Outcomes from a proof-of-concept specialist lymphoedema clinic in the community

The Health and Safety Execultive lymphoedema model of care was published in 2018 highlighting the lack of dedicated lymphoedema services in Ireland. This led to the introduction of a proof-of-concept primary care specialist lymphoedema clinic. The clinic was responsible for all patients from their county. A comprehensive dataset was gathered which included the patient's history for 1 year prior to their presentation at clinic and then 6 monthly. A quality of life tool (LymQoL) and a patient satisfaction survey were completed. Completed 1-year data showed a significant reduction in GP and public health nurse visits as well as a reduction in the occurrence of cellulitis and associated hospital admissions. All areas of quality of life were improved and patient satisfaction was either excellent (89%) or very good (11%). The 1-year findings strongly support the roll-out of specialist clinics to all regional health areas.

Microbial interactions with phosphorus containing glasses representative of vitrified radioactive waste

The presence of phosphorus in borosilicate glass (at 0.1 - 1.3 mol% P2O5) and in iron-phosphate glass (at 53 mol% P2O5) stimulated the growth and metabolic activity of anaerobic bacteria in model systems. Dissolution of these phosphorus containing glasses was either inhibited or accelerated by microbial metabolic activity, depending on the solution chemistry and the glass composition. The breakdown of organic carbon to volatile fatty acids increased glass dissolution. The interaction of microbially reduced Fe(II) with phosphorus-containing glass under anoxic conditions decreased dissolution rates, whereas the interaction of Fe(III) with phosphorus-containing glass under oxic conditions increased glass dissolution. Phosphorus addition to borosilicate glasses did not significantly affect the microbial species present, however, the diversity of the microbial community was enhanced on the surface of the iron phosphate glass. Results demonstrate the potential for microbes to influence the geochemistry of radioactive waste disposal environments with implication for wasteform durability.

Development and characterisation of mgTHP-1, a novel in vitro model for neural macrophages with microglial characteristics

Neuroinflammation is primarily characterised by activation of the brain's resident macrophages - the microglia. However, other central nervous system (CNS) cells also contribute to this response, including the astrocytes and endothelial cells. In addition, there is infiltration into the CNS of peripherally derived immune cells. Together these cells mediate inflammation by the production of cytokines, chemokines, reactive oxygen species, and secondary messengers, and enacting of the appropriate response to those signals. However, deciphering the specific contributions of each cell type has been challenging. Studying CNS cell biology is often challenging, as the isolation of primary cells is not always feasible, and differentiation towards microglia-like cells is complex. Here, we demonstrate a novel method whereby THP-1 monocytic cells are differentiated into neural macrophage cells with microglia-like cell characteristics. The cells, designated mgTHP-1, show typical morphological and gene expression patterns of resident CNS macrophages and functionally respond to inflammatory stimuli by producing inflammatory cytokines. Furthermore, with the addition of Vicenin-2 (an anti-inflammatory flavonoid) such responses can be reversed. This novel cell model will allow further investigations, and hence insights, into the neuroinflammatory mechanisms associated with CNS diseases.

Quantifying Radiation Induced Vaginal Stenosis for the Development of a Novel Dilator Device: A Prospective Cohort Study of Patients with Cervical Cancer Treated with Definitive Chemoradiation Therapy

PURPOSE/OBJECTIVE(S)

Chemoradiation therapy (CRT) is the standard of care for the treatment of locally advanced cervical cancer (LACC). Vaginal stenosis (VS) is a common side effect of CRT and leads to sexual dysfunction, pain, and difficulty with vaginal intercourse, resulting in decreasing quality-of-life (QOL). However, there is scant data on the timeline of VS development, and patient use and satisfaction with a standard vaginal dilator (VD). In this study, we plan to develop a standardized technique to assess VS using physical exam measurements at specified timepoints after CRT. Secondarily, we will assess patient preferences and use of available VDs with the goal of developing a novel VD device with our multidisciplinary engineering team. We report the rationale, methods, and objectives of this clinical study.

MATERIALS/METHODS

Patients with LACC treated with CRT and brachytherapy are eligible. CT-based imaging pre-CRT and 3-months post-CRT to assess radiographic changes in the vaginal length and width will be collected. Vaginal measurements and physical exam will be recorded at baseline and 3-, 6-, and 12-months following CRT. Patients will also be given a set of VDs that range in diameter and length. Patient vaginal capacity, defined as the largest VD that can be comfortably accommodated in the vagina during pelvic exam, and compliance with VD use will be recorded at each visit. Patients will be given the EORTC Sexual Health Questionnaire (EORTC SHQ-22). Toxicity grading will use the CTCAE v5. We plan to assess patient preference using a VD-specific questionnaire to help guide the development of a personalized VD.

RESULTS

For the primary analysis, we will examine the VS CTCAE v5 toxicity at baseline vs 1 year for 20 patients. The sample size we propose is sufficient to achieve at least 80% power at 5% significance level for detecting a significant non-zero proportion with a margin of 20%. For the secondary analysis, we will test the Spearman's coefficient and Kendall's tau between VS CTCAE and EORTC questions: "has the treatment affected your sexual activity?"; "have you felt pain during/after sexual activity?"; "have you been sexually active?" We will use permutation tests in which the ID will be permuted for vaginal stricture but kept as original for the EORTC questions. We will test the null hypothesis of no correlation by comparing the observed Spearman's coefficient and Kendall's tau to the permutation distributions. We plan to incorporate the specific VD questionnaire responses into the development of a novel device using qualitative measures.

