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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of storage conditions and time on DNA yield from ammunition cartridges

Recovery of suitable amounts of DNA from ammunition cartridges for short tandem repeat (STR) or mitochondrial (mt) DNA analysis has been a challenge for crime laboratories. The metal composition of cartridge cases and projectiles exposes the DNA to harmful ions that damage and ultimately degrade the DNA such that it cannot be effectively amplified. The current study assessed the impact of time and storage conditions on touch DNA deposited on cartridge components of varying metal content: aluminum, nickel, brass, and copper. Elevated humidity levels facilitated greater DNA degradation and loss compared to low humidity (or "dry") conditions, indicating that recovered cartridge component evidence should be stored in a low-humidity environment immediately after collection, preferably with a desiccant. As expected, a relationship was observed between the amount of time elapsed since the cartridge components were handled and the associated DNA yield. Interestingly, while yields dropped considerably in the first 48-96 h post-handling, regardless of the storage conditions, a layering effect was observed that helps maintain a relatively constant level of surface DNA over extended periods of time. An apparent layering effect was also observed on cartridge components following multiple surface depositions, where yields were two times higher than single deposition samples at similar timepoints. Overall, these findings suggest that storage conditions and a layering affect play an important role in the preservation of DNA on ammunition components.

Emergency admissions' diagnoses and risk of in-hospital death according to the primary ICD-10 chapter assigned at discharge and the National Early Warning Score on admission

BACKGROUND

The relationship between diagnosis, illness severity, and mortality risk for unselected emergency admissions is poorly defined.

AIM

To define primary ICD-10 diagnostic chapters at discharge, admission illness severity by the National Early Warning Score, and in-hospital mortality for all unselected emergency admissions.

METHOD

Retrospective, observational, cohort study of 122,259 unselected, adult emergency admissions to Salford Royal Hospital between 2014 and 2022.

RESULTS

In-hospital mortality was 4.3% but most patients had an ICD-10 chapter associated with a lower risk of death. 60% of in-hospital deaths were in four chapters, infections, circulatory and respiratory diseases, or neoplasms. An admission NEWS ≥3 was associated with earlier mortality and an eight-fold increased risk of in-hospital mortality. 45% of all in-hospital deaths occurred in patients with an admission NEWS <3.

CONCLUSION

Mortality in emergency hospital admissions is associated with illness severity and four diagnostic chapters. NEWS should not be the only arbiter of hospital admission, as for certain diagnostic chapters the risk of death is high even if vital signs on presentation are normal.

Acute Medicine: How will we grow? - An analysis of organisational capabilities for quality improvement, research & education from SAMBA 2021

BACKGROUND

Education, research, and Quality Improvement (QI) are key enablers for high quality care. We aimed to map the capability of Acute Medical Units (AMUs) to facilitate excellence in these areas.

METHODS

AMUs were surveyed in an organisational questionnaire within the Society for Acute Medicine Benchmarking Audit 2021.

RESULTS

143 units participated. 80 units had a QI lead, 24 had a research lead and 99 had a medical education lead. 15 units had all three leadership roles. Most QI work considered service structure rather than changes in processes or care outcomes.

CONCLUSION

The organisational capability of AMUs in the strategic areas considered is variable. Improving leadership and disseminating learning could help build a strategic foundation for acute medicine to grow.

Rates and Reasons for Readmission after Hospitalisation on the Acute Medical Unit

INTRODUCTION

Readmission after hospital discharge is an ongoing challenge that healthcare systems face worldwide, with multimorbidity increasing the readmission risk significantly. Identifying higher risk groups of patients allows for safety netting at discharge to be implemented to prevent harm. The aim of this study was to compare readmission rates and reasons across common diagnostic groups presenting to the acute medical unit.

METHOD

A retrospective analysis was performed on an anonymous dataset extracted from Salford Royal Hospital from 2014 - 2022 covering all non-elective inpatient admissions to AMU or medical same day emergency care where the patient survived to discharge. Episodes were grouped according to ICD-10 diagnostic codes, with readmission rates and reasons at 30 and 90 day calculated and compared using descriptive statistics. Further subgroups were evaluated according to demographic and co-morbid features.

RESULTS

There were 89,897 admissions to AMU and SDEC where patients survived to discharge: age 68±19 years, 53% female. 5,880 episodes were excluded due to inpatient death. The most common first admission reasons were pneumonia (n=9,121), COPD (4,800) and sepsis (3,440). The overall 30 day readmission rate was 12.3%, with the highest rates being found where first admission episode was due to liver disease (21.9%), chronic obstructive pulmonary disease (COPD, 21.1%), and falls (17.9%). 6% of all patients were readmitted within 30 days due to recurrence of the primary presenting illness, representing 49% of all readmissions. After primary illness recurrence, pneumonia was the second most common readmission reason in 17 of 22 diagnostic groups and accounted for 25% of all readmissions excluding primary illness recurrence. Overall 90 day readmission rate was 24.2% with the same 3 most common diagnostic groups (liver disease 44%, COPD 39% and falls 34%). For 90 day readmission reasons according to specified comorbidities, the highest rates were seen in heart failures (34.1%) and COPD (33.1%). The highest readmission reason in the diagnostic groups was 41.4% of heart failure patients being readmitted with respiratory causes. Heart failure was the most impactful co-morbid factor associated with higher likelihood of 90 day readmission in other disease presentations (34.4% with heart failure, 22.8% without).

