subsequently, a genome-wide MEGA-analysis, combining both samples, tested genetic correlation with risk-taking self-report in the UK Biobank sample and psychiatric phenotypes characterized by risk-taking (ADHD, Bipolar Disorder, Alcohol Use Disorder, prior cannabis use) in the Psychiatric Genomics Consortium. The PRS for BART performance in one dataset predicted task performance in the replication sample (r = 0.13, p = 0.000012, pFDR = 0.000052), as did the reciprocal analysis (r = 0.09, p = 0.0083, pFDR=0.04). Excluding participants with psychiatric diagnoses produced similar results. The MEGA-GWAS identified a single SNP (rs12023073; p = 3.24 × 10-8) near IGSF21, a protein involved in inhibitory brain synapses; replication samples are needed to validate this result. A PRS for self-reported cannabis use (p = 0.00047, pFDR = 0.0053), but not self-reported risk-taking or psychiatric disorder status, predicted behavior on the BART in our MEGA-GWAS sample. The findings reveal polygenic architecture of risky decision-making as measured by the BART and highlight its overlap with cannabis use.

Pragmatic review of interventions to prevent catheter-associated urinary tract infections (CAUTIs) in adult inpatients

BACKGROUND

Urinary tract infections (UTIs) are one of the most common hospital-acquired complications. Insertion of a urinary catheter and the duration of catheterization are the main risk factors, with catheter-associated UTIs (CAUTIs) accounting for 70-80% of hospital-acquired UTIs. Guidance is available regarding the prevention of hospital-acquired CAUTIs; however, how best to operationalize this guidance remains a challenge.

AIM

To map and summarize the peer-reviewed literature on model-of-care interventions for the prevention of CAUTIs in adult inpatients.

METHODS

PubMed, CINAHL and SCOPUS were searched for articles that reported UTI, CAUTI or urinary catheter outcomes. Articles were screened systematically, data were extracted systematically, and interventions were classified by intervention type.

FINDINGS

This review included 70 articles. Interventions were classified as single component (N=19) or multi-component (N=51). Single component interventions included: daily rounds or activities (N=4), protocols and procedure changes (N=6), reminders and order sets (N=5), audit and feedback interventions (N=3), and education with simulation (N=1). Overall, daily catheter reviews and protocol and procedure changes demonstrated the most consistent effects on catheter and CAUTI outcomes. The components of multi-component interventions were categorized to map common elements and identify novel ideas.

CONCLUSION

A range of potential intervention options with evidence of a positive effect on catheter and CAUTI outcomes was identified. This is intended to provide a 'menu' of intervention options for local decision makers, enabling them to identify interventions that are relevant and feasible in their local setting.

Abstract 70: Mechanisms of tumor dormancy induction mediated by abrogation of myeloid tgfβ signaling

Persistence in a dormant state of residual tumor cells can occur following extended periods of clinical remission which may last decades. The disseminated tumor cells in distant organ sites eventually gain context dependent metastasis advantage during tumor progression. The mechanisms for dormancy induction or reactivation remain unclear. We found that the abrogation of myeloid TGF-β signaling induced tumor dormancy in breast cancer metastasis models. When given extended time, the TGFβRIImyeKO mice eventually developed similar number of metastatic nodules to that of control mice. We further validated our finding using an inducible system where reintroduction of TβRII diminished the tumor dormancy induction. RNAseq of dormant vs proliferative tumor cells identify 504 differential expressed genes, including those involving cell cycle arrest, IFNg response, MTOR signaling as well as MYC targeted genes. Immune cell profiling showed differential immune composition in micro and macro-tumor microenvironment between WT and TβRIImyeKO lung tissues. Of great interest, abrogation of myeloid specific TGF-β signaling increased the number of CD103+DCs that displayed elevated TNFa production, which in turn increased IFNg+ production in T cells leading to improved innate

and adaptive immunity. Importantly, depletion of CD103 DCs in tumor-bearing TβRIImyeKO mice diminished the dormancy phenotype, which was not observed for the pDC depletion in the WT control mice. These data demonstrate that abrogation of myeloid specific TGF-β signaling improved the immune microenvironment, which induced tumor dormancy. Our data provide mechanistic insight and resources to understand the tumor dormancy.

Citation Format: Abdul Ahad, Feng Leng, Hiroshi Ichise, Justin Gray, Olga Aprelikova, Maura O’Neill, Ronald Holewinski, Vishal N. Kopardé4, Yasuhiro Moriwaki, Christine Hollander, Ronald Germain, Thorkell Andresson, Yang Li. Mechanisms of tumor dormancy induction mediated by abrogation of myeloid tgfβ signaling [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 70.

