The Lucy Thermal Emission Spectrometer (L'TES) Instrument

The Lucy Thermal Emission Spectrometer (L'TES) will provide remote measurements of the thermophysical properties of the Trojan asteroids studied by the Lucy mission. L'TES is build-to-print hardware copy of the OTES instrument flown on OSIRIS-REx. It is a Fourier Transform spectrometer covering the spectral range 5.71-100 μm (1750-100 cm-1) with spectral sampling intervals of 8.64, 17.3, and 34.6 cm-1 and a 7.3-mrad field of view. The L'TES telescope is a 15.2-cm diameter Cassegrain telescope that feeds a flat-plate Michelson moving mirror mounted on a linear voice-coil motor assembly to a single uncooled deuterated l-alanine doped triglycine sulfate (DLATGS) pyroelectric detector. A significant firmware change from OTES is the ability to acquire interferograms of different length and spectral resolution with acquisition times of 0.5, 1, and 2 seconds. A single ∼0.851 μm laser diode is used in a metrology interferometer to provide precise moving mirror control and IR sampling at 772 Hz. The beamsplitter is a 38-mm diameter, 1-mm thick chemical vapor deposited diamond with an antireflection microstructure to minimize surface reflection. An internal calibration cone blackbody target, together with observations of space, provides radiometric calibration. The radiometric precision in a single spectrum is ≤2.2 × 10-8 W cm-2 sr-1 /cm-1 between 300 and 1350 cm-1. The absolute temperature error is <2 K for scene temperatures >75 K. The overall L'TES envelope size is 37.6 × 29.0 × 30.4 cm, and the mass is 6.47 kg. The power consumption is 12.6 W average. L'TES was developed by Arizona State University with AZ Space Technologies developing the electronics. L'TES was integrated, tested, and radiometrically calibrated on the Arizona State University campus in Tempe, AZ. Initial data from space have verified the instrument's radiometric and spatial performance.

Management of recurrent localised bladder amyloid, has methotrexate helped?

Background

Amyloidosis of the bladder is a benign condition which can present with a multitude of symptoms including bladder mass, irritative voiding symptoms and haematuria.

Case presentation

We report on the investigation and management of a patient with recurrent localised amyloidosis of the bladder, which appears to have been managed fortuitously by concurrent methotrexate prescribed for another indication.

Conclusion

We provide further assessment and management with a focus on the possible benefit of methotrexate for management of localised bladder amyloidosis.

Evaluating the cost implications of integrating SARS-CoV-2 genome sequencing for infection prevention and control investigation of nosocomial transmission within hospitals

BACKGROUND

The COG-UK hospital-onset COVID-19 infection (HOCI) trial evaluated the impact of SARS-CoV-2 whole-genome sequencing (WGS) on acute infection, prevention, and control (IPC) investigation of nosocomial transmission within hospitals.

AIM

To estimate the cost implications of using the information from the sequencing reporting tool (SRT), used to determine likelihood of nosocomial infection in IPC practice.

METHODS

A micro-costing approach for SARS-CoV-2 WGS was conducted. Data on IPC management resource use and costs were collected from interviews with IPC teams from 14 participating sites and used to assign cost estimates for IPC activities as collected in the trial. Activities included IPC-specific actions following a suspicion of healthcare-associated infection (HAI) or outbreak, as well as changes to practice following the return of data via SRT.

FINDINGS

The mean per-sample costs of SARS-CoV-2 sequencing were estimated at £77.10 for rapid and £66.94 for longer turnaround phases. Over the three-month interventional phases, the total management costs of IPC-defined HAIs and outbreak events across the sites were estimated at £225,070 and £416,447, respectively. The main cost drivers were bed-days lost due to ward closures because of outbreaks, followed by outbreak meetings and bed-days lost due to cohorting contacts. Actioning SRTs, the cost of HAIs increased by £5,178 due to unidentified cases and the cost of outbreaks decreased by £11,246 as SRTs excluded hospital outbreaks.

CONCLUSION

Although SARS-CoV-2 WGS adds to the total IPC management cost, additional information provided could balance out the additional cost, depending on identified design improvements and effective deployment.

265 A PHYSIOTHERAPY-LED TRANSITION TO HOME INTERVENTION FOR OLDER ADULTS FOLLOWING EMERGENCY DEPARTMENT DISCHARGE: A PILOT FEASIBILITY RANDOMISED-CONTROLLED TRIAL

Background

Older adults frequently attend the Emergency Department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. A presentation to an ED can be viewed as an opportunity to assess those at risk of adverse outcomes and initiate a care plan in those deemed as ‘high risk'. Our aim was to evaluate the feasibility of a physiotherapy led integrated care intervention for older adults discharged from the ED (ED-PLUS).

Methods

Older adults presenting to the ED with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED-PLUS (Trial registration: NCT04983602). ED-PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient’s own home. Feasibility (recruitment and retention rates) and acceptability of the programme were assessed quantitatively and qualitatively. Functional decline was examined post-intervention using the Barthel Index. All outcomes were assessed by a research nurse blinded to group allocation.

