Retinoids in the treatment of photoageing: A histological study of topical retinoid efficacy in black skin

BACKGROUND

Photoageing describes complex cutaneous changes that occur due to chronic exposure to solar ultraviolet radiation (UVR). The 'gold standard' for the treatment of photoaged white skin is all-trans retinoic acid (ATRA); however, cosmetic retinol (ROL) has also proven efficacious. Recent work has identified that black skin is susceptible to photoageing, characterized by disintegration of fibrillin-rich microfibrils (FRMs) at the dermal-epidermal junction (DEJ). However, the impact of topical retinoids for repair of black skin has not been well investigated.

OBJECTIVES

To determine the potential of retinoids to repair photoaged black skin.

METHODS

An exploratory intervention study was performed using an in vivo, short-term patch test protocol. Healthy but photoaged black volunteers (>45 years) were recruited to the study, and participant extensor forearms were occluded with either 0.025% ATRA (n = 6; 4-day application due to irritancy) or ROL (12-day treatment protocol for a cosmetic) at concentrations of 0.3% (n = 6) or 1% (n = 6). Punch biopsies from occluded but untreated control sites and retinoid-treated sites were processed for histological analyses of epidermal characteristics, melanin distribution and dermal remodelling.

RESULTS

Treatment with ATRA and ROL induced significant acanthosis (all p < 0.001) accompanied by a significant increase in keratinocyte proliferation (Ki67; all p < 0.01), dispersal of epidermal melanin and restoration of the FRMs at the DEJ (all p < 0.01), compared to untreated control.

CONCLUSIONS

This study confirms that topical ATRA has utility for the repair of photoaged black skin and that ROL induces comparable effects on epidermal and dermal remodelling, albeit over a longer timeframe. The effects of topical retinoids on black photoaged skin are similar to those reported for white photoaged skin and suggest conserved biology in relation to repair of UVR-induced damage. Further investigation of topical retinoid efficacy in daily use is warranted for black skin.

Statistical Analysis to Determine the Predictors of Liver Segmental Hypertrophy Observed Post-Radiotherapy

PURPOSE/OBJECTIVE(S)

Prediction of liver segment hypertrophy based on radiotherapy (RT) dose is crucial for maximizing functional liver volume and avoiding hepatic failure after RT. We determined predictors associated with liver hypertrophy with stratification based on induction chemo (IC) and tumor location.

MATERIALS/METHODS

RT planning, CT images, and 3-month-followup CTs were analyzed from 148 patients who underwent RT for primary or metastatic liver cancers. A nnUNet based model was trained (train/test = 160/40 CTs) to contour the liver segments (1, 2, 3, 4, 5-8) with accuracy assessed using Dice Similarity Coefficients (DSC). 52 features corresponding to segments 1, 2, 3, 2+3, 4, 5-8, were collected including equivalent dose to 2Gy fractions metrics-mean dose (Dmean), dose received by 95% of the volume (D95), volume spared from x gy (Vx), cancer type, tumor location, and IC status. Descriptive statistics were reported as percentage of segments showing hypertrophy under all stratification. Predictors were compared with 6 response variables using Chi-squared/Fisher-Exact test (CST/FET) and logistic regression (LR) for categorical and numerical predictors.

RESULTS

The nnUNet model had an average DSC of 0.91 across all segments. Overall, segments 1, 4, and 5-8 showed hypertrophy in 35% of cases, and segments 2, 3 and 2+3 showed hypertrophy in 45-49% of patients. Stratification based on tumor location resulted in segment 2+3 hypertrophy in 66% of patients when the tumor was in segments 5-8. For bilobed tumors, segment 2+3 hypertrophy was observed in 34% of patients. CST/FET showed that tumor location, IC, and tumor type were significant predictors of segment 5-8 hypertrophy. Tumor location was also a significant predictor of segments 3 and 2+3 hypertrophy. In LR analysis, all segment-based dose metrics were significant predictors of segment hypertrophy except Dmean in segment 4, and D95 in segment 2 and 4. Overall, the strongest association was obtained for V35 significantly predicting for each segment hypertrophy. The mean dose for segments with hypertrophy was significantly lower (range: 15-30 Gy) than segments with atrophy (p<0.01), except for segment 4 where the mean dose was 10Gy lower but did not reach significance. IC impacts the threshold mean dose that leads to hypertrophy, with more toxic drugs reducing the mean dose threshold.

CONCLUSION

Tumor location and IC significantly impact the response of segments to RT. Dose volume metrics are strong predictors of volumetric response with segment volume spared from 35 Gy being the strongest predictor.

