Impact of COVID-19 on patient experience of kidney care: a rapid review

INTRODUCTION

In March 2020, a pandemic state was declared due to SARS-COV-2 (COVID-19). Patients with kidney disease, especially those on replacement therapies, proved more susceptible to severe infection. This rapid literature review aims to help understand how the pandemic impacted patient experience of kidney care.

METHODS

It was conducted in accordance with Cochrane Rapid Review interim guidance. Search terms, 'coronavirus', 'kidney care', and 'patient-reported experience' and terms with similar semantic meaning, identified 1,117 articles in Medline, Scopus, and Worldwide Science. Seventeen were included in the narrative synthesis.

RESULTS

The findings were summarised into three themes: remote consultation and telemedicine (n = 9); psychosocial impact (n = 2); and patient satisfaction and patient-reported experience (n = 6). Patients were mostly satisfied with remote consultations, describing them as convenient and allowing avoidance of hospital visits. Anxieties included missing potentially important clinical findings due to lack of physical examination, poor digital literacy, and technical difficulties. Psychosocial impact differed between treatment modalities-transplant recipients expressing feelings of instability and dread of having to return to dialysis, and generally, were less satisfied, citing reduced ability to work and difficulty accessing medications. Those on home dialysis treatments tended to feel safer. Findings focused on aspects of patient experience of kidney care during the pandemic rather than a holistic view.

CONCLUSIONS

There was little direct evaluation of modality differences and limited consideration of health inequalities in care experiences. A fuller understanding of these issues would guide policy agendas to support patient experience during future public health crises.

Impact of the COVID-19 pandemic on services for patients with chronic kidney disease: findings of a national survey of UK kidney centres

BACKGROUND

Services for patients with kidney disease underwent radical adaptations in response to the COVID-19 pandemic. We undertook an online national survey of UK kidney centres to understand the nature, range, and degree of variation in these changes and to explore factors contributing to differing practice.

METHODS

The survey was designed by a multidisciplinary team of kidney professionals, service users and researchers. It enquired about centre services and staffing, including psychosocial provision, and changes to these in response to the COVID-19 pandemic. Links to the survey were sent to all 68 UK kidney centres and remained active from December 2021 to April 2022, and a revised version to nurses in late 2022 for additional data. Quantitative data were analysed descriptively. Content analysis on free-text responses identified common themes.

RESULTS

Analysable responses were received from 41 out of the 68 UK centres (60%), with partial data from an additional 7 (11%). Adaptations were system-wide and affected all aspects of service provision. Some changes were almost universal such as virtual consultations for outpatient appointments, with significant variation in others. Outpatient activity varied from fully maintained to suspended. Many centres reduced peritoneal dialysis access provision but in some this was increased. Centres considered that changes to transplant surgical services and for patients with advanced CKD approaching end-stage kidney disease had the greatest impact on patients. Few centres implemented adjustments aimed at vulnerable and underrepresented groups, including the frail elderly, people with language and communication needs, and those with mental health needs. Communication issues were attributed to rapid evolution of the pandemic, changing planning guidance and lack of resources. Staffing shortages, involving all staff groups particularly nurses, mainly due to COVID-19 infection and redeployment, were compounded by deficiencies in staffing establishments and high vacancy levels. Centres cited three main lessons influencing future service delivery, the need for service redesign, improvements in communication, and better support for staff.

CONCLUSION

Kidney centre responses to the pandemic involved adaptations across the whole service. Though some changes were almost universal, there was wide variation in other areas. Exploring the role of centre characteristics may help planning for potential future severe service disruptions.

Definitive Stereotactic Body Radiation Therapy in Early-Stage Solitary Hepatocellular Carcinoma: An Australian Multi-Institutional Review of Outcomes

AIMS

Standard curative options for early-stage, solitary hepatocellular carcinoma (HCC) are often unsuitable due to liver dysfunction, comorbidities and/or tumour location. Stereotactic body radiation therapy (SBRT) has shown high rates of local control in HCC; however, limited data exist in the treatment-naïve, curative-intent setting. We report the outcomes of patients with solitary early-stage HCC treated with SBRT as first-line curative-intent therapy.

MATERIALS AND METHODS

A multi-institutional retrospective study of treatment-naïve patients with Barcelona Clinic Liver Cancer stage 0/A, solitary ≤5 cm HCC, Child-Pugh score (CPS) A liver function who underwent SBRT between 2010 and 2019 as definitive therapy. The primary end point was freedom from local progression. Secondary end points were progression-free survival, overall survival, rate of treatment-related clinical toxicities and change in CPS >1.

RESULTS

In total, 68 patients were evaluated, with a median follow-up of 20 months (range 3-58). The median age was 68 years (range 50-86); 54 (79%) were men, 62 (91%) had cirrhosis and 50 (74%) were Eastern Cooperative Oncology Group 0. The median HCC diameter was 2.5 cm (range 1.3-5) and the median prescription biologically effective dose with a tumour a/b ratio of 10 Gy (BED10) was 93 Gy (interquartile range 72-100 Gy). Two-year freedom from local progression, progression-free survival and overall survival were 94.3% (95% confidence interval 86.6-100%), 59.5% (95% confidence interval 46.3-76.4%) and 88% (95% confidence interval 79.2-97.6%), respectively. Nine patients (13.2%) experienced grade ≥2 treatment-related clinical toxicities. A rise >1 in CPS was observed in six cirrhotic patients (9.6%).

CONCLUSION

SBRT is an effective and well-tolerated option to consider in patients with solitary, early-stage HCC. Prospective, randomised comparative studies are warranted to further refine its role as a first-line curative-intent therapy.

Outcomes of Patients with Oral Cavity Squamous Cell Carcinomas Treated with Adjuvant IMRT with Perineural Invasion

PURPOSE/OBJECTIVE(S)

Patients with advanced oral cavity squamous cell carcinoma (OCSCC) have high rates of recurrence and dismal outcomes. Treatment consists of definitive surgery followed by risk-adapted adjuvant radiation therapy based on pathologic review. Perineural invasion (PNI) is thought to be an intermediate risk factor, leading to clinical uncertainty as to adjuvant therapy in the setting of PNI. We performed a single institution retrospective review of patients with OCSCC treated with adjuvant radiation with or without PNI and examined relapse-free survival (RFS) and overall survival (OS).

MATERIALS/METHODS

We performed a single-institutional retrospective review of patients with OCSCC treated with adjuvant IMRT +/- chemotherapy after surgical resection from July 2002- August 2021 using our institution's Head and Neck SPORE database. Time to recurrence or death was calculated from end of RT. OCSCC within 5 years of RT was considered a recurrence, beyond this timeframe any OCSCC was considered a new primary. Univariate analysis of predictors for RFS and OS were performed using the Kaplan-Meier method with log-rank test. Factors significant on univariable analysis were entered into parsimonious cox multivariable analysis using forward selection methodology. A p-value <0.05 was considered significant in both analyses.