Results

29 participants were recruited, indicating 97% of our recruitment target. 90% of participants completed the ED-PLUS intervention. All participants expressed positive feedback about the intervention. The incidence of functional decline at 6 weeks was 10% in the ED-PLUS group versus 70-89% in the usual care and CGA-only groups.

Conclusion

High adherence and retention rates were observed among participants and preliminary findings indicate a lower incidence of functional decline in the ED-PLUS group. Recruitment challenges existed in the context of COVID-19. Data collection is ongoing for six-month outcomes.

Diagnostic utility of canine cerebrospinal fluid preserved by 10% buffered formalin

OBJECTIVES

To examine the diagnostic utility of canine cerebrospinal fluid samples collected into tubes containing ethylenediaminetetraacetic acid (EDTA) with and without the addition of 10% buffered formalin analysed within 6 to 20 hours.

MATERIALS AND METHODS

Inclusion criteria were dogs presenting to a referral hospital with neurological signs and having cerebrospinal fluid analysis performed. Samples were submitted to an external laboratory in tubes containing ethylenediaminetetraacetic acid as paired-samples; one with the addition of one drop of 10% buffered formalin and the other without formalin. Cytology report, total nucleated cell counts, and protein concentration were reviewed. Three different categories of cell preservation were defined: diagnostic, non-diagnostic and unclassified. Each sample was included in one of these categories depending on cytological features, and the diagnostic quality between samples was compared. Samples were further divided in two groups depending on protein concentration using 50 mg/dL as cut-off value and the diagnostic quality between samples was compared.

RESULTS

254 samples from 127 dogs were included. 47% of samples without formalin were non-diagnostic, 46% diagnostic and 6% unclassified. In the formalin group, 2% samples were non-diagnostic, 92% diagnostic and 6% unclassified. Samples with formalin preservation were statistically more likely to be diagnostic than samples without formalin preservation. In both protein groups (≥50 and <50 mg/dL) formalin samples were statistically more likely to be diagnostic as well.

CLINICAL SIGNIFICANCE

The addition of one drop of 10% formalin is a simple, widely available method which can help to improve the accuracy of cytological assessment in canine cerebrospinal fluid by preserving cellular morphology when analysis is performed within 6 to 20 hours.

The SCN5A point mutation M1875T, associated with familial atrial fibrillation, causes a gain-of-function effect of the cardiac Nav1.5 channel in atrial cardiomyocytes

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Leducq Foundation

Background

The point mutation M1875T in the SCN5A gene, which encodes the pore-forming α-subunit of the cardiac voltage-gated Na+ channel Nav1.5, has been associated with familial atrial fibrillation (AF), but its effects on atrial cardiomyocyte electrophysiology is unclear.

Aim

To investigate the effect of the point mutation M1875T on atrial electrophysiological parameters.

Methods

In a novel heterozygous knock-in murine model (Scn5a-M1875T+/-), whole-cell patch clamp electrophysiology was used to investigate Na+ currents in left atrial (LA) cardiomyocytes isolated from hearts of young adult mice (10-16 weeks). LA microelectrode and optical mapping recordings were used to study action potential (AP) characteristics. Cardiac size and function were measured by transthoracic echocardiography. Atrial Scn5a gene and Nav1.5 protein expression were assessed by Rt-PCR and Western blot.

Results

The Na+ current was increased in cardiomyocytes isolated from Scn5a-M1875T+/- LA (wildtype (WT) -22.7 ± 0.9 pA/pF (N = 14, n = 115); Scn5a-M1875T+/- -28.3 ± 1.1 pA/pF (N = 15, n = 117)). Scn5a-M1875T+/- intact isolated superfused LA had an elevated AP amplitude (100 ms pacing cycle length (PCL): WT 86.4 ± 0.9 mV (N = 8, n = 24); Scn5a-M1875T+/- 91.2 ± 0.7 mV (N = 8, n = 25)) and a faster peak upstroke velocity (100 ms PCL: WT 127.98 ± 3.28 mV/ms; Scn5a-M1875T+/- 142.80 ± 3.98 mV/ms). AP duration (APD) was not different apart from a small APD shortening at slow rates. Echocardiography revealed no difference in size and function at the age of investigation. Atrial Scn5a gene and Nav1.5 protein expression were comparable. When challenged with flecainide (1 µM), Scn5a-M1875T+/- LA showed less conduction slowing than WT (100 ms PCL: WT -10.43 ± 1.27 cm/s (N = 12); Scn5a-M1875T+/- -6.10 ± 1.34 cm/s (N = 12)).  5 µM flecainide caused significant increase in WT refractoriness (7/12 atria lost 1:1 capture at PCL ≤ 120 ms) compared to Scn5a-M1875T+/- (1/12).

Conclusion(s): SCN5A point mutation M1875T increases the Na+ current in atrial cardiomyocytes and intact atria, leading to a faster AP upstroke and an attenuated response to flecainide. Abstract Figure 1: Current-Voltage relationship

Cutaneous Plasmacytosis: A Pitfall For B and Plasma Cell Neoplasms

Introduction/Objective

Cutaneous plasmacytosis (CP) is an uncommon condition typically affecting Asian males in the 3rd to 5th decades. It is thought to be a reactive process that classically presents with asymptomatic, red-brown, plaques and nodules on the face and neck. It has been associated with polyclonal hypergammaglobulinemia and systemic involvement. Histologically it is characterized by dense superficial and deep dermal infiltrates of mature plasma cells with polyclonal differentiation on in-situ hybridization (ISH). The differential diagnosis includes neoplastic plasma cell processes, characteristically with monoclonal plasma cell infiltrate, and mature B cell neoplasms with polyclonal plasma cell differentiation.

