Metagenomes from microbial populations beneath a chromium waste tip give insight into the mechanism of Cr (VI) reduction

Dumped Chromium Ore Processing Residue (COPR) at legacy sites poses a threat to health through leaching of toxic Cr(VI) into groundwater. Previous work implicates microbial activity in reducing Cr(VI) to less mobile and toxic Cr(III), but the mechanism has not been explored. To address this question a combined metagenomic and geochemical study was undertaken. Soil samples from below the COPR waste were used to establish anaerobic microcosms which were challenged with Cr(VI), with or without acetate as an electron donor, and incubated for 70 days. Cr was rapidly reduced in both systems, which also reduced nitrate, nitrite then sulfate, but this sequence was accelerated in the acetate amended microcosms. 16S rRNA gene sequencing revealed that the original soil sample was diverse but both microcosm systems became less diverse by the end of the experiment. A high proportion of 16S rRNA gene reads and metagenome-assembled genomes (MAGs) with high completeness could not be taxonomically classified, highlighting the distinctiveness of these alkaline Cr impacted systems. Examination of the coding capacity revealed widespread capability for metal tolerance and Fe uptake and storage, and both populations possessed metabolic capability to degrade a wide range of organic molecules. The relative abundance of genes for fatty acid degradation was 4× higher in the unamended compared to the acetate amended system, whereas the capacity for dissimilatory sulfate metabolism was 3× higher in the acetate amended system. We demonstrate that naturally occurring in situ bacterial populations have the metabolic capability to couple acetate oxidation to sequential reduction of electron acceptors which can reduce Cr(VI) to less mobile and toxic Cr(III), and that microbially produced sulfide may be important in reductive precipitation of chromate. This capability could be harnessed to create a Cr(VI) trap-zone beneath COPR tips without the need to disturb the waste.

Validation of remote child weight and height measurements within a weight management trial

OBJECTIVE

The aim of this substudy within the Treatment Efforts Addressing Child Weight Management by Unifying Patients, Parents, and Providers (TEAM UP) pragmatic clinical trial was to compare the validity of anthropometric measurements collected remotely versus in person (≤7 days apart) among youth with obesity who were 6 to 15 years of age.

METHODS

Child (n = 37) weight and height were measured in person by a trained data assessor. These were compared with measurements taken remotely by the child's parent with live videoconferencing observation by a study data assessor. In-person and remote measurements were compared using Bland-Altman plots, Pearson correlations, and two one-sided paired t tests. A priori bounds of acceptability were set at ±0.68 kg to allow for typical weight fluctuations within the 7-day comparison period.

RESULTS

Measurements were highly correlated (height: r = 0.991, p < 0.0001; weight: r = 0.999; p = 0.03). For height, two one-sided t tests for upper, t(36) = 3.95, and lower, t(36) = -2.63, bounds (-1, 1) revealed an overall p = 0.006; absolute error was 3.5 cm. For weight, two one-sided t tests for upper, t(36) = 1.93, and lower, t(36) = -7.91, bounds (-0.68, 0.68) revealed an overall p = 0.03; absolute error was 1.7 kg.

CONCLUSIONS

The present findings support the utility and interpretation of remotely assessed weight management outcomes for both research and clinical purposes. These procedures may offer greater accessibility to evidence-based measurement.

A pragmatic trial of a family-centered approach to childhood obesity treatment: Rationale and study design

BACKGROUND

Family-based behavioral treatment (FBT) is an effective intensive health behavior and lifestyle treatment for obesity reduction in children and adolescents, but families have limited access. The purpose of this randomized, pragmatic, comparative effectiveness trial was to examine changes in child relative weight in a 12-month, enhanced standard of care (eSOC) intervention combined with FBT (eSOC+FBT) vs. eSOC alone.

METHODS

Children aged 6 to 15 years with obesity, and their primary caregiver, were recruited from primary care clinics. Families were randomized 1:1 to eSOC, a staged approach led by the primary care provider that gradually intensified dependent on a child's response to care and aligns with the American Medical Association guidelines, or the eSOC+FBT arm, which included regular meetings with a health coach for healthy eating, physical activity, positive parenting strategies, and managing social and environmental cues. Both treatments align with the 2023 American Academy of Pediatrics clinical practice guidelines. Assessments occurred at baseline, midpoint (month 6), end-of-intervention (month 12), and follow-up (month 18). Primary outcome was change from baseline to 12 months in child percent overweight (percentage above the median body mass index in the general US population normalized for age and sex). Secondary outcomes were parent weight, child psychosocial factors, heterogeneity of treatment effects, and cardiometabolic risk factors. Exploratory outcomes assessed reach, effectiveness, adoption, implementation, and maintenance.

CONCLUSION

This pragmatic trial will generate evidence for the comparative effectiveness of implementing two guidelines-based approaches in primary care for obesity reduction in children and adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03843424.

Prospects for developing allergen-depleted food crops

In addition to the challenge of meeting global demand for food production, there are increasing concerns about food safety and the need to protect consumer health from the negative effects of foodborne allergies. Certain bio-molecules (usually proteins) present in food can act as allergens that trigger unusual immunological reactions, with potentially life-threatening consequences. The relentless working lifestyles of the modern era often incorporate poor eating habits that include readymade prepackaged and processed foods, which contain additives such as peanuts, tree nuts, wheat, and soy-based products, rather than traditional home cooking. Of the predominant allergenic foods (soybean, wheat, fish, peanut, shellfish, tree nuts, eggs, and milk), peanuts (Arachis hypogaea) are the best characterized source of allergens, followed by tree nuts (Juglans regia, Prunus amygdalus, Corylus avellana, Carya illinoinensis, Anacardium occidentale, Pistacia vera, Bertholletia excels), wheat (Triticum aestivum), soybeans (Glycine max), and kidney beans (Phaseolus vulgaris). The prevalence of food allergies has risen significantly in recent years including chance of accidental exposure to such foods. In contrast, the standards of detection, diagnosis, and cure have not kept pace and unfortunately are often suboptimal. In this review, we mainly focus on the prevalence of allergies associated with peanut, tree nuts, wheat, soybean, and kidney bean, highlighting their physiological properties and functions as well as considering research directions for tailoring allergen gene expression. In particular, we discuss how recent advances in molecular breeding, genetic engineering, and genome editing can be used to develop potential low allergen food crops that protect consumer health.

Bifidobacterium adolescentis - a beneficial microbe

Bifidobacterium adolescentis is one of the most abundant bifidobacterial species in the human large intestine, and is prevalent in 60-80% of healthy human adults with cell densities ranging from 109-1010 cells/g of faeces. Lower abundance is found in children and in elderly individuals. The species is evolutionary adapted to fermenting plant-derived glycans and is equipped with an extensive sugar transporter and degradation enzymes repertoire. Consequently, the species is strongly affected by dietary carbohydrates and is able to utilize a wide range of prebiotic molecules. B. adolescentis is specialized in metabolizing resistant starch and is considered a primary starch degrader enabling growth of other beneficial bacteria by cross-feeding. The major metabolic output is acetate and lactate in a ratio of 3:2. Several health-beneficial properties have been demonstrated in certain strains of B. adolescentis in vitro and in rodent models, including enhancement of the intestinal barrier function, anti-inflammatory and immune-regulatory effects, and the production of neurotransmitters (GABA), and vitamins. Although causalities have not been established, reduced abundance of B. adolescentis as part of a dysbiotic colonic microbiota in human observational studies has been associated with inflammatory bowel diseases, irritable bowel syndrome, coeliac disease, cystic fibrosis, Helicobacter pylori infection, type 1 and 2 diabetes, metabolic syndrome, nonalcoholic steatohepatitis, and certain allergies. It is therefore reasonable to conceive B. adolescentis as a health-associated, or even health-promoting bacterial species in humans.