DISCUSSION

Readmission rates vary significantly between diagnostic and co-morbid groups meaning that targeting high risk groups for safety netting may be possible using only simple admission details.

"We are the forgotten grievers": Bereaved family members' experiences of support and mental ill-health following a road traffic collision

Road traffic collisions (RTCs) are a global public health concern; however, research on the impact of bereavement on families remains limited. A critical realist approach was adopted to explore experiences of families suffering bereavement following RTCs, using interviews with 14 participants in the United Kingdom (UK) who have lost a family member. Three key themes were identified: (1) worsening mental health following bereavement, (2) negative impact of an RTC-related bereavement upon family members, (3) limited support following an RTC. Findings highlighted the requirement for appropriate support for bereaved families, and outlined significant flaws within the UK legal system, sentencing, and treatment of families.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Society for Acute Medicine Benchmarking Audit 2021 (SAMBA21): assessing national performance of acute medicine services

INTRODUCTION

The Society for Acute Medicine Benchmarking Audit 2021 (SAMBA21) took place on 17th June 2021, providing the first assessment of performance against the Society for Acute Medicine's Clinical Quality Indicators (CQIs) within acute medical units since the start of the COVID-19 pandemic.

METHODS

All acute hospitals in the UK were invited to participate. Data were collected on unit structure, and for patients admitted to acute medicine services over a 24-hour period, with follow-up at 7 days.

RESULTS

158 units participated in SAMBA21, from 156 hospitals. 8973 patients were included. The number of admissions per unit had increased compared to SAMBA19 (Sign test p<0.005). An early warning score was recorded within 30 minutes of hospital arrival in 77.4% of patients. 87.4% of unplanned admissions were seen by a tier 1 clinician within 4 hours of arrival. Overall, the medical team performed the initial clinician assessment for 36.4% of unplanned medical admissions. More than a third of medical admissions had their initial assessment in Same Day Emergency Care (SDEC) in 25.4% of hospitals. 62.1% of unplanned admissions were seen by two other clinical decision makers prior to consultant review. Of those unplanned admissions requiring consultant review, 67.8% were seen within the target time. More than a third of unplanned admissions were discharged the same day in 41.8% of units.

CONCLUSION

Performance against the CQIs for acute medicine was maintained in comparison to previous rounds of SAMBA, despite increased admissions. There remains considerable variation in unit structure and performance within acute medical services.

Length of stay in Acute Medical Admissions: Analysis from the Society for Acute Medicine Benchmarking Audit

INTRODUCTION

Medical admissions to hospital represent a diverse range of patients, from those managed on ambulatory pathways through Same Day Emergency Care (SDEC) services, to those requiring prolonged inpatient admission. An understanding of current patterns of admission through acute medicine services and patient factors associated with longer hospital admission is needed to guide service planning and improvement.

METHODS

Data from the Society for Acute Medicine Benchmarking Audit (SAMBA) 2021 were analysed. Patients admitted to acute medicine services during a 24-hour period on 17th June 2021 were included, with data recording patient demographics, frailty score, acuity and follow-up of outcomes after seven days.

RESULTS

8101 unplanned medical admissions were included, from 156 hospitals. 31.6% were discharged without overnight admission; the median hospital performance was 30.1% (IQR 19.3-39.3%). 22.1% of patients remained in hospital for more than 7 days. Those remaining in hospital for more than 48 hours and for more than seven days were more likely to be aged over 70, to be frail, or to have a NEWS2 of 3 or more on arrival to hospital.

CONCLUSION

The proportion of acute medical attendances receiving overnight admission varies between hospitals. Length of stay is impacted by patient factors and illness acuity. Strategies to reduce inpatient service pressures must ensure effective care for older patients and those with frailty.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Developing priorities for quality improvement in acute medicine using a modified Delphi method A consensus process hosted by the Society for Acute Medicine Quality Improvement Committee (SAM-QI)

INTRODUCTION

The SAM Quality Improvement Committee (SAM-QI), set up in 2016, has worked over the last year to determine the priority Acute Medicine QI topics. They have also discussed and put forward proposals to improve QI training for Acute Medicine professionals.

METHODS

A modified Delphi process was completed over four rounds to determine priority QI topics. Online meetings were also used to develop proposals for QI training.

RESULTS

Same Day Emergency Care (SDEC) was chosen as the priority topic for QI work within Acute Medicine.

CONCLUSION

The SAM-QI group settled on SDEC being the priority topic for Acute Medicine QI development. Throughout the Delphi process SAM-QI has also developed proposals for QI training that will help Acute Medicine professionals deliver coordinated meaningful improvements in care.