RESULTS

In total, 494 patients with OCSCC were identified that received surgery and adjuvant IMRT. In this cohort, 48.8% of patients had pT4 tumors, 62.2% of patients had nodal involvement, and 40.3% of patients had extranodal extension. PNI was present in 63.6% of patients (n = 314). With regards to tumor subsite, 40.9% originated from the oral tongue, 21.5% originated from the gums, 18% originated from the floor of mouth, and 19.6% from the other sites. Median age was 59 years, and median adjuvant RT dose was 63 Gy (Interquartile range [IQR]) 60-66 Gy). The majority of patient received platinum-based chemotherapy (51.8%), and 44.1% of patients did not receive adjuvant chemotherapy. The 3-year RFS and OS with a median follow-up of 32 months (IQR 12-69 months) is presented in Table 1. On univariable analysis for OS, T stage (p = 0.003), N stage (p<0.001), PNI (p = 0.005), extranodal extension (ENE) (p<0.001), margin status (p = 0.038), and chemotherapy (p<0.001) were significant. On multivariable analysis, T stage (p<0.001), N stage (p = 0.010), PNI (p = 0.017), and ENE (p = 0.007) remained significant. Similar results were seen in the RFS analysis.

CONCLUSION

In this large single institution study, PNI was a significant and independent negative predictive factor for RFS and OS in patients with OCSCC that had received definitive surgery followed by adjuvant IMRT. To our knowledge this is the largest study of its kind, and these findings can help guide clinical decision making for these patients.

TROG 15.03/ANZUP International Multicenter Phase II Trial of Focal Ablative STereotactic RAdiotherapy for Cancers of the Kidney (FASTRACK II)

PURPOSE/OBJECTIVE(S)

Stereotactic body radiotherapy (SBRT) is an emerging non-invasive alternative for primary renal cell cancer (RCC) in patients unsuitable for surgery. The objective of the FASTRACK II clinical trial was to investigate the efficacy of SBRT for primary RCC.

MATERIALS/METHODS

This non-randomized, intergroup multi-institutional phase II study was activated in 7 Australian centers and 1 Dutch center, through the Trans Tasman Radiation Oncology Group (TROG) and the Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP). Eligible patients had biopsy confirmed diagnosis of primary RCC with a single lesion within a kidney, ECOG performance ≤2 and were medically inoperable, high risk or declined surgery. For tumors ≤4 cm a single fraction of 26 Gy was prescribed, for tumors > 4 cm, 42 Gy in three fractions was prescribed. The primary outcome of the study was to estimate the efficacy of SBRT for primary RCC, defined as local control based on RECIST criteria. The study was powered assuming that 1-year local control would be 90%, with the null hypothesis of ≤80% considered undesirable and not worthy of proceeding to a future randomized controlled trial.

RESULTS

Between July 2016 and February 2020, 70 patients were enrolled with a median follow-up of 42 months. Median age was 77 years. Forty-nine patients were male (70%), median BMI was 32 and median Charlson comorbidity score was 7. The median [IQR] RENAL complexity score was 8 [7-10]. Biopsy confirmation was 100%. Twenty-three patients (33%) had T1a disease. The median (interquartile range [IQR]) tumor size was 4.6cm [3.7-5.5]; it was 3.3cm [3.0-3.6] in those receiving single fraction (n = 23), and 5.3cm [4.6-6.0] in those receiving 3-fraction SBRT (n = 47). During real-time pre-treatment quality assurance review, 10 cases (14.3%) required resubmission for protocol deviation, 2119 variables were assessed at final review, and final protocol compliance was 99.3%. Seven (10%) patients experienced grade 3 treatment-related adverse events, with no grade 4 or 5 events observed. Eleven (16%) patients reported no adverse events. Local control was 100% throughout the lifetime of the trial (p<0.001). Cancer-specific survival was also 100% throughout the lifetime of the trial. Freedom from distant failure (95% CIs) at 1 and 3 years was 99% (90-100%). Overall survival (95% CIs) at 1 and 3 years was 99% (90-100%) and 82% (70-89%), respectively. Baseline mean eGFR (95% CI) was 61.1 mLs/min (56.6; 65.6) and reduced by -10.8 mLs/min (-13.0; -8.6) by 1-year, by -14.6 mLs/min (-17.0; -12.2) by 2-years and plateaued thereafter.

CONCLUSION

In the first multicenter prospective trial of a non-surgical primary RCC cohort, enrolling mostly T1b+ disease, SBRT was an effective treatment strategy with no observed local failures. We observed an acceptable side effect profile and renal function after SBRT. These outcomes support the design of a future randomized clinical trial of SBRT versus surgery for primary RCC. The trial was registered with ID: NCT02613819.

Ultra-Endurance Participation and Acute Kidney Injury: A Narrative Review

Increasingly popular, ultra-endurance participation exposes athletes to extremely high levels of functional and structural damage. Ultra-endurance athletes commonly develop acute kidney injury (AKI) and other pathologies harmful to kidney health. There is strong evidence that non-steroidal anti-inflammatory drugs, common amongst ultra-athletes, is linked to increased risk and severity of AKI and potentially ischaemic renal injury, i.e., acute tubular necrosis. Ultra-endurance participation also increases the risk of exertional rhabdomyolysis, exercise-associated hyponatremia, and gastrointestinal symptoms, interlinked pathologies all with potential to increase the risk of AKI. Hydration and fuelling both also play a role with the development of multiple pathologies and ultimately AKI, highlighting the need for individualised nutritional and hydration plans to promote athlete health. Faster athletes, supplementing nitrates, and being female also increase the risk of developing AKI in this setting. Serum creatinine criteria do not provide the best indicator for AKI for ultra-athletes therefore further investigations are needed to assess the practicality and accuracy of new renal biomarkers such as neutrophil gelatinase-associated lipocalin (NGAL). The potential of recurring episodes of AKI provide need for further research to assess the longitudinal renal health impact of ultra-participation to provide appropriate advice to athletes, coaches, medical staff, and event organisers.

Strategies to prevent SARS-CoV-2 transmission in hemodialysis centres across Europe - Lessons for the future

Background

Early reports on the pandemic nature of COVID-19 directed the nephrology community to develop infection prevention and control guidance. We aimed to make an inventory of strategies that dialysis centres followed to prevent infection with COVID-19 in the first pandemic wave.

Methods

We analyzed IPC measures taken by hemodialysis centres treating patients presenting with COVID-19 between March 1, 2020 and July 31, 2020 and that completed the European Renal Association COVID-19 Database centre questionnaire. Additionally, we made an inventory of guidelines published in European countries to prevent spread of SARS-CoV-2 in dialysis centres.