CONCLUSION

This clinical trial is an observational cohort study that aims to quantify CRT-induced VS, obtain patient reported sexual health, and understand specific preferences and compliance with VD use for the development of a novel engineered device.

The All-Ireland Guidelines for the diagnosis, assessment and management of lymphoedema

The last decade has produced a plethora of lymphoedema-based research. As such, a new All-Ireland Guideline for lymphoedema diagnosis, assessment and management was required to replace the 2008 CREST Guideline. A research team was commissioned to work with healthcare staff and service users following international research standards practice. An evidence-based clinical practice guideline was developed to aid clinicians in the diagnosis, assessment, and management of lymphoedema. Recommendations were formulated based on the evidence available to answer each clinical question and were assigned a grade based on the strength of the evidence. In the absence of sufficient evidence and in an effort to maximise clinical applicability, recommendations were also based on expert opinion, which was gathered via guideline member consensus. The recommendations from the guideline, which aim to provide healthcare professionals with clear, evidence-based guidance on the diagnosis, assessment and management of patients with all types of lymphoedema, should be communicated at all levels regarding responsibility for implementation in clinical care and service development. Audit should be a core component of the implementation. A budget impact analysis should be completed to determine additional costs required to fully implement the guideline.

Early but reversible haemostatic changes in a-symptomatic females expressing COVID-19 antibodies

The coronavirus, COVID-19 pandemic spread across the globe in 2020, with an initial high case mortality in those requiring intensive care treatment due to serious complication. A vaccine programme was quickly developed and currently the UK is one of highest double vaccinated and boosted countries in the world. Despite tremendous efforts by the UK, new cases of COVID-19 are still occurring, due to viral mutation. A major problem associated with COVID-19 is the large a-symptomatic spread within the population. Little investigation into the a-symptomatic population has been carried out and therefore we pose that the residual effects of a-symptomatic infection is still largely unknown. Prior to mass vaccination, a multi-phased single cohort study of IgM and IgG COVID-19 antibody prevalence and the associated haemostatic changes were assessed in a Welsh cohort of 739 participants, at three time points. Positive antibody participants with age and gender matched negative antibody controls were assessed at 0, 3 and 6 months. Antibody positive females appeared to have lower antibody responses in comparison to their a-symptomatic male counterparts. Despite this initial testing showed a unique significant increase in TRAP-6-induced platelet aggregation, prothrombin time (PT) and clot initiation time. Despite coagulation parameters beginning to return to normal at 3 months, significant decreases are observed in both haemoglobin and haematocrit levels. The production of extracellular vesicles (EV) was also determined in this study. Although the overall number of EV does not change throughout the study, at the initial 0 months' time point a significant increase in the percentage of circulating pro-coagulant platelet derived EV is seen, which does not appear to be related to the extent of platelet activation in the subject. We conclude that early, but reversible changes in haemostatic pathways within the a-symptomatic, female, antibody positive COVID-19 individuals are present. These changes may be key in identifying a period of pro-coagulative risk for a-symptomatic female patients.

Impaired fibrinolysis in severe Covid-19 infection is detectable in early stages of the disease

BACKGROUND

A significant degree of mortality and morbidity in Covid-19 is due to thromboembolic disease. Coagulopathy has been well described in critically unwell patients on ICU. There is less clear evidence regarding these changes at the time of presentation to the Emergency Department and the progression of disease over time.

OBJECTIVE

We sought to investigate whether coagulation markers can predict severity and how they change over the disease course.

METHODS

Patients presenting to a single University Teaching Hospital were recruited and followed up if PCR was positive. Alongside routine blood testing, Rotational Thromboelastometry (ROTEM) was performed. Outcome data was recorded for all patients, and ROTEM values were compared across outcome groups.

RESULTS

Extem and Intem Maximum Lysis were significantly reduced in those who died or required an ICU admission, indicating a reduced ability to break down clot mass in the most critically unwell patients.

CONCLUSION

Comparisons between groups demonstrated that one distinguishing feature between those who require ICU admission or die of Covid-19 compared with those who survive a hospital stay to discharge was the extent to which fibrinolysis could occur. Mortality and morbidity in Covid-19 infection appears in part driven by an inability to break down clot mass.

A Snapshot of Lymphedema in Ireland: Results from LIMPRINT

Background: To estimate the prevalence and impact of chronic edema (CE) in two Irish health care settings as part of LIMPRINT, an international study developed and co-ordinated by the International Lymphoedema Framework (ILF), and researched in Ireland by the National Lymphoedema Framework Ireland (NLFI). Methods and Results: Data were collected using clinical assessment tools previously validated by the ILF. Three hospital settings were chosen, both an in-patient and out-patient oncology unit in Galway and a vascular out-patient unit in Dublin. Patients attending an oncology clinic or in an in-patient ward on a specified day were invited to participate as desired, and all patients attending vascular out-patients for a 4-week period were included in the study. All patients were assessed for the presence of CE, and if present, patients were asked to answer several questionnaires regarding diagnosis, available services, quality of life, and wound care where appropriate. The collection of data was anonymized and was inputted to a central database (Clindex). A total of 152 patients were assessed, 76 from the oncology service and 76 from the vascular service. Eighty-seven (57%) patients were female and 65 (43%) patients were male. The mean age was 65 years with a range 15-93 years. Twenty-five patients (16%) had CE, 8 (11%) in the oncology service and 17 (22%) in the vascular service. All the oncology patients were normal weight while almost 60% (n = 10) of the vascular patients were obese. Two (25%) of the oncology patients had a history of cellulitis, whereas seven (41%) of the vascular patients had a history of cellulitis. Four of the oncology patients (50%) received full lymphedema management whereas two oncology patients (20%) received no treatment at all. In contrast, in the vascular group, only two patients (12%) received full lymphedema management. Eight patients (47%) were receiving no treatment at all and seven (41%) were in compression garments and received skin care advice only. Conclusion: Though number of patients are small, these results highlight the high prevalence of CE in both oncology and vascular service patients as well as the disparities in management. In addition, there is a high incidence of cellulitis reported that is possibly not surprising given the low number of patients receiving full lymphedema care. Good data collection is essential if we are to provide and fund a comprehensive service in the future.

