A quantitative evaluation of aerosol generation during cardiopulmonary resuscitation

It is unclear if cardiopulmonary resuscitation is an aerosol-generating procedure and whether this poses a risk of airborne disease transmission to healthcare workers and bystanders. Use of airborne transmission precautions during cardiopulmonary resuscitation may confer rescuer protection but risks patient harm due to delays in commencing treatment. To quantify the risk of respiratory aerosol generation during cardiopulmonary resuscitation in humans, we conducted an aerosol monitoring study during out-of-hospital cardiac arrests. Exhaled aerosol was recorded using an optical particle sizer spectrometer connected to the breathing system. Aerosol produced during resuscitation was compared with that produced by control participants under general anaesthesia ventilated with an equivalent respiratory pattern to cardiopulmonary resuscitation. A porcine cardiac arrest model was used to determine the independent contributions of ventilatory breaths, chest compressions and external cardiac defibrillation to aerosol generation. Time-series analysis of participants with cardiac arrest (n = 18) demonstrated a repeating waveform of respiratory aerosol that mapped to specific components of resuscitation. Very high peak aerosol concentrations were generated during ventilation of participants with cardiac arrest with median (IQR [range]) 17,926 (5546-59,209 [1523-242,648]) particles.l-1 , which were 24-fold greater than in control participants under general anaesthesia (744 (309-2106 [23-9099]) particles.l-1 , p < 0.001, n = 16). A substantial rise in aerosol also occurred with cardiac defibrillation and chest compressions. In a complimentary porcine model of cardiac arrest, aerosol recordings showed a strikingly similar profile to the human data. Time-averaged aerosol concentrations during ventilation were approximately 270-fold higher than before cardiac arrest (19,410 (2307-41,017 [104-136,025]) vs. 72 (41-136 [23-268]) particles.l-1 , p = 0.008). The porcine model also confirmed that both defibrillation and chest compressions generate high concentrations of aerosol independent of, but synergistic with, ventilation. In conclusion, multiple components of cardiopulmonary resuscitation generate high concentrations of respiratory aerosol. We recommend that airborne transmission precautions are warranted in the setting of high-risk pathogens, until the airway is secured with an airway device and breathing system with a filter.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Assessing Breast Cancer Molecular Subtypes Using Extracellular Vesicles' mRNA

Extracellular vesicles (EVs) carry RNA cargo that is believed to be associated with the cell-of-origin and thus have the potential to serve as a minimally invasive liquid biopsy marker for supplying molecular information to guide treatment decisions (i.e., precision medicine). We report the affinity isolation of EV subpopulations with monoclonal antibodies attached to the surface of a microfluidic chip that is made from a plastic to allow for high-scale production. The EV microfluidic affinity purification (EV-MAP) chip was used for the isolation of EVs sourced from two-orthogonal cell types and was demonstrated for its utility in a proof-of-concept application to provide molecular subtyping information for breast cancer patients. The orthogonal selection process better recapitulated the epithelial tumor microenvironment by isolating two subpopulations of EVs: EVEpCAM (epithelial cell adhesion molecule, epithelial origin) and EVFAPα (fibroblast activation protein α, mesenchymal origin). The EV-MAP provided recovery >80% with a specificity of 99 ± 1% based on exosomal mRNA (exo-mRNA) and real time-droplet digital polymerase chain reaction results. When selected from the plasma of healthy donors and breast cancer patients, EVs did not differ in size or total RNA mass for both markers. On average, 0.5 mL of plasma from breast cancer patients yielded ∼2.25 ng of total RNA for both EVEpCAM and EVFAPα, while in the case of cancer-free individuals, it yielded 0.8 and 1.25 ng of total RNA from EVEpCAM and EVFAPα, respectively. To assess the potential of these two EV subpopulations to provide molecular information for prognostication, we performed the PAM50 test (Prosigna) on exo-mRNA harvested from each EV subpopulation. Results suggested that EVEpCAM and EVFAPα exo-mRNA profiling using subsets of the PAM50 genes and a novel algorithm (i.e., exo-PAM50) generated 100% concordance with the tumor tissue.