The Certificate of Added Competence credentialling program in family medicine: a descriptive survey of the family physician perspective of enhanced skill practices in Canada

Introduction

The College of Family Physicians of Canada (CFPC) offers the Certificate of Added Competence (CAC) program to designate a family physician with enhanced skills. In 2015, the College expanded its program to introduce enhanced certification in four new domains: Palliative Care, Care of the Elderly, Sports and Exercise Medicine, and Family Practice Anesthesia. In this study, we elicited perceptions from Canadian family physicians with and without the CAC on practice impacts associated with the program.

Methods

Active family physicians in Canada with and without CACs were surveyed between November 2019 to January 2020. Descriptive statistics were generated to describe the perceptions of family physicians regarding the CAC program and its impacts on practice.

Results

Respondents agreed with several benefits of the program including enhancing the capacity to deliver comprehensive care, alleviating the burden of patient travel by increasing the availability of care in rural and remote communities, and providing opportunities to engage in various collaborative care models and new leadership roles. All respondents perceived CAC holders to pursue the certificate to meet both professional interests and community needs.

Conclusions

There is a need for strong and continued investment in systemic practice improvements that incentivize the delivery of comprehensive family medicine practice.

First Dark Matter Search Results from the LUX-ZEPLIN (LZ) Experiment

The LUX-ZEPLIN experiment is a dark matter detector centered on a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility in Lead, South Dakota, USA. This Letter reports results from LUX-ZEPLIN's first search for weakly interacting massive particles (WIMPs) with an exposure of 60 live days using a fiducial mass of 5.5 t. A profile-likelihood ratio analysis shows the data to be consistent with a background-only hypothesis, setting new limits on spin-independent WIMP-nucleon, spin-dependent WIMP-neutron, and spin-dependent WIMP-proton cross sections for WIMP masses above 9  GeV/c^{2}. The most stringent limit is set for spin-independent scattering at 36  GeV/c^{2}, rejecting cross sections above 9.2×10^{-48}  cm at the 90% confidence level.

Overexpression of PSR1 in Chlamydomonas reinhardtii induces luxury phosphorus uptake

Remediation using micro-algae offers an attractive solution to environmental phosphate (PO4 3-) pollution. However, for maximum efficiency, pre-conditioning of algae to induce 'luxury phosphorus (P) uptake' is needed. To replicate this process, we targeted the global regulator PSR1 (Myb transcription factor: Phosphate Starvation Response 1) for over-expression in algae. Manipulating a single gene (PSR1) drove uptake of both PO4 3- and a Mg2+ counter-ion leading to increased PolyP granule size, raising P levels 4-fold to 8% dry cell weight, and accelerated removal of PO4 3- from the medium. Examination of the gene expression profile showed that the P-starvation response was mimicked under P-replete conditions, switching on luxury uptake. Hyper-accumulation of P depended on a feed-forward mechanism, where a small set of 'Class I' P-transporter genes were activated despite abundant external PO4 3- levels. The transporters drove a reduction in external PO4 3- levels, permitting more genes to be expressed (Class II), leading to more P-uptake. Our data pointed toward a PSR1-independent mechanism for detection of external PO4 3- which suppressed Class II genes. This model provided a plausible mechanism for P-overplus where prior P-starvation elevates PSR1 and on P-resupply causes luxury P-uptake. This is because the Class I genes, which include P-transporter genes, are not suppressed by the excess PO4 3-. Taken together, these discoveries facilitate a bio-circular approach of recycling nutrients from wastewater back to agriculture.

Catalase: A critical node in the regulation of cell fate

Catalase (CAT) is an extensively studied if somewhat enigmatic enzyme that is at the heart of eukaryotic antioxidant systems with a canonical role in peroxisomal function. The CAT family of proteins exert control over a wide range of plant growth and defence processes. CAT proteins are subject to many types of post-translational modification (PTM), which modify activity, ligand binding, stability, compartmentation and function. The CAT interactome involves many cytosolic and nuclear proteins that appear to be essential for protein functions. Hence, the CAT network of roles extends far beyond those associated with peroxisomal metabolism. Some pathogen effector proteins are able to redirect CAT to the nucleus and recent evidence indicates CAT can traffic to the nucleus in the absence of exogenous proteins. While the mechanisms that target CAT to the nucleus are not understood, CAT activity in the cytosol and nucleus is promoted by interactions with nucleoredoxin. Here we discuss recent findings that have been pivotal in generating a step change in our understanding of CAT functions in plant cells.

Family Physicians with Certificates of Added Competence in Palliative Care Contribute to Comprehensive Care in Their Communities: A Qualitative Descriptive Study

Background

Since 2015, the College of Family Physicians of Canada has certified enhanced skills in palliative care (PC) with a certificate of added competence.

Aim

This study aimed to describe the ways family physicians with enhanced skills in PC contribute within their communities, the factors that influence ways of practicing, and the perceived impacts.

Design

Secondary analysis of data from a multiple case study on the role and impacts of family physicians with enhanced skills (i.e., PC physicians) was undertaken.

Setting/Participants

Interviews were conducted in 2018 to 2019 with PC and generalist family physicians and residents associated with six family medicine practice cases across Canada. An unconstrained qualitative content analysis was performed.

Results

Twenty-one participants (nine PC physicians, five generalist family physicians, two residents, and five physicians with enhanced skills in other domains) contributed data. PC physicians worked by enhancing their own family practice or as focused PC physicians. Roles included collaborating with other physicians through consultations, comanaging patients (shared care), or assuming care of the patient as the main provider (takeover). PC physicians increased capacity among their colleagues, with some patient care and education activities not being remunerated. Funding models and other structures were perceived as incentivizing the takeover model.

Conclusion

Family physicians with enhanced skills in PC contribute to comprehensive care through the end of life. Remuneration should support system capacity and relationships that enable family physicians to provide primary PC especially outside the takeover model.

Using the Superfolder GFP (sfGFP) System to Study Plant Peroxisomal Protein Import

The fusing of a protein of interest to a fluorescent protein followed by fluorescence microscopy is a very common method of determining protein localization and dynamics. However even small fluorescent proteins can be large enough to affect protein folding and localization, therefore the ability to use a smaller tag but still be able to detect a fluorescent signal in live cell imaging experiments is extremely valuable. The self-assembling split sfGFP^OPT system allows the fusion of the protein of interest with the 11th β-strand of super-folder GFP (sfGFP11) which is only 13 amino acids long. When this construct is delivered into protoplasts made from transgenic plants expressing sfGFP1-10 (sfGFP1-10^OPT) targeted to the desired compartment, the two parts assemble and fluorescence is reconstituted that can be detected by confocal laser scanning microscopy. Here, we present the application of this method for protein targeting to plant peroxisomes using Catalase (CAT2 of Arabidopsis thaliana) as an example. As peroxisomes are able to import folded and oligomeric proteins, careful consideration of appropriate controls is also required to ensure correct interpretation of the results.

The psychedelic renaissance: the next trip for psychiatry?

The psychedelic research renaissance is gaining traction. Preliminary clinical studies of the hallucinogenic fungi, psilocybin, with psychological support, have indicated improvements in mood, anxiety and quality of life. A seminal, open-label study demonstrated marked reductions in depression symptoms in participants with treatment-resistant depression (TRD). The associated neurobiological processes involve alterations in brain connectivity, together with altered amygdala and default mode network activity. At the cellular level, psychedelics promote synaptogenesis and neural plasticity. Prompted by the promising preliminary studies, a randomized, double-blind trial has recently been launched across Europe and North America to investigate the efficacy of psilocybin in TRD. One of these centres is based in Ireland - CHO Area 7 and Tallaght University Hospital. The outcome of this trial will determine whether psilocybin with psychological support will successfully translate into the psychiatric clinic for the benefit of patients.