Results

Data from 73 dialysis units located in and bordering Europe were analyzed. All participating centres implemented IPC measures to mitigate the impact of SARS-CoV-2 during the first pandemic wave. Measures mentioned most often included triage with questions before entering the dialysis ward, measuring body temperature, hand disinfection, masking for all patients and staff, and personal protective equipment for staff members. These measures were also recommended in most of the 14 guidelines that were identified in the inventory of national guidelines and were also scored as being among the most important measures by the authors of this paper. Heterogeneity existed between centres and national guidelines regarding the minimal distance between dialysis chairs and recommendations regarding isolation and cohorting.

Conclusions

Although variation existed, measures to prevent transmission of SARS-CoV-2 were relatively similar across centres and national guidelines. Further research is needed to assess causal relationships between measures taken and spread of SARS-CoV-2.

Recovery of dialysis patients with COVID-19: health outcomes 3 months after diagnosis in ERACODA

BACKGROUND

Coronavirus disease 2019 (COVID-19)-related short-term mortality is high in dialysis patients, but longer-term outcomes are largely unknown. We therefore assessed patient recovery in a large cohort of dialysis patients 3 months after their COVID-19 diagnosis.

METHODS

We analyzed data on dialysis patients diagnosed with COVID-19 from 1 February 2020 to 31 March 2021 from the European Renal Association COVID-19 Database (ERACODA). The outcomes studied were patient survival, residence and functional and mental health status (estimated by their treating physician) 3 months after COVID-19 diagnosis. Complete follow-up data were available for 854 surviving patients. Patient characteristics associated with recovery were analyzed using logistic regression.

RESULTS

In 2449 hemodialysis patients (mean ± SD age 67.5 ± 14.4 years, 62% male), survival probabilities at 3 months after COVID-19 diagnosis were 90% for nonhospitalized patients (n = 1087), 73% for patients admitted to the hospital but not to an intensive care unit (ICU) (n = 1165) and 40% for those admitted to an ICU (n = 197). Patient survival hardly decreased between 28 days and 3 months after COVID-19 diagnosis. At 3 months, 87% functioned at their pre-existent functional and 94% at their pre-existent mental level. Only few of the surviving patients were still admitted to the hospital (0.8-6.3%) or a nursing home (∼5%). A higher age and frailty score at presentation and ICU admission were associated with worse functional outcome.

CONCLUSIONS

Mortality between 28 days and 3 months after COVID-19 diagnosis was low and the majority of patients who survived COVID-19 recovered to their pre-existent functional and mental health level at 3 months after diagnosis.

Characteristics of Frailty in Haemodialysis Patients

Background: Both frailty and cachexia increase mortality in haemodialysis (HD) patients. The clinical frailty score (CFS) is a seven-point scale and less complex than other cachexia and frailty assessments. We wished to determine the characteristics of frail HD patients using the CFS. Methods: Single centre cross-sectional study of HD patients completing physical activity questionnaires with bioimpedance measurements of body composition and hand grip strength (HGS). Results: We studied 172 HD patients. The CFS classified 54 (31.4%) as frail, who were older (70.4±12.2 vs 56.2 ± 16.1 years, p < 0.001), greater modified Charlson co-morbidity (3 (2–3) versus 1.5 (0–3), p < 0.001), and body fat (33 (25.4–40.2) versus 26.2 (15.8–34) %, p < 0.01), but lower total energy expenditure (1720 (1574–1818) versus 1870 (1670–2194) kcal/day, p < 0.01), lean muscle mass index (9.1 (7.7–10.1) versus 9.9 (8.9–10.8) kg/m2), and HGS (15.3 (10.3–21.9) versus 23.6 (16.7–34.4) kg), both p < 0.001. On multivariable logistic analysis, frailty was independently associated with lower active energy expenditure (odds ratio (OR) 0.98, 95% confidence limits (CL) 0.98–0.99, p = 0.001), diabetes (OR 5.09, CL 1.06–16.66) and HGS (OR 0.92, CL 0.86–0.98). Discussion: Frail HD patients reported less active energy expenditure, associated with reduced muscle mass and strength. Frail patients were more likely to have greater co-morbidity, particularly diabetes. Whether physical activity programmes can improve frailty remains to be determined.

Determinants of active energy expenditure in haemodialysis patients

BACKGROUND

Less active haemodialysis patients have an increased risk of mortality. We wished to determine which factors were associated with active energy expenditure (AEE), METHODS: We used the validated recent physical activity questionnaire to determine AEE, and estimated dietary protein intake and creatinine generation rates. We measured extracellular and total body water ratio (ECW/TBW) and appendicular lean muscle with bioimpedance, and arm strength by hand grip strength (HGS). Patients were graded using the Charlson co-morbidity, and the Clinical Frailty Score (CFS).

RESULTS

AEE was calculated in 98 patients (64 male), mean age 62.1±15.5 years, and AEE was negatively associated with CFS (r=-0.48), ECW/TBW (r=-0.47), and age (r=-0.4), all p<0.001, Charlson co-morbidity score (-0.27, p=0.007), and positively with serum creatinine (r=0.38, p<0.010), and HGS (r=0.25, p=0.016). Although protein nitrogen accumulation and creatinine generation were associated with resting energy expenditure (r=0.7 and r=0.44 respectively, both p<.0001), neither were associated with AEE. On multivariable analysis only CFS remained independently associated with AEE (β-0.031, 95% limits -0.057 to -0.004, p=0.024), although both age (negative p=0.07), and ALM (positive p=0.081) were retained in the model.

CONCLUSIONS

We found that AEE was lower with increasing frailty, age, loss of cell mass, co-morbidity and inflammation, and greater AEE in patients with higher serum creatinine and albumin, and greater muscle strength on univariate analysis, but only frailty remained independently associated on multivariable analysis. Whether exercise programmes designed to increase AEE in haemodialysis patients can improve frailty scores, and so reduce mortality risk reman to be determined. This article is protected by copyright. All rights reserved.

Emergency Dynamic Central Venous Cannulation in Preterm Neonates- A Case Series

Neonatal venous cannulation is one of the challenges faced by Anaesthesiologists in routine practice. Neonatal cannulation is extremely difficult and time consuming and it has become an inevitable procedure in neonatal intensive care unit, because of the small vessel diameter and sometimes it is impossible to differentiate between artery and vein. Routinely umbilical vein, scalp vein and peripherally inserted central catheters cannulation are done during initial neonatal period. Central vein cannulation is needed in sick neonates for nutrition, antibiotics, venous sampling, and inotropic support and enables haemodynamics monitoring. Even with the point of care ultrasound, neonatal cannulation is technically challenging in well-experienced hands. Cannulation in a preterm neonate is highly demanding and nightmarish for all intensivists. The present case series aimed to show the successful placement of ultrasound guided supraclavicular subclavian cannulation in a very low birth preterm (less than 1500 gm) in three septic neonates. All three cannulations were done bedside in Neonatal Intensive Care Unit (NICU) with close monitoring of heart rate, pulse oximeter and electrocardiogram. Venipuncture was done under ultrasound guidance. After identifying the anatomic landmarks, subclavian cannulation was done using Seldinger technique. Subclavian cannulation was preferred because of easy accessibility, comfortable fixation and low infection rate

An unusual presentation of an adrenal tumour-a case report

INTRODUCTION AND IMPORTANCE

Adrenal myelolipomas are rare, benign tumours with an incidence of 0.08-0.2%. They present between the fifth and seventh decade of life [1].