PAPA-like syndrome with heterozygous mutation in the MEFV gene

A patient presented with a history of recurrent pyoderma gangrenosum, arthritis and extensive acne, prompting a genetic workup for PAPA syndrome. An MEFV mutation was identified and a change in therapeutic strategy from anakinra to colchicine was successful.

A qualitative analysis of online misinformation and conspiracy theories in psoriasis

Psoriasis is a chronic, hereditary disease with a complex immunopathogenesis, rendering it susceptible to misinformation. Misinformation related to psoriasis can have negative effects both on the public perception of psoriasis and on patients' knowledge of psoriasis. To characterize misinformation related to psoriasis available online, we performed a formal literature review via PubMed and a thematic review via Google. Key themes of misinformation included 'victim-blaming' (hygiene), 'vector' (contagion), 'vaccination', 'vilification' of conventional therapy, 'validation' of natural treatment and diet, 'veneration' of cures and 'vocalization' from celebrities. Misinformation related to psoriasis is pervasive on social media and other websites. Dermatologists, as patient advocates, should be aware of the content of misinformation available online and combat misleading health information to optimize health outcomes for patients with psoriasis.

Confidence of Irish dermatologists in caring for patients with skin of colour

To assess Irish dermatologists' confidence with dermatology in patients with skin of colour (SOC), an online survey was distributed to all members of the Irish Association of Dermatology (IAD) by email. Half (50%) of respondents were 'not confident' or 'not at all confident' in diagnosing skin conditions and one-third (33.9%) were 'not confident' or 'not at all confident' in managing skin conditions in patients with SOC. Irish dermatologists have low confidence with skin pathology in SOC, and specific training could reduce this disparity.

Anakinra for recalcitrant pyoderma gangrenosum

Pyoderma gangrenosum (PG) is an autoinflammatory neutrophilic dermatosis characterized by rapidly enlarging, painful ulcers. Anakinra is a recombinant interleukin (IL)-1 receptor antagonist that blocks the activity of IL-1α and IL-1β by competitively inhibiting IL-1 binding to the IL-1 type 1 receptor. We present a series of two patients with recalcitrant PG, who had limited therapeutic options and multiple comorbidities and multiple previous treatment failures, who obtained 100% healing with anakinra. Compared with conventional first-line therapies for PG, the safety profile of anakinra may be preferable for patients with multiple comorbidities. Further research is needed to assess the safety and efficacy of anakinra for PG.

Machine learning prediction of sleep stages in dairy cows from heart rate and muscle activity measures

Sleep is important for cow health and shows promise as a tool for assessing welfare, but methods to accurately distinguish between important sleep stages are difficult and impractical to use with cattle in typical farm environments. The objective of this study was to determine if data from more easily applied non-invasive devices assessing neck muscle activity and heart rate (HR) alone could be used to differentiate between sleep stages. We developed, trained, and compared two machine learning models using neural networks and random forest algorithms to predict sleep stages from 15 variables (features) of the muscle activity and HR data collected from 12 cows in two environments. Using k-fold cross validation we compared the success of the models to the gold standard, Polysomnography (PSG). Overall, both models learned from the data and were able to accurately predict sleep stages from HR and muscle activity alone with classification accuracy in the range of similar human models. Further research is required to validate the models with a larger sample size, but the proposed methodology appears to give an accurate representation of sleep stages in cattle and could consequentially enable future sleep research into conditions affecting cow sleep and welfare.

Measurement of the Charge-Averaged Elastic Lepton-Proton Scattering Cross Section by the OLYMPUS Experiment

We report the first measurement of the average of the electron-proton and positron-proton elastic scattering cross sections. This lepton charge-averaged cross section is insensitive to the leading effects of hard two-photon exchange, giving more robust access to the proton's electromagnetic form factors. The cross section was extracted from data taken by the OLYMPUS experiment at DESY, in which alternating stored electron and positron beams were scattered from a windowless gaseous hydrogen target. Elastic scattering events were identified from the coincident detection of the scattered lepton and recoil proton in a large-acceptance toroidal spectrometer. The luminosity was determined from the rates of Møller, Bhabha, and elastic scattering in forward electromagnetic calorimeters. The data provide some selectivity between existing form factor global fits and will provide valuable constraints to future fits.

Scratching the surface: a review of online misinformation and conspiracy theories in atopic dermatitis

Misinformation is one of the greatest threats to global health. Atopic dermatitis (AD) is a common skin disorder with a complex multifactorial aetiology, rendering it susceptible to misinformation. Little is known about the content of misinformation regarding AD online. We performed a review of AD-related misinformation available online, via PubMed for scientific papers and Google for nonscientific websites. Key areas of misinformation were identified, including 'simple cures' for AD, diet, chemicals, dust, vaccines, red skin syndrome and alternative therapies. Patients with AD and their families are vulnerable to misinformation given the severe impact of AD on quality of life. Dermatologists must be aware of the false AD-related content being shared online, and be prepared to refute and rebut misinformation by providing appropriate evidence.

