Establishing intersectoral ‘Schools Teams’ to mitigate SARS-CoV-2 school transmission, 2020/2021

 

The SARS-CoV-2 pandemic disrupted the lives of up to 100,000 school-going children in Ireland. Consequently, intersectoral ‘Schools Teams’ were established for the 2020/2021 school year to reduce SARS-CoV-2 transmission in school settings. This novel public health intervention provides learning to inform future cross-sectoral collaborative work in Public Health in responding to infectious disease threats. For the 2020/2021 school year in Ireland, intersectoral Schools Teams were formed within each of eight regional Departments of Public Health to manage mitigation of SARS-CoV-2 transmission in school settings. These teams comprised of staff from Departments of Public Health and redeployed staff from the Department of Education. A nationally agreed schools process was followed by Schools Teams to manage SARS-CoV-2 cases and outbreaks in schools. Relevant cases were referred to the regional Schools Team for a public health risk assessment (PHRA). Close contacts were determined using appropriate definitions of close contact within a school setting through the PHRA. This model with centralised procedures and linked health/education teams was novel and adaptable to additional settings. Results from the East region of Ireland showed testing of close contacts of COVID-19 was conducted in 71.8% (676/942) of schools, with 43881 tests completed. Most Schools Team members reported efficient communication within the team (88.7%), a positive team culture (96.3%) and feeling comfortable in their roles following training (82.7%). The majority of members felt the team was able to effectively support schools to reduce COVID-19 transmission (92.5%). Lessons learnt include the synergistic working of educational and health professionals towards a common goal, maximising the skills of all, ensuring a better outcome for school children. Involving educational teams in active contact tracing of COVID-19 cases in schools maximised engagement of the educational sector in the COVID-19 response.

Key messages

• Establishing intersectoral ‘Schools Teams’ pooled skills, resources and expertise, enabling development of synergistic solutions to a complex problem.

• This exemplifies a large national cross-sectoral collaborative working process involving education and public health sectors, providing a model for future responses to infectious disease threats.

Infectious Mononucleosis: diagnosis and clinical interpretation

EBV is the sole causative agent of the acute illness in humans described either as infectious mononucleosis (IM), or glandular fever. IM, when not clinically silent, can present in patients with at least two of the classic triad of symptoms of fever, pharyngitis, and lymphadenopathy. Challenges for the clinician arise when atypical cases present. Early, accurate and informed laboratory test results are vital for diagnosis, appropriate treatment, and management. A key challenge for the practitioner, particularly in cases where the illness can present atypically, is distinguishing bacterial tonsillitis infections from early acute IM. The ability to draw on timely, clear, and insightful laboratory results to distinguish viral from bacterial infection is vital. Correct and prompt diagnosis of IM can help prevent the unnecessary administration of antibiotics and mitigate the need for other expensive exploratory tests in cases of IM that present with splenomegaly, lymphadenopathy, or suspect haematological conditions. Good communication between the requesting clinician and those carrying out the investigative process, and between the different laboratory departments involved, is good practice and would ultimately benefit the patient. This communication will comprehensively review the aetiology, clinical presentation, and laboratory findings in IM with a view to promoting further research and so derive a standard diagnostic algorithm of the condition.

Risks for Surgical Site Infection after Infra-inguinal Bypass

Aims To define the burden of wound complications in patients with infra-inguinal bypass surgery. Methods A retrospective review of 50 consecutive patients from January 2012 to July 2017. Data collected included patient demographics, operative details, length of stay (LOS) and postoperative complications. Results The average age was 64 years (range 25-88 years) and 10 had a body mass index (BMI) ≥25 kg/m2. Pre-operative methicillin-resistant Staphylococcus aureus (MRSA) screening was performed in 17 patients (n=4 positive). Surgical antimicrobial prophylaxis (SAP) continued longer than 24 hours in 25. Surgical site infection (SSI) was the most common complication (n=10) and associated with female gender (p= 0.039), high BMI (p=0.017), shorter preoperative (p=0.039) and longer postoperative LOS (p=0.022). Three of 46 patients and four of 38 had graft occlusion at 30 days and one year respectively. Conclusion Pre-operative co-morbidity (e.g., BMI reduction), and MRSA screening optimization and SAP are areas identified for improvement.