CASE PRESENTATION

Our patient presented with complaints of vomiting and left lumbar pain of four weeks duration. Blood work revealed dyselectrolytemia. Contrast enhanced computed tomography of the abdomen and pelvis confirmed the diagnosis and the patient was planned for an adrenalectomy. Histopathology report revealed the pathology. She is currently on routine follow up and is disease free. Written informed consent was obtained from the patient for publication of this case report and its accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. This case report has been reported in line with the SCARE criteria [2].

CLINICAL DISCUSSION

With the increased use of imaging modalities of the abdomen, they are now considered to be the second most common cause of adrenal incidentalomas (6-16%) [3]. Most tumours are small, asymptomatic and often go undiagnosed. Large tumours can cause chronic pain and other nonspecific symptoms.

CONCLUSION

Though myelolipomas are identified on routine CT scans, on a background of dyselectrolytemia, a further evaluation is of utmost importance to rule out the possibility of a functioning tumour.

Energy expenditure estimates in chronic kidney disease using a novel physical activity questionnaire

BACKGROUND

Physical activity (PA) levels are low in patients with advanced chronic kidney disease (CKD), and associate with increased morbidity and mortality. Reliable tools to assess PA in CKD are scarce. We aimed to develop and validate a novel PA questionnaire for use in CKD (CKD-PAQ).

METHODS

In phase 1, a prototype questionnaire was developed based on the validated Recent Physical Activity Questionnaire (RPAQ). Structured feedback on item relevance and clarity was obtained from 40 CKD patients. In phase 2, the questionnaire was refined in 3 iterations in a total of 226 CKD patients against 7-day accelerometer and RPAQ measurements. In phase 3, the definitive CKD-PAQ was compared with RPAQ in 523 CKD patients.

RESULTS

In the final iteration of phase 2, CKD-PAQ data were compared to accelerometer-derived and RPAQ data in 60 patients. Mean daily Metabolic Equivalent of Task (MET) and Total Energy Expenditure (TEE) levels were similar by all methods. Intraclass correlation coefficients showed fair agreement (MET) and good (TEE) between accelerometry and both CKD-PAQ and RPAQ. Agreement between questionnaires was excellent. For mean daily MET bias was 0.035 (SD 0.312) for CKD-PAQ and 0.018 (SD 0.326) for RPAQ. For TEE bias was 91 (SD 518) for CKD-PAQ and 44 (SD 548) kcal for RPAQ. Limits of agreement were wide for both parameters, with less dispersion of CKD-PAQ values. In phase 3, agreement between questionnaires was good (MET) and excellent (TEE). Bias of CKD-PAQ-derived mean daily MET from RPAQ-derived values was 0.031 (SD 0.193) with 95% limits of agreement -0.346 to 0.409. Corresponding values for TEE were 48 (SD 325) and -588 to 685 kcal/day. CKD-PAQ appeared to improve discrimination between low activity groups.

CONCLUSIONS

CKD-PAQ performs comparably to RPAQ though is shorter, easier to complete, may better capture low level activity and improve discrimination between low-activity groups.

COVID-19-related mortality in kidney transplant and dialysis patients: results of the ERACODA collaboration

BACKGROUND

Patients on kidney replacement therapy comprise a vulnerable population and may be at increased risk of death from coronavirus disease 2019 (COVID-19). Currently, only limited data are available on outcomes in this patient population.

METHODS

We set up the ERACODA (European Renal Association COVID-19 Database) database, which is specifically designed to prospectively collect detailed data on kidney transplant and dialysis patients with COVID-19. For this analysis, patients were included who presented between 1 February and 1 May 2020 and had complete information available on the primary outcome parameter, 28-day mortality.

RESULTS

Of the 1073 patients enrolled, 305 (28%) were kidney transplant and 768 (72%) dialysis patients with a mean age of 60 ± 13 and 67 ± 14 years, respectively. The 28-day probability of death was 21.3% [95% confidence interval (95% CI) 14.3-30.2%] in kidney transplant and 25.0% (95% CI 20.2-30.0%) in dialysis patients. Mortality was primarily associated with advanced age in kidney transplant patients, and with age and frailty in dialysis patients. After adjusting for sex, age and frailty, in-hospital mortality did not significantly differ between transplant and dialysis patients [hazard ratio (HR) 0.81, 95% CI 0.59-1.10, P = 0.18]. In the subset of dialysis patients who were a candidate for transplantation (n = 148), 8 patients died within 28 days, as compared with 7 deaths in 23 patients who underwent a kidney transplantation <1 year before presentation (HR adjusted for sex, age and frailty 0.20, 95% CI 0.07-0.56, P < 0.01).

CONCLUSIONS

The 28-day case-fatality rate is high in patients on kidney replacement therapy with COVID-19 and is primarily driven by the risk factors age and frailty. Furthermore, in the first year after kidney transplantation, patients may be at increased risk of COVID-19-related mortality as compared with dialysis patients on the waiting list for transplantation. This information is important in guiding clinical decision-making, and for informing the public and healthcare authorities on the COVID-19-related mortality risk in kidney transplant and dialysis patients.

Impact of incremental versus conventional initiation of haemodialysis on residual kidney function: study protocol for a multicentre feasibility randomised controlled trial

INTRODUCTION

Preserving residual kidney function (RKF) may be beneficial to patients on haemodialysis (HD) and it has been proposed that commencing dialysis incrementally rather than three times a week may preserve RKF. In Incremental HD, target dose includes a contribution from RKF, which is added to HD dose, allowing individualisation of the HD prescription. We will conduct a feasibility randomised controlled trial (RCT) comparing incremental HD and conventional three times weekly treatments in incident HD patients. The study is designed also to provide pilot data to allow determination of effect size to power a definitive study.