Concordance between a gastrointestinal consultant radiologist, a consultant radiologist and qualified reporting radiographers interpreting abdominal radiographs

INTRODUCTION

Radiographers can accurately report musculoskeletal and chest radiographs, but there is paucity of research comparing the performance of reporting radiographers (RRs) with consultant radiologists when interpreting and reporting abdominal radiographs. This study assessed interobserver agreement in the clinical setting between reporting radiographers and a consultant radiologist compared to an expert gastrointestinal radiologist in a District General Hospital. Major discordant reports affecting patient management were also examined.

METHODS

126 abdominal radiographs reported by 3 RRs in clinical practice were randomly selected and reported by a consultant radiologist and index gastrointestinal radiologist. The reports of the RRs and consultant radiologist were compared against the reports made by the index radiologist for agreement by a colorectal consultant surgeon. All 126 reports were scored as being in either complete agreement, minor disagreement or major disagreement which would have resulted in a change to patient management.

RESULTS

There was no significant difference in overall agreement between the consultant radiologist (CR) and RRs when compared to the index radiologist (CR: n = 90/126, 71.4% and RRs: n = 94/126, 74.6%. p = 0.57). Major disagreements were found, but there was no significant difference between both groups (CR: n = 23/126, 18.3% and RRs: n = 17/126, 13.5%. p = 0.30).

CONCLUSION

RRs can report abdominal radiographs to a comparable level of agreement as a consultant radiologist in the clinical setting. There was no significant difference in reports deemed to affect patient management.

IMPLICATIONS FOR PRACTICE

This study addresses the gap in assessing the performance of RRs reporting abdominal radiographs. This small scale study indicates that radiographers could provide additional support in the reporting of abdominal radiographs. This would help to reduce radiologist workload and enhance the role of the reporting radiographer.

CLASSIFICATION

Agreement between reporting radiographers and radiologists interpreting and reporting abdominal radiographs.

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.

Rapid response to medical device recalls: an organized patient-centered team effort

As more patients depend upon mechanical or electronic technologies for treatment, medical device recalls-like the recent recall of common positive airway pressure treatment devices-impact millions of patients, often causing significant anxiety, extra costs, and interruption of care for patients. When recalls require health care and/durable medical equipment providers to be part of the solution, the burden on practices and businesses can be significant, creating strains on access for new patients and on limited medical supplies. We have observed that having an established and well-organized medical device recall plan in place allows for a rapid response, decreased practice burden, and reduced provider stress. Coupling the organized response with proactive, empathic, and clear communication with patients reduces their anxiety, provides clear directions for how to address the issue constructively, and reduces reactive communications. We share what we believe are key components of a medical device and produce recall procedure as we describe our institutions response in hopes that others can build on these basics as they design their own response plans.

CITATION

Morgenthaler TI, Linginfelter EA, Gay PC, et al. Rapid response to medical device recalls: an organized patient-centered team effort. J Clin Sleep Med. 2022;18(2):663-667.

Facial discoid dermatosis: A cosmetically disfiguring and challenging condition to treat

Facial discoid dermatosis (FDD) is a recently described condition comprising discrete facial papulo‐squamous lesions. We report three cases that clinically and histologically resemble FDD and demonstrate its resistance to treatment. Awareness of this new clinical entity will allow early diagnosis and the ability to make patients aware that there is unlikely to be a successful treatment. However, our study suggests that although FDD can persist for many years, it appears to remain stable.

A prospective, observational study of the performance of MEWS, NEWS, SIRS and qSOFA for early risk stratification for adverse outcomes in patients with suspected infections at the emergency department

BACKGROUND

Many patients with suspected infection are presented to the emergency Department. Several scoring systems have been proposed to identify patients at high risk of adverse outcomes.