The impact of care of the elderly certificates of added competence on family physician practice: results from a pan-Canadian multiple case study

Background

Family physicians serve an important role in the care of older adults, and have variable levels of training and comfort navigating this complex patient population. The Care of the Elderly (COE) Certificate of Added Competence offered by The College of Family Physicians of Canada recognizes family physicians with advanced expertise in older adult healthcare. We explored how COE training and certification impacts primary care delivery to older patients, including factors that impact group practice.

Methods

We conducted a secondary analysis of multiple case study data to explore similarities and differences within and across cases. We defined cases as a practice or collective of family physicians working within a defined group of patients in an interconnected community. We analyzed semi-structured interview transcripts (n = 48) from six practice groups of family physicians across Canada using conventional (unconstrained, inductive) content analysis.

Results

We identified similarities and differences in how COE family physicians function within their group practice and the broader healthcare system. In some cases, COE certifications increased patients’ access to geriatric resources by reducing travel and wait times. Some physicians observed minimal changes in their role or group practice after earning the COE designation, including continuing to largely function as a generalist. While family physicians tended to highly value their COE CAC, this designation was differentially recognized by others.

Conclusions

Our findings highlight the impacts and limitations of COE training and certification, including an opportunity for COE family physicians to fill knowledge and practice gaps. As the number of older adults in Canada continues to grow and increasingly rely on primary care services, COE family physicians are uniquely positioned to strengthen the health system’s capacity to deliver specialized geriatric care.

Key Predictors of Primary Care Providers' Self-Efficacy in Caring for Children with Overweight or Obesity

OBJECTIVE

Self-efficacy is a crucial factor in enabling pediatric primary care providers (PCPs) to deliver recommended care to children with overweight and obesity. This study, conducted with a large, national sample of PCPs, aimed to identify key factors, which may contribute to PCP self-efficacy for obesity-related care, from a list of previously reported barriers and facilitators.

METHODS

A national random sample of American Academy of Pediatrics members was surveyed in 2017 (analytic n = 704). Factor analysis was used to identify self-efficacy variables from relevant indicators and assess fit. Multivariable linear regression analyses were conducted to identify key predictors of PCP self-efficacy from reported facilitators or barriers to care, including characteristics of the PCP, practice, community, and payment systems.

RESULTS

Two PCP self-efficacy variables were identified: health risk assessment and patient-centered counseling. Both were positively predicted by relevant training, the belief that pediatricians play an important role in obesity, and awareness of barriers to payment for dietitians or weight management programs. Both were negatively predicted by a perceived lack of available PCP time for counseling and inadequacy of available referral resources to assist with treatment. Additional predictors of counseling self-efficacy included PCP beliefs that they are paid for treatment (+) and that patients/families lack time for healthy behaviors (-). Electronic health record clinical decision supports or registries and patient social disadvantage were not predictive.

CONCLUSIONS

Results suggest multiple potential roles and strategies for local and national organizations seeking to facilitate improvements to PCP self-efficacy in caring for children with overweight and obesity.

Kenneth Percy Baker

A talented veterinary dermatologist and educator who retained a fascination for the diversity of nature.

Motivations for Pursuing Enhanced Skill Credentials in Family Medicine: A Study of the Certificates of Added Competence in Canada

Background and Objectives: The College of Family of Physicians of Canada’s Certificates of Added Competence (CACs) denote enhanced-skill family physicians who function beyond the scope of family practice or in specialized areas fundamental to family medicine practice. The credential provides recognition for skill development in areas of need and is intended to augment comprehensive care; however, there are concerns that it increases focused practice and decreases commitment to generalist care. To inform credentialing policies, we elucidated physician and trainee motivations for pursuing the CAC credential. Methods: We conducted secondary analyses of interview data collected during a multiple case study of the impacts of the CACs in Canada. We collected data from six cases, sampled to reflect variability in geography, patient population, and practice arrangement. The 48 participants included CAC holders, enhanced-skill family physicians, generalist family physicians, residents, specialists, and administrative staff. We subjected data to qualitative descriptive analysis, beginning with inductive code generation, and concluding in unconstrained deduction. Results: Family physicians and trainees pursue the credential to meet community health care needs, limit or promote diversity in practice, secure perceived professional benefits, and/or validate their sense of expertise. Notably, family physicians face barriers to engaging in enhanced skill training once their practice is established. Conclusions: While the CACs can enhance community-adaptive comprehensive care, they can also incentivize migration away from generalist practice. Credentialing policies should support enhanced skill designations that respond directly to pervasive community needs.

Nuclear and peroxisomal targeting of catalase

Catalase is a well-known component of the cellular antioxidant network, but there have been conflicting conclusions reached regarding the nature of its peroxisome targeting signal. It has also been reported that catalase can be hijacked to the nucleus by effector proteins of plant pathogens. Using a physiologically relevant system where native untagged catalase variants are expressed in a cat2-1 mutant background, the C terminal most 18 amino acids could be deleted without affecting activity, peroxisomal targeting or ability to complement multiple phenotypes of the cat2-1 mutant. In contrast, converting the native C terminal tripeptide PSI to the canonical PTS1 sequence ARL resulted in lower catalase specific activity. Localisation experiments using split superfolder green fluorescent protein revealed that catalase can be targeted to the nucleus in the absence of any pathogen effectors, and that C terminal tagging in combination with alterations of the native C terminus can interfere with nuclear localisation. These findings provide fundamental new insights into catalase targeting and pave the way for exploration of the mechanism of catalase targeting to the nucleus and its role in non-infected plants.

Within arm's reach: The role of proximity in speech generating device use of ambulatory children with autism

Purpose: Augmentative and Alternative Communication (AAC) provides an alternative means of communication for individuals who are unable to effectively communicate using spoken language. The present study seeks to investigate the role of proximity in facilitating AAC (specifically Speech Generating Devices; SGD) use in a homogeneous population: ambulatory school-aged children with autism spectrum disorder (ASD).Method: Twelve school-age children with ASD who use an SGD as their primary mode of communication participated in the study. The percentage of time the child was within the proximity of their device was calculated over nine videotaped sessions and data logging provided information regarding device use over an 18-week period.Result: Children were in proximity to their device 65% of the time. There was a significant positive correlation between percentage of time in proximity to device and the average minutes of device use on the day video recorded. Exploratory analyses revealed that communicative abilities may be more connected to proximity than school context.Conclusion: These results support the importance of developing a program for assuring device proximity in order to encourage consistent device use in minimally verbal ambulatory school-age children with ASD.

Colorectal cancer outcomes determined by mode of presentation: analysis of population data in England between 2010 and 2014

BACKGROUND

The purpose of this study was to investigate associations between mode of presentation; categorized as emergency, suspected cancer outpatient referral pathway (2-week wait or 2WW pathway), non-cancer suspected outpatient referral (non-2-week wait pathway) or following screening, and stage of diagnosis and survival in patients with colorectal cancer in England.

METHODS

This was a retrospective cohort observational study of patients diagnosed with colorectal cancer between January 2010 and December 2014 in England using data from Public Health England collated from regional cancer registries.

RESULTS

The most common route to diagnosis among 167,501 patients diagnosed with colorectal cancer was via the non-cancer suspect (non-2WW) outpatient referral pathway (35.1%) followed by the suspected cancer (2WW) referral pathway (31.6%), emergency presentation (22.8%) and most infrequently following screening (10.6%) (p < 0.01). Screening confers the greatest likelihood of early-stage diagnosis (61.6%) compared to other modes of presentation. The 5-year overall survival was 81.8%, 53.3%, 53.0% and 27.6% in those diagnosed via screening, 2WW, non-2WW pathway and emergency presentation, respectively. Patients from most deprived regions were more likely to be diagnosed following emergency presentation (27.7 vs 19.7%, p < 0.01) and less likely via screening (8.1 vs 12%, p < 0.01).