The Effect of Spousal Military Deployment during Pregnancy on Birth Outcomes: A Systematic Review

Background

Stress experienced during pregnancy is associated with adverse birth outcomes including pre-term delivery and low birth weight. Pregnant spouses and partners of deployed military personnel can experience heightened stress due to several factors associated with the military lifestyle which may increase the risk of pre-term delivery and low birth weight. This systematic review aims to establish the potential effect of spousal deployment on birth outcomes in a population who have increased psychosocial risks for birth complications.

Methods

A systematic review following the PRISMA guidelines was conducted of English language literature to assess the effect of deployment on the birth outcomes (pre-term delivery <37 weeks; low birth weight < 2500g) of babies born to partners of serving military personnel who were deployed at the time of delivery. Comparison was made to pregnant women whose military partners were not deployed at the time of delivery. EMBASE, Medline, Global Health, Web of Science and PubMed databases were searched for relevant articles using a keyword Boolean search strategy. A quality review and risk of bias was conducted on each of the three included studies.

Results

Three cohort or cross-sectional studies fulfilled the eligibility criteria. Each study was conducted in the US military, involved a total of 11,028 participants and were published between 2005 and 2016. Evidence suggests that spousal deployment may be a risk factor for pre-term delivery. No association between spousal deployment and low birth weight was found.

Conclusions

Pregnant partners or spouses of deployed military personnel may be at increased risk of pre-term delivery. There is a paucity of rigorous research in this area and more research is required to help inform healthcare professionals of the needs of this cohort of women and whether tailored public health interventions are required to reduce the risk of adverse birth outcomes in this population.

Key messages

Pregnant partners or spouses of deployed military personnel may be at increased risk of pre-term delivery due to psychosocial factors associated with the military lifestyle. Stress is a risk factor for birth complications. More research involving military spouses is required to understand the antenatal needs of this population.

The treatment effect of rivaroxaban on clot characteristics in patients who present acutely with first time deep vein thrombosis

BACKGROUND

The acute vascular disease deep vein thrombosis (DVT) requires oral anticoagulants to prevent progression. Monitoring therapeutic efficacy of direct oral anticoagulants (DOAC), including rivaroxaban, is problematic as no reliable test is available. Advances in rheometry have led to the development of a functional coagulation biomarker using Gel Point (GP) analysis which assesses clot structure formation. The biomarker measures incipient clot formation time (TGP) and quantifies fibrin clot structure in terms of fractal dimension (df).

OBJECTIVE

This study aimed to investigate clot structure formation in first time DVT and the effect of rivaroxaban treatment.

METHODS

This prospective observational cohort study measured the GP and standard laboratory markers at three sample points: pre-treatment and at 20 and 60 days following 15 mg BD and 20 mg OD rivaroxaban respectively.

RESULTS

Forty DVT patients (mean age 64 years [SD±14.8]; 23 males, 17 female) were recruited. The results show that DVT vs non-DVT patients did not have a significantly different GP profile (df: 1.72±0.06 vs 1.70±0.06 and TGP: 267±68 sec vs 262±73 sec) with both within the defined healthy index. In addition, rivaroxaban therapy increased TGP to 392 s (±135 s) after 20 days, and subsequently increased to 395 s (±194 s) at 60 days but did not significantly increase df (from 1.69±0.05 to 1.71±0.06).

CONCLUSIONS

The results indicate in this cohort of DVT patients there was no underlying hypercoagulable effect as determined by gel point analysis. Furthermore, the anticoagulant effect of rivaroxaban prolonged clotting, suggesting a protective effect against clot formation, without significantly reducing clot microstructural properties.

Public reporting of performance measures in long-term care in Canada: does it make a difference?

Background

Evidence of the impact of public reporting of healthcare performance on quality improvement is not yet sufficient to draw conclusions with certainty, despite the important policy implications. This study explored the impact of implementing public reporting of performance indicators of long-term care facilities in Canada. The objective was to analyse whether improvements can be observed in performance measures after publication.

Methods

We considered 16 performance indicators in long-term care in Canada, 8 of which are publicly reported at a facility level, while the other 8 are privately reported. We analysed data from the Continuing Care Reporting System managed by the Canadian Institute for Health Information and based on information collection with RAI-MDS 2.0 © between the fiscal years 2011 and 2018. A multilevel model was developed to analyse time trends, before and after publication, which started in 2015. The analysis was also stratified by key sample characteristics, such as the facilities' jurisdiction, size, urban or rural location and performance prior to publication.