Improving and Sustaining the Quality of Discharge Summaries

High quality discharge information communication has been linked to a reduction in the incidence of adverse events, decreasing the risk of prescription errors and lost follow up. In this paper we describe how our trust-wide quality improvement project, led by acute physicians, successfully improved discharge documentation. We demonstrate how we identified obstacles to continued success, and the interventions we implemented. We recommend how discharge summary quality can be optimised through training of junior doctors, recruitment of local champions, and use of novel methods to preserve engagement, such as gamification.

Guest Editorial - Acute Medicine and Pandemics: Getting It Right Next Time!

For those of you who are not aware of what GIRFT (Getting It Right First Time) is, let me start by saying it is a brilliant idea, genius perhaps. The vision of its founder, Professor Tim Briggs CBE, was to optimise orthopaedic care by using the most clinically and cost effective treatments, minimising waste, reducing variation and eliminating poor practice. Since 2014 in orthopaedics alone, operational and financial opportunities to save the NHS £696 million have been generated. Acute medicine, coupled with general medicine, has been part of the GIRFT programme since 2017. The mischievous reader might question the name, as clearly this is about getting things right at the second time of asking at the very earliest. Apart from that pedantic note, GIRFT is a force for good.

Quality: What does it mean in Acute Medicine and how do we measure it?

Acute Medicine is a specialty that is not defined by a single organ system and sits at the interface between primary and secondary care. In order to document improvements in the quality of care delivered a system of metrics is required. A number of frameworks for measurements exist to quantify quality of care at the level of patients, teams and organisations, such as measures of population health, patient satisfaction and cost per patient. Measures can capture whether care is safe, effective, patient-centred, timely, efficient and equitable. Measurement in Acute Medicine is challenged by the often-transient nature of the contact between Acute Medicine clinicians and patients, the lack of diagnostic labels, a low degree of standardisation and difficulties in capturing the patient experience in the context. In a time of increasing ecological and financial constraints, reflecting about the most appropriate metrics to document the impact of Acute Medicine is required.

102 Process Evaluation Exploring the Delivery and Uptake of Posture and Mobility Training for Staff in Care Homes

Introduction

Provision of care for care home residents with complex needs is challenging. Physiotherapists can play a major role in enhancing the confidence, skills and abilities of care home staff. The Skilful Care Training Package (SCTP) aims to provide staff with an understanding of good posture and training in skilled facilitation of movement. This process evaluation explored barriers and facilitators to delivery and uptake of the SCTP within the context of a feasibility cluster randomised controlled trial (cRCT) in 10 care homes.

Methods

A mixed methods process evaluation, incorporating non-participant observations and interviews, conducted in the five care homes receiving the SCTP intervention. Interviews were audio recorded and transcribed verbatim; resident conversations were captured via a Dictaphone and/or field-notes. Data analysis used the Framework approach.

Results

Fourteen staff training sessions were observed. Interviews with 22 staff and four trainers, and 13 conversations with residents were completed. Five factors influenced delivery and uptake of the SCTP:Organisational factors: strategies to publicise and facilitate access to training improved attendance; a convenient training location and trainer flexibility encouraged attendance and staff engagement.Intervention delivery: a practical participatory element to the training was highly valued; adapting the training to meet the needs of the homes was well-received.Engagement and interaction: relating training to workplace and residents’ experiences engaged staff; high levels of engagement and positive interaction within the training sessions were reported; challenges relating to staff hierarchy affected training delivery in some homes.Intervention content: posture and mobility elements were seen as important; however, some repetition with prior training was highlighted.Training impact: there were indications that staff adopted SCTP techniques. Staff reported an increase in their wellbeing and confidence in movement facilitation; cascade training was reported in some homes.

Conclusions

Training was well-received, and feedback on its impact was largely positive. Practical elements were viewed favourably over classroom-based learning. Intervention content should be revised to optimise focus and avoid overlap with other training.

101 A Posture and Mobility Training Package for Care Home Staff: Results of A Cluster Randomised Controlled Feasibility Trial

Introduction

Provision of care for care home residents with complex needs is challenging. Physiotherapy and activity interventions can improve physical well-being but are often time-limited and resource intensive. A sustainable approach is to enhance the confidence, skills and abilities of care home staff. This trial assessed the feasibility of undertaking a definitive evaluation of the Skilful Care Training Package (SCTP) - a posture and mobility training programme developed by physiotherapists for care home staff.

Methods

A parallel-group, cluster randomised controlled feasibility trial was undertaken in ten care homes in Yorkshire. Five were randomised to receive SCTP, five to usual care. SCTP was delivered by specialist physiotherapists, with the intention of training all direct care staff. Following consent, data were collected from and about residents with restricted mobility (those fulfilling the eligibility criteria) at baseline, three and six months post-randomisation by blinded researchers. Outcome measurement included resident mobility, posture, pain and quality of life. The feasibility of recruitment, retention, data collection and intervention delivery was assessed.