Systematic development and feasibility testing of a multibehavioural digital prehabilitation intervention for patients approaching major surgery (iPREPWELL): A study protocol

Improving outcomes for people undergoing major surgery, specifically reducing perioperative morbidity and mortality remains a global health challenge. Prehabilitation involves the active preparation of patients prior to surgery, including support to tackle risk behaviours that mediate and undermine physical and mental health and wellbeing. The majority of prehabilitation interventions are delivered in person, however many patients express a preference for remotely-delivered interventions that provide them with tailored support and the flexibility. Digital prehabilitation interventions offer scalability and have the potential to benefit perioperative healthcare systems, however there is a lack of robustly developed and evaluated digital programmes for use in routine clinical care. We aim to systematically develop and test the feasibility of an evidence and theory-informed multibehavioural digital prehabilitation intervention 'iPREPWELL' designed to prepare patients for major surgery. The intervention will be developed with reference to the Behaviour Change Wheel, COM-B model, and the Theoretical Domains Framework. Codesign methodology will be used to develop a patient intervention and accompanying training intervention for healthcare professionals. Training will be designed to enable healthcare professionals to promote, support and facilitate delivery of the intervention as part of routine clinical care. Patients preparing for major surgery and healthcare professionals involved with their clinical care from two UK National Health Service centres will be recruited to stage 1 (systematic development) and stage 2 (feasibility testing of the intervention). Participants recruited at stage 1 will be asked to complete a COM-B questionnaire and to take part in a qualitative interview study and co-design workshops. Participants recruited at stage 2 (up to twenty healthcare professionals and forty participants) will be asked to take part in a single group intervention study where the primary outcomes will include feasibility, acceptability, and fidelity of intervention delivery, receipt, and enactment. Healthcare professionals will be trained to promote and support use of the intervention by patients, and the training intervention will be evaluated qualitatively and quantitatively. The multifaceted and systematically developed intervention will be the first of its kind and will provide a foundation for further refinement prior to formal efficacy testing.

Morphological Characteristics of Malignancy in Circulating Tumor Cells (CTCs): A New Approach to Liquid Biopsies Utilizing Affordable Standard Cytology Techniques and the FDA Cleared Parsortix® System

Introduction/Objective

The process of metastasis is responsible for most cancer deaths. Identification of tumor cells circulating in blood (CTCs) has the potential to offer important information to patients and clinicians regarding disease status, longitudinal monitoring, remission status and assessment of patient prognosis, among others. However, currently CTC tests in the market are expensive and are not covered by medical insurance, making them unaffordable for most cancer patients. Legacy CTC technologies also require the use of expensive immunofluorescence microscopes and reagents, and are not easily implemented in standard clinical laboratory settings, thus preventing their use as standard of care. Onc-ADaPT™ Clinical Laboratories have explored a method to identify CTCs using the FDA cleared Parsortix® System (ANGLE plc, Guildford, UK) followed by standard cytology processing, staining and analysis, significantly reducing the cost of operations and increasing the likelihood of affordability to patients everywhere.

Methods/Case Report

The basic features of malignancy were listed by a Senior Cytologist (CT) and reviewed by another CT. Cancer cell lines were spiked into normal donor blood collected in Streck tubes. Non-spiked healthy volunteer blood was used to establish the background. The samples were then processed through the Parsortix® system producing 200µL suspension of separated cells. The harvest was then processed using Cytospin, stained with standard Pap Stain and reviewed with bright field microscopy by qualified CTs.

Results (if a Case Study enter NA)

Spiked tumor cells were identified and correctly categorized by the Cytologists. Non-spiked normal donor samples were negative for malignancy. Cells of interest were identified in the non-spiked HNV samples and classified as non-malignant (NOS). Using the training set, CTs later analyzed the available patient sample. The positive cancer patient sample showed cells with obvious characteristics of malignancy.

Conclusion

The basic characteristics of malignancy used for analysis of standard cytology specimens are adequate to identify CTCs using the established background to eliminate the NOS cells. CTC testing can be performed using the combination of Parsortix® System, standard cytology staining and analysis by qualified Cytologists.