CONCLUSIONS

Asymptomatic individuals diagnosed following screening have earlier stage cancers and better survival, the opposite was observed in those diagnosed following emergency presentation. Patients referred via the 2WW pathway do not have better survival outcomes when compared to those referred via the non-2WW pathway. In addition, this study has identified socio-economic groups that need to be targeted with public health campaigns to improve screening uptake.

Impacts of the Certificates of Added Competence credentialling program: a qualitative case study of enhanced-skill family medicine practice across Canada

BACKGROUND

In 2015, the College of Family Physicians of Canada (CFPC) expanded its Certificates of Added Competence (CAC) program to include enhanced-skill certification in Care of Elderly, Family Practice Anesthesia, Palliative Care, and Sports and Exercise Medicine. We aimed to describe the impact of these 4 CACs on the provision of comprehensive care in Canada, while also identifying the factors of influence that foster these impacts.

METHODS

Between September 2018 and June 2019, we conducted qualitative case studies of 6 family medicine practices across Canada, sampled to represent geographic, population and practice arrangement diversity. We developed a framework of relevant factors and their relations to CAC-mediated comprehensive care delivery. We took an exploratory approach to the first 4 case studies, guided by theoretical propositions based on a literature review, and the CFPC's 4 principles of family medicine and goals for practice. The emerging theory was confirmed and adapted through the final 2 explanatory case studies. Data were obtained through semistructured qualitative interviews with enhanced-skill and generalist physicians, specialists, trainees and administrators associated with these cases. We performed a descriptive content analysis, within and across cases.

RESULTS

Interviews with 48 participants showed considerable variation in the way CACs are operationalized related to the specific domain of care, the community, relationships among practitioners, motivations of the practitioner and needs of the patient population. The presence of CAC holders in communities expands the scope of available services, reduces the need for patients to travel and encourages continuity of care; however, comprehensive care may be negatively affected when CAC holders develop enhanced-skill practices according to clinical interests rather than community needs. Factors associated with collaborative care models, practice requirements, remuneration structure, community culture and individual aspirations interact to reinforce or undermine the effectiveness of enhanced-skill practices.

INTERPRETATION

Holders of CACs have a positive impact when they work in collaborative models that align with the needs of communities and that support local generalist family physicians. Health care policies should incentivize CAC activities that contribute to planned care delivery at the practice and community levels.

Peripherally inserted central cathether migration in neonates: Incidence, timing and risk factors

BACKGROUND

PICC line use is a common practice in neonatal units, but it is associated with various complications. Catheter migration is the most common complication in neonates. Periodic imaging is recommended to monitor the tip position of the PICCs, but the optimal frequency is undetermined. The incidence, timing and risk factors that are associated with PICC migration have not been fully investigated beyond 24 hrs in neonates. The aim of the study was to determine the incidence, timing and risk factors that are associated with peripherally inserted central venous catheter (PICC) migration in neonates.

METHODS

This was a single center, retrospective study of 168 PICCs placed in 141 neonates in the neonatal intensive care unit (NICU) between 2015 and 2016. The incidence of catheter migration was determined radiographically at 12-24 hrs and every third day after insertion until it was removed.

RESULTS

Overall incidence of PICC migration was 28%and most commonly was detected within the first three days after PICC placement (83%). The incidence of PICC migration was higher in males. The PICC migration was associated with difficulty advancing the PICC at the time of insertion and PICC dressing change.

CONCLUSION

Serial evaluation of PICC placement in neonates is required to maintain proper position. Based on our experience in our unit, we recommend periodic imaging at 12-24 hrs and on the third day after PICC placement as most migration occurred within three days after insertion.

Planned Evaluation of the Healthy Weight Clinic Pediatric Weight Management and Implementation: Massachusetts-CORD 3.0

Background: Despite evidence that offering multidisciplinary treatment for children with obesity is effective, access to evidence-based pediatric weight management interventions (PWMIs) is limited. The Healthy Weight Clinic PWMI is a multidisciplinary approach in primary care that improves BMI among children with a BMI ≥ 85th percentile. Objective: To describe the method by which we will evaluate the adoption, acceptability, and feasibility of integrating and implementing a multidisciplinary Healthy Weight Clinic (HWC) into primary care. Design/Methods: We used the Consolidated Framework for Implementation Research (CFIR) domains and constructs to inform our implementation strategies. We will use a Type III hybrid effectiveness-implementation design to test our implementation strategies and improvement in BMI. Sources of data collection will include qualitative interviews with patient caregivers, HWC staff and surveys with HWC staff, patient caregivers, and electronic health record data. Our outcomes are guided by the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. Results: We identified all five CFIR domains as integral for successful implementation. Some strategies to address barriers within these domains include online self-paced training modules for the HWC staff, a virtual learning collaborative, and engagement of site leadership. Outcomes will be measured at the patient and pilot site levels, and they will include patients reached, patient health outcomes such as BMI and quality of life, level of adoption, acceptability, feasibility, and sustainability of the PWMI. Conclusion: Our use of implementation science frameworks in the planning of Healthy Weight Clinic PWMI could create a sustainable and effective program for dissemination.

Design and Approach of the Healthy Weight Clinic Pediatric Weight Management Intervention Package and Implementation: Massachusetts-CORD 3.0

Background: Although proven effective interventions for childhood obesity exist, there remains a substantial gap in the adoption of recommended practices by clinicians. Objective: The aims are to: (1) package implementation and training supports to facilitate the adoption of the evidence-based Healthy Weight Clinic Pediatric Weight Management Intervention (PWMI) (based on three previous effectiveness trials); (2) pilot and evaluate the packaged Healthy Weight Clinic PWMI; and (3) develop a sustainability and dissemination plan. Design/Methods: We used the Consolidated Framework of Implementation Research constructs to create an Implementation Research Logic Model that defined the facilitators and barriers of the Healthy Weight Clinic PWMI. We linked these constructs to implementation strategies and mechanisms. Packaging and design will be informed by the core essential components and functions of the PWMI along with stakeholder engagement. Once the package is complete, we will pilot the PWMI by using a Type III effectiveness-implementation hybrid design. Implementation outcomes will be evaluated by using the RE-AIM framework. Results: We will create an integrated, multisystems level package for national dissemination. The package will include training and a suite of resources for primary care physicians and healthy weight clinic staff, including: patient and caregiver facing videos, patient and caregiver handouts, group curriculum guide, online provider trainings, and access to a virtual learning collaborative. Conclusion: The results will highlight the extent to which the package of the Healthy Weight Clinic PWMI facilitates the adoption of effective strategies for treating childhood obesity. Lessons learned will inform modifications to the Healthy Weight Clinic PWMI and strategies for future scaling.