Methods

We report a case of a 69 year old Caucasian male who presented with asymptomatic, enlarging red-brown nodules on bilateral nasal ala. Histologic examination revealed dense, superficial plasma cell infiltrate, concerning for a plasma cell neoplasm. CD138 and Kappa/Lambda ISH demonstrated plasma cell polyclonality. Further workup ruled out infectious or systemic involvement and a plasma cell dyscrasia was ruled out by Hematology/Oncology.

Results

These findings supported the diagnosis of CP. Treatment with intralesional steroids showed initial improvement with regrowth of the nodules. To date, treatment with topical steroids and CO2 laser ablation are being considered.

Conclusion

CP is reported as type of pseudolymphoma, which is described as a reactive lymphoproliferation that histopathologically and/or clinically imitates cutaneous lymphoma. The pathogenesis is unknown, however, there are studies suggesting an association with increased interleukin-6, which is involved in the differentiation of B cells to mature plasma cells. The majority of patients with CP have a favorable prognosis. There has been variable success with both topical and intralesional treatment to include, cyclophosphamide, topical tacrolimus, prednisone, intralesional steroid therapy, topical psoralens combined with ultraviolet A exposure, and other chemotherapies. Familiarity with this rare entity is imperative to prevent misdiagnosis and overtreatment.

Imerslund-Grasbeck syndrome in a cross-breed dog

Imerslund-Gräsbeck syndrome is an autosomal recessive disease reported only in certain pure-breed dogs. An 18-month-old, male neutered beagle cross-breed was presented for evaluation of severe lethargy, progressive weakness and anorexia. Main clinicopathological findings included low body condition score (2.5/9), severe muscle atrophy, several neurological abnormalities, mild normochromic, normocytic, non-regenerative anaemia, severe hypocobalaminemia and mild proteinuria. Extensive diagnostic tests ruled out most of differential diagnoses for the aforementioned clinicopathological abnormalities and genetic evaluation showed that the dog was heterozygous for two previously described mutations affecting the CUBN gene, the beagle and the border collie variants. The dog showed an excellent clinical response to oral cobalamin supplementation with no relapse after 4 months. In conclusion, this case creates awareness that Imerslund-Gräsbeck syndrome should be considered even in mixed-breed dogs with compatible clinical signs and that two different pathogenic CUBN mutations in compound heterozygosity can lead to a typical Imerslund-Gräsbeck syndrome phenotype.

Sara Alert: An enduring national resource to support public health monitoring & disease containment

Background

Public health agencies had to respond swiftly to the novel coronavirus that emerged in 2019 (COVID-19) to try to contain the virus, which requires early identification of new cases. Monitoring exposed individuals is labor intensive and available tools are often limited. MITRE, a company that operates federally funded research and development centers for the U.S. government, rapidly developed a configurable monitoring tool that allows public health authorities to monitor potentially exposed individuals in their jurisdictions.

Methods

A team, including public health leaders, field epidemiologists, software engineers, and health communication specialists, was quickly assembled to design and develop an open source, disease-independent monitoring tool called Sara Alert. Outreach to key public health stakeholders, including partner organizations and local and state health departments, was conducted early for requirements gathering and to validate assumptions. Public health law experts were consulted regarding data privacy and security.

Results

By four weeks, a minimally viable monitoring tool was available for testing by public health partners. Exposed individuals can be enrolled and reminded daily to enter a temperature and any symptoms by web or mobile interface, SMS messaging or phone. Public health officials monitor and can quickly take action if symptoms consistent with COVID-19 are reported of if there is failure to report within a configurable time frame. Dashboards provide insight into aggregated data appropriate to level of view.

Conclusions

Sara Alert serves as a force multiplier that supports disease containment and allows resources to be directed where they are most needed. Successful development was possible because key stakeholders across public health practice were consulted early. Sara Alert is available, free, to state and local public health departments and serves as an enduring resource easily configured for the next public health emergency.

Key messages

Sara Alert serves as a force multiplier that supports disease containment and allows resources to be directed where they are most needed.

Sara Alert serves as an enduring resource easily configured for the next public health emergency.