Bare necessities? The utility of full skin examination in the COVID-19 era

Full skin examination (FSE) may improve the detection of malignant melanoma (MM). The objective of this study was to assess the safety of targeted lesion examination (TLE) compared with FSE in our Pigmented Lesion Clinic (PLC). Patients attending the PLC were randomized in a 2 : 1 ratio to FSE (intervention) or TLE (standard care). Demographic details and risk factors were documented, and the time taken to perform FSE and TLE was noted. Of 763 participants, 520 were assigned to FSE and 243 were assigned to TLE. On average, FSE took 4.02 min and TLE took 30 s to perform. Of the 520 participants assigned to FSE, 37 (7.1%) had incidental findings, of whom 12 patients (2.3%) had additional lesions biopsied. No additional melanomas were detected that would have been missed by use of the standard protocol. This study suggests that in low-risk patients referred to a PLC with a lesion of concern, the possibility of missing incidental cutaneous malignancies using lesion-directed examination is low.

Indicators of dehydration in healthy 4- to 5-day-old dairy calves deprived of feed and water for 24 hours

Our objective was to identify practical indicators of calf dehydration that could be used in an industry context. Eleven healthy 4-d-old commercial dairy calves were fed 2 L of mixed colostrum, then deprived of food and water for 24 h. Total body water was determined in the fed state using the deuterium dilution method. Body weight, along with a range of behavioral and physiological variables, was recorded 1 h after feeding, then at 90-min intervals through to 24 h. Blood samples were collected at every second sampling to assess changes in plasma hemoglobin, hematocrit, and osmolality. Linear mixed-effects models were used to explore associations between hydration status (% body water) and outcome variables. All calves remained bright and alert with good suckling reflexes throughout the 24-h period. After 24 h, total body water had decreased by an average of 8.4% (standard error 1.18), consistent with mild to moderate dehydration. Skin tent return time, capillary refill time, and detectable enophthalmos were associated with hydration status. Calves with skin tent return times of 3 s or longer were 4.4 percentage points less hydrated than those with return times of less than 3 s. Similarly, a capillary refill time of 3 s or longer was associated with a 4.3 percentage point reduction in hydration compared with refill times of less than 3 s. Calves with detectable enophthalmos (≥1 mm) were 3.5 percentage points less hydrated than those without enophthalmos. The skin tent, capillary refill, and enophthalmos tests are all relatively simple to perform and, although requiring the calf to be briefly restrained, can easily be performed by a single operator. The outcome of these tests was relatively consistent, in that calves above the threshold in any test were 3.5 to 4.5% less hydrated than calves below the threshold. As such, these tests may be of practical utility to identify calves with mild to moderate dehydration in an industry setting.

Optimal sunscreen use, during a sun holiday with a very high ultraviolet index, allows vitamin D synthesis without sunburn

Background

Sunlight contains ultraviolet (UV)A and UVB radiation. UVB is essential for vitamin D synthesis but is the main cause of sunburn and skin cancer. Sunscreen use is advocated to reduce the sun's adverse effects but may compromise vitamin D status.

Objectives

To assess the ability of two intervention sunscreens to inhibit vitamin D synthesis during a week‐long sun holiday.

Methods

The impact of sunscreens on vitamin D status was studied during a 1‐week sun holiday in Tenerife (28° N). Comparisons were made between two formulations, each with a sun protection factor (SPF) of 15. The UVA‐protection factor (PF) was low in one case and high in the other. Healthy Polish volunteers (n = 20 per group) were given the sunscreens and advised on the correct application. Comparisons were also made with discretionary sunscreen use (n = 22) and nonholiday groups (51·8° N, n = 17). Sunscreen use in the intervention groups was measured. Behaviour, UV radiation exposure, clothing cover and sunburn were monitored. Serum 25‐hydroxyvitamin D₃ [25(OH)D₃] was assessed by high‐performance liquid chromatography–tandem mass spectrometry.

Results

Use of intervention sunscreens was the same (P = 0·60), and both equally inhibited sunburn, which was present in the discretionary use group. There was an increase (P < 0·001) in mean ± SD 25(OH)D₃ (28·0 ± 16·5 nmol L⁻¹) in the discretionary use group. The high and low UVA‐PF sunscreen groups showed statistically significant increases (P < 0·001) of 19·0 ± 14·2 and 13·0 ± 11·4 nmol L⁻¹ 25(OH)D₃, respectively with P = 0·022 for difference between the intervention sunscreens. The nonholiday group showed a fall (P = 0·08) of 2·5 ± 5·6 nmol L⁻¹ 25(OH)D₃.