Food fraud and the perceived integrity of European food imports into China

Background/Aims

Persistent incidents of food fraud in China have resulted in low levels of consumer trust in the authenticity and safety of food that is domestically produced. We examined the relationship between the concerns of Chinese consumers regarding food fraud, and the role that demonstrating authenticity may play in relieving those concerns.

Methods

A two-stage mixed method design research design was adopted. First, qualitative research (focus groups n = 7) was conducted in three Chinese cities, Beijing, Guangzhou and Chengdu to explore concerns held by Chinese consumers in relation to food fraud. A subsequent quantitative survey (n = 850) tested hypotheses derived from the qualitative research and theoretical literature regarding the relationship between attitudinal measures (including risk perceptions, social trust, and perceptions of benefit associated with demonstrating authenticity), and behavioral intention to purchase “authentic” European products using structural equation modelling.

Results

Chinese consumers perceive food fraud to be a hazard that represents a food safety risk. Food hazard concern was identified to be geographically influenced. Consumers in Chengdu (tier 2 city) possessed higher levels of hazard concern compared to consumers in Beijing and Guangzhou (tier 1). Structural trust (i.e. trust in actors and the governance of the food supply chain) was not a significant predictor of attitude and intention to purchase authenticated food products. Consumers were shown to have developed ‘risk-relieving’ strategies to compensate for the lack of trust in Chinese food and the dissonance experienced as a consequence of food fraud. Indexical and iconic authenticity cues provided by food manufacturers and regulators were important elements of product evaluations, although geographical differences in their perceived importance were observed.

Conclusions

Targeted communication of authenticity assurance measures, including; regulations; enforcement; product testing; and actions taken by industry may improve Chinese consumer trust in the domestic food supply chain and reduce consumer concerns regarding the food safety risks associated with food fraud. To support product differentiation and retain prestige, European food manufactures operating within the Chinese market should recognise regional disparities in consumer risk perceptions regarding food fraud and the importance of personal risk mitigation strategies adopted by Chinese consumers to support the identification of authentic products.

Endovascular versus open repair of ruptured abdominal aortic aneurysm

INTRODUCTION

Endovascular aneurysm repair (EVAR) is a comparatively less invasive technique than open repair (OR). Debate remains with regard to the benefit of EVAR for patients with ruptured abdominal aortic aneurysm (RAAA). We sought to evaluate and report outcomes of EVAR for RAAA in an Irish tertiary vascular referral centre.

METHODS

Patients undergoing emergency surgery for ruptured or symptomatic AAA were identified from theatre logbooks and HIPE database. Retrospective chart review was undertaken. Data were exported to IBM SPSS version 21 for statistical analysis with p < 0.05 considered significant.

RESULTS

A total of 41 patients underwent surgery for RAAA. The mean age was 74 years old with a range from 55 to 89 years. The majority (n = 25, 61%) were baseline American Society of Anaesthesiology (ASA) grade 3-4. Of these 56% underwent EVAR with the remaining 44% repaired open. Mortality rate in those undergoing emergency EVAR was 34.8%, compared with 38.9% in those undergoing open surgery. This difference was not statistically significant. The mean overall length of stay was 13 days. With regard to prognostic indicators of patient outcome, increasing patient age was noted to be significantly associated with increased mortality (p = 0.013), as was increased ASA score at time of surgery (p = 0.029).

CONCLUSIONS

Mortality rates in those undergoing EVAR for RAAA are comparable with those undergoing open repair. Increasing age and ASA score are significant predictors of mortality in patients with RAAA undergoing intervention.

The Use of Arteriovenous Fistulae as an Adjunct to Peripheral Arterial Bypass: A Systematic Review and Meta-analysis

BACKGROUND

Peripheral arterial bypass is an effective procedure for the management of patients with critical limb ischaemia. However, it is commonly associated with high rates of graft occlusion and subsequent limb loss. This is particularly apparent when the distal anastomosis is to the below-knee arterial segment. A number of studies have suggested that an arteriovenous fistula (AVF) sited at the distal anastomosis may reduce afterload, improve graft patency, and boost subsequent limb salvage. The aim of this study was to assess the effects of adjuvant AVF on the outcomes of peripheral arterial bypass.