Outcomes following robot-assisted versus laparoscopic sleeve gastrectomy: the New York State experience

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) represents more than half of all bariatric procedures in the USA, and robot-assisted sleeve gastrectomy (RSG) is becoming increasingly common. There is a paucity of evidence regarding postoperative surgical outcomes (> 30 days) in RSG patients, especially as these patients move between multiple hospital systems.

METHODS

Using 2012-2018 New York State's inpatient and ambulatory data from the Statewide Planning and Research Cooperative System, bivariate and multivariate analyses were employed to examine patient long-term outcomes, postoperative complications, and charges following RSG versus LSG in unmatched and propensity score-matched (PSM) samples.

RESULTS

Among the 72,157 minimally invasive sleeve gastrectomies identified, 2365 (2.6%) were RSGs. In the PSM sample (2365 RSG matched to 23,650 LSG), RSG cases were more likely to be converted to an open procedure (2.3% vs 0.2% LSG patients, p < 0.01) and had a longer mean length of stay (LOS; 2.1 vs. 1.8 days LSG, p < 0.01). Postoperative complications were not different between RSG and LSG patients, but the proportion of emergency room visits resulting in inpatient readmissions was higher among RSG patients (5.5% vs. 4.2% in LSG patients, p < .01). Among the super obese (body mass index ≥ 50) patients, conversions to open procedure and LOS were also significantly higher for RSG versus LSG cases. Average hospital charges for the index admission ($47,623 RSG vs $35,934 LSG) and cumulative changes for 1 year from the date of surgery ($57,484 RSG vs $43,769 LSG) were > 30% higher for RSG patients.

CONCLUSIONS

RSG patients were more likely to have conversions to open procedures, longer postoperative stay, readmissions, and higher charges for both the index admission and beyond, compared to LSG patients. No clear advantages emerged for the utilization of the robotic platform for either average risk or extremely obese patients.

Maternity services response to the COVID-19 pandemic: how Public Health England guidance was implemented in practice

Introduction

The rapidly evolving COVID-19 pandemic required systemic change in how healthcare was delivered to minimize virus transmission whilst maintaining safe service delivery. Deemed at ‘moderate-high risk’, maternity patients are an important patient group that require consideration. Public Health England (PHE) issued national guidance on how to adjust these services.

Aim

To explore how maternity units in England implemented PHE guidance.

Methods

An online survey of 22 items was distributed to individuals that had worked on an England-based maternity unit during the COVID-19 pandemic. The questionnaire was designed and tested by the multidisciplinary research team. Data was collected from November 2020 to July 2021.

Findings

Forty-four participants across 33 maternity units responded. Ninety-three percent were able to test all women requiring an overnight stay for COVID-19. Only 27% reported birth partners were tested for COVID-19. Only 73% reported they were able to isolate all COVID-19-positive patients in single rooms. Eighty-four percent stated they were aware of current PHE guidance on personal protective equipment (PPE) and 82% felt ‘confident’ in donning/doffing of PPE. Priorities for the future include rapid testing and a focus on community service provision.

Conclusions

PHE COVID-19 guidance was implemented differently in maternity units across England due to the varying resources available at each trust leading to variable ability to test and isolate patients as recommended. More specific, tailored guidance for infection control measures against COVID-19 is needed for maternity settings due to their unique position.

A fast, fully validated GC-MS method using a simplified pretreatment for the quantification of short and branched chain fatty acids in human stool

The study of short (SCFAs) and branched chain fatty acids (BCFAs) in human stool related to gastrointestinal diseases, gut microbiota, metabolism, and diet has dramatically increased. As a result, a fast, reliable method with minimal pretreatment is needed for quantification of these metabolites (acetic, propionic, isobutyric, butyric, isovaleric, valeric, and caproic acid) in stool. Therefore, a GC-MS method meeting this criterion was developed. A bias sampling study showed no statistical difference (p > 0.05) in analyte means when comparing 100 mg subsamples of homogenized to non-homogenized samples (n = 6, p values 0.153-0.910). Stool samples were homogenized, diluted with 80:20 water:methanol (v/v), and adjusted to a pH of 1.5-2.5. Samples were vortexed, centrifuged, and directly injected into the GC-MS using pulsed splitless injection offering twofold-to-threefold signal enhancement over a 10:1 split injection. DB-FATWAX Ultra Inert Polyethylene Glycol (PEG) Column showed no peak tailing, reduced responses, or retention time shifts after 1,476 stool injections, while other columns failed before 361 injections. Intra- and inter-day accuracy for stool supernatant samples ranged from -10.21% to 8.88% and -13.25% to 9.91%, while intra- and inter-day precision ranged from 0.21% to 1.21% and 0.89% to 2.84% coefficient of variation (CV), respectively. This method demonstrates excellent linearity (0.9999-1.0000) and low limits of quantification (1.50-8.01 μM). Stool samples proved stable stored at -20°C up to 28 days, and recoveries ranged from 85.04% to 106.59%. Matrix effects in stool are non-significant determined by comparing standard and stool supernatant calibration curve slopes (p > 0.05).