METHODS

We compared generic early warning scores (MEWS and NEWS) to the (SIRS) criteria and quick Sequential Organ Failure Assessement (qSOFA), for early risk stratification in 1400 patients with suspected infection in the ED. The primary study end point was 30-day mortality.

RESULTS

The AUROC of the NEWS score for predicting 30-day mortality was 0.740 (95% Confidence Interval 0.682- 0.798), higher than qSOFA (AUROC of 0.689, 95% CI 0.615- 0.763), MEWS (AUROC 0.643 (95% CI 0.583-0.702) and SIRS (AUROC 0.586, 95%CI 0.521 - 0.651). The sensitivity was also highest for NEWS⋝ 5 (sensitivity 75,8% specificity of 67,4%).

CONCLUSION

Among patients presenting to the ED with suspected infection, early risk stratification with NEWS (cut-off of ⋝5) is more sensitive for prediction of mortality than qSOFA, MEWS or SIRS, with adequate specificity.

Quantification of regional murine ozone-induced lung inflammation using [18F]F-FDG microPET/CT imaging

Ozone (O₃) is a highly potent and reactive air pollutant. It has been linked to acute and chronic respiratory diseases in humans by inducing inflammation. Our studies have found evidence that 0.05 ppm of O₃, within the threshold of air quality standards, is capable of inducing acute lung injury. This study was undertaken to examine O₃-induced lung damage using [¹⁸F]F-FDG (2-deoxy-2-[¹⁸F]fluoro-D-glucose) microPET/CT in wild-type mice. [¹⁸F]F-FDG is a known PET tracer for inflammation. Sequential [¹⁸F]F-FDG microPET/CT was performed at baseline (i.e. before O₃ exposure), immediately (0 h), at 24 h and at 28 h following 2 h of 0.05 ppm O₃ exposure. The images were quantified to determine O₃ induced spatial standard uptake ratio of [¹⁸F]F-FDG in relation to lung tissue density and compared with baseline values. Immediately after O₃ exposure, we detected a 72.21 ± 0.79% increase in lung [¹⁸F]F-FDG uptake ratio when compared to baseline measures. At 24 h post-O₃ exposure, the [¹⁸F]F-FDG uptake becomes highly variable (S.D. in [¹⁸F]F-FDG = 5.174 × 10^–4 units) with a 42.54 ± 0.33% increase in lung [¹⁸F]F-FDG compared to baseline. At 28 h time-point, [¹⁸F]F-FDG uptake ratio was similar to baseline values. However, the pattern of [¹⁸F]F-FDG distribution varied and was interspersed with zones of minimal uptake. Our microPET/CT imaging protocol can quantify and identify atypical regional lung uptake of [¹⁸F]F-FDG to understand the lung response to O₃ exposure.

Visible photorelease of liquid biopsy markers following microfluidic affinity-enrichment

We detail a heterobifunctional, 7-aminocoumarin photocleavable (PC) linker with unique properties to covalently attach Abs to surfaces and subsequently release them with visible light (400-450 nm). The PC linker allowed rapid (2 min) and efficient (>90%) release of CTCs and EVs without damaging their molecular cargo.

AgVenture: Establishing the Link between STEM and Agriculture

Science, technology, engineering, and math (STEM) education is an integral part of primary school curriculum. AgVenture allows Extension to teach 4th graders about the connection between STEM and agriculture. Extension educators in Maryland developed hands-on activities around animals, plant sciences and nutrition, while linking station-specific activities back to STEM standards. Pretests and posttests show a statistically significant change in STEM-related knowledge by students, while feedback from teachers demonstrates the educational value of the program. Because of these results, AgVenture has grown and now has a waiting list of interested schools. The success of the AgVenture program can be replicated in other Extension programs throughout Maryland and nationwide.