Building resilient and responsive research collaborations to tackle antimicrobial resistance-Lessons learnt from India, South Africa, and UK

Research, collaboration, and knowledge exchange are critical to global efforts to tackle antimicrobial resistance (AMR). Different healthcare economies are faced with different challenges in implementing effective strategies to address AMR. Building effective capacity for research to inform AMR-related strategies and policies is recognised as an important contributor to success. Interdisciplinary, intersector, as well as international collaborations are needed to span global to local efforts to tackle AMR. The development of reciprocal, long-term partnerships between collaborators in high-income and in low- and middle-income countries (LMICs) needs to be built on principles of capacity building. Using case studies spanning local and international research collaborations to codesign, implement, and evaluate strategies to tackle AMR, we have evaluated and build upon the ESSENCE criteria for capacity building in LMICs. The first case study describes the local codesign and implementation of antimicrobial stewardship (AMS) in the state of Kerala in India. The second case study describes an international research collaboration investigating AMR surgical patient pathways in India, the UK, and South Africa. We describe the steps undertaken to develop robust, agile, and flexible AMS research and implementation teams. Notably, investing in capacity building ensured that the programmes described in these case studies were sustained through the current severe acute respiratory syndrome coronavirus pandemic. Describing the strategies adopted by a local and an international collaboration to tackle AMR, we provide a model for capacity building in LMICs that can support sustainable and agile AMS programmes.

A systematic scoping review of multidisciplinary cancer team and decision-making in the management of men with advanced prostate cancer

PURPOSE

The early diagnosis of prostate cancer and subsequent access to the treatment options helps to achieve optimal cancer outcomes. As the treatment options for patients with advanced prostate cancer continues to evolve, patients need to access a multidisciplinary team (MDT) meeting to receive best-practice care.

METHODS

In this paper a MEDLINE review was performed to assess clinical decision making in the context of MDT discussions for patients with advanced prostate cancer.

RESULTS

From 441 returned articles and abstracts, 50 articles were assessed for eligibility and 16 articles included for analysis. Sixteen articles were identified, 9 of the 16 articles used quantitative methodology including three retrospective analysis of clinical registry data, patient medical records and/or MDT meeting notes and three cross-sectional surveys. Other study designs included one observation study and one study using a combination of qualitative and quantitative methodologies and one mini-review. There were also four editorials included in the review and two consensus statements.

CONCLUSION

This paper highlights the important role the inter-disciplinary MDT has on shared decision making for men with advanced prostate cancer. The application of MDT care is a rapidly growing trend in uro-oncology and an efficient MDT service requires further research to assess its efficiency so that it may expand through all aspect of uro-oncology.

The Portsmouth protocol for intra-operative ultrasound of the small bowel in Crohn's disease

AIM

Bowel preservation is paramount in Crohn's disease surgery as affected patients are typically young adults at risk of having several abdominal surgical procedures during their lifetime. Intra-operative assessment of the extent and location of Crohn's disease is not standardized and is left to a mixture of the surgeon's experience, tactile feedback, macroscopic appearance and preoperative imaging. The aim of this study was to describe the technical steps of a standardized protocol for intra-operative ultrasound assessment of the small bowel in patients undergoing surgery for ileocolic Crohn's disease.

METHOD

After laparoscopic mobilization of the bowel, a periumbilical incision is performed for extracorporeal division of the mesentery and the resection and anastomosis. A gastrointestinal consultant radiologist, with expertise in Crohn's disease imaging and abdominal ultrasound, performs full intra-operative assessment of the small bowel by applying a sterile ultrasound probe directly to the bowel, prior to resection being performed by the surgeon. The bowel is assessed through the wound protector with a sterile technique and the length, location and number of segments is documented together with further quantitative assessment using the METRIC (MR enterography or ultrasound in Crohn's disease) scoring guide.

RESULTS

A step-by-step protocol for intra-operative ultrasound evaluation of the entire small bowel is described.

CONCLUSIONS

A standardized approach to intra-operative evaluation of the extent and location of Crohn's disease is desirable. Intra-operative ultrasound may provide added value for assessment of proximal and multifocal Crohn's disease.

How do surgeons feel about the 'Getting it Right First Time' national audit? Results from a qualitative assessment

The implementation of the national 'Getting It Right First Time' was assessed by interviewing six surgeons involved at various levels in surgical site infection (SSI) audit. The positive impacts were to create new professional collaboration, improve stakeholder engagement, and increase the profile of SSIs. One particular knowledge gap highlighted was that some participants had been unaware until that point of the criteria for diagnosing an SSI. The quality of data collected was felt to be poor due to methodological flaws. The audit was described as highly time-consuming and unsustainable if leaning on junior surgeons, without protected time and designated responsibility.

Evaluating a digital sepsis alert in a multi-site hospital: a natural experiment

Background

This study investigated the impact of a digital sepsis alert on patient outcomes in a busy London multi-site hospital. Sepsis is a serious illness and common cause of death, but rapid diagnosis and treatment improve patient outcomes. Digital health records allow algorithms to be embedded which ‘alert’ clinicians to patients who are at risk of developing sepsis. Despite the current promotion of ‘digital health’, evidence of the impact of algorithm driven alerts on patient outcomes is limited.

Methods

A retrospective natural experiment utilising the phased introduction of a digital sepsis alert into a large, multi-site hospital in England. Silent alerts (not visible to clinicians) acted as controls. Outcome measures were in-hospital all-cause mortality within 30 days of the alert, extended hospital stay (≥7 days) and timely antibiotics (≤60 minutes of the alert). Inversely weighted multivariable logistic regression was used to determine associations between alert and patient outcomes.