Is New York State good at managing hollow viscus injury?

BACKGROUND

There are an estimated 100,000 cases of abdominal injury (ABI) in the USA, annually resulting in over $12 billion in direct medical cost and $18 billion in lost productivity. This study assesses the timeliness, safety, and efficacy of the surgical management of abdominal injuries (ABIs), hollow viscus injuries (HVIs), and colonic injuries (CIs) for patients residing in New York State (NYS).

METHODS

Using data from NYS's Statewide Planning and Research Cooperative System (SPARCS), we identified all trauma patients with ABI admitted between 2006 and 2015. We subdivided ABI into HVI and CI using diagnosis and procedure codes and examined processes of care and outcomes adjusting for patient characteristics, injury severity score, structural, and process indicators.

RESULTS

We identified 31,043 hospitalized patients with ABI, 71% were incurred from blunt forces. Most patients with ABI (72%) were treated at a Level I/II trauma center (TC) and 7% patients were transferred to Level I/II TC. Failure to be treated at Level I/II TC was associated with 16% increased hazard of death. HVI was diagnosed in 23% of ABI patients (n = 7294); 18% experienced delayed hollow viscus repair (dHVR); dHVR was associated with a 76% increased hazard of death. CI was diagnosed in 9% of ABI patients (n = 2921) and 18% experienced dHVR. Seventy-five percent of CI were repaired primarily (n = 1354). Less than 37% of stomas were reversed by 4 years of index trauma.

CONCLUSION

Most abdominal trauma in NYS was caused by motor vehicle accidents, falls, and assault. dHVR and not being treated at Level I/II TC were associated with worse outcomes. More research is needed to reduce under-triage and delays in the operative treatment of blunt abdominal trauma.

Resource Allocation in a National Dental Service Using Program Budgeting Marginal Analysis

INTRODUCTION

In any health system, choices must be made about the allocation of resources (budget), which are often scarce. Economics has defined frameworks to aid resource allocation, and program budgeting marginal analysis (PBMA) is one such framework. In principle, patient and public values can be incorporated into these frameworks, using techniques such as willingness to pay (WTP). However, this has not been done before, and few formal resource allocation processes have been undertaken in dentistry. This study aimed to undertake a PBMA with embedded WTP values in a national dental setting.

METHODS

The PBMA process was undertaken by a panel of participant-researchers representing commissioners, dentists, dental public health staff, and academics. The panel reviewed current allocations and generated a set of weighted criteria to evaluate services against. Services to be considered for removal and investment were determined by the panel and wider discussion and then scored against the criteria. Values from a nationally representative WTP survey of the public contributed to the scores for interventions. Final decisions on removal and investment were taken after panel discussion using individual anonymous electronic voting.

RESULTS

The PBMA process resulted in recommendations to invest in new program components to improve access to general dentists, care home dentistry, and extra support for dental public health input into local government decisions. Disinvestments were recommended in orthodontics and to remove routine scaling and polishing of teeth.

DISCUSSION

The PBMA process was successful in raising awareness of resource allocation issues. Implementation of findings will depend on the ability of decision makers to find ways of operationalizing the decisions. The process illustrates practical aspects of the process that future dental PBMAs could learn from.

KNOWLEDGE TRANSFER STATEMENT

This study illustrates a framework for resource allocation in dental health services and will aid decision makers in implementing their own resource allocation systems.

The art and science of priority-setting: assessing the value of Public Health England's Prioritization Framework

BACKGROUND

Findings are presented from the evaluation of Public Health England's (PHE) Prioritization Framework (PF) aimed to assist local authority commissioners with their public health investment and disinvestment decisions. The study explored the take up of the PF in three early adopter local authority settings.

METHODS

Semi-structured interviews (n = 30) across three local authorities supplemented by participant observation of workshops.