Educational Preparation and Perceived Proficiency of Nurses Working in Oncology Units at the University College Hospital, Ibadan, Nigeria

Background: Cancer is a malignant pathologic disorder, which poses a global threat to the health and survival of an individual, both young and old. Globally, nurses are considered very vital in all aspects of cancer control due to their impact on the quality of care outcomes which is greatly influenced by specialized training in oncology nursing. However, in Nigeria and some parts of Africa, there is dearth of information and documentation on the nurses' educational preparation and proficiency of nurses in delivery of oncology care. Aim: This study assessed educational preparation and perceived proficiency of nurses working in oncology units at University College Hospital, Ibadan to provide information oncology nursing training of these nurses as well as their perceived proficiency. Methods: The study used a descriptive cross-sectional design. Permission and clearance were obtained from the Joint University of Ibadan/UCH ethical review committee and subsequently head nurses in each unit and the nurses that participated. A purposive sampling method was used for selection of participants and a structured questionnaire with reliability coefficient value of 0.94 was used for data collection. Data were entered using SPSS version 20 and data analysis was done using descriptive and inferential statistics. Results: A total of 104 nurses working in oncology units fully participated in the study. For age, mean ± SD was 35 years ± 6. 54.4% of respondents had diploma professional training in general nursing as their highest level of education. Most of the respondents 88.5% did not have certification in oncology nursing, 77.9% had no form of specialized training in oncology care. The only exposure to oncology nursing training for most of the participants was during their basic training in nursing and midwifery schools but duration of exposure could not be ascertained. Most 64.4% of respondents felt their exposure to oncology nursing care wasn't adequate. 62.7% affirmed there was no educational institution that caters for specialized oncology training in their locality. However, 55.8% of the respondents considered themselves as highly proficient in giving oncology care. There was no statistically significant association between years of experience in oncology care and perceived proficiency χ2 value χ2 = 3.05, pv = 0.11. Conclusion: This findings revealed the training in oncology nursing among nurses is not adequate as the only oncology nursing training exposure was at the basic nursing schools. Hence the need to establish oncology nursing training programs for nurses in cancer care in Nigeria. This will go a long way to influence cancer control.

Utility values for childhood obesity interventions: a systematic review and meta-analysis of the evidence for use in economic evaluation

Rigorous estimates of preference-based utilities are important inputs into economic evaluations of childhood obesity interventions, yet no published review currently exists examining utility by weight status in paediatric populations. A comprehensive systematic literature review and meta-analysis was therefore undertaken, pooling data on preference-based health state utilities by weight status in children using a random-effects model. Tests for heterogeneity were performed, and publication bias was assessed. Of 3,434 potentially relevant studies identified, 11 met our eligibility criteria. Estimates of Cohen's d statistic suggested a small effect of weight status on preference-based utilities. Mean utility values were estimated as 0.85 (95% uncertainty interval [UI] 0.84-0.87), 0.83 (95% UI 0.81-0.85), 0.82 (95% UI 0.79-0.84) and 0.83 (95% UI 0.80-0.86) for healthy weight, overweight, obese and overweight/obese states, respectively. Meta-analysis of studies reporting utility values for both healthy weight and overweight/obese participants found a statistically significant weighted mean difference (0.015, 95% UI 0.003-0.026). A small but statistically significant difference was also estimated between healthy weight and overweight participants (0.011, 95% UI 0.004-0.018). Study findings suggest that paediatric-specific benefits of obesity interventions may not be well reflected by available utility measures, potentially underestimating cost-effectiveness if weight loss in childhood/adolescence improves health or well-being.

[A woman with swelling and blue-red discolouration of the leg]

A 61-year-old woman presented with a sudden marked swelling and blue-red discolouration of her entire left leg. The diagnosis phlegmasia cerulea dolens was made. This is an extreme case of lower-extremity deep venous thrombosis that can cause critical limb ischaemia and possible limb loss.