METHODS

The following databases were searched up to May 2015: Medline through Pubmed; the Cochrane Library; EMBASE; and reference lists of articles.

STUDY ELIGIBILITY

All randomised controlled and observational studies that assessed the role of AVF as an adjunct to peripheral arterial bypass were included. Studies were required to include at least one pre-defined outcome. Data were extracted and assessed by two reviewers with any disagreements adjudicated on by the senior author. Pooled risk ratios were calculated using a random effects model. Additional subgroup analyses were performed.

RESULTS

Two randomised controlled trials and seven retrospective cohort studies comprising 966 participants were included. Pooled standardized data showed no difference in primary graft patency (pooled RR = 1.25, 95% CI 0.73-2.16), secondary patency (pooled RR = 1.16, 95% CI 0.82-1.66), or limb salvage at 12-months (pooled RR = 1.13, 95% CI 0.80-1.60) for the peripheral bypass with AVF group compared with peripheral bypass alone. Subgroup analysis indicated a reduction in reintervention rates associated with AVF when performed in conjunction with a synthetic graft (pooled RR = 0.55, 95% CI 0.30-0.98).

CONCLUSION

Although adjuvant AVF is not associated with additional operative complication there is little evidence to support its use. The evidence assessing its merits is weakened by small, retrospective studies with heterogeneous cohorts.

Concurrent colorectal malignancy and abdominal aortic aneurysm: a multicentre experience and review of the literature

OBJECTIVES

There is lack of consensus regarding concurrent vs. staged approaches, and the prioritisation of staged procedures in cases presenting with colorectal carcinoma (CRC) and abdominal aortic aneurysm (AAA) synchronously. We aim to present our experience, review the literature on this therapeutic dilemma and examine the role of endovascular aortic repair (EVAR).

DESIGN, MATERIALS AND METHODS

An observational study of the experience of two centres and a systematic review of the published literature.

RESULTS

Twenty-four patients were identified from the prospective databases of two tertiary referral centres between 2001 and 2006. Intervention for both malignancy and aneurysm was performed in 13 patients. In 10 patients, cancer resection was performed initially and was followed by open aneurysm repair (n=3) or EVAR (n=7). Two patients (AAA diameters: 7.0 and 8.0cm) underwent EVAR prior to colonic resection. One patient was selected for synchronous surgery. There were no interval AAA ruptures, graft infection or postoperative mortalities. Literature review identified 269 such cases; of these 101 were treated by combined surgery. In staged surgery, there were nine interval aneurysmal ruptures and one aortic graft infection.

CONCLUSIONS

In our experience, staged management can be undertaken, without interval aneurysmal rupture. EVAR has an evolving role in preventing delay in CRC management, in high-risk patients, and during combined intervention.

Spontaneous coronary artery dissection

Spontaneous coronary artery dissection is a rare cause of myocardial ischaemia or sudden death, predominantly affecting young women with no known risk factors for cardiovascular disease. The case described emphasises the benefit of early diagnosis and the need to individualise management based on patient response to treatment.

Neoadjuvant treatment of oesophageal adenocarcinoma

Oesophageal adenocarcinoma is an enigma. It has emerged, seemingly from nowhere, in the late 20th century to dominate the oesophageal oncological landscape. This review will examine whether the current outcome for adenocarcinoma is as good as it gets or whether additional treatment is necessary and if so whether neoadjuvant therapy is effective.

Laparoscopic repair of a strangulated Bochdalek hernia

BACKGROUND

Bochdalek herniae are rare. They are usually repaired by open abdominal surgery or by a thoracic video-assisted approach. When strangulated and in a compromised patient the options are fewer.

AIM

To describe a case treated by a laparoscopic approach.

RESULTS

The procedure was technically difficult, but the patient recovered without recurrence.