Results

Data from 1087 long-term care facilities were included. Among the 8 publicly reported indicators, the trend in the period after publication did not change significantly in 5 cases, improved in 2 cases and worsened in 1 case. Among the 8 privately reported indicators, no change was observed in 7, and worsening in 1 indicator. The stratification of the data suggests that for those indicators that were already improving prior to public reporting, there was either no change in trend or there was a decrease in the rate of improvement after publication. For those indicators that showed a worsening trend prior to public reporting, the contrary was observed.

Conclusions

Our findings suggest public reporting of performance data can support change. The trends of performance indicators prior to publication appear to have an impact on whether further change will occur after publication.

Key messages

Public reporting is likely one of the factors affecting change in performance in long-term care facilities. Public reporting of performance measures in long-term care facilities may support improvements in particular in cases where improvement was not observed before publication.

Aerial baiting for feral cats is unlikely to affect survivorship of northern quolls in the Pilbara region of Western Australia

Abstract ContextFeral cats (Felis catus) are known predators of northern quolls (Dasyurus hallucatus). Management to suppress feral cat densities often uses the poison sodium monofluoroacetate (compound 1080) in baits broadcast aerially. Eradicat® baits have demonstrated efficacy at reducing feral cat densities in some environments. However, these are not registered for use in northern Australia because their risk to non-target northern quolls remains unknown. AimsWe investigated the risks of aerially deployed feral cat Eradicat® baits containing 4.5mg of the poison 1080 on the survival of free-ranging northern quolls. MethodsThe study was conducted over a 20000-ha area in the Pilbara bioregion in Western Australia. Twenty-one wild northern quolls from a baited area and 20 quolls from a nearby reference area were fitted with radio-collars, and their survivorship was compared following the aerial deployment of over 9700 feral cat baits. Survivorship of quolls was assessed before and after the baiting campaign. Key resultsFive radio-collared quolls died at the baited area; four mortalities were due to feral cat predation, and the cause of one death was uncertain. At the reference area, seven radio-collared quolls were confirmed dead; three mortalities were due to feral cat predation, two from wild dog predation, and the cause of death of two could not be determined. Evidence for sublethal poison impacts on quolls, inferred by monitoring reproductive output, was lacking; average litter size was higher in quolls from the baited area than in those from the unbaited area, and within range of litters reported elsewhere, suggesting that acute effects of 1080 (if ingested) on reproductive success were unlikely. ConclusionsRadio-collared northern quolls survived the trial using Eradicat® baits, and females showed no acute effects of sublethal poisoning on the basis of reproductive output. A lack of quoll deaths attributed to 1080 poisoning suggests that the use of Eradicat® poses a low risk to northern quolls in the Pilbara. Importantly, the high level of mortalities associated with predation by feral cats, and to a lesser extent, canids, validates the threats of these introduced predators on quolls, suggesting that their control in areas where quolls are present is likely to be beneficial for the recovery of this species. ImplicationsLand managers aiming to conserve northern quolls in the Pilbara would see conservation benefits if they introduced an operational landscape-scale feral cat baiting program using Eradicat® baits, with appropriate monitoring.

The effect of the acute inflammatory response of burns and its treatment on clot characteristics and quality: A prospective case controlled study

INTRODUCTION

Burns are known to have an effect on coagulation in the early period after burn. Current coagulation tests have been criticised in acute burns due to their inherent limitations. This study aims to investigate the potential for a new quantitative functional biomarker of clot quality, fractal dimension, to identify changes in clot microstructure as a result of the burn inflammatory response and its treatment.

METHODS

A total of fifty-eight burn patients were included in this prospective case-controlled study. The control group (29 patients mean TBSA 1%), and case group (29 patients mean TBSA 30%) were compared at baseline and the case group investigated further over four time points (baseline, 12h, 24h and 5-7 days). Fractal analysis was performed, as well as current markers of coagulation, inflammatory markers and point-of-care tests, Thromboelastography and Multiplate analysis.

RESULTS

Fractal dimension did not differ between groups at admission (1.73±0.06 and 1.72±0.1), and fell within the healthy index normal range (1.74±0.7), suggesting a normal clot microstructure in the early period after burn. Fractal dimension significantly reduced from baseline over the first 24h following injury (1.59±0.03 p<0.005), indicating a significant reduction in mechanical clot strength and functionality consistent with a hypocoagulable state, not identified with other markers.

CONCLUSIONS

This is the first study to quantify the changes in clot microstructure following burn injury. This study confirms clot microstructure is significantly altered during the first 24h after burn, with the production of a weaker, more porous fibrin clot, consistent with a hypocoagulable state.

Prognostic value of circulating tumour cells in limited-stage small-cell lung cancer: analysis of the concurrent once-daily versus twice-daily radiotherapy (CONVERT) randomised controlled trial

BACKGROUND

The clinical significance of circulating tumour cells (CTCs) in limited-stage small-cell lung cancer (LS-SCLC) is not well defined. We report a planned exploratory analysis of the prevalence and prognostic value of CTCs in LS-SCLC patients enrolled within the phase III randomised CONVERT (concurrent once-daily versus twice-daily chemoradiotherapy) trial.

PATIENTS AND METHODS

Baseline blood samples were enumerated for CTCs using CellSearch in 75 patients with LS-SCLC who were enrolled in the CONVERT trial and randomised between twice- and once-daily concurrent chemoradiation. Standard statistical methods were used for correlations of CTCs with clinical factors. Log-rank test and Cox regression analyses were applied to establish the associations of 2, 15 and 50 CTC thresholds with progression-free survival (PFS) and overall survival (OS). An optimal CTC count threshold for LS-SCLC was established.