Conclusions

Sunscreens may be used to prevent sunburn yet allow vitamin D synthesis. A high UVA‐PF sunscreen enables significantly higher vitamin D synthesis than a low UVA‐PF sunscreen because the former, by default, transmits more UVB than the latter.

What's already known about this topic?

Action spectra (wavelength dependence) for erythema and the cutaneous formation of vitamin D overlap considerably in the ultraviolet (UV)B region.

Theoretically, sunscreens that inhibit erythema should also inhibit vitamin D synthesis.

To date, studies on the inhibitory effects of sunscreens on vitamin D synthesis have given conflicting results, possibly, in part, because people typically apply sunscreen suboptimally.

Many studies have design flaws.

What does this study add?

Sunscreens (sun protection factor, SPF 15) applied at sufficient thickness to inhibit sunburn during a week‐long holiday with a very high UV index still allow a highly significant improvement of serum 25‐hydroxyvitamin D₃ concentration.

An SPF 15 formulation with high UVA protection enables better vitamin D synthesis than a low UVA protection product. The former allows more UVB transmission.

Linked Editorial: https://doi.org/10.1111/bjd.18273.

https://doi.org/10.1111/bjd.18492 available online

https://www.bjdonline.com/article/optimal-sunscreen-use-during-a-sun-holiday-with-a-very-high-ultraviolet-index-allows-vitamin-d-synthesis-without-sunburn/

Cow Lying Behaviour and Bedding Quality Changes during Five Weeks on a Stand-Off Pad

Simple Summary

New Zealand dairy farmers place cows in uncovered off-paddock facilities for a part (e.g., 18 h) of the day to reduce their impact on pasture during winter. Lying time is a key indicator of whether these hybrid pasture systems are meeting welfare requirements. While it is easy to measure lying time in a research setting using accelerometers, it is not yet common to measure it on farm, and more convenient indicators are needed. We investigated the lying behaviour of dairy cows as bedding quality deteriorated over a five-week period to determine what measures may be useful as farmer-friendly indicators of cow welfare. The daily lying time of the two groups of cows on bedding according to normal farm practice (NFP) declined over the five weeks and was significantly less than that of cows on fresh bedding during the last 10 days of the trial. The fresh woodchip bedding contained less than 65% moisture throughout the trial. By week 3 and week 4, the moisture content of the lying surface exceeded 75% for NFP Group 2 and Group1, respectively. A bedding moisture threshold of 75% assessed by a ‘gumboot score’ and cows lying rather than grazing when on pasture may be useful farmer-friendly indicators of cow welfare because of their relationship with reduced lying time.

Abstract

Bedding quality and cow lying time were measured during five weeks in a normal farm practice (NFP) off-paddock system with no bedding refreshment. Two groups of 100 non-lactating dairy cows were compared to groups of 8 cows with fresh bedding (FB). The cows were on a woodchip pad for 18 h/d at a space allowance of 5.4 m²/cow, with 6 h/d on pasture for 5 weeks. Lying times were recorded continuously for 60 cows per group using accelerometers. Bedding moisture content was measured weekly. Data for each NFP group were analysed and compared with those of their respective FB group using repeated measures. The lying time declined over five weeks from 11.6 h/day during the first week to 5.6 h/day during the fifth week (SED = 0.3; F_1,25 = 351.56; p < 0.001). The moisture content of the bedding increased over the five weeks and was significantly higher for both NFP groups (NFP Group 1: F_5,59 = 8.33; p < 0.001; NFP Group 2: F_5,61 = 5.54; p < 0.001) than those of the respective FB groups. The percentage of total time lying when in the paddock increased for the NFP groups, reaching 15% in the last week of the trial. During five weeks on a stand-off pad, bedding quality deteriorated, and cows lay down less, to such an extent that welfare was compromised.

Prevalence of lameness in sheep transported to meat processing plants in New Zealand and associated risk factors