Results

In a sample of 21,183 inpatients, the mortality rate was 5.9%. The active, visible alert was associated with lower odds of death (Odds Ratio (OR):0.76; 95%CI:(0.70, 0.84)). In 9988 emergency department attendances ending in admission, 40.6% had an extended hospital stay and 41.5% received timely antibiotics. The active alert was associated with lower odds of extended hospital stay (OR:0.93; 95%CI:(0.88, 0.99)) and increased odds of receiving timely antibiotics (OR:1.71; 95%CI:(1.57, 1.87)).

Conclusions

This study demonstrates that a move to digital health, through an automated sepsis alert, embedded in digital health records, was associated with improved health outcomes. Further work is needed to identify the causal pathway, which is likely to include more rapid treatment with antibiotics, and possible unintended consequences. These findings support the ongoing roll out of digital alerting and provide a model for robustly evaluating their impact.

Key messages

The introduction of an automated sepsis alert associated with the use of improvement methodology was associated with improved process measures and patient outcomes. Introduction of digital health interventions can, and should, be robustly evaluated with appropriate statistical approaches.

P6011NKX2-5 contributes to EndoMT and endothelial dysfunction in pulmonary arterial hypertension

Background

The onset of inflammation, hypoxia or shear stress within blood vessels can result in endothelial-to-mesenchymal transition (EndoMT), a disease-associated process where endothelial cells (ECs) downregulate endothelial markers and acquire mesenchymal features. EndoMT is observed in patients with scleroderma-associated pulmonary hypertension (SSc-PAH), which have the highest mortality amongst all the scleroderma patient subgroups. The homeobox transcriptional factor NKX2-5 is fundamental for cardiovascular development. However, NKX2-5 expression has not been reported yet in ECs of adult pulmonary blood vessels.

Purpose

To investigate the role of NKX2-5 in the pulmonary endothelium of SSc-PAH.

Methods

Human pulmonary artery endothelial cells (HPAECs) were treated with a cocktail of TGF-β (5 ng/mL), TNF-α (5 ng/mL), and IL-1β (0.1 ng/mL) for 5 days. Immunofluorescence was used to detect NKX2-5 and other markers in ECs. Western blotting and qPCR evaluated, respectively, protein and gene expression. Lentiviral transduction forced NKX2-5 expression in the cells. Transendothelial electrical resistance (TEER) measurements evaluated endothelial barrier function. Pharmacological inhibition was performed to determine the pathways that lead to NKX2-5 activation. Casein kinase 2 (CK2)-inhibition (CX4945) of a chronic hypoxia mouse model of PAH was used to assess right ventricular systolic pressure (RVSP).

Results

Immunofluorescence showed a strong expression of NKX2-5 in the endothelium of SSc-PAH human lungs (p<0.0001). Western blot analysis demonstrated a 5.3-fold downregulation of CD31 (p<0.001), and an increased production of NKX2-5 (5.6-fold, p<0.0001) and of Procollagen I (12-fold, p=0.0009) after 5 days of cytokine stimulation on HPAECs. Relative mRNA expression has shown a 3-fold gene downregulation of CD31 (p=0.0002) and a reduction of VE-Cadherin (2.3-fold, p=0.0008) and of vWF (10.4-fold, p=0.003) in EndoMT, whereas gene expression of COL1α2 (8.5-fold, p<0.0001) and of NKX2-5 (1.5-fold, p=0.003) were upregulated. Immunofluorescence of cells has revealed a decreased VE-Cadherin expression concomitant with upregulation of NKX2-5 in EndoMT cells. Forced expression of NKX2-5 downregulated endothelial markers and endothelial barrier function was impaired whereas proliferation rate of cells was increased. Inhibition of PI3K, ERK5, ALK5 and CK2 reduced NKX2-5 protein expression within cells. CK2-inhibited mice under hypoxia conditions resembled the normoxia mice group by normalising RVSP.

Conclusion

HPAECs undergoing EndoMT express NKX2-5 in vitro and in vivo, via mediation of CK2, TGF-β, ERK5 and PI3K signalling. NKX2-5 downregulates key adherence junctional proteins, disrupting endothelial barrier function. This study highlights the involvement of NKX2-5 in EndoMT and in endothelial dysfunction, leading to vascular disease progression in SSc-PAH.

Acknowledgement/Funding

British Heart Foundation, Arthritis Research UK, Scleroderma Research UK and Royal Free Hospital Charity

The impact of neurally adjusted ventilatory assist mode on respiratory severity score and energy expenditure in infants: a randomized crossover trial

OBJECTIVE

Examine respiratory severity scores (RSS) (mean airway pressure × fraction of inspired oxygen) and resting energy expenditure (REE) on neurally adjusted ventilatory assist (NAVA) compared with synchronized intermittent mandatory ventilation with pressure controlled and supported breath (SIMV (PC)PS).

STUDY DESIGN

A randomized, crossover trial in a level IV neonatal intensive care unit. Twenty-four patients were ventilated with NAVA or SIMV (PC) PS for 12 h and then crossed over to the alternative mode for 12 h. The primary outcome (RSS) and additional secondary respiratory outcomes were analyzed.

RESULTS

RSS and measured REE were not different between modes. On NAVA, peak inspiratory pressures were lower (17.8 vs 19.9 cmH₂O (P<0.05)) without higher oxygen requirements. Respiratory rates were higher on NAVA (52 vs 39 (P<0.05)), estimated work of breathing (WOB) (0.01 vs 0.04 J l^-1 (P<0.05)) was improved.