Diagnostic accuracy of magnetic resonance imaging in detecting depth of invasion of tongue cancers

The recent eighth edition of the American Joint Committee on Cancer (AJCC) staging system has introduced depth of invasion (DOI) as one of its important components. DOI is also important for deciding neck management in superficial tongue cancers. Magnetic resonance imaging (MRI) is mainly used to assess DOI, and in this study we have evaluated the efficacy of MRI to detect it. This is a retrospective study consisting of 60 treatment-naïve tongue cancer patients operated on between July 2017 and June 2019. Patients underwent MR imaging on an Optima MR450W 1.5T unit, and MRI was reported by two experienced ead and eck adiologistss. Postoperative histological DOI was considered the gold standard. The correlation coefficient was derived for postoperative DOI and MRI-detected DOI. A subgroup analysis of superficial tongue cancer was also done. The mean MRI DOI was 13.7 mm and the mean histological DOI 12.45 mm. The shrinkage factor was 0.6 mm. Pearson's correlation coefficient was 0.80 (p=<0.001) for Radiologist 1 and 0.85 (p=<0.001) for Radiologist 2. The interobserver variation was low, with a correlation coefficient between the two radiologists of 0.965 (p=<0.001). For superficial tongue cancers there was moderate correlation for MRI and histologically-detected DOI with a kappa value of 0.681 (p=0.03). As per the ROC curve, the cut-off value for MRI DOI to predict nodal metastasis was 4.6 mm. MRI has high reliability to predict the DOI of tongue cancers. The interobserver variation was low. The diagnostic accuracy in cases of superficial tongue cancer was moderate.

Dural Arteriovenous Fistulas of the Foramen Magnum Region: Clinical Features and Angioarchitectural Phenotypes

BACKGROUND AND PURPOSE

AVFs of the foramen magnum region, including fistulas of the marginal sinus and condylar veins, have complex arterial supply, venous drainage, symptoms, and risk features that are not well-defined. The purpose of this study was to present the angioarchitectural and clinical phenotypes of a foramen magnum region AVF from a large, single-center experience.

MATERIALS AND METHODS

We retrospectively reviewed cases from a 10-year neurointerventional data base. Arterial and venous angioarchitectural features and clinical presentation were extracted from the medical record. Venous drainage patterns were stratified into 4 groups as follows: type 1 = unrestricted sinus drainage, type 2 = sinus reflux (including the inferior petrosal sinus), type 3 = reflux involving sinuses and cortical veins, and type 4 = restricted cortical vein outflow or perimedullary congestion.

RESULTS

Twenty-eight patients (mean age, 57.9 years; 57.1% men) had 29 foramen magnum region AVFs. There were 11 (37.9%) type 1, nine (31.0%) type 2, six (20.7%) type 3, and 3 (10.3%) type 4 fistulas. Pulsatile tinnitus was the most frequent symptom (82.1%), followed by orbital symptoms (31.0%), subarachnoid hemorrhage (13.8%), cranial nerve XII palsy (10.3%), and other cranial nerve palsy (6.9%). The most frequent arterial supply was the ipsilateral ascending pharyngeal artery (93.1% ipsilateral, 55.5% contralateral), vertebral artery (89.7%), occipital artery (65.5%), and internal carotid artery branches (48.3%).

CONCLUSIONS

We present the largest case series of foramen magnum region AVFs to date and show that clinical features relate to angioarchitecture. Orbital symptoms are frequent when sinus reflux is present. Hemorrhage was only observed in type 3 and 4 fistulas.

Bronchiectasis is associated with delayed diagnosis and adverse outcomes in the New Zealand Common Variable Immunodeficiency Disorders cohort study

Common variable immunodeficiency disorders (CVID) are multi-system disorders where target organ damage is mediated by infective, autoimmune and inflammatory processes. Bronchiectasis is probably the most common disabling complication of CVID. The risk factors for bronchiectasis in CVID patients are incompletely understood. The New Zealand CVID study (NZCS) is a nationwide longitudinal observational study of adults, which commenced in 2006. In this analysis, the prevalence and risk factors for bronchiectasis were examined in the NZCS. After informed consent, clinical and demographic data were obtained with an interviewer-assisted questionnaire. Linked electronic clinical records and laboratory results were also reviewed. Statistical methods were applied to determine if variables such as early-onset disease, delay in diagnosis and increased numbers of infections were associated with greater risk of bronchiectasis. One hundred and seven adult patients with a diagnosis of CVID are currently enrolled in the NZCS, comprising approximately 70% of patients known to have CVID in New Zealand. Fifty patients (46·7%) had radiologically proven bronchiectasis. This study has shown that patients with compared to those without bronchiectasis have an increased mortality at a younger age. CVID patients with bronchiectasis had a greater number of severe infections consequent to early-onset disease and delayed diagnosis. Indigenous Māori have a high prevalence of CVID and a much greater burden of bronchiectasis compared to New Zealand Europeans. Diagnostic latency has not improved during the study period. Exposure to large numbers of infections because of early-onset disease and delayed diagnosis was associated with an increased risk of bronchiectasis. Earlier diagnosis and treatment of CVID may reduce the risk of bronchiectasis and premature death in some patients.

Perceptions of a Pragmatic Family-Centered Approach to Childhood Obesity Treatment

Background: Few studies have examined both parent and child preferences regarding family-based weight management programs (WMPs) delivered in primary care settings, especially among racial minority populations. The purpose of this study was to determine the perceptions that parents and their children/adolescents have about the components that should be included in a family-based WMP and to identify perceived preferences, benefits, and/or barriers to participation. Methods: A sample of 60 participants (30 parents and 30 children/adolescents) participated in 1 of 5 separate structured focus groups, using probing questions and the nominal group technique (NGT). Parents reported demographics for themselves and their children/adolescents. Themes from probing questions were identified using thematic analysis. Results: Parents were primarily African American (93%) and diverse in income. NGT sessions revealed that parents across all groups perceived that education on healthy eating, parental involvement, and effective program leaders are most important and have the greatest impact, while parental involvement was perceived as the easiest method to implement in a family-based WMP for childhood obesity. Children/adolescents perceived that education on healthy eating and exercise would have the greatest impact, while healthy eating and meal plans were perceived as the easiest methods to implement with a family. Parents and children/adolescents also identified improved psychological well-being (eg, decreased bullying, increased self-esteem, and motivation) as a desired program outcome. Conclusion: Parents and their children/adolescents highlighted the importance of physical and psychological health as targets in treatment. Feedback from patients can inform the design and implementation of family-based WMPs delivered in primary care settings.

The Saccharomyces cerevisiae ABC subfamily D transporter Pxa1/Pxa2p co-imports CoASH into the peroxisome

ATP-binding cassette (ABC) subfamily D transporters are important for the uptake of fatty acids and other beta-oxidation substrates into peroxisomes. Genetic and biochemical evidence indicates that the transporters accept fatty acyl-coenzyme A that is cleaved during the transport cycle and then re-esterified in the peroxisomal lumen. However, it is not known whether free coenzyme A (CoA) is released inside or outside the peroxisome. Here we have used Saccharomyces cerevisiae and isolated peroxisomes to demonstrate that free CoA is released in the peroxisomal lumen. Thus, ABC subfamily D transporter provide an import pathway for free CoA that controls peroxisomal CoA homeostasis and tunes metabolism according to the cell's demands.

GSK2245035, a TLR7 agonist, Does Not Increase Pregnancy Loss in Cynomolgus Monkeys

GSK2245035, a small molecule Toll-like Receptor 7 (TLR7) agonist developed for immunomodulatory treatment for allergic airways disease, aimed to reduce Th2 and enhance Th1/Treg responses to aeroallergens via the local induction of type I interferons (IFNs). GSK2245035 demonstrated selectivity for potent release of type I IFNs compared to TNF-α and IL-6, with dose dependent increases in the interferon inducible chemokine, IP-10, in the nasal compartment. Implantation and parturition require pro-inflammatory processes including IFNs, Interferon Stimulated Genes, TNFα and IP-10 while pregnancy requires immune regulation to maintain maternal fetal immune tolerance, and recombinant type I IFNs induced abortions in monkeys. Due to its mechanism of action, GSK2245035 was studied at pharmacologically and clinically relevant doses in a monkey pregnancy model. Monkeys received 0, 3 or 30 ng/kg/week GSK2245035 intranasally once weekly, from Day 20 postcoitum through Day 63 postpartum. Although systemic IFN-α and IP-10 levels were approximately 14.8 or 40 -fold (respectively) above predose levels at 3 or 30 ng/kg/week, respectively, there were no effects on pregnancy and infant outcome. Non-adverse effects included increased incidence of nasal discharge, increased maternal body temperature at 30 ng/kg/week and dose-dependent increases in maternal IP-10 and IFN-α and decreased infant anti-KLH IgM and IgG titers following KLH immunization at ≥3 ng/kg/week, relative to controls. Potentially, lower IFN-α and IP-10 levels as well as once-weekly intranasal dosing vs daily subcutaneous or intramuscular dosing with recombinant type I IFNs could explain the lack of pregnancy effects; however, there was an undesired impact on offspring immune function.