METHODS AND ANALYSIS

After screening to ensure native renal urea clearance >3 mL/min/1.73 m², the study will randomise 54 patients within 3 months of HD initiation to conventional in-centre thrice weekly dialysis or incremental in-centre HD commencing 2 days a week. Subjects will be followed up for 12 months. The study will be carried out across four UK renal centres.The primary outcome is to evaluate the feasibility of conducting a definitive RCT and to estimate the difference in rate of decline of RKF between the two groups at 6 and 12 months time points. Secondary outcomes will include the impact of dialysis intensity on vascular access events, major adverse cardiac events and survival. Impact of dialysis intensity on patient-reported outcomes measures, cognition and frailty will be assessed using EQ-5D-5L, PHQ-9, Illness Intrusiveness Rating Score, Montreal Cognitive assessment and Clinical Frailty Score. Safety outcomes include hospitalisation, fluid overload episodes, hyperkalaemia events and vascular access events.This study will inform the design of a definitive study, adequately powered to determine whether RKF is better preserved after incremental HD initiation compared with conventional initiation.

ETHICS AND DISSEMINATION

Ethics approval has been granted by Cambridge South Research Ethics Committee, United Kingdom(REC17/EE/0311). Results will be disseminated via peer-reviewed publication.

TRIAL REGISTRATION NUMBER

NCT03418181.

Initiating haemodialysis twice-weekly as part of an incremental programme may protect residual kidney function

BACKGROUND

Initiating twice-weekly haemodialysis (2×HD) in patients who retain significant residual kidney function (RKF) may have benefits. We aimed to determine differences between patients initiated on twice- and thrice-weekly regimes, with respect to loss of kidney function, survival and other safety parameters.

METHODS

We conducted a single-centre retrospective study of patients initiating dialysis with a residual urea clearance (KRU) of ≥3 mL/min, over a 20-year period. Patients who had 2×HD for ≥3 months during the 12 months following initiation of 2×HD were identified for comparison with those dialysed thrice-weekly (3×HD).

RESULTS

The 2×HD group consisted of 154 patients, and the 3×HD group 411 patients. The 2×HD patients were younger (59 ± 15 versus 62 ± 15 years: P = 0.014) and weighed less (70 ± 16 versus 80 ± 18 kg: P < 0.001). More were females (34% versus 27%: P = 0.004). Fewer had diabetes (25% versus 34%: P = 0.04) and peripheral vascular disease (PVD) (13% versus 23%: P = 0.008). Baseline KRU was similar in both groups (5.3 ± 2.4 for 2 × HD versus 5.1 ± 2.8 mL/min for 3 × HD: P = 0.507). In a mixed effects model correcting for between-group differences in comorbidities and demographics, 3×HD was associated with increased rate of loss of KRU and separation of KRU. In separate mixed effects models, group (2×HD versus 3×HD) was not associated with differences in serum potassium or phosphate, and the groups did not differ with respect to total standard Kt/V. Survival, adjusted for age, gender, weight, baseline KRU and comorbidity (prevalence of diabetes, cardiac disease, PVD and malignancy) was greater in the 2×HD group (hazard ratio 0.755: P = 0.044). In sub-analyses, the survival benefit was confined to women, and those of less than median bodyweight.

CONCLUSION

2×HD initiation as part of an incremental programme with regular monthly monitoring of KRU was safe and associated with a reduced rate of loss of RKF early after dialysis initiation and improved survival. Randomized controlled trials of this approach are indicated.

Comprehensive Study on Tropical (10°N-15°N) Mesospheric Inversion Layers Using Lidar and Satellite (Timed-Saber) Observations

One of the interesting and poorly understood features of mesosphere and lower thermosphere (MLT) region is the phenomenon of Mesospheric Inversion Layers (MILs). The poor understanding of MILs is due to limited access of their occurrence height region, however the lidars are more efficient tools which provide stratosphere and mesosphere nocturnal temperatures with high temporal and vertical resolutions. The state-of-the-art lidar system comprising Mie, Rayleigh lidars installed at National Atmospheric Research Laboratory (NARL), Gadanki (13.5°N, 79.2°E), India has provided an excellent opportunity to undertake this study. The Nd:YAG laser source with lower power (11W) has been replaced by the one with higher power (30W) in January 2007. As the laser power has been increased, the molecular back scatter signal is also increased and consequently the top height level of the temperature retrieval has been increased to ~90-95 km. In the present study, the role of dominant causative mechanisms for the occurrence of MILs has been discussed using mainly the lidar and satellite (TIMED-SABER) observations over Gadanki region.

Malignant peripheral nerve sheath tumour-A case report

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Pre-sacral mass presenting with right thigh shooting pain in the setting of Von Recklinghausen.

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Radiological imaging was crucial in providing a road map pre-op.

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Mass abutting the internal iliac artery and possibly pressing on the sacral nerve roots.

Introduction

Malignant peripheral nerve sheath tumors (MPNST) are rare, aggressive sarcomatous tumors that arise from peripheral nerve sheaths and show schwann cell differentiation (Thangadurai, 2017) [1]. They commonly arise among patients with neurofibromatosis I and following radiation therapy (Farid et al., 2014). High resolution PET scans confirm the diagnosis and the definitive treatment is surgical excision. Post operative radiotherapy plays an important role in disease free survival rates. Chemotherapy is offered to people who have a systemic disease.

Presentation of case

This case report is on a 47 year old lady, a known case of Von Recklinghausen, who complained of a vague mass in the pelvis with recent history of pain to her right thigh. Pelvic examination revealed a vague mass on the right side of her pelvis. She was planned for excision of the mass. Intraoperative findings were consistent with the clinical and radiological findings. She is currently on regular follow-up and disease free.

Discussion

MPNSTs are rare tumours that arise in patients with neurofibromatosis I. Mutations at the genetic level is responsible for the development of MPNST. Early presentation, radiological confirmation, aggressive margin free surgery followed by chemoradiation helps in near complete cure of the disease.

Conclusion

MPNST are difficult to manage because of their aggressive nature and the limitations in early diagnosis and management. In patients with Von Recklinghausens disease, malignancy must be suspected when a patient presents with the complaints as mentioned in this case report.

Lessons learned from a comprehensive electronic patient record procurement process-implications for healthcare organisations

Background

This study describes learning from procurement of a comprehensive electronic patient record (EPR/electronic health record (EHR)), system for a specialist clinical academic institution.

Method

Retrospective review of procurement process in addition to evaluation of peer-reviewed literature in the field.

Results

Main lessons learned include the importance of detailed preparation of organisational requirements/specifications and organisational ‘readiness’. Early staff involvement, resulting in ownership of the selected system by the organisation was a key achievement. The scoring process used required significant resource commitment but, despite being extensive in scope, provided relatively poor distinction between suppliers, despite significant variation in supplier self-scoring. Other elements, such as demonstrations and site visits, provided superior evaluation of functional abilities, and specification requirements should be regarded as threshold evaluation.

Conclusion

While principles should be followed, the procurement process must be modified to meet the needs of the specific organisation, in terms of its clinical activities, digital maturity, existing infrastructure and budget.