Results

All residents (348) at participating homes were screened for eligibility. 250 were eligible and 146 took part. Follow-up was balanced between arms, with an overall loss-to-follow-up rate of 28.8% at six months. Where residents were available for six-month follow-up, proxy data provision was excellent (97.1% - 100% of expected data). Difficulty collecting data directly from residents was experienced (43.3% of expected data) due to high levels of cognitive impairment. Staff attendance at training met or was close to pre-specified criteria for acceptability in three homes, with 63.0%, 63.6% and 65.8% direct care staff attending all sessions, and &gt;85% attending at least one session across all three homes. However attendance fell short of acceptability in two homes, with only 21.4% and 12.5% staff attending all sessions.

Conclusions

It is feasible to recruit and follow-up residents in a randomised trial comparing SCTP and usual care. Proxy data collection is a successful method, but collection of data from residents is difficult. Intervention delivery success was variable, illustrating heterogeneity between care homes. Future research will be informed by learning from those homes with greater intervention compliance. Work should be undertaken to investigate how best to collect meaningful data from residents.

Acute care service performance during winter: report from the winter SAMBA 2020 national audit of acute care

The Winter Society for Acute Medicine Benchmarking Audit (SAMBA) provides the first comparison of performance within acute medicine against clinical quality indicators during winter, a time of increased pressure and demand on acute services. 105 hospitals participated in Winter SAMBA, collecting data over 24-hours on 30th January 2020. 5626 patients were included. Participating units saw a median of 48 patients (range 13-131). Comparison between Winter SAMBA and SAMBA19 found less patients had an early warning score within 30 minutes during winter (74.3% vs 78.9%) and less were seen by a clinical decision maker within four hours (84.9% vs 87.9%). Unplanned admissions represented a higher proportion of workload (92.5% vs 90.1%). Patients were more likely to have a NEWS2 score of 3 or higher (30.1% vs 25.7%). Performance is poorer in winter, and patients are more unwell, needing prompt treatment. Services should ensure high quality care can be maintained through times of increased pressure, including winter.

Society for Acute Medicine Benchmarking Audit 2019 (SAMBA19): Trends in Acute Medical Care

INTRODUCTION

The eighth Society for Acute Medicine Benchmarking Audit (SAMBA19) took place on Thursday 27th June 2019. SAMBA gives a broad picture of acute medical care in the UK and allows individual units to compare their performance against their peers.

METHOD

All UK hospitals were invited to participate. Unit and patient level were collected. Data were analysed against published Clinical Quality indicators (CQI) and standards. This was the biggest SAMBA to date, with data from 7170 patients across 142 units in 140 hospitals.

RESULTS

84.5% of patients had an Early Warning Score measured within 30 minutes of arrival in hospital (SAMBA18 84.1%), 90.4% of patients were seen by a competent clinical decision maker within four hours of arrival in hospital (SAMBA18 91.4 %) and 68.6% of patients were seen by a consultant within the timeframe standard (SAMBA18 62.7%). Ambulatory Emergency Care is provided in 99.3% of hospitals. 61.8% of patients are initially seen in the Emergency Department (ED). Since SAMBA18 death rates and planned discharge rates, while the use of NEWS2 increased from 2.5% to 59.2% of hospitals.

CONCLUSION

SAMBA19 highlighted the evolving complexity of acute medical pathways for patients. The challenge now is to increase sample frequency, assess the impact of SAMBA open a broader debate to define optimal CQIs.

Lassa virus circulating in Liberia: a retrospective genomic characterisation

BACKGROUND

An alarming rise in reported Lassa fever cases continues in west Africa. Liberia has the largest reported per capita incidence of Lassa fever cases in the region, but genomic information on the circulating strains is scarce. The aim of this study was to substantially increase the available pool of data to help foster the generation of targeted diagnostics and therapeutics.

METHODS

Clinical serum samples collected from 17 positive Lassa fever cases originating from Liberia (16 cases) and Guinea (one case) within the past decade were processed at the Liberian Institute for Biomedical Research using a targeted-enrichment sequencing approach, producing 17 near-complete genomes. An additional 17 Lassa virus sequences (two from Guinea, seven from Liberia, four from Nigeria, and four from Sierra Leone) were generated from viral stocks at the US Centers for Disease Control and Prevention (Atlanta, GA) from samples originating from the Mano River Union (Guinea, Liberia, and Sierra Leone) region and Nigeria. Sequences were compared with existing Lassa virus genomes and published Lassa virus assays.

FINDINGS

The 23 new Liberian Lassa virus genomes grouped within two clades (IV.A and IV.B) and were genetically divergent from those circulating elsewhere in west Africa. A time-calibrated phylogeographic analysis incorporating the new genomes suggests Liberia was the entry point of Lassa virus into the Mano River Union region and estimates the introduction to have occurred between 300-350 years ago. A high level of diversity exists between the Liberian Lassa virus genomes. Nucleotide percent difference between Liberian Lassa virus genomes ranged up to 27% in the L segment and 18% in the S segment. The commonly used Lassa Josiah-MGB assay was up to 25% divergent across the target sites when aligned to the Liberian Lassa virus genomes.