Infusing Adult Education Principles Into a Health Insurance Literacy Program

Health insurance literacy is an emerging concept in the health education and health promotion field. The passage of the Affordable Care Act highlighted the link between health insurance and health outcomes. However, the law does not specifically address how the public should be educated on choosing an appropriate health insurance plan. Research shows adults, regardless of previous health insurance status, are likely confused and uncertain about their selection. The University of Maryland Extension developed and created health insurance Smart Choice Health Insurance™ to reduce confusion and increase confidence and capability to make this decision. Andragogy, an adult learning theory, was used to guide the development of the program and help ensure best practices are used to achieve desired outcomes. Using the six principles of andragogy, the team incorporated reality-based case studies, allowed adults time to practice, and emphasized choice making and many other elements to create an atmosphere conducive to adult learning. Results from Smart Choice indicate the program is successful in reducing confusion and increasing confidence. Furthermore, feedback from participants and trained educators indicates that adults were engaged in the program and found the materials useful. Based on program success, creation of new health insurance literacy programs grounded in adult education principles is under way.

Active transport and obesity prevention - A transportation sector obesity impact scoping review and assessment for Melbourne, Australia

Given the alarming prevalence of obesity worldwide and the need for interventions to halt the growing epidemic, more evidence on the role and impact of transport interventions for obesity prevention is required. This study conducts a scoping review of the current evidence of association between modes of transport (motor vehicle, walking, cycling and public transport) and obesity-related outcomes. Eleven reviews and thirty-three primary studies exploring associations between transport behaviours and obesity were identified. Cohort simulation Markov modelling was used to estimate the effects of body mass index (BMI) change on health outcomes and health care costs of diseases causally related to obesity in the Melbourne, Australia population. Results suggest that evidence for an obesity effect of transport behaviours is inconclusive (29% of published studies reported expected associations, 33% mixed associations), and any potential BMI effect is likely to be relatively small. Hypothetical scenario analyses suggest that active transport interventions may contribute small but significant obesity-related health benefits across populations (approximately 65 health adjusted life years gained per year). Therefore active transport interventions that are low cost and targeted to those most amenable to modal switch are the most likely to be effective and cost-effective from an obesity prevention perspective. The uncertain but potentially significant opportunity for health benefits warrants the collection of more and better quality evidence to fully understand the potential relationships between transport behaviours and obesity. Such evidence would contribute to the obesity prevention dialogue and inform policy across the transportation, health and environmental sectors.

Saccade Programming in Strabismic Suppression

Individuals with strabismus frequently show a suppression phenomenon in which part of the visual input in one eye is apparently ignored when both eyes are seeing, although the eye may have normal vision when used monocularly. This is often described as an adaptive response to avoid diplopia. We have examined two patients with microstrabismus (angle of squint less than 5 deg) who show strong suppression but with only mild amblyopia. We studied saccade generation in the two eyes using a red — green anaglyph display which allowed us to present stimuli independently to each eye.

When single targets were presented in the suppressing eye, saccadic responses usually occurred. However the latencies of these saccades were increased with respect to those elicited from the normal eye (by about 70 ms for one subject and 270 ms for the other). The amplitudes of the saccades were less consistent than those of the normal eye, and saccades were sometimes made in the opposite direction to the target. We also investigated the remote distractor effect. This effect is found consistently in normal subjects and consists of an increase in the latency of a target-elicited saccade when a distractor is simultaneously presented elsewhere in the visual field. When distractors were presented in the suppressing eye, they had no effect on the latency of saccades to a simultaneous target in the other eye. We conclude that visual stimulation in a suppressing eye has no rapid access to the saccadic system.

Smart Choice Health Insurance©: A New, Interdisciplinary Program to Enhance Health Insurance Literacy

Smart Choice Health Insurance© is a consumer education program based on the definition and emerging measurement of health insurance literacy and a review of literature and appropriate theoretical frameworks. An interdisciplinary team of financial and health educators was formed to develop and pilot the program, with the goal of reducing confusion and increasing confidence in the consumer's ability to make a smart health insurance decision. Educators in seven states, certified to teach the program, conducted workshops for 994 consumers. Results show statistically significant evidence of increased health insurance literacy, confidence, and capacity to make a smart choice health insurance choice. Discussion centers on the impact the program had on specific groups, next steps to reach a larger audience, and implications for educators, consumers, and policymakers nationwide.