RESULTS

Participants acknowledged that the PF provided a systematic means of guiding priority-setting and one that encouraged transparency over investment and disinvestment decisions. The role performed by PHE and its regional teams in facilitating the process was especially welcomed and considered critical to the adoption process. However, uptake of the PF required a significant investment of time and commitment from public health teams at a time when resources were stretched. The impact of the political environment in the local government was a major factor determining the likely uptake of the PF. Ensuring committed leadership and engagement from senior politicians and officers was regarded as critical to success.

CONCLUSIONS

The study assessed the value and impact of PHE's PF tool in three early adopter local authorities. Further research could explore the value of the tool in aiding investment and disinvestment decisions and its impact on spending.

Metabolic and bariatric surgery among endometrial cancer survivors: Are we missing an opportunity to help?

5591

Background: Multiple studies have delineated a clear link between the estrogenic effects of obesity and the incidence of endometrial cancer (EC). Obese EC patients are less likely to receive guideline-recommended surgical treatment (ST) relying instead on chemotherapy and radiation therapy. Furthermore, EC patients are more likely to die from obesity-related complications than from cancer-related causes. Several small-scale studies have demonstrated that metabolic and bariatric surgery (MBS) could offer EC patients fast, safe and effective weight loss, which provides an opportunity to improve survival. This is the first population-based study that examines uptake and outcomes of MBS among EC survivors in New York State (NYS). Methods: This study was based on the all-payer longitudinal data from the NYS’s Statewide Planning and Research Cooperative System and included inpatient and ambulatory surgeries performed between 2006 and 2012. Using ICD and CPT diagnostic and procedure codes, we identified patients diagnosed with EC for the first time, and we further examined whether they received ST within one year of their initial EC diagnosis. We followed EC patients with ST for 4 years to examine the rates of MBS, and we assessed long-term patient outcomes through 2019. We conducted bivariate and multivariate analyses to evaluate all-cause mortality and identify risk factors for poor surgical outcomes and readmissions. Results: Among 24,950 EC patients (2006-2012), 16,156 (65%) of them underwent ST within 1 year of EC diagnosis. Compared to those who did not receive ST, patients who underwent ST were younger, less likely to be White and more likely to be from urban counties, had private insurance, diagnosed with diabetes and hypertension, and had lower Elixhauser scores for readmission and mortality ( p < 0.01 for all). Within 4 years following ST, 136 (0.8%) EC patients underwent MBS. Those who underwent MBS were younger ( p < 0.01), predominantly white, privately insured, morbidly obese ( p < 0.01) and diabetic ( p = 0.01) compared to those who did not undergo MBS. Conclusions: Despite having higher risk of mortality from obesity-related complications such as diabetes and cardiovascular disease, the proportion of EC patients obtaining MBS (0.8%) was similar to that seen among the US population eligible for MBS (1.0%). More research is needed to understand barriers to MBS among eligible women with EC.

725 Monthly Antibiotic Use in The Sheffield Children’s Hospital ED: A Hospital-Based Clinical Audit

Aim: To evaluate guideline compliance of antibiotics prescription in Emergency Department (ED).

To improve documentation of antibiotic prescription.

To highlight the need for good antibiotic stewardship.

To optimise the use of antibiotics.

Method

A cross-sectional, retrospective patient record review was conducted regarding antibiotic prescription over 1 month in Sheffield Children’s Hospital ED. All antibiotic prescriptions over that period were collected. From the total number of prescriptions, a convenience sample of 100 prescriptions was selected to correlate their indications with local guidelines.

Results

A total of 290 prescriptions for 310 antibiotics were collected. The most frequent antibiotic prescribed was Penicillin V (26.7%), followed by Amoxicillin (21.3%), Co-amoxiclav (20.3%), and Flucloxacillin (16.5%). From the convenience sample, 12 antibiotics were prescribed inappropriately, with the most frequent being Co-amoxiclav (41.7%), followed by Penicillin V (25%), Amoxicillin and Flucloxacillin (both 16.7%). Overall, there has been good stewardship of antibiotic use with 88% of antibiotic prescribing conducted appropriately as per ED guidelines.

Conclusions

Antibiotic resistance is a growing concern, with one of the leading causes being inappropriate prescription of antibiotics. Adhering to local guidelines can help to prevent them from developing resistance. Adherence can be improved through induction and training of clinicians.

COVID-19: how prepared are front-line healthcare workers in England?