INTERPRETATION

The large amount of novel genomic diversity of Lassa virus observed in the Liberian cases emphasises the need to match deployed diagnostic capabilities with locally circulating strains and underscores the importance of evaluating cross-lineage protection in the development of vaccines and therapeutics.

FUNDING

Defense Biological Product Assurance Office of the US Department of Defense and the Armed Forces Health Surveillance Branch and its Global Emerging Infections Surveillance and Response Section.

Differences in identification of patients' deterioration may hamper the success of clinical escalation protocols

BACKGROUND

Timely and consistent recognition of a 'clinical crisis', a life threatening condition that demands immediate intervention, is essential to reduce 'failure to rescue' rates in general wards.

AIM

To determine how different clinical caregivers define a 'clinical crisis' and how they respond to it.

DESIGN

An international survey.

METHODS

Clinicians working on general wards, intensive care units or emergency departments in the Netherlands, the United Kingdom and Denmark were asked to review ten scenarios based on common real-life cases. Then they were asked to grade the urgency and severity of the scenario, their degree of concern, their estimate for the risk for death and indicate their preferred action for escalation. The primary outcome was the scenarios with a National Early Warning Score (NEWS) ≥7 considered to be a 'clinical crisis'. Secondary outcomes included how often a rapid response system (RRS) was activated, and if this was influenced by the participant's professional role or experience. The data from all participants in all three countries was pooled for analysis.

RESULTS

A total of 150 clinicians participated in the survey. The highest percentage of clinicians that considered one of the three scenarios with a NEWS ≥7 as a 'clinical crisis' was 52%, while a RRS was activated by <50% of participants. Professional roles and job experience only had a minor influence on the recognition of a 'clinical crisis' and how it should be responded to.

CONCLUSION

This international survey indicates that clinicians differ on what they consider to be a 'clinical crisis' and on how it should be managed. Even in cases with a markedly abnormal physiology (i.e. NEWS ≥7) many clinicians do not consider immediate activation of a RRS is required.

Transcatheter embolization of systemic-to-pulmonary artery fistulas in a dog using embolization coils and silk suture

A 4-month-old intact female Cavalier King Charles spaniel presented for evaluation of a left, basilar continuous murmur. Transthoracic echocardiography suggested anomalous vessels around the main pulmonary artery, and computed tomography angiography revealed two systemic-to-pulmonary artery fistulas. Transcatheter embolization of these fistulas was achieved with a combination of embolization coils and silk suture threads delivered through a microcatheter.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Vertical Gate-All-Around Nanowire GaSb-InAs Core-Shell n-Type Tunnel FETs

Tunneling Field-Effect Transistors (TFET) are one of the most promising candidates for future low-power CMOS applications including mobile and Internet of Things (IoT) products. A vertical gate-all-around (VGAA) architecture with a core shell (C-S) structure is the leading contender to meet CMOS footprint requirements while simultaneously delivering high current drive for high performance specifications and subthreshold swing below the Boltzmann limit for low power operation. In this work, VGAA nanowire GaSb/InAs C-S TFETs are demonstrated experimentally for the first time with key device properties of subthreshold swing S = 40 mV/dec (V_d = 10 mV) and current drive up to 40 μA/wire (V_d = 0.3 V, diameter d = 50 nm) while dimensions including core diameter d, shell thickness and gate length are scaled towards CMOS requirements. The experimental data in conjunction with TCAD modeling reveal interface trap density requirements to reach industry standard off-current specifications.

SAMBA18 Report - A National Audit of Acute Medical Care in the UK

SAMBA18 took place on Thursday 28th June 2018 with follow up data at 7 days. Acute medical teams from 127 Acute Medical Units (AMUs) across the UK collected data relating to operational performance, clinical quality indicators and standards from NHS Improvement. Data was collected from 6114 patients.

Study of physical function in adolescents with haemophilia: The SO-FIT study

INTRODUCTION

Contemporary haemophilia care demands Patient-Reported Outcomes. SO-FIT is a UK multi-centre study, assessing self-reported function, health-related quality of life (HRQoL) and joint health in boys with severe haemophilia.

METHODS

Subjective physical function (PedHAL, HEP-Test-Q) and HRQoL (Haemo-QoL Short Form [SF]) were assessed alongside joint health using the objective Haemophilia Joint Health Score (HJHS v2.1). Demographic and clinical data were collected.