Uncoupling growth from phosphorus uptake in Lemna: Implications for use of duckweed in wastewater remediation and P recovery in temperate climates

Phosphorus (P) is an essential nutrient for crop growth and the second most limiting after N. Current supplies rely on P-rich rocks that are unevenly distributed globally and exploited unsustainably, leading to concerns about future availability and therefore food security. Duckweeds (Lemnaceae) are aquatic macrophytes used in wastewater remediation with the potential for nutrient recycling as feed or fertilizer. The use of duckweeds in this way is confined to tropical regions as it has previously been assumed that growth in the colder seasons of the temperate regions would be insufficient. In this study, the combined effects of cool temperatures and short photoperiods on growth and P uptake and accumulation in Lemna were investigated under controlled laboratory conditions. Growth and P accumulation in Lemna can be uncoupled, with significant P removal from the medium and accumulation within the plants occurring even at 8°C and 6-hr photoperiods. Direct measurement of radiolabeled phosphate uptake confirmed that while transport is strongly temperature dependent, uptake can still be measured at 5°C. Prior phosphate starvation of the duckweed and use of nitrate as the nitrogen (N) source also greatly increased the rate of P removal and in-cell accumulation. These results form the basis for further examination of the feasibility of duckweed-based systems for wastewater treatment and P recapture in temperate climates, particularly in small, rural treatment works.

Comparative analysis of paediatric and adult surgically drained dental infections at a university teaching hospital

In the United Kingdom (UK) the estimated prevalence of dental infection involving the supporting bone is 2%, and from 2014-2015 there were 2281 admissions in England alone due to dental abscess. We undertook an analysis of 184 dental abscesses that required surgical drainage, as there is surprisingly little in the literature on the subject. This was a retrospective study of 184 consecutive patients with dental abscesses who were admitted between January 2016 and September 2019. On admission, all patients had orthopantomograms (OPG) and baseline blood tests. Surgical drainage was performed under a general or local anaesthetic and a pus swab sent for culture and sensitivity. The submandibular space was the most commonly involved site and paediatric patients most often presented with buccal space abscesses. A lower molar tooth was the cause in 132 patients. White blood cells (WBC) and C-reactive protein (CRP) were both raised in 63.6% (n=117), but were normal in 4.9% (n=9). The remaining patients had either raised WBC (2.7%) or CRP (28.8%). Streptococcus milleri was the most common organism isolated in 66.6% (n=42). There was no association between CRP or WBC values and duration of hospital stay. Paediatric patients had a shorter duration of admission (1.96 days vs 2.81 days) and significantly lower CRP values (120.9 vs 45.7; p=0.001). The submandibular space was the commonest site involved and mandibular molars the most frequent source of infection. An elevated CRP value appeared to be a more sensitive indicator of infection in this study population. Adult and paediatric patients present in a different manner.

Wild fallow deer (Dama dama) as definitive hosts of Fasciola hepatica (liver fluke) in alpine New South Wales

To determine the extent to which wild deer are contributing in the transmission of Fasciola hepatica (liver fluke) livers from deer shot by hunters, farmers undertaking population control on their farms and vertebrate pest controllers were collected and frozen. The livers were later thawed, sliced and examined for the presence of adult flukes or evidence of past infection. Livers from 19 deer were examined (18 fallow [Dama dama] and one sambar [Rusa unicolor]). Seventeen of the fallow deer were animals collected on farms near Jindabyne, New South Wales. The remaining fallow deer was collected in the Australian Capital Territory and one sambar deer was collected in north-eastern Victoria. Nine of the 17 deer (53%) from the Jindabyne area were either infected with Fasciola hepatica (liver fluke) or had thickened bile ducts indicating past infection. Infection levels in the infected animals varied widely from 3 liver fluke to over 50 per liver. No sign of infection was present in the deer from the Australian Capital Territory or Victoria. Fallow deer are wide-spread in the Jindabyne area and their population is increasing. It is likely their contribution to the maintenance and distribution of F. hepatica to livestock in the Jindabyne area, and in other livestock rearing areas of south-eastern Australia, is important and increasing.

A Simple and Non-destructive Method for Chlorophyll Quantification of Chlamydomonas Cultures Using Digital Image Analysis

Growing interest in the use of microalgae as a sustainable feedstock to support a green, circular, bio-economy has led to intensive research and development initiatives aimed at increasing algal biomass production covering a wide range of scales. At the heart of this lies a common need for rapid and accurate methods to measure algal biomass concentrations. Surrogate analytical techniques based on chlorophyll content use solvent extraction methods for chlorophyll quantification, but these methods are destructive, time consuming and require careful disposal of the resultant solvent waste. Alternative non-destructive methods based on chlorophyll fluorescence require expensive equipment and are less suitable for multiple sampling of small cultures which need to be maintained under axenic growth conditions. A simple, inexpensive and non-destructive method to estimate chlorophyll concentration of microalgal cultures in situ from digital photographs using the RGB color model is presented. Green pixel intensity and chlorophyll a, b and total chlorophyll concentration, measured by conventional means, follow a strong linear relationship (R² = 0.985–0.988). In addition, the resulting standard curve was robust enough to accurately estimate chlorophyll concentration despite changes in sample volume, pH and low concentrations of bacterial contamination. In contrast, use of the same standard curve during nitrogen deprivation (causing the accumulation of neutral lipids) or in the presence of high quantities of bacterial contamination led to significant errors in chlorophyll estimation. The low requirement for equipment (i.e., a simple digital camera, available on smartphones) and widely available standard software for measuring pixel intensity make this method suitable for both laboratory and field-based work, particularly in situations where sample, qualified personnel and/or equipment is limited. By following the methods described here it should be possible to produce a standard curve for chlorophyll analysis in a wide range of testing conditions including different microalga cultures, culture vessel and photographic set up in any particular laboratory.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Fixing the Broken Phosphorus Cycle: Wastewater Remediation by Microalgal Polyphosphates

Phosphorus (P), in the form of phosphate derived from either inorganic (Pi) or organic (Po) forms is an essential macronutrient for all life. P undergoes a biogeochemical cycle within the environment, but anthropogenic redistribution through inefficient agricultural practice and inadequate nutrient recovery at wastewater treatment works have resulted in a sustained transfer of P from rock deposits to land and aquatic environments. Our present and near future supply of P is primarily mined from rock P reserves in a limited number of geographical regions. To help ensure that this resource is adequate for humanity's food security, an energy-efficient means of recovering P from waste and recycling it for agriculture is required. This will also help to address excess discharge to water bodies and the resulting eutrophication. Microalgae possess the advantage of polymeric inorganic polyphosphate (PolyP) storage which can potentially operate simultaneously with remediation of waste nitrogen and phosphorus streams and flue gases (CO2, SOx, and NOx). Having high productivity in photoautotrophic, mixotrophic or heterotrophic growth modes, they can be harnessed in wastewater remediation strategies for biofuel production either directly (biodiesel) or in conjunction with anaerobic digestion (biogas) or dark fermentation (biohydrogen). Regulation of algal P uptake, storage, and mobilization is intertwined with the cellular status of other macronutrients (e.g., nitrogen and sulphur) in addition to the manufacture of other storage products (e.g., carbohydrate and lipids) or macromolecules (e.g., cell wall). A greater understanding of controlling factors in this complex interaction is required to facilitate and improve P control, recovery, and reuse from waste streams. The best understood algal genetic model is Chlamydomonas reinhardtii in terms of utility and shared resources. It also displays mixotrophic growth and advantageously, species of this genus are often found growing in wastewater treatment plants. In this review, we focus primarily on the molecular and genetic aspects of PolyP production or turnover and place this knowledge in the context of wastewater remediation and highlight developments and challenges in this field.