CONCLUSION

Laparoscopic repair is possible even with strangulation.

Interaction of heme with nitroxyl or nitric oxide amplifies heme oxygenase-1 induction: involvement of the transcription factor Nrf2

Heme oxygenase-1 (HO-1) is a cytoprotective enzyme, the expression of which is highly sensitive to induction by pro-oxidant stimuli including the substrate heme and reactive oxygen species. Conceptually, the perception that HO-1 plays a key role in response to oxidative damage is paralleled by evidence showing high expression of HO-1 in a variety of cell systems challenged with nitric oxide (NO) or NO-derivatives, thus revealing a potential biological function for HO-1 against nitrosative stress. In this study, we report that exposure of cardiac cells to hemin (5-20 microM) in combination with compounds that liberate nitroxyl (HNO/NO-) or release NO significantly potentiates HO-1 mRNA and protein expression leading to a remarkable increase in heme oxygenase activity under both normoxic and hypoxic conditions. The amplification of the heme oxygenase pathway appears to involve a direct interaction between heme and the NO groups, as the ability of both NO(-)- and NO-releasing agents to induce HO-1 is totally lost by their pre-incubation for 1 hr in complete medium prior to cell treatment but is highly preserved by addition of hemin during the preincubation step. In addition, we show that the redox-sensitive transcription factor Nrf2 is highly expressed in the nuclear fraction of cells exposed to the NO- generator and that this effect is totally abolished by the presence of N-acetyl-L-cysteine. Interestingly, the expression of Nrf2 is gradually intensified by treating cells with a combination of the NO- releaser and increasing concentrations of hemin. Thus, a strict parallelism exists between the extent of HO-1 induction and expression of Nrf2 elicited by the heme-NO interaction. We propose that modification of the iron protoporphyrin centers by NO groups to modulate HO-1 expression might be regarded as a molecular switch to maximize heme oxygenase enzymatic activity and consequently mitigate the redox imbalance imposed by oxidative and nitrosative stress.

Two year longitudinal followup of premature infants weighing less than or equal to 1,200 grams at birth: sequelae of intracranial hemorrhage

Intracranial hemorrhage (ICH) is a major problem for the premature infant, occurring in more than one-third of surviving infants weighing less than or equal to 1,500 g at birth. The literature on perinatal ICH, as it relates to neurodevelopment outcome, is briefly reviewed, and preliminary results from our two-year followup of 75 less than or equal to 1,200-g infants are summarized. An analysis of pathophysiology, diagnosis, classification, and followup indicates that risk for ICH and its sequelae increases as gestational age and birth weight decrease. Hydrocephalus apparently no longer presents significant risk beyond that conveyed by the original hemorrhage. However, persistent posthemorrhagic ventriculomegaly and/or periventricular abnormalities serve as significant "markers" of risk for neuromotor delay through two years of age. In contrast, recovery of normal ventricular morphology by term gestational age apparently indexes a degree of recovery from ICH and predicts a more normal developmental outcome through the first two postnatal years.

Adenosine and ATP effects on isolated guinea pig gallbladder

Effects of adenosine, ATP and several derivatives of adenosine were measured in isolated strips of guinea pig gallbladder. Adenosine caused relaxations which were antagonized by theophylline and potentiated by an inhibitor of adenosine uptake, 6-(1-hydroxy-5-nitrobenzylthio)-guanosine (HNBTG). Among several adenosine derivatives, 2-chloroadenosine and 5'-N-ethylcarboxy-midoadenosine were similarly effective while 1-N6-phenylisopropyladenosine was only a weak relaxant. None of the derivatives caused maximal relaxations at 100 microM, and thus absolute potencies could not be determined. ATP caused predominantly contractile effects, with relaxations sometimes being evident at high concentrations. Indomethacin abolished contractile effects of ATP, suggesting prostaglandin involvement, and only relaxations were evident in its presence. Adenosine deaminase abolished the effects of adenosine and partly reduced the relaxant effects of ATP in the presence of indomethacin. In view of the low potency of adenosine and ATP, physiological roles for these compounds in gallbladder motility are not readily evident.