Indexing dialysis dose for gender, body size and physical activity: Impact on survival

Current practice basing dialysis dose on urea distribution volume (V) has been questioned. We explored the impact on survival of scaling dialysis dose (Kt) to parameters reflective of metabolic activity. In a multicentre prospective cohort study of 1500 patients on thrice-weekly haemodialysis, body surface area (BSA) and resting energy expenditure (REE) were estimated using validated equations and physical activity by the Recent Physical Activity Questionnaire. Total energy expenditure (TEE) was estimated from REE and physical activity data. Kt was calculated from delivered (single-pool Kt/V)*Watson V. Kt/BSA, Kt/REE and Kt/TEE were then calculated at baseline and 6 monthly during follow-up for 2 years. In adjusted Cox models Kt/TEE, Kt/BSA, Kt/REE, in that order, had lower hazard ratios for death than single-pool Kt/V. On the basis of adjusted survival differences, putative minimum target doses were estimated for Kt/BSA as 27119 ml/m² and Kt/TEE as 25.79 ml/kcal. We identified spKt/V values equivalent to these estimated targets, ranging from 1.4 to 1.8 in patient groups based on gender, body size and physical activity. For sedentary patients, the minimum target dose was 1.4 for large males, 1.5 for small males and 1.7 for women. For active patients the target was 1.8 irrespective of gender and body-weight. Patients achieving these individualised minimum targets had greater adjusted two-year survival compared to those achieving conventional minimum targets. Metabolic activity related parameters, such as Kt/TEE and Kt/BSA, may have a clinically important role in scaling haemodialysis dose. Using such parameters or their spKt/V equivalents to adjust minimum target doses based on gender, body size and habitual physical activity may have a positive impact on survival.

Amplitude Analysis of the Decay B[over ¯]^{0}→K_{S}^{0}π^{+}π^{-} and First Observation of the CP Asymmetry in B[over ¯]^{0}→K^{*}(892)^{-}π^{+}

The time-integrated untagged Dalitz plot of the three-body hadronic charmless decay B[over ¯]^{0}→K_{S}^{0}π^{+}π^{-} is studied using a pp collision data sample recorded with the LHCb detector, corresponding to an integrated luminosity of 3.0  fb^{-1}. The decay amplitude is described with an isobar model. Relative contributions of the isobar amplitudes to the B[over ¯]^{0}→K_{S}^{0}π^{+}π^{-} decay branching fraction and CP asymmetries of the flavor-specific amplitudes are measured. The CP asymmetry between the conjugate B[over ¯]^{0}→K^{*}(892)^{-}π^{+} and B^{0}→K^{*}(892)^{+}π^{-} decay rates is determined to be -0.308±0.062.

Studies of the resonance structure in D 0 → K ∓ π ± π ± π ∓ decays

Amplitude models are constructed to describe the resonance structure of D 0 → K - π + π + π - and D 0 → K + π - π - π + decays using pp collision data collected at centre-of-mass energies of 7 and 8 TeV with the LHCb experiment, corresponding to an integrated luminosity of 3.0  f b - 1 . The largest contributions to both decay amplitudes are found to come from axial resonances, with decay modes D 0 → a 1 ( 1260 ) + K - and D 0 → K 1 ( 1270 / 1400 ) + π - being prominent in D 0 → K - π + π + π - and D 0 → K + π - π - π + , respectively. Precise measurements of the lineshape parameters and couplings of the a 1 ( 1260 ) + , K 1 ( 1270 ) - and K ( 1460 ) - resonances are made, and a quasi model-independent study of the K ( 1460 ) - resonance is performed. The coherence factor of the decays is calculated from the amplitude models to be R K 3 π = 0.459 ± 0.010 ( stat ) ± 0.012 ( syst ) ± 0.020 ( model ) , which is consistent with direct measurements. These models will be useful in future measurements of the unitary-triangle angle γ and studies of charm mixing and C P violation.

Measurement of the Ratio of the B^{0}→D^{*-}τ^{+}ν_{τ} and B^{0}→D^{*-}μ^{+}ν_{μ} Branching Fractions Using Three-Prong τ-Lepton Decays

The ratio of branching fractions R(D^{*-})≡B(B^{0}→D^{*-}τ^{+}ν_{τ})/B(B^{0}→D^{*-}μ^{+}ν_{μ}) is measured using a data sample of proton-proton collisions collected with the LHCb detector at center-of-mass energies of 7 and 8 TeV, corresponding to an integrated luminosity of 3  fb^{-1}. For the first time, R(D^{*-}) is determined using the τ-lepton decays with three charged pions in the final state. The B^{0}→D^{*-}τ^{+}ν_{τ} yield is normalized to that of the B^{0}→D^{*-}π^{+}π^{-}π^{+} mode, providing a measurement of B(B^{0}→D^{*-}τ^{+}ν_{τ})/B(B^{0}→D^{*-}π^{+}π^{-}π^{+})=1.97±0.13±0.18, where the first uncertainty is statistical and the second systematic. The value of B(B^{0}→D^{*-}τ^{+}ν_{τ})=(1.42±0.094±0.129±0.054)% is obtained, where the third uncertainty is due to the limited knowledge of the branching fraction of the normalization mode. Using the well-measured branching fraction of the B^{0}→D^{*-}μ^{+}ν_{μ} decay, a value of R(D^{*-})=0.291±0.019±0.026±0.013 is established, where the third uncertainty is due to the limited knowledge of the branching fractions of the normalization and B^{0}→D^{*-}μ^{+}ν_{μ} modes. This measurement is in agreement with the standard model prediction and with previous results.

Determination of thiamethoxam residues in banana stem and fruit through LC-MS/MS

An analytical method based on liquid chromatography coupled with mass spectroscopy/mass spectroscopy was developed and validated for the determination of thiamethoxam residues in banana fruit and stem tissue samples. In this study, Waters Alliance LC and Acquity TQD were used with an electrospray ionization interface in the positive ion mode. An isocratic flow of 0.5% HCOOH in water and 0.05% HCOOH in CH₃CN was used for separation. Thiamethoxam residue was extracted from the samples using CH₃CN and a dispersive solid-phase extraction method was used for subsequent cleanup. Linearity studies were conducted between 0.001 and 0.1 μg mL^-1 of standard solution with three replicates for each concentration. Satisfactory recoveries (107.21 to 115.16% and 90.94 to 109.22%) and high precision (relative standard deviations of 3.71 to 12.83% and 3.24 to 10.78%) were obtained for the banana stem and banana fruit matrix, respectively. The lower limits of detection and quantification achieved were 0.002 and 0.008 μg g^-1 for banana stem and 0.001and 0.005 μg g^-1for banana fruit, respectively. The developed method was used to analyze the banana stem and fruit samples collected from thiamethoxam-treated fields and stems from the local market.