National efforts are underway to prepare the UK National Health Service (NHS) for the COVID-19 pandemic; however, the efficacy of these interventions is unknown. In view of this, a cross-sectional survey of front-line healthcare workers (HCWs) at two large acute NHS hospital trusts in England was undertaken to assess their confidence and perceived level of preparedness for the virus. The survey found that there has been moderate success in readying HCWs to manage COVID-19, but that more still needs to be done, particularly in relation to educating HCWs about laboratory diagnostics.

Improving paediatric antimicrobial stewardship in hospital-based settings: why, where and how?

Background

Antimicrobial resistance (AMR) is being recognized as a priority by healthcare organizations across the world. However, many children are managed on IV antimicrobials in hospital with very little consideration of antimicrobial stewardship issues.

Objectives

A nurse-led paediatric ambulatory outpatient parenteral antimicrobial therapy (OPAT) service, managing children with common infections being ambulated on short courses of IV antimicrobials, was introduced within Southampton Children’s Hospital in January 2018. We evaluated the impact of this service in terms of the quality of antimicrobial prescribing and timing of ambulation in children presenting with common infections.

Methods

All cases managed within the service were reviewed in two separate 2 month time periods: prior to introduction of the service (September–October 2016) and then prospectively after its introduction (September–October 2018).

Results

A total of 96% of IV antibiotic management decisions at 48 h were deemed appropriate in 2018, compared with 75% in 2016. A total of 64% of patients were ambulated on IV antibiotics at some point during their treatment course in 2018, compared with 19% in 2016. However, a significant proportion of antimicrobial decisions made at the point of presentation to hospital remained suboptimal in 2018.

Conclusions

Children are commonly managed with IV antibiotics in hospital. We demonstrate marked improvements in appropriate antimicrobial use through the introduction of a nurse-led ambulatory OPAT service. In addition, such a service can promote a greater proportion of children being ambulated from hospital, freeing up valuable inpatient beds and potentially delivering cost savings that can be used to fund such services.

Shifting the Gravity of Spending: Assessing the impact of PHE’s Prioritisation Framework

Background

Findings are presented from the evaluation of Public Health England’s (PHE) new Prioritisation Framework (PF) conducted between September 2017 and December 2018 aimed to help local authority commissioners with their public health investment and disinvestment decisions. The study explored the take up of the PF in three early adopter local authority settings.

Methods

Data collection was based on semi-structured interviews (n = 30) across three local authorities supplemented by participant observation of workshops and data concerning the implementation process as well as spend and outcomes both before and, where possible, after using the PF.

Results

Participants acknowledged that the PF provided a systematic way to guide prioritisation decisions and one that encouraged transparency over investment and disinvestment decisions. The role performed by PHE and its regional teams in facilitating the process was especially welcomed and considered to be critical to the adoption process. However, uptake of the PF required a significant investment of time and commitment from public health teams at a time when resources were stretched. The impact of the political environment in local government was a major factor determining the likely uptake of the PF. Ensuring committed leadership and engagement from senior politicians and officers was regarded as critical to success.

Conclusions

The study assessed the value of the PF and the processes surrounding its implementation and use. Further research could further explore the value of the tool in aiding investment and disinvestment decisions and its impact on spending.

Key messages

The PF provides a platform for engaged and informed deliberation about priorities and does so in an open, structured and transparent manner. Organisational and political context in which prioritisation occur shape the adoption of the PF tool.

Host identification in unfed ticks from stable isotope compositions (δ13 C and δ15 N)

Determination of the ratios of natural stable isotopes (¹³ C/¹² C and ¹⁵ N/¹⁴ N) in unfed Ixodes ricinus nymphs and adults, which, in their previous stage, fed on captive wild rodents (Apodemus sylvaticus and Myodes glareolus), wild birds (Parus major and Cyanistes caeruleus) or domestic ruminants (Ovis aries and Bos taurus), demonstrated that it is possible to identify each host category with confidence. First, the tick-blood spacing, which is the difference between values obtained from ticks and the blood of hosts that they had fed on in the previous stage, was consistent (152 spacings investigated from 15 host individuals in total). Second, potential confounding factors (tick age and sex) did not affect the discriminatory power of the isotope patterns, nor did different rearing conditions (room temperature vs. 4 °C) or the duration of development (maximum of 430 days). The findings that the tick-blood isotope spacings, across a diverse range of hosts, were similar and predictable, and that confounders had little or no effect on this, strongly support the usage of the isotope approach. Because each of the host categories has a different role in the population dynamics of I. ricinus and in tick-borne pathogen ecology, the method described here has great potential for the clarification of tick and tick-borne pathogen ecology in the field.