RESULTS

CTCs were detected in 60% (45/75) of patients (range 0-3750). CTC count thresholds of 2, 15 and 50 CTCs all significantly correlate with PFS and OS. An optimal CTC count threshold in LS-SCLC was established at 15 CTCs, defining 'favourable' and 'unfavourable' prognostic risk groups. The median OS in <15 versus ≥15 CTCs was 26.7 versus 5.9 m (P = 0.001). The presence of ≥15 CTCs at baseline independently predicted ≤1 year survival in 70% and ≤2 years survival in 100% of patients.

CONCLUSION

We report the prognostic value of baseline CTC count in an exclusive LS-SCLC population at thresholds of 2, 15 and 50 CTCs. Specific to LS-SCLC, ≥15 CTCs was associated with worse PFS and OS independent of all other factors and predicted ≤2 years survival. These results may improve disease stratification in future clinical trial designs and aid clinical decision making.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00433563.

Bone turnover markers in relation to vitamin D status and disease activity in adults with systemic lupus erythematosus

OBJECTIVE

Patients with systemic lupus erythematosus (SLE) have altered bone metabolism and are at risk of osteoporosis. The aim of this study was to examine bone turnover markers in relation to vitamin D, disease activity, and clinical risk factors in patients with established SLE.

METHODS

Clinical registry and biorepository data of 42 SLE patients were assessed. Serum samples were analyzed for osteocalcin as a marker of bone formation, C-terminal telopeptide of type 1 collagen (CTX) as a marker for bone resorption, and 25-hydroxy vitamin D.

RESULTS

Patients with a Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI) score of 3 or greater had a lower median osteocalcin level ( P = 0.02) and lower 25-hydroxy vitamin D levels ( P = 0.03) than those with a score of less than 3. No significant differences in bone turnover markers were observed between patients dichotomized into subgroups using a 25-hydroxy vitamin D cut-off of 30 ng/mL or by a daily prednisone dose greater than or 5 mg or less. Osteocalcin levels were negatively correlated with SLEDAI scores ( P = 0.034), and were positively correlated with the CTX index (a ratio of measured CTX value to the upper limit of the normal value for age and gender) ( P < 0.01). No association between the CTX index and SLEDAI scores was found.

CONCLUSION

SLE disease activity may have direct effects on bone formation, but no effects on bone resorption in this cohort of established SLE patients, probably related to the inflammation-suppressing effects of glucocorticoids, thereby inhibiting cytokine-induced osteoclast activity. A fine balance exists between disease control and the use of glucocorticoids with regard to bone health.

Neuroinvasive West Nile Virus Post-Heart Transplantation: A Case Report

First described in the United States in the late 1990s, West Nile virus (WNV) infection following solid organ transplantation is a rare but life-threatening complication. The many ways in which WNV may be acquired, patient specific risk factors, and variability in clinical severity present challenges to health care providers caring for these patients.

Accuracy of a history of blood donation from surrogate witnesses: data from the UK TMER study

Look-back studies of blood transfusion in Creutzfeldt-Jakob disease commonly rely on reported history from surrogate witnesses. Data from the UK Transfusion Medicine Epidemiology Review have been analysed to determine the accuracy of the blood donation history provided by the relatives of cases. Our results show that only a small percentage of cases were found to be registered as donors on UK Blood Service (UKBS) databases when there was no family report of blood donation. In contrast, a history of reported donation was less accurate.

KidsBrainIT: A New Multi-centre, Multi-disciplinary, Multi-national Paediatric Brain Monitoring Collaboration

OBJECTIVES

Validated optimal cerebral perfusion pressure (CPP) treatment thresholds in children do not exist. To improve the intensive care unit (ICU) management of the paediatric traumatic brain injury (TBI) population, we are forming a new paediatric multi-centre collaboration to recruit standardised ICU data for running and reporting upon models for assessing autoregulation and optimal CCP (CPPopt).

MATERIALS AND METHODS

We are adapting the adult BrainIT group's approach to develop a new Paediatric Brain Monitoring and Information Technology Group (KidsBrainIT), which will include a repository to store prospectively collected high-resolution physiological, clinical, and outcome data. In the first phase of this project there are 7 UK Paediatric Intensive Care Units, 1 Spanish, 1 Belgium, and 1 Romanian Centre interested in participating. In subsequent phases, we plan to open recruitment to other centres both within Europe, US and abroad. We are collaborating with the Leuven Group and plan to use their LAx (low-frequency autoregulation index), DATACAR (dynamic adaptive target of active cerebral autoregulation), CPPopt and visualisation methodologies. We also plan to use the continuous diffuse optical monitoring and tomography technology developed in Barcelona as an acute surrogate end-point for optimising brain perfusion. This technology allows non-invasive continuous monitoring of deep tissue perfusion and oxygenation in adults but its clinical application in infants and children with TBI has not been studied previously.

RESULTS

We report on the current status of setting up this new collaboration and also on pilot analyses in two centres which are the basis of our rationale for the need for a prospective validation study of CPPopt in children. Specifically, we demonstrated that CPPopt varied with time for each patient during their paediatric intensive care unit (PICU) stay, and the median overall CPPopt levels for children aged 2-6 years, 7-11 years and 12-16 years were 68.83, 68.09, and 72.17 mmHg respectively. Among survivors and patients with favourable outcome (GOS 4 and 5), there were significantly higher proportions with CPP monitoring time within CPPopt (p = 0.04 and p = 0.01 respectively).