CONCLUSION

NAVA mode can be safe without increase in RSS or REE. Although respiratory rates were higher, this was offset by lower peak inspiratory pressures and WOB during NAVA.

Clinical and pathological feature of bone marrow granulomas: A modern Australian series

INTRODUCTION

Marrow granulomas have been commonly associated with mycobacterial infections, prompting extensive investigations in some cases where they are found, but in the setting of changing infectious epidemiology, there is a lack of recent data to guide the search for probable causes.

METHODS

A retrospective case series examining the clinical and pathological findings in all cases where marrow granulomas were reported over a 10-year period at The Canberra Hospital, Australia.

RESULTS

Of the 6062 marrow biopsies performed, 73 (1.2%) from 66 individuals had confirmed granulomas. Some patients had multiple potential causes found. B-cell non-Hodgkin Lymphoma, sarcoidosis and autoimmune disease were the most frequently observed causes. Infections were less common in this cohort than in the previous series, with no tuberculosis seen. The presence of granulomas in the marrow did not signify the presence of active malignancy in the marrow. There were no associations with any specific morphological characteristics of the granulomas and the presumed causes.

CONCLUSION

Marrow granulomas are seen in a variety conditions. Neither their presence nor their morphological features are a guide to further investigations, which should be determined by the clinical presentation as appropriate.

Opportunities for system level improvement in antibiotic use across the surgical pathway

Optimizing antibiotic prescribing across the surgical pathway (before, during, and after surgery) is a key aspect of tackling important drivers of antimicrobial resistance and simultaneously decreasing the burden of infection at the global level. In the UK alone, 10 million patients undergo surgery every year, which is equivalent to 60% of the annual hospital admissions having a surgical intervention. The overwhelming majority of surgical procedures require effectively limited delivery of antibiotic prophylaxis to prevent infections. Evidence from around the world indicates that antibiotics for surgical prophylaxis are administered ineffectively, or are extended for an inappropriate duration of time postoperatively. Ineffective antibiotic prophylaxis can contribute to the development of surgical site infections (SSIs), which represent a significant global burden of disease. The World Health Organization estimates SSI rates of up to 50% in postoperative surgical patients (depending on the type of surgery), with a particular problem in low- and middle-income countries, where SSIs are the most frequently reported healthcare-associated infections. Across European hospitals, SSIs alone comprise 19.6% of all healthcare-acquired infections. Much of the scientific research in infection management in surgery is related to infection prevention and control in the operating room, surgical prophylaxis, and the management of SSIs, with many studies focusing on infection within the 30-day postoperative period. However it is important to note that SSIs represent only one of the many types of infection that can occur postoperatively. This article provides an overview of the surgical pathway and considers infection management and antibiotic prescribing at each step of the pathway. The aim was to identify the implications for research and opportunities for system improvement.

The neural basis of reversal learning: An updated perspective

Reversal learning paradigms are among the most widely used tests of cognitive flexibility and have been used as assays, across species, for altered cognitive processes in a host of neuropsychiatric conditions. Based on recent studies in humans, non-human primates, and rodents, the notion that reversal learning tasks primarily measure response inhibition, has been revised. In this review, we describe how cognitive flexibility is measured by reversal learning and discuss new definitions of the construct validity of the task that are serving as a heuristic to guide future research in this field. We also provide an update on the available evidence implicating certain cortical and subcortical brain regions in the mediation of reversal learning, and an overview of the principal neurotransmitter systems involved.

2-arachidonoylglycerol signaling impairs short-term fear extinction

Impairments in fear extinction are thought to be central to the psychopathology of posttraumatic stress disorder, and endocannabinoid (eCB) signaling has been strongly implicated in extinction learning. Here we utilized the monoacylglycerol lipase inhibitor JZL184 to selectively augment brain 2-AG levels combined with an auditory cue fear-conditioning paradigm to test the hypothesis that 2-AG-mediated eCB signaling modulates short-term fear extinction learning in mice. We show that systemic JZL184 impairs short-term extinction learning in a CB1 receptor-dependent manner without affecting non-specific freezing behavior or the acquisition of conditioned fear. This effect was also observed in over-conditioned mice environmentally manipulated to re-acquire fear extinction. Cumulatively, the effects of JZL184 appear to be partly due to augmentation of 2-AG signaling in the basolateral nucleus of the amygdala (BLA), as direct microinfusion of JZL184 into the BLA produced similar results. Moreover, we elucidate a short ~3-day temporal window during which 2-AG augmentation impairs extinction behavior, suggesting a preferential role for 2-AG-mediated eCB signaling in the modulation of short-term behavioral sequelae to acute traumatic stress exposure.

Defining the user role in infection control

BACKGROUND

Health policy initiatives continue to recognize the valuable role of patients and the public in improving safety, advocating the availability of information as well as involvement at the point of care. In infection control, there is a limited understanding of how users interpret the plethora of publicly available information about hospital performance, and little evidence to support strategies that include reminding healthcare staff to adhere to hand hygiene practices.