RESULTS

Data from 127 boys mean age 12.38 ± 2.5 (range 8-17) treated at 16 sites were analysed. One-hundred-and-thirteen had haemophilia A, 25/9 past/current inhibitor, 124 were treated prophylactically (46.8% primary) and three on-demand. In the preceding 6 months, boys reported median 0 joint bleeds (range 0-8) with a median HJHS score of 1 (range 0-30). Boys reported good physical functioning; HEP-Test-Q (M = 80.32 ± 16.1) showed the highest impairments in the domain "endurance" (72.53 ± 19.1), in PedHAL (M = 85.44 ± 18.9) highest impairments were in the domains "leisure activities & sports" (M = 82.43 ± 23.4) and "lying/sitting/kneeling/standing" (M = 83.22 ± 20.3). Boys reported generally good HRQoL in Haemo-QoL SF SF (M = 22.81 ± 15.0) with highest impairments in the domains "friends" (M = 28.81 ± 30.5) and "sports & school" (M = 26.14 ± 25.1). HJHS revealed low correlations with the Haemo-QoL SF (r = .251, P < .006), the PedHAL (r = -.397, P < .0001) and the HEP-Test-Q (r = -.323, P < .0001). A moderate correlation was seen between HEP-Test-Q and Haemo-QoL SF of r = -.575 (P < .0001) and between PedHAL and Haemo-QoL SFr = -.561 (P < .0001) implying that good perceived physical function is related to good HRQoL.

CONCLUSIONS

The SO-FIT study has demonstrated that children with severe haemophilia in the UK report good HRQoL and have good joint health as reflected in low HJHS scores.

Acute medicine targets: when should the clock start and 7-day consultant impact?

BACKGROUND

Early consultant review has been shown to improve outcomes in patients presenting to the Acute Medical Unit (AMU). The Society for Acute Medicine (SAM) clinical quality indicators use the time of arrival on the AMU for target rather than arrival in the Emergency Department (ED) although this is where most acute medical patients present.

AIM

To determine the effect of a 7-day Consultant Acute Physician model on patient waiting times and assess the impact of starting the clock for medical patients at time of ED arrival.

DESIGN

We performed an audit at a University Hospital AMU in the North West of England.

METHODS

Data were collected prospectively for 15 consecutive days in May-June 2013 for all patients presenting to the AMU at University Hospital of South Manchester and were repeated for the same time period in 2014 following the introduction of a new Consultant working model.

RESULTS

Four hundred and five patients were admitted to the AMU in the 2013 cohort compared to 456 in the 2014 cohort. There was a significant improvement in the median waiting time for Consultant review from AMU admission to 5 h 53 min from 8 h 15 min (P < 0.001). The compliance with the SAM quality indicator for Consultant review improved from 88.7 to 93.7% (P = 0.022).

CONCLUSION

A 7-day Acute Physician working model is improving performance with regards to patient waiting times. We suggest that starting the clock for acute medical patients in the ED is a better measure of performance than on arrival to the AMU.

A Novel Inherited Cerebellar Abiotrophy in a Cohort of Related Goats

Cerebellar abiotrophies, also known as cerebellar ataxias, are characterized by premature post-natal degeneration of cerebellar neurons. This report describes the clinical, magnetic resonance imaging (MRI), gross, histopathological and immunohistochemical features of a novel inherited cerebellar abiotrophy in a cohort of three closely related mixed-breed goats (Capra aegagrus hircus) in the southeastern USA. The animals all presented with early juvenile-onset ataxia, hypermetria, wide-based stance, head tremors and nystagmus. On MRI and at gross examination, there was moderate thinning of the cerebellar vermis and sharpening of the folia. Histologically, the vermis, paravermis and flocculonodular lobe had moderate to severe segmental loss of Purkinje cells with sparing of the hemispheres and secondary loss of granule cells and astrogliosis. Heritable cerebellar ataxias have been reported in many domestic animal species, but not, to the authors' knowledge, as a heritable condition in goats.

Suppressing the loss of ultracold molecules via the continuous quantum Zeno effect

We investigate theoretically the suppression of two-body losses when the on-site loss rate is larger than all other energy scales in a lattice. This work quantitatively explains the recently observed suppression of chemical reactions between two rotational states of fermionic KRb molecules confined in one-dimensional tubes with a weak lattice along the tubes [Yan et al., Nature (London) 501, 521 (2013)]. New loss rate measurements performed for different lattice parameters but under controlled initial conditions allow us to show that the loss suppression is a consequence of the combined effects of lattice confinement and the continuous quantum Zeno effect. A key finding, relevant for generic strongly reactive systems, is that while a single-band theory can qualitatively describe the data, a quantitative analysis must include multiband effects. Accounting for these effects reduces the inferred molecule filling fraction by a factor of 5. A rate equation can describe much of the data, but to properly reproduce the loss dynamics with a fixed fillingfraction for all lattice parameters we develop a mean-field model and benchmark it with numerically exacttime-dependent density matrix renormalization group calculations.

The perils of Grandma's medication: colchicine toxicity causing pneumomediastinum

A 19 year old male presented with a deliberate overdose of colchicine (50mg). He had no other significant medical history. 36 hours following admission he developed widespread surgical emphysema. An urgent CT scan of his chest and abdomen demonstrated mediastinal gas of lung origin. He also developed bone marrow suppression and disseminated intravascular coagulopathy. He was treated supportively with intravenous fluids, high flow oxygen and intravenous antibiotics and made a full recovery. Colchicine toxicity is a rare, but important presentation with high levels of morbidity and mortality. Pneumomediastinum is a potentially important complication. It may be appropriate to monitor patients in the later stages of the condition through an ambulatory setting.