CONCLUSIONS

There is a need and an interest in forming a multi-centre PICU collaboration for acquiring data and performing analyses for determining validated CPPopt thresholds in the paediatric TBI population. KidsBrainIT is being formed to meet that need.

The ClosER study: results from a three-year pan-European longitudinal surveillance of antibiotic resistance among prevalent Clostridium difficile ribotypes, 2011-2014

OBJECTIVES

Until the introduction of fidaxomicin, antimicrobial treatment for Clostridium difficile infection (CDI) was limited to metronidazole and vancomycin. The changing epidemiology of CDI and the emergence of epidemic C. difficile PCR ribotype 027 necessitate continued surveillance to identify shifts in antibiotic susceptibility. ClosER, currently the largest pan-European epidemiological study of C. difficile ribotype distribution and antibiotic susceptibility, aimed to undertake antimicrobial resistance surveillance pre- and post-introduction of fidaxomicin.

METHODS

Between July 2011 and July 2014, 39 sites across 22 European countries submitted 2830 C. difficile isolates for ribotyping, toxin testing and susceptibility testing to metronidazole, vancomycin, fidaxomicin, rifampicin, moxifloxacin, clindamycin, imipenem, chloramphenicol and tigecycline.

RESULTS

Ribotypes 027, 014, 001, 078, 020, 002, 126, 015 and 005 were most frequently isolated, and emergent ribotypes 198 and 356 were identified in Hungary and Italy, respectively. All isolates were susceptible to fidaxomicin, with scarce resistance to metronidazole (0.2%, 6/2694), vancomycin (0.1%, 2/2694) and tigecycline (0%). Rifampicin, moxifloxacin and clindamycin resistance was evident in multiple ribotypes. Lack of ribotype diversity correlated with greater antimicrobial resistance. Epidemic ribotypes (027/001) were associated with multiple antimicrobial resistance, and ribotypes 017, 018 and 356 with high-level resistance. Additional factors may also influence local ribotype prevalence.

CONCLUSIONS

Fidaxomicin susceptibility was retained post-introduction, and resistance to metronidazole and vancomycin was rare. Continued surveillance is needed, with more accurate classification and clarification of ribotype subtypes to further understand their role in the spread of resistance. Other factors may also influence changes in prevalence of C. difficile ribotypes with reduced antibiotic susceptibility.

Characterising legacy spent nuclear fuel pond materials using microfocus X-ray absorption spectroscopy

Analysis of a radioactive, coated concrete core from the decommissioned, spent nuclear fuel cooling pond at the Hunterston-A nuclear site (UK) has provided a unique opportunity to study radionuclides within a real-world system. The core, obtained from a dividing wall and sampled at the fill level of the pond, exhibited radioactivity (dominantly (137)Cs and (90)Sr) heterogeneously distributed across both painted faces. Chemical analysis of the core was undertaken using microfocus spectroscopy at Diamond Light Source, UK. Mapping of Sr across the surface coatings using microfocus X-ray fluorescence (μXRF) combined with X-ray absorption spectroscopy showed that Sr was bound to TiO2 particles in the paint layers, suggesting an association between TiO2 and radiostrontium. Stable Sr and Cs sorption experiments using concrete coupons were also undertaken to assess their interactions with the bulk concrete in case of a breach in the coating layers. μXRF and scanning electron microscopy showed that Sr was immobilized by the cement phases, whilst at the elevated experimental concentrations, Cs was associated with clay minerals in the aggregates. This study provides a crucial insight into poorly understood infrastructural contamination in complex systems and is directly applicable to the UK's nuclear decommissioning efforts.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Treatment of aplastic anaemia with lower-dose anti-thymocyte globulin produces similar response rates and survival as per standard dose anti-thymocyte globulin schedules

BACKGROUND

Aplastic anaemia (AA) is a rare acquired bone marrow failure syndrome resulting from the immune-mediated destruction of haemopoietic stem cells. For adults in whom first-line haemopoietic progenitor cell transplantation is not feasible, combination anti-thymocyte globulin (ATGAM) plus cyclosporine A is standard therapy; however, there are minimal data available regarding the optimal ATGAM dosage in terms of efficacy and survival.

AIMS

Our institutions have historically used different dosing protocols of ATGAM in the treatment of AA. We aimed to review the outcome of AA patients treated with these protocols and compare them to the published literature.

METHODS

We conducted a retrospective study of 31 adults who received first-line ATGAM for AA and compared response rates and survival between cohorts who received standard (40 mg/kg/day D1-4) versus lower-dose (15 mg/kg/day D1-5) ATGAM schedules.

RESULTS

There were similar rates of response (64 vs 71%, P = 1.0), relapse (33 vs 33%, P = 1.0), transformation (14 vs 24%, P = 0.66) or infection (43 vs 47%, P = 1.0), respectively, between standard and lower-dose cohorts. At a median follow up of 24 months, there was no statistical difference between standard and lower-dose cohorts in either event-free (42.2 vs 64.7%, P = 0.91) or overall survival (73.1 vs 88.2%, P = 0.75).

CONCLUSION

Our experience suggests that lower-dose ATGAM at 15 mg/kg/day D1-5 as treatment of AA produces similar responses and outcomes as per standard-dose ATGAM schedules. Prospective trials comparing ATGAM dose schedules in AA are warranted.