Phenotypic responses of foxtail millet (Setaria italica) genotypes to phosphate supply under greenhouse and natural field conditions

Food insecurity is a looming threat for the burgeoning world population. Phosphorus (P), which is absorbed from soil as inorganic phosphate (Pi), is an essential macronutrient for the growth of all agricultural crops. This study reports phenotype analysis for P responses in natural field and greenhouse conditions, using 54 genotypes of foxtail millet (Setaria italica) representing wide geographic origins. The genotype responses were assessed in natural field conditions in two different seasons (monsoon and summer) under Pi-fertilized (P+) and unfertilized (P-) soil for eight above-ground traits. Enormous variations were seen among the genotypes in phenotypic responses for all the measured parameters under low P stress conditions. Variations were significant for plant height, leaf number and length, tillering ability and seed yield traits. Genotypes ISe 1234 and ISe 1541 were P+ responders, and the genotypes ISe 1181, ISe 1655, ISe 783 and ISe 1892 showed tolerance to low P for total seed yield. Genotypes that performed well under P- conditions were almost as productive as genotypes that performed well under P+ conditions suggesting some genotypes are well adapted to nutrient-poor soils. In the greenhouse, most of the genotypes produced changes in root architecture that are characteristic of P- stress, but to differing degrees. Significant variation was seen in root hair density and root hair number and in fresh and dry weight of shoot and root under P- stress. However, there was not much difference in the shoot and root total P and Pi levels of five selected high and low responding genotypes. We noticed contrasting responses in the greenhouse and natural field experiments for most of these genotypes. The leads from the study form the basis for breeding and improvement of foxtail millet for better Pi-use efficiency.

Metabolic measures 12 months after a randomised controlled trial of treatment of clozapine associated obesity and diabetes with exenatide (CODEX)

Clozapine is associated with obesity and type 2 diabetes. Glucagon-like-peptide-1 (GLP-1) receptor agonists such as exenatide can counter clozapine-associated GLP-1 dysregulation. Our 24-week randomized, controlled, open-label, pilot trial of once-weekly extended-release subcutaneous exenatide or usual care (CODEX) (n = 28), found exenatide was associated with significantly greater weight loss. We examined whether this effect was maintained at 12-months post-intervention. We followed up CODEX trial participants at 12-months post trial endpoint, collecting information on weight, BMI, waist circumference, blood pressure, fasting glucose, HbA1c, and use of metformin. The primary outcome of interest was change in weight from trial baseline to 12-months post endpoint and trial endpoint to 12-months post endpoint compared between former exenatide and usual care participants. Only HbA1c differed between baseline and 12-months post endpoint between the exenatide and control groups. From endpoint to 12-month follow up there were significantly greater increases among the former exenatide versus former usual care participants for weight, BMI, HbA1c and proportion with >5% weight gain. Stratifying results by whether participants used metformin post trial did not alter proportion with >5% weight gain. Although there were no significant differences in weight and BMI between baseline and 12-month post endpoint, there were significant increases in weight and BMI in the 12 months post endpoint for the former exenatide group. This was irrespective of metformin use and is in keeping with studies of other GLP-1RA agents. Further studies on GLP-1RAs use beyond 24 weeks for people with clozapine associated weight gain are needed.

Lithium and strontium isotope dynamics in a carbonate island aquifer, Rottnest Island, Western Australia

Water-rock interactions in aquifer systems are a key control on water quality but remain poorly understood. Lithium (Li) isotopes are useful for understanding water-rock interactions, but there are few data available for groundwater aquifers. Here we present a Li isotope dataset for rainfall and groundwater samples from a carbonate island aquifer system: Rottnest Island, Western Australia. This dataset was complemented by strontium (Sr) isotope and major and trace element data for groundwaters, and leaching experiments on bedrock samples. The δ⁷Li values and ⁸⁷Sr/⁸⁶Sr ratios of fresh groundwaters ranged from +23 to +36‰ and 0.709167 to 0.709198, respectively. Mass balance calculations indicated that silicate weathering supplied ~60 and 70% of dissolved Li and Sr in fresh groundwaters, respectively, with the remainder provided by atmospheric input, and carbonate weathering; for major cations, the majority of calcium and sodium (Na) are supplied by carbonate weathering and atmospheric input, respectively. The estimated low proportion of Sr produced by carbonate weathering was surprising in a carbonate aquifer, and the ⁸⁷Sr/⁸⁶Sr data indicated that the silicate Sr source had low Rb/Sr and ⁸⁷Sr/⁸⁶Sr ratios. There was an increase in the maximum δ⁷Li values in fresh groundwaters (+36‰) relative to the maximum value in rainfall and seawater (ca. +31‰). As clay minerals are undersaturated in fresh groundwaters, this increase may be explained by Li isotope fractionation associated with ion-exchange reactions on clays and iron(oxy)hydroxides. In the more saline groundwaters, the minimum δ⁷Li values decreased with depth to +14.5‰, suggesting increased silicate mineral dissolution in the deeper aquifer. These results reveal the importance of water-rock interactions in a coastal carbonate aquifer, and demonstrate the usefulness of Li isotopes for tracing weathering reactions in an environmental setting where traditional weathering tracers, such as sodium and Sr isotopes, are less appropriate.

What to look for during constant observations: Expert consensus and a tool for observations recording

WHAT IS KNOWN ON THE SUBJECT?: Supportive observations is the practice of closely monitoring patients who are acutely unwell in order to keep them safe. There are no formal guidelines for nursing staff on what to observe during observations. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: A consensus of expert opinion suggests that the clinically meaningful behaviours in supportive observations focus on six factors: agitation, self-harm and suicide, violence, negative influence, disengagement and positive behaviour. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: These aspects of patient presentation should be a part of the decision-making discussions about observations. The Mersey Care Supportive Observations Recording Tool that emerged from this consensus may assist with recording the relevant information. Abstract Introduction Supportive observations are common in mental health care but there are no guidelines on best practice or what should be documented in observations records. Aim To develop expert consensus on the important aspects of patient presentation that inform clinical decision-making about observations and to develop a recording tool from this consensus. Method A Delphi methodology was used to consult an expert panel of mental health clinicians and academics to agree on what aspects of patient presentation during constant observations are important in informing clinical decisions. Thematic analysis was applied to the agreed item set to extract common aspects of presentation and behaviour. Results The panel considered 118 individual items across three rounds of consultation and agreed that 51 items were important to clinical decisions about observations. Thematic analysis found six man themes: agitation, self-harm and suicide, violence, negative influence, disengagement and positive behaviour. Subthemes were used to create the MerseyCare Supportive Observations Recording Tool (MSORT). Discussion These data represent the first expert consensus on the aspects of patient presentation that are important to clinical decisions. Implications for practice Consensus items should be recorded in observations records and be considered in decision-making about observations. The MSORT may aid observations recording.