Aims: To estimate the prevalence of lameness in sheep transported to meat processing plants in New Zealand, and to identify factors associated with the prevalence of lameness. Methods: The survey was conducted over the main meat processing season, running from October 2012 to the end of May 2013, at 10 sheep processing premises (five North Island and five South Island). A sample of 50 sheep selected from approximately six sheep consignments per week from each of the processing plants were scored for lameness, using a scale from Grade 1 (mild) to 3 (severe, non-weight-bearing). For each consignment the breed, age class and mean carcass weight were recorded. A multivariable regression model was fitted to identify the risk factors for prevalence of lame sheep (Grade 1-3) within a consignment. Results: In total, 1,854/78,833 (2.4 (95% CI = 2.2-2.5)%) sheep were diagnosed with lameness. Of the 1,854 lame sheep, lameness severity was Grade 1 in 1,349 (72.8%), Grade 2 in 450 (24.3%) and Grade 3 in 55 (3.0%) sheep. Within consignments ≥1 lame sheep was observed in 600/1,682 (35.7 (95% CI = 33.4-38.0)%) consignments. In Merino lambs and ewes the prevalence of lameness was greater than that of other breeds (p < 0.001), but in rams/wethers, the prevalence of lameness was lower in Merino than other breeds (p < 0.05). In sheep originating from the North Island, increasing mean carcass weight was associated with an increase in the prevalence of lameness (p < 0.001), but in the South Island prevalence was similar for different carcass weights (p = 0.5). In the North Island increasing yarding time was associated with an increase in the lameness prevalence (p < 0.01), but not in the South Island (p = 0.7). Sheep from the South Island generally had a higher prevalence of lameness than the North Island and the prevalence of lameness was lower over summer and autumn relative to the previous spring (p < 0.01). Conclusion: The results from this survey provided a measure of the prevalence of lameness in a section of the New Zealand sheep population, namely those animals sent for slaughter; as well as identification of several risk factors associated with lameness.

Ageing profiles of Caucasian and Chinese cohorts - focus on hands skin

OBJECTIVE

In spite of hand care being a dynamic segment of skin care, hands skin physiology has been receiving little attention in comparison to facial skin. In the present study, we aimed at gathering a comprehensive set of skin data from the dorsal part of the hand to study age related-changes in two ethnic groups (Caucasian and Chinese).

METHODS

Skin topographic, skin colour/colour heterogeneities, skin chromophores and skin biophysical measurements of 116 Caucasian and Chinese female volunteers aged 30-65 years old were collected in Ireland and in China as part of a cross-sectional study.

RESULTS

Topographic alterations happened at both micro and macro scales with a noticeable delay in the onset of 10 years for the Chinese cohort. Similar evolution of skin colour with ageing was observed between the two cohorts and strong dissimilarities were seen when it came to colour heterogeneities and melanin hyper concentration, with a 20-year delay in severity for the Chinese cohort. A similar sharp drop of skin hydration occurred when reaching the 60's regardless of the group and substantial differences were recorded for skin biomechanical properties of the skin.

CONCLUSION

These results provide additional insights about hand skin physiology in relation to ageing and ethnic differences, especially when put into perspective with what is currently known about facial ageing. This research yield additional material for hand cream product rationale and strategies for mitigating the appearance of ageing hands.

Sunscreen applied at ≥ 2 mg cm-2 during a sunny holiday prevents erythema, a biomarker of ultraviolet radiation-induced DNA damage and suppression of acquired immunity

BACKGROUND

Sun protection factor (SPF) is assessed with sunscreen applied at 2 mg cm^-2 . People typically apply around 0·8 mg cm^-2 and use sunscreen daily for holidays. Such use results in erythema, which is a risk factor for skin cancer.

OBJECTIVES

To determine (i) whether typical sunscreen use resulted in erythema, epidermal DNA damage and photoimmunosuppression during a sunny holiday, (ii) whether optimal sunscreen use inhibited erythema and (iii) whether erythema is a biomarker for photoimmunosuppression in a laboratory study.

METHODS

Holidaymakers (n = 22) spent a week in Tenerife (very high ultraviolet index) using their own sunscreens without instruction (typical sunscreen use). Others (n = 40) were given SPF 15 sunscreens with instructions on how to achieve the labelled SPF (sunscreen intervention). Personal ultraviolet radiation (UVR) exposure was monitored electronically as the standard erythemal dose (SED) and erythema was quantified. Epidermal cyclobutane pyrimidine dimers (CPDs) were determined by immunostaining, and immunosuppression was assessed by contact hypersensitivity (CHS) response.

RESULTS

There was no difference between personal UVR exposure in the typical sunscreen use and sunscreen intervention groups (P = 0·08). The former had daily erythema on five UVR-exposed body sites, increased CPDs (P < 0·001) and complete CHS suppression (20 of 22). In comparison, erythema was virtually absent (P < 0·001) when sunscreens were used at ≥ 2 mg cm^-2 . A laboratory study showed that 3 SED from three very different spectra suppressed CHS by around ~50%.

CONCLUSIONS

Optimal sunscreen use prevents erythema during a sunny holiday. Erythema predicts suppression of CHS (implying a shared action spectrum). Given that erythema and CPDs share action spectra, the data strongly suggest that optimal sunscreen use will also reduce CPD formation and UVR-induced immunosuppression.