Moderate-intensity exercise alters markers of alternative activation in circulating monocytes in females: a putative role for PPARγ

PURPOSE

Monocytes may be primed towards differentiation into classically activated M1 macrophages or alternatively activated M2 macrophages. M1 macrophages greatly contribute to the inflammation which promotes insulin resistance, whereas M2 macrophages resolve inflammation. We have previously shown that exercise increases M2 marker expression in mixed mononuclear cells, possibly via activation of the nuclear transcription factor PPARγ. However, these effects have not been demonstrated specifically within monocytes. Thus, we aimed to investigate whether moderate-intensity exercise elicited similar effects on monocytic M1/M2 marker expression and PPARγ activity to those reported previously in mononuclear cells, so as to further elucidate the mechanisms by which exercise may alter inflammatory status and, accordingly, prevent insulin resistance.

METHODS/RESULTS

19 sedentary females completed an 8 week moderate-intensity exercise programme (walking 45 min, thrice weekly). Monocytes were isolated from blood via immunomagnetic separation; monocyte expression of M2 markers (Dectin-1: 2.6 ± 1.9-fold; IL-10: 3.0 ± 2.8-fold) significantly increased, whilst the expression of the M1 marker MCP-1 significantly decreased (0.83 ± 0.2 cf. basal), over the duration of the programme. Serum PPARγ activity levels and PPARγ target-genes (CD36: 1.9 ± 1.5-fold; LXRα: 5.0 ± 4.7-fold) were significantly increased after the 8 week exercise programme. Associated with these effects were significant improvements in systemic insulin sensitivity (McAuley's ISI: Δ0.98 M/mU/L cf. basal).

CONCLUSION

Exercise participation suppressed M1 markers and induced M2 markers in monocytes, potentially via PPARγ-triggered signalling, and these effects may contribute (perhaps via priming of monocytes for differentiation into M2 tissue-macrophages) to improved systemic insulin sensitivity in exercising participants. These findings provide an alternative mechanism by which exercise may exert its anti-inflammatory effects in order to prevent insulin resistance and type 2 diabetes.

Evaluation of cardiovascular risk-lowering health benefits accruing from laboratory-based, community-based and exercise-referral exercise programmes

Background

To evaluate the ability of community-based exercise programmes to facilitate public participation in exercise and hence improved cardiovascular health, we assessed the respective impacts of: a continuously monitored exercise programme based within our university (study 1); a Valleys Regional Park-facilitated community-based outdoor exercise programme (study 2); a Wales National Exercise Referral Scheme-delivered exercise-referral programme (study 3).

Methods

Biomolecular (monocytic PPARγ target gene expression), vascular haemodynamic (central/peripheral blood pressure, arterial stiffness), clinical (insulin sensitivity, blood lipids) and anthropometric (body mass index, waist circumference, heart rate) parameters were investigated using RT-PCR, applanation tonometry, chemical analysis and standard anthropometric techniques.

Results

In studies 1–3, 22/28, 32/65 and 11/14 participants adhered to their respective exercise programmes, and underwent significant increases in physical activity levels. Importantly, beneficial effects similar to those seen in our previous studies (eg, modulations in expression of monocytic PPARγ target genes, decreases in blood pressure/arterial stiffness, improvements in blood lipids/insulin sensitivity) were observed (albeit to slightly differing extents) only in participants who adhered to their respective exercise programmes. While study 1 achieved more intense exercise and more pronounced beneficial effects, significant cardiovascular risk-lowering health benefits related to biomolecular markers, blood pressure, arterial stiffness and blood lipids were achieved via community/referral-based delivery modes in studies 2 and 3.

Conclusions

Because cardiovascular health benefits were observed in all 3 studies, we conclude that the majority of benefits previously reported in laboratory-based studies can also be achieved in community-based/exercise-referral settings. These findings may be of use in guiding policymakers with regard to introduction and/or continued implementation of community/referral-based exercise programmes.

Healthcare workers' decision-making about transmission-based infection control precautions is improved by a guidance summary card

BACKGROUND

Transmission-based precautions (TBPs) are infection control measures designed to interrupt pathogen transmission. Success relies on early recognition of patients with potentially infectious syndromes, then the implementation of appropriate TBPs. We are aware of no literature evaluating interventions to facilitate healthcare workers (HCWs) in implementing TBPs.

AIM

To evaluate the impact of a TBP guidance summary card on HCWs' decision-making about the appropriate implementation of TBPs.

METHODS

A prospective audit was carried out to assess HCWs' ability to make decisions about TBP implementation. Following the first audit phase, staff were issued with a guidance card summarizing local TBP guidelines, identifying and addressing relevant TBP measures for infectious syndromes and specific organisms. The audit cycle was then completed to assess the impact of this intervention.

FINDINGS

Baseline knowledge of appropriate TBP measures was low. Provision of a TBP summary card was significantly associated with the ability of staff carrying the card to correctly decide what TBPs are required in a variety of clinical situations, including Clostridium difficile infection [N = 107; odds ratio (OR): 27.0; 95% confidence interval (CI): 8.37-86.8; P < 0.0001], norovirus diarrhoea and vomiting (N = 107; OR: 94.3, 95% CI: 25.0-356; P < 0.0001), influenza-like illness (N = 107; OR: 85.2; 95% CI: 4.94-1470; P < 0.0001) and the difference between surgical and FFP3 masks (N = 107; OR: 412; 95% CI: 23.4-7246; P < 0.0001).