AIM

To understand how users define their own role in patient safety, specifically in infection control.

METHODS

Through group interviews, self-completed questionnaires and scenario evaluation, user views of 41 participants (15 carers and 26 patients with recent experience of inpatient hospital care in London, UK) were collected and analysed. In addition, the project's patient representative performed direct observation of the research event to offer inter-rater reliability of the qualitative analysis.

FINDINGS

Users considered evidence of systemic safety-related failings when presented with hospital choices, and did not discount hospitals with high ('red' flagged) rates of meticillin-resistant Staphylococcus aureus. Further, users considered staff satisfaction within the workplace over and above user satisfaction. Those most dissatisfied with the care they received were unlikely to ask staff, 'Have you washed your hands?'

CONCLUSION

This in-depth qualitative analysis of views from a relatively informed user sample shows 'what matters', and provides new avenues for improvement initiatives. It is encouraging that users appear to take a holistic view of indicators. There is a need for strategies to improve dimensions of staff satisfaction, along with understanding the implications of patient satisfaction.

Placental expression of imprinted genes varies with sampling site and mode of delivery

Imprinted genes, which are monoallelically expressed by virtue of an epigenetic process initiated in the germline, are known to play key roles in regulating fetal growth and placental development. Numerous studies are investigating the expression of these imprinted genes in the human placenta in relation to common complications of pregnancy such as fetal growth restriction and preeclampsia. This study aimed to determine whether placental sampling protocols or other factors such as fetal sex, gestational age and mode of delivery may influence the expression of imprinted genes predicted to regulate placental signalling.

METHODS

Term placentas were collected from Caucasian women delivering at University Hospital of Wales or Royal Gwent Hospital within two hours of delivery. Expression of the imprinted genes PHLDA2, CDKN1C, PEG3 and PEG10 was assayed by quantitative real time PCR. Intraplacental gene expression was analysed (N = 5). Placental gene expression was compared between male (N = 11) and female (N = 11) infants, early term (N = 8) and late term (N = 10) deliveries and between labouring (N = 13) and non-labouring (N = 21) participants.

RESULTS

The paternally expressed imprinted genes PEG3 and PEG10 were resilient to differences in sampling site, fetal sex, term gestational age and mode of delivery. The maternally expressed imprinted gene CDKN1C was elevated over 2-fold (p < 0.001) in placenta from labouring deliveries compared with elective caesarean sections. In addition, the maternally expressed imprinted gene PHLDA2 was elevated by 1.8 fold (p = 0.01) in samples taken at the distal edge of the placenta compared to the cord insertion site.

CONCLUSION

These findings support the reinterpretation of existing data sets on these genes in relation to complications of pregnancy and further reinforce the importance of optimising and unifying placental collection protocols for future studies.

Pharmacology of cognitive enhancers for exposure-based therapy of fear, anxiety and trauma-related disorders

Pathological fear and anxiety are highly debilitating and, despite considerable advances in psychotherapy and pharmacotherapy they remain insufficiently treated in many patients with PTSD, phobias, panic and other anxiety disorders. Increasing preclinical and clinical evidence indicates that pharmacological treatments including cognitive enhancers, when given as adjuncts to psychotherapeutic approaches [cognitive behavioral therapy including extinction-based exposure therapy] enhance treatment efficacy, while using anxiolytics such as benzodiazepines as adjuncts can undermine long-term treatment success. The purpose of this review is to outline the literature showing how pharmacological interventions targeting neurotransmitter systems including serotonin, dopamine, noradrenaline, histamine, glutamate, GABA, cannabinoids, neuropeptides (oxytocin, neuropeptides Y and S, opioids) and other targets (neurotrophins BDNF and FGF2, glucocorticoids, L-type-calcium channels, epigenetic modifications) as well as their downstream signaling pathways, can augment fear extinction and strengthen extinction memory persistently in preclinical models. Particularly promising approaches are discussed in regard to their effects on specific aspects of fear extinction namely, acquisition, consolidation and retrieval, including long-term protection from return of fear (relapse) phenomena like spontaneous recovery, reinstatement and renewal of fear. We also highlight the promising translational value of the preclinial research and the clinical potential of targeting certain neurochemical systems with, for example d-cycloserine, yohimbine, cortisol, and L-DOPA. The current body of research reveals important new insights into the neurobiology and neurochemistry of fear extinction and holds significant promise for pharmacologically-augmented psychotherapy as an improved approach to treat trauma and anxiety-related disorders in a more efficient and persistent way promoting enhanced symptom remission and recovery.

Syndromic surveillance of surgical site infections--a case study in coronary artery bypass graft patients

OBJECTIVE

There is a wealth of data routinely collected and stored by healthcare facilities, which are not consistently exploited for surveillance of healthcare associated infections (HCAI). Syndromic surveillance has not yet been widely applied to HCAI. This study aimed to create syndromic surveillance for surgical site infections (SSI) following coronary artery bypass graft (CABG) procedures.

METHODS

A cohort of CABG patients from Imperial College Healthcare NHS Trust was investigated. Data from the local Patient Administration System, Laboratory Information Management System, radiology department, cardiac registry and Health Protection Agency SSI surveillance were linked. This data was explored for biological markers and proxies of infection, which were used to develop syndromic surveillance algorithms; sensitivity analysis was used to determine the best algorithms.