Measurement of the Ratio of Branching Fractions B(B_{c}^{+}→J/ψτ^{+}ν_{τ})/B(B_{c}^{+}→J/ψμ^{+}ν_{μ})

A measurement is reported of the ratio of branching fractions R(J/ψ)=B(B_{c}^{+}→J/ψτ^{+}ν_{τ})/B(B_{c}^{+}→J/ψμ^{+}ν_{μ}), where the τ^{+} lepton is identified in the decay mode τ^{+}→μ^{+}ν_{μ}ν[over ¯]_{τ}. This analysis uses a sample of proton-proton collision data corresponding to 3.0  fb^{-1} of integrated luminosity recorded with the LHCb experiment at center-of-mass energies of 7 and 8 TeV. A signal is found for the decay B_{c}^{+}→J/ψτ^{+}ν_{τ} at a significance of 3 standard deviations corrected for systematic uncertainty, and the ratio of the branching fractions is measured to be R(J/ψ)=0.71±0.17(stat)±0.18(syst). This result lies within 2 standard deviations above the range of central values currently predicted by the standard model.

Search for Dark Photons Produced in 13 TeV pp Collisions

Searches are performed for both promptlike and long-lived dark photons, A^{'}, produced in proton-proton collisions at a center-of-mass energy of 13 TeV, using A^{'}→μ^{+}μ^{-} decays and a data sample corresponding to an integrated luminosity of 1.6  fb^{-1} collected with the LHCb detector. The promptlike A^{'} search covers the mass range from near the dimuon threshold up to 70 GeV, while the long-lived A^{'} search is restricted to the low-mass region 214<m(A^{'})<350  MeV. No evidence for a signal is found, and 90% confidence level exclusion limits are placed on the γ-A^{'} kinetic-mixing strength. The constraints placed on promptlike dark photons are the most stringent to date for the mass range 10.6<m(A^{'})<70  GeV, and are comparable to the best existing limits for m(A^{'})<0.5  GeV. The search for long-lived dark photons is the first to achieve sensitivity using a displaced-vertex signature.

Exploring the uncharted territory of social media: the next frontier of medical education in nephrology

Social media is gaining popularity amongst both medical educators and life-long learners. One of the most popular social media platforms used by the medical community is Twitter, which is popular amongst physicians, students and patients, and particularly in medical societies. Major international and regional societies commonly use Twitter to amplify their reach beyond what their live annual meetings can achieve. There has been a unique and notable effort by Nephrology societies to craft a structured social media strategy that results in the broadest reach to the community of nephrology providers. We report on the first three such experiments performed by three separate nephrology organizations.

Rayleigh lidar observation of tropical mesospheric inversion layer: a comparison between dynamics and chemistry

The Rayleigh lidar at National Atmospheric Research Laboratory, Gadanki (13.5°N, 79.2°E), India operates at 532 nm green laser with ~600 mJ/pulse since 2007. The vertical temperature profiles are derived above ~30 km by assuming the atmosphere is in hydrostatic equilibrium and obeys ideal gas law. A large mesospheric inversion layer (MIL) is observed at ~77.4-84.6 km on the night of 22 March 2007 over Gadanki. Although dynamics and chemistry play vital role, both the mechanisms are compared for the occurrence of the MIL in the present study.

First Observation of the Rare Purely Baryonic Decay B^{0}→pp[over ¯]

The first observation of the decay of a B^{0} meson to a purely baryonic final state, B^{0}→pp[over ¯], is reported. The proton-proton collision data sample used was collected with the LHCb experiment at center-of-mass energies of 7 and 8 TeV and corresponds to an integrated luminosity of 3.0  fb^{-1}. The branching fraction is determined to be B(B^{0}→pp[over ¯])=(1.25±0.27±0.18)×10^{-8}, where the first uncertainty is statistical and the second systematic. The decay mode B^{0}→pp[over ¯] is the rarest decay of the B^{0} meson observed to date. The decay B_{s}^{0}→pp[over ¯] is also investigated. No signal is seen and the upper limit B(B_{s}^{0}→pp[over ¯])<1.5×10^{-8} at 90% confidence level is set on the branching fraction.

χ_{c1} and χ_{c2} Resonance Parameters with the Decays χ_{c1,c2}→J/ψμ^{+}μ^{-}

The decays χ_{c1}→J/ψμ^{+}μ^{-} and χ_{c2}→J/ψμ^{+}μ^{-} are observed and used to study the resonance parameters of the χ_{c1} and χ_{c2} mesons. The masses of these states are measured to be m(χ_{c1})=3510.71±0.04(stat)±0.09(syst)  MeV and m(χ_{c2})=3556.10±0.06(stat)±0.11(syst)  MeV, where the knowledge of the momentum scale for charged particles dominates the systematic uncertainty. The momentum-scale uncertainties largely cancel in the mass difference m(χ_{c2})-m(χ_{c1})=45.39±0.07(stat)±0.03(syst)  MeV. The natural width of the χ_{c2} meson is measured to be Γ(χ_{c2})=2.10±0.20(stat)±0.02(syst)  MeV. These results are in good agreement with and have comparable precision to the current world averages.

Updated search for long-lived particles decaying to jet pairs

A search is presented for long-lived particles with a mass between 25 and 50 GeV / c 2 and a lifetime between 2 and 500 ps, using proton-proton collision data corresponding to an integrated luminosity of 2.0 fb - 1 , collected by the LHCb detector at centre-of-mass energies of 7 and 8 TeV. The particles are assumed to be pair-produced in the decay of a 125 GeV / c 2 Standard-Model-like Higgs boson. The experimental signature is a single long-lived particle, identified by a displaced vertex with two associated jets. No excess above background is observed and limits are set on the production cross-section as a function of the mass and lifetime of the long-lived particle.

Observation of D^{0} Meson Decays to π^{+}π^{-}μ^{+}μ^{-} and K^{+}K^{-}μ^{+}μ^{-} Final States

The first observation of the D^{0}→π^{+}π^{-}μ^{+}μ^{-} and D^{0}→K^{+}K^{-}μ^{+}μ^{-} decays is reported using a sample of proton-proton collisions collected by LHCb at a center-of-mass energy of 8 TeV, and corresponding to 2  fb^{-1} of integrated luminosity. The corresponding branching fractions are measured using as normalization the decay D^{0}→K^{-}π^{+}[μ^{+}μ^{-}]_{ρ^{0}/ω}, where the two muons are consistent with coming from the decay of a ρ^{0} or ω meson. The results are B(D^{0}→π^{+}π^{-}μ^{+}μ^{-})=(9.64±0.48±0.51±0.97)×10^{-7} and B(D^{0}→K^{+}K^{-}μ^{+}μ^{-})=(1.54±0.27±0.09±0.16)×10^{-7}, where the uncertainties are statistical, systematic, and due to the limited knowledge of the normalization branching fraction. The dependence of the branching fraction on the dimuon mass is also investigated.