Bold Ideas for the 4th H in 4-H: Teen Identified Concerns and Actions

This article summarizes a literature review; teen-identified health concerns and issues; and teen bold ideas for actions. Findings from the National 4-H Council and Molina Healthcare Teens Take on Health initiative are provided and implications for 4-H programming tied to the new Cooperative Extension National Framework for Health and Wellness are addressed. The article is intended as background for Extension educators, volunteers and administrators as they review the 4-H Healthy Living Mission Mandate, learn what mattered to teens and consider how to incorporate the findings into state and local 4-H youth development programming.

Intranasal delivery of a peptide with antidepressant-like effect

A critical issue in drug development is developing effective, noninvasive delivery routes to the central nervous system (CNS). Major depressive disorder (MDD) is an illness associated with significant morbidity. Even with multiple antidepressant trials, 10-15% of patients continue to experience persistent depressive symptoms. We previously developed an interfering peptide that has antidepressant-like effects in rats when injected directly into the brain. To be clinically viable, it must demonstrate efficacy via a noninvasive administration route. We report here that the interfering peptide designed to disrupt the interaction between the D1 and D2 dopamine receptors can be delivered to relevant brain areas using the Pressurized Olfactory Device (POD), a novel intranasal delivery system developed by Impel NeuroPharma. We validate this delivery method by demonstrating that, at doses ⩾1.67 nmol/g, the D1-D2 interfering peptide has a significant antidepressant-like effect comparable to that of imipramine in the forced swimming test (FST), a common test for antidepressant efficacy. The antidepressant-like effect of the interfering peptide can be detected for 2 h after intranasal administration. Furthermore, we show that the interfering peptide disrupts the D1-D2 interaction and it can be detected in the prefrontal cortex after intranasal administration. This study provides strong preclinical support for intranasal administration of the D1-D2 interfering peptide as a new treatment option for patients suffering from MDD.

Denosumab: mechanism of action and clinical outcomes

AIMS

To describe the mechanisms of action of denosumab, a novel antiresorptive agent, contrasting it with other antiresorptive and anabolic osteoporosis treatments.

METHODS

Published papers related to the mechanism of action of approved osteoporosis treatments were sought through MEDLINE searches.

FINDINGS

Osteoporotic fractures carry a substantial burden of morbidity and mortality, but pharmacotherapy can prevent such fractures in high-risk individuals. Antiresorptive drugs (e.g. bisphosphonates, oestrogen, denosumab) reduce bone turnover by distinct mechanisms. Denosumab, a recently approved therapy, is a fully human monoclonal antibody that binds the cytokine RANKL (receptor activator of NFκB ligand), an essential factor initiating bone turnover. RANKL inhibition blocks osteoclast maturation, function and survival, thus reducing bone resorption. In contrast, bisphosphonates bind bone mineral, where they are absorbed by mature osteoclasts, inducing osteoclast apoptosis and suppressing resorption. These differences in mechanism influence both the onset and reversibility of treatment.

DISCUSSION

Effective pharmacotherapy is necessary for patients at high risk of fracture. Among the treatment options for postmenopausal osteoporosis, there are significant differences in mechanism and dosing. Denosumab acts by a novel mechanism and is administered twice yearly by subcutaneous injection. Identified by Osteoporosis Canada Clinical Practice Guidelines as a first-line agent for treatment of postmenopausal osteoporosis, denosumab represents an important addition to our treatment options.

Minimal access excision of aortic valve fibroelastoma: a case report and review of the literature

Papillary fibroelastomas are rare primary tumours of cardiac origin accounting for approximately 10% of all primary cardiac neoplasms. Due to a high thromboembolic risk, surgical excision is the mainstay of treatment in these patients and median sternotomy the most widely used approach. We describe the case of a 43 year-old lady presenting with acute myocardial infarction secondary to aortic valve papillary fibroelastoma subsequently excised using a minimal access technique. From our experience mini-sternotomy offers excellent exposure and allows for safe resection in such cases, improving cosmesis without compromising either intra or post-operative outcome.