A new in vitro assay to test UVR protection of dermal extracellular matrix components by a flat spectrum sunscreen

The efficacy of topical sunscreens is currently assessed by crude, costly and time consuming in vivo assays. We have previously demonstrated that components of the dermal extracellular matrix (ECM), rich in UV-absorbing amino acids, are susceptible to damage by solar simulated radiation (SSR) in vitro. Here we developed an in vitro method to test the ability of sunscreens to protect fibrillin-rich microfibrils (FRM) and fibronectin, key components of the dermal ECM from UV-induced damage. Solutions of FRM or fibronectin were irradiated without protection, in the presence of a vehicle or a commercially-available flat-spectrum sunscreen. The effect of SSR on molecular structure was determined by atomic force microscopy (FRM) and SDS-PAGE (fibronectin). Following irradiation, FRM periodicity became bi-modally distributed (peaks: 40nm & 59nm) compared to the unimodal distribution in unexposed controls (peak: 50nm). Irradiation in the presence of flat-spectrum sunscreen protected against this change, maintaining the unimodal distribution. SSR induced significant aggregation of fibronectin (p=0.005), which was abrogated by sunscreen. These results demonstrate that this in vitro assay system is sufficiently sensitive to act as an initial/additional screen of sunscreen efficacy. We conclude that sunscreen can reduce UV-mediated damage of key dermal ECM in vitro and thereby prevent remodelling associated with photoageing.

Early and mid-term outcomes after transcatheter aortic valve implantation (TAVI) in Ireland

BACKGROUND

TAVI is a percutaneous approach to aortic valve replacement in high surgical risk patients deemed inoperable.

AIM

To evaluate the early and mid-term outcomes for an Irish TAVI cohort over a six-year period at St James's Hospital and Blackrock Clinic, Dublin, Ireland.

RESULTS

In total 147 patients, 56% male with an average age of 82 underwent TAVI between December 2008 and December 2014. Thirty day, one year and two year survival was 90.5%, 83% and 71% respectively. Major vascular complications and renal failure were the biggest predictors of mortality at 30 days (p = 0.02). We observed a pacing rate of 13.5%, the majority in patients who had Medtronic Corevalve implants (p < 0.05). With increasing procedural experience there was a reduction in length of stay from 10 days to 7.5 days.

CONCLUSION

This review, the first of its kind in Ireland showed favorable rates of 30 day and one year and two year survival post TAVI with procedural success and complication rates similar to international registry data.

Hard Two-Photon Contribution to Elastic Lepton-Proton Scattering Determined by the OLYMPUS Experiment

The OLYMPUS Collaboration reports on a precision measurement of the positron-proton to electron-proton elastic cross section ratio, R_{2γ}, a direct measure of the contribution of hard two-photon exchange to the elastic cross section. In the OLYMPUS measurement, 2.01 GeV electron and positron beams were directed through a hydrogen gas target internal to the DORIS storage ring at DESY. A toroidal magnetic spectrometer instrumented with drift chambers and time-of-flight scintillators detected elastically scattered leptons in coincidence with recoiling protons over a scattering angle range of ≈20° to 80°. The relative luminosity between the two beam species was monitored using tracking telescopes of interleaved gas electron multiplier and multiwire proportional chamber detectors at 12°, as well as symmetric Møller or Bhabha calorimeters at 1.29°. A total integrated luminosity of 4.5  fb^{-1} was collected. In the extraction of R_{2γ}, radiative effects were taken into account using a Monte Carlo generator to simulate the convolutions of internal bremsstrahlung with experiment-specific conditions such as detector acceptance and reconstruction efficiency. The resulting values of R_{2γ}, presented here for a wide range of virtual photon polarization 0.456<ε<0.978, are smaller than some hadronic two-photon exchange calculations predict, but are in reasonable agreement with a subtracted dispersion model and a phenomenological fit to the form factor data.

A review of anaesthetic outcomes in patients with genetically confirmed mitochondrial disorders

Mitochondrial disorders are a clinically and biochemically diverse group of disorders which may involve multiple organ systems. General anaesthesia (GA) poses a potential risk of decompensation in children with mitochondrial disorders, and there is little guidance for anaesthetists and other clinicians regarding the optimal anaesthetic agents and perioperative management to provide to patients with mitochondrial disease[15]. The aim of this review was to document adverse events and perioperative complications from GA in patients with genetically confirmed mitochondrial disorders. A retrospective chart review of patients with genetically confirmed mitochondrial disorders who had undergone GA was undertaken. The indication for GA, anaesthetic agents utilised, length of admission and post anaesthetic complications were documented and analysed. Twenty-six patients with genetically proven mitochondrial disease underwent 65 GAs. Thirty-four (52%), received propofol as their induction agent. Thirty-three (51%) patients received sevoflurane for the maintenance of anaesthesia, while 8 (12%) received isoflurane and 24 (37%) received propofol. The duration of most GAs was short with 57 (87%) lasting less than 1 h. Perioperative complications occurred in five patients while under GA including ST segment depression, hypotension and metabolic acidosis in one. All five patients were stabilised successfully and none required ICU admission as a consequence of their perioperative complications. The duration of hospital stay post GA was <24 h in 25 (38%) patients.