Palliative and end of life care on the Acute Medical Unit

INTRODUCTION

Early and appropriate recognition of patients requiring palliative care is essential to delivering high quality management and Acute Medical Units have a pivotal role to play in ensuring its implementation.

AIM

To identify the prevalence of patients admitted to Acute Medical Unit (AMU) who met palliative criteria, the overall prevalence of terminal diagnoses and the frequency of appropriate referrals to the units Palliative Care in reach team.

METHODS

An audit was performed at a University Hospital AMU to examine these issues. The NHS Supportive and Palliative Care Tool (SPCIT) was used to identify palliative patients. 409 patients were admitted to the AMU during the study period.

RESULTS

66 (16.1%) of patients were identified as palliative. Two-thirds of these patients had a non-malignant diagnosis. 30% of palliative patients were referred to the palliative care team of which 85.4% had a diagnosis of cancer. 88% of patients that received ongoing palliative care review had a diagnosis of cancer.

CONCLUSION

There is a high prevalence of patients with a terminal diagnosis presenting to the AMU reflecting an aging population and increasingly complex co-morbidities. Palliative patients with a non-cancer diagnosis are less likely to be referred to the palliative care team, which has the potential to disadvantage their care.

II-VI nanowire radial heterostructures

There are many reports of ZnSe nanowire synthesis, but photoluminescence measurements on these nanowires indicate weak band-edge and high sub-bandgap defect emission. The two main contributors to the non-optimal photoluminescence are nanowire growth at high temperatures and unpassivated surface states. In this paper, the synthesis of II-VI core-shell nanowires by metal organic vapor phase epitaxy is reported. We demonstrate that larger bandgap shells that passivate the nanowire surface states can be deposited around the nanowires by increasing the partial pressures of the shell reactants without a large increase in growth temperature, allowing high quality material to be obtained. The deposition of nearly lattice-matched ZnMgSSe shells on the ZnSe nanowires increases the band-edge luminescent intensity of the ZnSe nanowires by more than four orders of magnitude and improves the band-edge to defect photoluminescence intensity ratio to 12,000:1. The corresponding full widths at half maximum of the band-edge exciton peaks of the core-shell nanowires can be as narrow as 2.8 nm. It is also shown that magnesium and chlorine can be incorporated into the ZnSe nanowire cores, which shortens the emission wavelength and is known to act as an n-type dopant, respectively.

Management of methylergonovine induced respiratory depression in a newborn with naloxone

INTRODUCTION

We report a case of a female neonate who developed respiratory depression following the unintentional administration of methylergonovine. The respiratory depression appeared to improve after the administration of bag mask ventilation, stimulation, and naloxone; and the baby was able to be managed without endotracheal intubation and prolonged positive-pressure ventilation.

CASE

A full-term female neonate was delivered vaginally without issue. Approximately 10 min after delivery, the infant was inadvertently administered 0.1 mg of methylergonovine intramuscularly instead of vitamin K. Thirty minutes later the child developed cyanotic extremities and respiratory depression with an oxygen saturation of 75%. Naloxone, 0.4 mg IM, was recommended to mitigate respiratory depression. Within 5 min the patient's respirations improved to 40 breaths per minute, cyanosis improved, and she began resisting ventilations and crying loudly. The child continued to improve and was back to baseline that evening.

DISCUSSION

Methylergonovine toxicity in neonates has been commonly associated with respiratory depression necessitating ventilatory support. In consideration of chemical structural similarity between methylergonovine and morphine, as well as signs/symptoms consistent with opioid-induced respiratory depression, naloxone was suggested.

CONCLUSION

It appears that naloxone may reverse methylergonovine toxicity in neonates. The identification of a safe and potentially useful antidote to mitigate respiratory depression, potentially avoiding the need for intubation and more invasive interventions in this patient population is important.

Forensic Mitochondrial DNA Analysis: Current Practice and Future Potential

Current practices for performing forensic mitochondrial DNA (mtDNA) sequence analysis, as employed in public and private laboratories across the United States, have changed remarkably little over the past 20 years. Alternative approaches have been developed and proposed, and new technologies have emerged, but the core methods have remained relatively unchanged. Once DNA has been recovered from biological material (for example, from older skeletal remains and hair shafts), segments of the mtDNA control region are amplified using a variety of approaches, dictated by the quality of the sample being tested. The amplified mtDNA products are subjected to Sanger-based sequencing and data interpretation is performed using one of many available software packages. These relatively simple methods, at least in retrospect, have remained robust, and have stood the test of time. However, alternative methods for mtDNA analysis remain viable options (for example, linear array assays and dHPLC), and should be revisited as the desire to streamline the testing process, interpret heteroplasmy, and deconvolute mixed mtDNA profiles intensifies. Therefore, it is important to periodically reassess the alternative methods available to the mtDNA practitioner, and to evaluate newer technologies being put forth by the scientific community, for example, next-generation sequencing. Although the basic mitochondrial DNA protocols and practices of public and private laboratories are similar, an overview of the current practices of forensic mtDNA analysis is provided, helping to frame the path forward.