High-resolution ion mobility spectrometry-mass spectrometry of isomeric/isobaric ribonucleotide variants

In this report, we explored the benefits of cyclic ion mobility (cIM) mass spectrometry in the analysis of isomeric post-transcriptional modifications of RNA. Standard methyl-cytidine samples were initially utilized to test the ability to correctly distinguish different structures sharing the same elemental composition and thus molecular mass. Analyzed individually, the analytes displayed characteristic arrival times (tD ) determined by the different positions of the modifying methyl groups onto the common cytidine scaffold. Analyzed in mixture, the widths of the respective signals resulted in significant overlap that initially prevented their resolution on the tD scale. The separation of the four isomers was achieved by increasing the number of passes through the cIM device, which enabled to fully differentiate the characteristic ion mobility behaviors associated with very subtle structural variations. The placement of the cIM device between the mass-selective quadrupole and the time-of-flight analyzer allowed us to perform gas-phase activation of each of these ion populations, which had been first isolated according to a common mass-to-charge ratio and then separated on the basis of different ion mobility behaviors. The observed fragmentation patterns confirmed the structures of the various isomers thus substantiating the benefits of complementing unique tD information with specific fragmentation data to reach more stringent analyte identification. These capabilities were further tested by analyzing natural mono-nucleotide mixtures obtained by exonuclease digestion of total RNA extracts. In particular, the combination of cIM separation and post-mobility dissociation allowed us to establish the composition of methyl-cytidine and methyl-adenine components present in the entire transcriptome of HeLa cells. For this reason, we expect that this technique will benefit not only epitranscriptomic studies requiring the determination of identity and expression levels of RNA modifications, but also metabolomics investigations involving the analysis of natural extracts that may possibly contain subsets of isomeric/isobaric species.

On the move: redox-dependent protein relocation in plants

Compartmentation of proteins and processes is a defining feature of eukaryotic cells. The growth and development of organisms is critically dependent on the accurate sorting of proteins within cells. The mechanisms by which cytosol-synthesized proteins are delivered to the membranes and membrane compartments have been extensively characterized. However, the protein complement of any given compartment is not precisely fixed and some proteins can move between compartments in response to metabolic or environmental triggers. The mechanisms and processes that mediate such relocation events are largely uncharacterized. Many proteins can in addition perform multiple functions, catalysing alternative reactions or performing structural, non-enzymatic functions. These alternative functions can be equally important functions in each cellular compartment. Such proteins are generally not dual-targeted proteins in the classic sense of having targeting sequences that direct de novo synthesized proteins to specific cellular locations. We propose that redox post-translational modifications (PTMs) can control the compartmentation of many such proteins, including antioxidant and/or redox-associated enzymes.

How helpful are Patient and Public Involvement strategic documents - Results of a framework analysis using 4Pi National Involvement Standards

BACKGROUND

Patient and Public Involvement (PPI) strategic documents are viewed as an essential feature of organisational commitment to openness and transparency. They provide a mechanism to communicate opportunities for wider community influence in healthcare. The absence of documentation can be negatively interpreted, for example during regulatory inspection, as a lack of intent by organisations to collaborate with a broad constituency. Published literature paints a confusing picture of rationale and evidence that could provide the foundation for strategic action. This makes it difficult for those responsible for turning goals into meaningful involvement. We investigated how content is presented and organised in strategic documents. This pragmatic study is intended to stimulate reflective practice, promote debate and generate further inquiry with a wide audience.

METHODS

We created and iterated a framework adapted from 4Pi National Involvement Standards to analyse organisational PPI strategic documents against five domains which are principles, purpose, presence, process and impact. Fifteen strategic documents were grouped into four categories (acute care providers; clinical commissioning groups; community healthcare providers; and other) and included for analysis. A matrix was produced. By reading the matrix vertically (down) and horizontally (across), comparisons can be made between 4Pi domains and across organisations.

RESULTS

There was no discernible pattern between domains or between organisations. There was variation in the level to which criteria were met. No single strategy fully met the criteria for all five domains of 4Pi National Involvement Standards. The criteria for purpose was fully met in eight strategic documents. Only two documents fully met impact criteria. Four organisations showed better completeness with fully or partially met criteria across five domains. A single organisation partially met the criteria for all domains. The remaining 10 were unable to meet the criteria in at least one domain.

CONCLUSION

Our findings align with published literature that suggests the underpinning rationale for PPI is confusing. A strategic aim is difficult to articulate. Context and complexity are at play making the sharing of generalisable knowledge elusive. We offer further critique about the value of these documents and consider: 'is there an alternative approach to construct PPI strategy to generate theory, capture learning and evaluate effectiveness at the same time?' We suggest testing the adoption of programme theory in PPI. The emergent nature and context sensitive features of programme theory enable curiosity, creativity and critical appraisal. It has the potential to release practitioners from the tokenistic cycle of monitoring and reporting and replace this with a richer understanding of 'what' works and 'how' tied to a 'why' - in order to achieve a shared aim that everyone can get behind.

P1718Veno-arterial ECMO versus Left Impella bleeding complications in cardiogenic shock patients on dual antiplatelet therapy

Background

Selective groups of patients, presenting with INTERMACS-1 cardiogenic shock due to acute ischaemic heart failure, may benefit from mechanical circulatory support (MCS). Patients with biventricular failure, severe septic shock or oxygenation problems should be selected for VA-ECMO, although the left Impella-CP heart pump can be considered as a less invasive alternative in supporting predominantly left ventricular failure. Bleeding issues are a major concern in patients on MCS, especially in this group where triple anticoagulation therapy (unfractionated heparin (UFH) for prevention of pump thrombosis and dual antiplatelet therapy (DAPT) after coronary stenting) is necessitated. We aim to investigate the bleeding and transfusion rate in DAPT-patients on VA-ECMO versus Impella.

Methods

We report single center data for 51 VA-ECMO and 8 Impella patients between 2011 and 2019. Indication for MCS was acute ischaemic cardiogenic shock. Patient demographics, transfusions and reported/radiographically diagnosed bleeding (BARC-classification) complications were analyzed. All patients received UFH and low dose aspirin plus clopidogrel or ticagrelor. Impella flow was at least 2.5 L/min. Transfusion targets were Hb >7 g/dl, fibrinogen >100 mg/dl (or >150 mg/dl when active bleeding) and platelet count >50/fL.

Results

Impella patients were significantly older (VA-ECMO 52.8 vs. Impella 62.4; p=0.02) as compared to the VA-ECMO group. Anti-Xa-levels and length of the MCS-run (mean 7.9 VA-ECMO vs. 6.4 days Impella) were comparable in both groups. Occurrences of minor bleeds was comparable between both groups (mainly oozing from the insertion site in the ImpellaTM group 63% vs. VA-ECMO 72%; p>0.05) but major bleedings with BARC score of 3 or more were significantly lower in the Impella group (13% vs. VA-ECMO 65%; p=0.005). Platelet and red blood cell transfusions were significantly lower in the Impella group (0.1 units of platelets per day vs. 1.1 units of platelets per day on VA-ECMO; p=0.002 and 0.8 units of RBCs per day vs. 2.6 units of RBCs per day on VA-ECMO; p=0.02).

Bleeding/transfusion VA-ECMO vs Impella

Conclusions

Bleeding is a frequent complication of MCS. However, in our cohort, triple anticoagulation in acute cardiogenic shock due to ischaemic left ventricle failure resulted in a lower major bleeding rate when support was given by the left Impella device as compared with VA-ECMO therapy group. As a result, platelet and red blood cell transfusions were lower in the Impella group. These findings are likely to be partly explained by the increased number and size of cannulas in VA-ECMO, as well as the increased risk of haemolysis and consumptive coagulopathy due to the complexity and extensive foreign body surface of the ECMO-circuit. We conclude that Impella support should be considered as a safer option than VA-ECMO with regards to bleeding in patients with ischaemic left ventricular failure who require DAPT and MCS as a bridge to recovery or other definitive therapy.