Biological conversion assay using Clostridium phytofermentans to estimate plant feedstock quality

BACKGROUND

There is currently considerable interest in developing renewable sources of energy. One strategy is the biological conversion of plant biomass to liquid transportation fuel. Several technical hurdles impinge upon the economic feasibility of this strategy, including the development of energy crops amenable to facile deconstruction. Reliable assays to characterize feedstock quality are needed to measure the effects of pre-treatment and processing and of the plant and microbial genetic diversity that influence bioconversion efficiency.

RESULTS

We used the anaerobic bacterium Clostridium phytofermentans to develop a robust assay for biomass digestibility and conversion to biofuels. The assay utilizes the ability of the microbe to convert biomass directly into ethanol with little or no pre-treatment. Plant samples were added to an anaerobic minimal medium and inoculated with C. phytofermentans, incubated for 3 days, after which the culture supernatant was analyzed for ethanol concentration. The assay detected significant differences in the supernatant ethanol from wild-type sorghum compared with brown midrib sorghum mutants previously shown to be highly digestible. Compositional analysis of the biomass before and after inoculation suggested that differences in xylan metabolism were partly responsible for the differences in ethanol yields. Additionally, we characterized the natural genetic variation for conversion efficiency in Brachypodium distachyon and shrub willow (Salix spp.).

CONCLUSION

Our results agree with those from previous studies of lignin mutants using enzymatic saccharification-based approaches. However, the use of C. phytofermentans takes into consideration specific organismal interactions, which will be crucial for simultaneous saccharification fermentation or consolidated bioprocessing. The ability to detect such phenotypic variation facilitates the genetic analysis of mechanisms underlying plant feedstock quality.

Extending the clinical research network approach to all of healthcare

The development of Clinical Research Networks (CRN) has been central to the work conducted by Health Departments and research funders to promote and support clinical research within the NHS in the UK. In England, the National Institute for Health Research has supported the delivery of clinical research within the NHS primarily through CRN. CRN provide the essential infrastructure within the NHS for the set up and delivery of clinical research within a high-quality peer-reviewed portfolio of studies. The success of the National Cancer Research Network is summarized in Chapter 5. In this chapter progress in five other topics, and more recently in primary care and comprehensively across the NHS, is summarized. In each of the 'topic-specific' networks (Dementias and Neurodegenerative Diseases, Diabetes, Medicines for Children, Mental Health, Stroke) there has been a rapid and substantial increase in portfolios and in the recruitment of patients into studies in these portfolios. The processes and the key success factors are described. The CRN have worked to support research supported by pharmaceutical, biotechnology and medical device companies and there has been substantial progress in improving the speed, cost and delivery of these 'industry' studies. In particular, work to support the increased speed of set up and delivery of industry studies, and to embed this firmly in the NHS, was explored in the North West of England in an Exemplar Programme which showed substantial reductions in study set-up times and improved recruitment into studies and showed how healthcare (NHS) organizations can overcome delays in set up times when they actively manage the process. Seven out of 20 international studies reported that the first patient to be entered anywhere in the world was from the UK. In addition, the CRN have supported research management and governance, workforce development and clinical trials unit collaboration and coordination. International peer reviews of all of the CRN have been positive and resulted in the continuation of the system for a further 5 years in all cases.

Effect of pentoxifylline on preventing acute kidney injury after cardiac surgery by measuring urinary neutrophil gelatinase - associated lipocalin

Background

Based on Acute Kidney Injury Network (AKIN) criteria, we considered acute kidney injury (AKI) as an absolute increase in the serum creatinine (sCr) level of more than or equal to 0.3 mg/dl or 50%. The introduction of Urinary neutrophil gelatinase-associated lipocalin (UNGAL) has conferred earlier diagnosis of AKI. Pentoxifylline (PTX), a non-specific phosphodiesterase inhibitor, can suppress the production of some factors of inflammatory response and presumably prevent AKI. We examined the PTX on the development of AKI in cardiac surgery patients by measuring the levels of UNGAL.