Management of suspected viral encephalitis in adults--Association of British Neurologists and British Infection Association National Guidelines

In the 1980s the outcome of patients with herpes simplex encephalitis was shown to be dramatically improved with aciclovir treatment. Delays in starting treatment, particularly beyond 48 h after hospital admission, are associated with a worse prognosis. Several comprehensive reviews of the investigation and management of encephalitis have been published. However, their impact on day-to day clinical practice appears to be limited. The emergency management of meningitis in children and adults was revolutionised by the introduction of a simple algorithm as part of management guidelines. In February 2008 a group of clinicians met in Liverpool to begin the development process for clinical care guidelines based around a similar simple algorithm, supported by an evidence base, whose implementation is hoped would improve the management of patients with suspected encephalitis.

5T4 oncofetal antigen is expressed in high risk of relapse childhood pre-B acute lymphoblastic leukemia and is associated with a more invasive and chemotactic phenotype

Although the overall prognosis in childhood acute lymphoblastic leukemia (ALL) is good, outcome after relapse is poor. Recurrence is frequently characterized by the occurrence of disease at extramedullary sites, such as the central nervous system and testes. Subpopulations of blasts able to migrate to such areas may have a survival advantage and give rise to disease recurrence. Gene expression profiling of 85 diagnostic pre-B-ALL bone marrow samples revealed higher 5T4 oncofetal antigen transcript levels in cytogenetic high-risk subgroups of patients (P<0.001). Flow cytometric analysis determined that bone marrow from relapse patients have a significantly higher percentage of 5T4-positive leukemic blasts than healthy donors (P=0.005). The high-risk Sup-B15 pre-B-ALL line showed heterogeneity in 5T4 expression, and the derived, 5T4(+) (Sup5T4) and 5T4(-) (Sup) subline cells, displayed differential spread to the omentum and ovaries following intraperitoneal inoculation of immunocompromised mice. Consistent with this, Sup5T4 compared with Sup cells show increased invasion in vitro concordant with increased LFA-1 and VLA-4 integrin expression, adhesion to extracellular matrix and secretion of matrix metalloproteases (MMP-2/-9). We also show that 5T4-positive Sup-B15 cells are susceptible to 5T4-specific superantigen antibody-dependent cellular toxicity providing support for targeted immunotherapy in high-risk pre-B-ALL.

118 INDUCING PLURIPOTENCY IN SOMATIC CELLS FROM THE SNOW LEOPARD (PANTHERA UNCIA), AN ENDANGERED FELID

Induced pluripotency is a new approach to produce embryonic stem-like cells from somatic cells that provides a unique means to understand both pluripotency and lineage assignment. To investigate whether this technology could be applied to endangered species, where the limited availability of gametes makes research on embryonic stem cells difficult, we attempted generation of induced pluripotent stem (iPS) cells from snow leopard (Panthera uncia) fibroblasts by retroviral transfection with Moloney-based retroviral vectors (pMX) encoding either 4 (Oct-4, Sox-2, Klf-4 and cMyc) or 5 (Oct-4, Sox-2, Klf-4, cMyc and Nanog) human transcription factors. Transduction efficiency of the retrovirus was ascertained using pMX-green fluorescent protein transgene expression and averaged 96% from 3 repeated experiments. The reprogramming efficiency of initial colony formation was 0.000308% (37/120 000 cells plated) for 4-factor induction compared with 0.000517% (62/120 000) for 5-factor induction. Transduction with 4 factors resulted in the formation of small colonies of cells, which could not be maintained for more than 4 passages (P4). However, addition of Nanog to the transfection cocktail produced stable iPS cell colonies, which formed as early as Day 3. Colonies of cells were selected at Day 5 and expanded in vitro on mouse embryonic fibroblast feeder cells. The resulting cell line was positive for alkaline phosphatase, Oct-4, Nanog and stage-specific embryonic antigen-4 at P14. Also, RT-PCR confirmed that endogenous Oct-4 and Nanog were expressed by snow leopard iPS cells from P4; although all 5 human transgenes were transcribed at P4, Oct-4, Sox-2 and Nanog transgenes were silenced as early as P14, suggesting that reprogramming of the endogenous pluripotent genes had occurred. When injected into immune-deficient mice, snow leopard iPS cells formed teratomas containing tissues representative of the 3 germ layers. This study describes the first derivation of iPS cells from the endangered snow leopard and is also the first report on induced pluripotency in felid species. Our results demonstrate that addition of Nanog to the reprogramming cocktail was essential for derivation of iPS lines in this felid and that iPS cells provide a unique source of pluripotent cells with utility in conservation for cryopreservation of genetics, as a source of reprogrammed donor cells for nuclear transfer or for directed differentiation to gametes in the future.