CONCLUSION

There is a lack of knowledge about TBP among HCWs. This study demonstrates how an inexpensive TBP summary card is an effective mechanism for improving (i) point-of-care access to TBP guidance and (ii) decision-making about appropriate implementation of TBP.

Wide-angle ITER-prototype tangential infrared and visible viewing system for DIII-D

An imaging system with a wide-angle tangential view of the full poloidal cross-section of the tokamak in simultaneous infrared and visible light has been installed on DIII-D. The optical train includes three polished stainless steel mirrors in vacuum, which view the tokamak through an aperture in the first mirror, similar to the design concept proposed for ITER. A dichroic beam splitter outside the vacuum separates visible and infrared (IR) light. Spatial calibration is accomplished by warping a CAD-rendered image to align with landmarks in a data image. The IR camera provides scrape-off layer heat flux profile deposition features in diverted and inner-wall-limited plasmas, such as heat flux reduction in pumped radiative divertor shots. Demonstration of the system to date includes observation of fast-ion losses to the outer wall during neutral beam injection, and shows reduced peak wall heat loading with disruption mitigation by injection of a massive gas puff.

Pan-European longitudinal surveillance of antibiotic resistance among prevalent Clostridium difficile ribotypes

Clostridium difficile infection remains a major healthcare burden. Until the recent introduction of fidaxomicin, antimicrobial treatments were limited to metronidazole and vancomycin. The emergence of epidemic C. difficile PCR ribotype 027 and its potential link to decreased antibiotic susceptibility highlight the lack of large-scale antimicrobial susceptibility and epidemiological data available. We report results of epidemiological and antimicrobial susceptibility investigations of C. difficile isolates collected prior to fidaxomicin introduction, establishing important baseline data. Thirty-nine sites in 22 countries submitted a total of 953 C. difficile isolates for PCR ribotyping, toxin testing, and susceptibility testing to metronidazole, vancomycin, fidaxomicin, rifampicin, moxifloxacin, clindamycin, imipenem, chloramphenicol, and tigecycline. Ninety-nine known ribotypes were identified. Ribotypes 027, 014, 001/072, and 078 were most frequently isolated in line with previous European studies. There was no evidence of resistance to fidaxomicin, and reduced susceptibility to metronidazole and vancomycin was also scarce. Rifampicin, moxifloxacin, and clindamycin resistance (13%, 40%, and 50% of total isolates, respectively) were evident in multiple ribotypes. There was a significant correlation between lack of ribotype diversity and greater antimicrobial resistance (measured by cumulative resistance score). Well-known epidemic ribotypes 027 and 001/072 were associated with multiple antimicrobial resistance, but high levels of resistance were also observed, particularly in 018 and closely related emergent ribotype 356 in Italy. This raises the possibility of antimicrobial exposure as the underlying reason for their appearance, and highlights the need for ongoing epidemiological and antimicrobial resistance surveillance.

An MRI rating scale for amyloid-related imaging abnormalities with edema or effusion

BACKGROUND AND PURPOSE

Immune therapy against amyloid-β appears to be a promising target in Alzheimer disease. However, a dose-related risk for ARIA on FLAIR images thought to represent parenchymal vasogenic edema or sulcal effusion (termed "ARIA-E"), has been observed in clinical trials. To assess the intensity of ARIA-E presentation, an MR imaging scale that is both reproducible and easily implemented would assist in monitoring and evaluating this adverse event.

MATERIALS AND METHODS

On the basis of a review of existing cases from a phase II bapineuzumab study, a scale was constructed with a 6-point score for the 6 regions on each side of the brain (range, 0-60). Scores would be obtained for both parenchymal and sulcal hyperintensities and frequently co-occurring gyral swelling. Inter-rater reliability between 2 neuroradiologists was evaluated in 20 patients, 10 with known ARIA-E and 10 without, by using the intraclass correlation coefficient.

RESULTS

The 2 raters had excellent agreement in the identification of ARIA-E cases. A high inter-rater agreement was observed for scores of parenchymal hyperintensity (ICC = 0.83; 95% CI, 48-96) and sulcal hyperintensity (ICC = 0.89; 95% CI, 63-97) and for the combined scores of the 2 ARIA-E findings (ICC = 0.89; 95% CI, 62-97). Gyral swelling scores were observed to have lower inter-rater agreement (ICC = 0.54; 95% CI, -0.06-0.86).

CONCLUSIONS

The proposed rating scale provides a reliable and easily implemented instrument to grade ARIA-E imaging findings. We currently do not recommend including swelling.

The use of microorganisms with broad range substrate utilisation for the ferricyanide-mediated rapid determination of biochemical oxygen demand

The feasibility of replacing oxygen with a synthetic electron acceptor in microbial catabolism was investigated as a rapid method for the determination of biochemical oxygen demand (BOD). Microorganisms known for their broad range organic substrate utilisation were investigated. It was shown that Trichosporon cutaneum, Pseudomonas putida and Bacillus licheniformis could utilize the ferricyanide ion as an alternative electron acceptor, in place of oxygen, for the catabolic oxidation of a range of simple organic compounds. The biochemical reactions were monitored by measuring the amount of microbially produced ferrocyanide using amperometry at a Pt disk microelectrode. Catabolic degradation efficiencies approaching those of the conventional 5-day assay were achieved in 1 h. BOD(5) equivalent values for a range of simple organic solutions were determined for each of the microorganisms. The effect of increased incubation time and the choice of appropriate calibration standards for rapid BOD assays were also considered.