RESULTS

303 patients were included, with a SSI incidence of 6.6%. Wound culture requests, raised platelet and fibrinogen levels were all found to be good indicators of SSI. Two algorithms were generated, one to detect all SSI (sensitivity: 90%; specificity: 93.8%) and one to detect organ space infections specifically (sensitivity: 100%; specificity: 98.5%).

CONCLUSION

Data which is routinely collected and stored in healthcare facilities can be used for syndromic surveillance of SSI, allowing for an efficient surveillance system without the need for resource intensive data collection.

Genome-wide single nucleotide polymorphism-based assay for high-resolution epidemiological analysis of the methicillin-resistant Staphylococcus aureus hospital clone EMRSA-15

The EMRSA-15 clone is a major cause of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infections in the UK and elsewhere but existing typing methodologies have limited capacity to discriminate closely related strains, and are often poorly reproducible between laboratories. Here, we report the design, development and validation of a genome-wide single nucleotide polymorphism (SNP) typing method and compare it to established methods for typing of EMRSA-15. In order to identify discriminatory SNPs, the genomes of 17 EMRSA-15 strains, selected to represent the breadth of genotypic and phenotypic diversity of EMRSA-15 isolates in Scotland, were determined and phylogenetic reconstruction was carried out. In addition to 17 phylogenetically informative SNPs, five binary markers were included to form the basis of an EMRSA-15 genotyping assay. The SNP-based typing assay was as discriminatory as pulsed-field gel electrophoresis, and significantly more discriminatory than staphylococcal protein A (spa) typing for typing of a representative panel of diverse EMRSA-15 strains, isolates from two EMRSA-15 hospital outbreak investigations, and a panel of bacteraemia isolates obtained in healthcare facilities in the east of Scotland during a 12-month period. The assay is a rapid, and reproducible approach for epidemiological analysis of EMRSA-15 clinical isolates in Scotland. Unlike established methods the DNA sequence-based method is ideally suited for inter-laboratory comparison of identified genotypes, and its flexibility lends itself to supplementation with additional SNPs or markers for the identification of novel S. aureus strains in other regions of the world.

The increasing role of pharmacists in antimicrobial stewardship in English hospitals

OBJECTIVES

To evaluate the development of pharmacist-led antimicrobial stewardship activities in English hospitals.

METHODS

Distribution of an electronic questionnaire to antimicrobial pharmacists or chief pharmacists in National Health Service hospitals in England.

RESULTS

Since a previous study, in 2005, overall numbers of specialist antimicrobial pharmacists, and their levels of experience, had increased. Over 95% of hospitals provided empirical usage guidance, antimicrobial formularies and surgical prophylaxis guidelines. Two-thirds of pharmacy departments provided antimicrobial usage reports in terms of defined daily doses at least yearly, and over 80% conducted yearly antimicrobial point prevalence studies. The vast majority of pharmacy departments indicated a willingness to supply data and audit results to a national database for benchmarking purposes.

CONCLUSIONS

The increasing role of specialist pharmacists and general pharmacists in antibiotic stewardship in acute care in England has enabled hospitals to deliver on the antibiotic stewardship agenda, although opportunity remains to expand this role further and ensure greater multidisciplinary engagement.

Understanding the determinants of antimicrobial prescribing within hospitals: the role of "prescribing etiquette"

Prescribing etiquette is an important determinant of antimicrobial prescribing behaviors. Prescribing etiquette recognizes clinical decision-making autonomy and the role of hierarchy in influencing practice. Existing clinical groups and clinical leadership should be utilized to influence antimicrobial prescribing behaviors.

Background. There is limited knowledge of the key determinants of antimicrobial prescribing behavior (APB) in hospitals. An understanding of these determinants is required for the successful design, adoption, and implementation of quality improvement interventions in antimicrobial stewardship programs.

Methods. Qualitative semistructured interviews were conducted with doctors (n = 10), pharmacists (n = 10), and nurses and midwives (n = 19) in 4 hospitals in London. Interviews were conducted until thematic saturation was reached. Thematic analysis was applied to the data to identify the key determinants of antimicrobial prescribing behaviors.

Results. The APB of healthcare professionals is governed by a set of cultural rules. Antimicrobial prescribing is performed in an environment where the behavior of clinical leaders or seniors influences practice of junior doctors. Senior doctors consider themselves exempt from following policy and practice within a culture of perceived autonomous decision making that relies more on personal knowledge and experience than formal policy. Prescribers identify with the clinical groups in which they work and adjust their APB according to the prevailing practice within these groups. A culture of “noninterference” in the antimicrobial prescribing practice of peers prevents intervention into prescribing of colleagues. These sets of cultural rules demonstrate the existence of a “prescribing etiquette,” which dominates the APB of healthcare professionals. Prescribing etiquette creates an environment in which professional hierarchy and clinical groups act as key determinants of APB.

Conclusions. To influence the antimicrobial prescribing of individual healthcare professionals, interventions need to address prescribing etiquette and use clinical leadership within existing clinical groups to influence practice.