Materials and methods

We performed a double blind randomized clinical trial, enrolling 28 consecutive patients undergoing elective coronary artery bypass graft (CABG) surgery. Patients were divided into two groups, one to receive PTX 5 mg/kg intravenous bolus injection, followed by 1.5 mg/kg/h continuous intravenous infusion until 3 hours after cessation of CPB and the other group received placebo. UNGAL was measured before, 3 and 24 hours after surgery. In addition serum creatinine was measured before and 24, 48, 72 and 96 hours after surgery and C-reactive protein (CRP) only 24 hours postoperatively.

Results

Both groups did not differ in demographic and baseline characteristics. 12 patients developed AKI 48 hours after surgery; 5 of them were in the intervention group and 7 in the control group (p= 0.445). There was an increase of UNGAL in both groups postoperatively, although not significant. Mean sCr was significantly increased in the control group at 24 and 48 hours after surgery (24-h mean: 0.79 ± 0.18 mg/dl vs. 1.03 ± 0.43 mg/dl, P value = 0.02; 48-h mean: 1.17 ± 0.24 mg/dl vs. 0.98 ± 0.20 mg/dl, P value = 0.03, respectively). PTX had a positive effect in preventing AKI reflecting in changes in sCr, and the increase of UNGAL was consistent with the emergence of AKI (Pearson's correlation = 0.30).

Conclusion

Our study demonstrates a weak correlation between UNGAL and sCr after cardiac surgery. The rise of UNGAL in these patients may be reduced by administration of PTX although we did not show significance. PTX could reduce the occurrence of AKI as determined by attenuation of sCr rise without causing hemodynamic instability or increased bleeding. Overall, we suggest future studies with larger sample sizes to elucidate this effect and determine the different aspects of administrating PTX.

Trial Registration

ISRCTN: IRCT138807302622N1

The HPV vaccination strategy: could male vaccination have a significant impact?

We investigate the potential success of the human papilloma virus (HPV) vaccine, taking into consideration possible waning immunity and the influence of behavioural parameters. We use a compartmental, population-level ordinary differential equation (ODE) model. We find the effective reproductive value for HPV, Re0, which measures the threshold for infection outbreak in a population that is not entirely susceptible, together with infection prevalence. We study the effects of different parameters on both of these quantities. Results show that waning immunity plays a large part in allowing infection to persist. The proportion of the population not sexually active when vaccination occurs affects Re0, as does the rate at which individuals become sexually active. In several cases, infection persists as a result of an infection reservoir in the male cohort. To explore this further, we introduce male vaccination and find the conditions for which vaccination of males could be considered appropriate.

2009 Melbourne metropolitan sewerage strategy: a portfolio of decentralised and on-site concept designs

The bulk and retail water companies of the greater Melbourne area are developing the 2009 Metropolitan Sewerage Strategy to provide sustainable sewerage services to 2060. The objective of the strategy is to establish long term principles and near term actions to produce a robust sewage management system for Melbourne. Melbourne's existing sewerage system is largely centralised and discharges to two major treatment plants. Several small satellite treatment plants service local urban areas generally more distant from the centralised system. Decentralised and on-site wastewater systems are options for future sewage management and could play a role in local recycling. A portfolio of 18 on-site and decentralised concept designs was developed, applicable to the full range of urban development types in Melbourne. The concepts can be used in evaluation of metropolitan system configurations as part of future integrated water cycle planning. The options included secondary and tertiary treatment systems incorporating re-use of water for non potable uses, urine separation, black and greywater separation and composting toilets. On-site and cluster treatment systems were analysed. Each option is described by its indicative capital and operating costs, energy use and water and nutrient balances. This paper summarises and compares the portfolio mix of decentralized and on-site options in Melbourne's context.