CONCLUSION

No relationship between choice of anaesthetic agent and subsequent perioperative complication was observed. It is likely that individual optimisation on a case-by-case basis is more important overall than choice of any one particular technique. What is Known: • General anaesthesia (GA) poses a potential risk of decompensation in children with mitochondrial disorders. • There is a great diversity in the anaesthetic approaches undertaken in this cohort, and little guidance exists for anaesthetists and other clinicians regarding the optimal anaesthetic agents and perioperative management to provide to patients with mitochondrial disease. What is New: • In this study of 26 patients with genetically confirmed mitochondrial disease who underwent 65 GAs, no relationship between choice of anaesthetic agent and subsequent perioperative complication was observed • It is likely that individual optimisation on a case-by-case basis is more important overall than choice of any one particular technique.

Colonisation with extended-spectrum beta-lactamase (ESBL) not detected in a prevalence study

BACKGROUND

The Mid-West of Ireland has higher than average national rates of invasive extended-spectrum beta-lactamase (ESBL) bloodstream infections and carbapenemase-producing Enterobacteriaceae (CPE), with increasing numbers of ESBL isolates detected in community-dwelling patients.

AIMS

To conduct a point prevalence study in a convenience sample of the Mid-West population with the aim of determining the extent of ESBL colonisation.

METHODS

Utilising anonymised community stool samples that had completed routine analysis, we conducted a point prevalence study over a 4-week period on all samples that met defined inclusion and exclusion criteria. Limited epidemiological data was recorded: (1) age of patient, (2) gender, and (3) sender location. From these stool specimens, rectal swabs were inoculated (eSwab™ 480CE, Copan, Italy), which were subsequently cultured on selective chromogenic agar (Colorex™ ESBL). Culture plates were incubated aerobically at 37 °C for 24 h.

RESULTS

Of 195 samples processed, 58 % (n = 112) were from females. The median patient age was 62.4 years (range 20-94 years). 186 samples (95 %) originated from general practitioner clinics. During the study period, only nine eligible stool samples were received from LTCF (6 public). From 195 Colorex™ ESBL chromogenic agar plates cultured, no ESBL-producing organisms were detected.

CONCLUSIONS

This community point prevalence study did not identify ESBL colonisation despite high numbers of patients with invasive ESBL bloodstream infections presenting for admission in our institution. We believe this may be because of our small sample size. Data regarding antimicrobial exposure and other risk factors for ESBL colonisation were also not available. We remain vigilant for ESBL-producing organisms.

Long Term Symptoms and Limitations of Activity of People with Traumatic Brain Injury: A Ten-Year Follow-up

This study examined the effect of Traumatic Brain Injury 10 years post-injury. Frequencies of head injury symptoms and activity limitation by level of severity were measured in a consecutive series of 61 adults who were admitted to a tertiary-care center for traumatic brain injury. Irritability and Anxiety were the most frequently reported symptoms from the Head Injury Symptom Checklist. Bothered by noise and Bothered by light were the least frequently reported. Trouble hearing what is said in a group conversation and Trouble hearing what is said in a one-to-one conversation were the most commonly reported limitations of activity from the Health and Activity Limitations Survey. Overall, this study illustrates that symptoms remain many years following brain injury, irrespective of the injury's severity.

An Irish outbreak of New Delhi metallo-β-lactamase (NDM)-1 carbapenemase-producing Enterobacteriaceae: increasing but unrecognized prevalence

BACKGROUND

Carbapenemase-producing Enterobacteriaceae (CPE) may cause healthcare-associated infections with high mortality rates. New Delhi metallo-β-lactamase-1 (NDM-1) is among the most recently discovered carbapenemases.

AIM

To report the first outbreak of NDM-1 CPE in Ireland, including microbiological and epidemiological characteristics, and assessing the impact of infection prevention and control measures.

METHODS

This was a retrospective microbiological and epidemiological review. Cases were defined as patients with a CPE-positive culture. Contacts were designated as roommates or ward mates.