Search for Baryon-Number Violating Ξ_{b}^{0} Oscillations

A search for baryon-number violating Ξ_{b}^{0} oscillations is performed with a sample of pp collision data recorded by the LHCb experiment, corresponding to an integrated luminosity of 3  fb^{-1}. The baryon number at the moment of production is identified by requiring that the Ξ_{b}^{0} come from the decay of a resonance Ξ_{b}^{*-}→Ξ_{b}^{0}π^{-} or Ξ_{b}^{'-}→Ξ_{b}^{0}π^{-}, and the baryon number at the moment of decay is identified from the final state using the decays Ξ_{b}^{0}→Ξ_{c}^{+}π^{-},Ξ_{c}^{+}→pK^{-}π^{+}. No evidence of baryon-number violation is found, and an upper limit at the 95% confidence level is set on the oscillation rate of ω<0.08  ps^{-1}, where ω is the associated angular frequency.

Sanitation marketing: A systematic review and theoretical critique using the capability approach

Sanitation is a human right that benefits health. As such, technical and behavioural interventions are widely implemented to increase the number of people using sanitation facilities. These include sanitation marketing interventions (SMIs), in which external support agencies (ESAs) use a hybrid of commercial and social marketing tools to increase supply of, and demand for, sanitation products and services. However, there is little critical discourse on SMIs, or independent rigorous analysis on whether they increase or reduce well-being. Most available information is from ESAs about their own SMI implementation. We systematically reviewed the grey and peer-reviewed literature on sanitation marketing, including qualitatively analysing and calculating descriptive statistics for the parameters measured, or intended to be measured, in publications reporting on 33 SMIs. Guided by the capability approach to development we identified that publications for most SMIs (n = 31, 94%) reported on commodities, whilst fewer reported on parameters related to impacts on well-being (i.e., functionings, n = 22, 67%, and capabilities, n = 20, 61%). When evaluating future SMIs, it may be useful to develop a list of contextualised well-being indicators for the particular SMI's location, taking into account local cultural norms, with this list ideally co-produced with local stakeholders. We identified two common practices in SMIs that can reduce well-being and widen well-being inequalities; namely, the promotion of conspicuous consumption and assaults on dignity, and we discuss the mechanisms by which such impacts occur. We recommend that ESAs understand sanitation marketing's potential to reduce well-being and design SMIs to minimize such detrimental impacts. Throughout the implementation phase ESAs should continuously monitor for well-being impacts and adapt practices to optimise well-being outcomes for all involved.

Improved limit on the branching fraction of the rare decay K S 0 → μ + μ -

A search for the decay K S 0 → μ + μ - is performed, based on a data sample of proton-proton collisions corresponding to an integrated luminosity of 3 fb - 1 , collected by the LHCb experiment at centre-of-mass energies of 7 and 8 TeV . The observed yield is consistent with the background-only hypothesis, yielding a limit on the branching fraction of B ( K S 0 → μ + μ - ) < 0.8 ( 1.0 ) × 10 - 9 at 90 % ( 95 % ) confidence level. This result improves the previous upper limit on the branching fraction by an order of magnitude.

Observation of the Doubly Charmed Baryon Ξ_{cc}^{++}

A highly significant structure is observed in the Λ_{c}^{+}K^{-}π^{+}π^{+} mass spectrum, where the Λ_{c}^{+} baryon is reconstructed in the decay mode pK^{-}π^{+}. The structure is consistent with originating from a weakly decaying particle, identified as the doubly charmed baryon Ξ_{cc}^{++}. The difference between the masses of the Ξ_{cc}^{++} and Λ_{c}^{+} states is measured to be 1334.94±0.72(stat.)±0.27(syst.)  MeV/c^{2}, and the Ξ_{cc}^{++} mass is then determined to be 3621.40±0.72(stat.)±0.27(syst.)±0.14(Λ_{c}^{+})  MeV/c^{2}, where the last uncertainty is due to the limited knowledge of the Λ_{c}^{+} mass. The state is observed in a sample of proton-proton collision data collected by the LHCb experiment at a center-of-mass energy of 13 TeV, corresponding to an integrated luminosity of 1.7  fb^{-1}, and confirmed in an additional sample of data collected at 8 TeV.

Study of charmonium production in b -hadron decays and first evidence for the decay B s 0 → ϕ ϕ ϕ

Using decays to ϕ -meson pairs, the inclusive production of charmonium states in b -hadron decays is studied with pp collision data corresponding to an integrated luminosity of 3.0 fb - 1 , collected by the LHCb experiment at centre-of-mass energies of 7 and 8 TeV. Denoting by B C ≡ B ( b → C X ) × B ( C → ϕ ϕ ) the inclusive branching fraction of a b hadron to a charmonium state C that decays into a pair of ϕ mesons, ratios R C 2 C 1 ≡ B C 1 / B C 2 are determined as R η c ( 1 S ) χ c 0 = 0.147 ± 0.023 ± 0.011 , R η c ( 1 S ) χ c 1 = 0.073 ± 0.016 ± 0.006 , R η c ( 1 S ) χ c 2 = 0.081 ± 0.013 ± 0.005 , R χ c 0 χ c 1 = 0.50 ± 0.11 ± 0.01 , R χ c 0 χ c 2 = 0.56 ± 0.10 ± 0.01 and R η c ( 1 S ) η c ( 2 S ) = 0.040 ± 0.011 ± 0.004 . Here and below the first uncertainties are statistical and the second systematic. Upper limits at 90% confidence level for the inclusive production of X(3872), X(3915) and χ c 2 ( 2 P ) states are obtained as R χ c 1 X ( 3872 ) < 0.34 , R χ c 0 X ( 3915 ) < 0.12 and R χ c 2 χ c 2 ( 2 P ) < 0.16 . Differential cross-sections as a function of transverse momentum are measured for the η c ( 1 S ) and χ c states. The branching fraction of the decay B s 0 → ϕ ϕ ϕ is measured for the first time, B ( B s 0 → ϕ ϕ ϕ ) = ( 2.15 ± 0.54 ± 0.28 ± 0 . 21 B ) × 10 - 6 . Here the third uncertainty is due to the branching fraction of the decay B s 0 → ϕ ϕ , which is used for normalization. No evidence for intermediate resonances is seen. A preferentially transverse ϕ polarization is observed. The measurements allow the determination of the ratio of the branching fractions for the η c ( 1 S ) decays to ϕ ϕ and p p ¯ as B ( η c ( 1 S ) → ϕ ϕ ) / B ( η c ( 1 S ) → p p ¯ ) = 1.79 ± 0.14 ± 0.32 .