FINDINGS

This outbreak involved 10 patients with a median age of 71 years (range: 45-90), located in three separate but affiliated healthcare facilities. One patient was infected (the index case); the nine others were colonized. Nine NDM-1-producing Klebsiella pneumoniae, an NDM-1-producing Escherichia coli and a K. pneumoniae carbapenemase (KPC)-producing Enterobacter cloacae were detected between week 24, 2014 and week 37, 2014. Pulsed-field gel electrophoresis demonstrated similarity. NDM-1-positive isolates were meropenem resistant with minimum inhibitory concentrations (MICs) ranging from 12 to 32 μg/mL. All were tigecycline susceptible (MICs ≤1 μg/mL). One isolate was colistin resistant (MIC 4.0 μg/mL; mcr-1 gene not detected). In 2015, four further NDM-1 isolates were detected.

CONCLUSION

The successful management of this outbreak was achieved via the prompt implementation of enhanced infection prevention and control practices to prevent transmission. These patients did not have a history of travel outside of Ireland, but several had frequent hospitalizations in Ireland, raising concerns regarding the possibility of increasing but unrecognized prevalence of NDM-1 and potential decline in value of travel history as a marker of colonization risk.

An optimized work-flow to reduce time-to-detection of carbapenemase-producing Enterobacteriaceae (CPE) using direct testing from rectal swabs

Rapid detection of patients with carbapenemase-producing Enterobacteriaceae (CPE) is essential for the prevention of nosocomial cross-transmission, allocation of isolation facilities and to protect patient safety. Here, we aimed to design a new laboratory work-flow, utilizing existing laboratory resources, in order to reduce time-to-diagnosis of CPE. A review of the current CPE testing processes and of the literature was performed to identify a real-time commercial polymerase chain reaction (PCR) assay that could facilitate batch testing of CPE clinical specimens, with adequate CPE gene coverage. Stool specimens (210) were collected; CPE-positive inpatients (n = 10) and anonymized community stool specimens (n = 200). Rectal swabs (eSwab™) were inoculated from collected stool specimens and a manual DNA extraction method (QIAamp® DNA Stool Mini Kit) was employed. Extracted DNA was then processed on the Check-Direct CPE® assay. The three step process of making the eSwab™, extracting DNA manually and running the Check-Direct CPE® assay, took <5 min, 1 h 30 min and 1 h 50 min, respectively. It was time efficient with a result available in under 4 h, comparing favourably with the existing method of CPE screening; average time-to-diagnosis of 48/72 h. Utilizing this CPE work-flow would allow a 'same-day' result. Antimicrobial susceptibility testing results, as is current practice, would remain a 'next-day' result. In conclusion, the Check-Direct CPE® assay was easily integrated into a local laboratory work-flow and could facilitate a large volume of CPE screening specimens in a single batch, making it cost-effective and convenient for daily CPE testing.

Cervical human papillomavirus infections in commercial sex workers—risk factors and behaviours

We have investigated the prevalence of, and risk factors for, cervical human papillomavirus (HPV) infection in commercial sex workers (CSWs) and controls attending the same sexual health clinics in Sydney. A self-administered 'risk factor' questionnaire was completed and a Pap smear and a specimen for HPV detection and typing were taken. Results from the 288 CSWs and 266 controls were assessed by univariate and multivariate analyses. No significant difference in the rates of cervical HPV infection in CSWs (31.6%) and controls (24.4%) was found but HPV related cytological abnormalities were more common on the CSWs ( P <0.05). In both groups, factors independently associated with HPV infection were the use of non-barrier contraception, cytological abnormalities, age under 36 and the number of non-paying sexual partners. A risk factor for CSWs only was sex-work in Japan. A detailed 'work' history from CSWs may be useful to identify unsafe practices or work in countries where safer sex may be less acceptable.

Review of cardiometabolic risk factors in a cohort of paediatric type 1 diabetes mellitus patients

BACKGROUND

Type 1 diabetes mellitus (T1DM) is a recognised risk factor for cardiometabolic disease. Other risk factors include age, gender, family history, glycaemic control, dyslipidaemia, weight, and activity levels.

AIMS

To estimate the point prevalence of cardiometabolic risk factors in a paediatric population with T1DM.

METHODS

Eighty-one patients with T1DM aged between 10 and 16 years attended during the study and 56 (69.1 %) patients agreed to participate. Mixed methods data collection included a questionnaire developed for this study, supplemented by retrospective and prospective data collected from the patient records.

RESULTS

Of 56 subjects with T1DM, aged 12.7 ± 1.7 years (10-16 years) 26 were male and 30 were female. Mean HbA1c was 72 ± 14 mmol/mol. 53 subjects (94.6 %) had at least one additional cardiometabolic risk factor.

CONCLUSIONS

Cardiometabolic risk factors are present in this population with T1DM. Identifying cardiometabolic risk factors in adolescent T1DM patients is the first step in prevention of future morbidity and mortality.

Combined education and skin antisepsis intervention for persistently high blood-culture contamination rates in neonatal intensive care

Contaminated blood cultures represent challenges regarding diagnosis, duration of hospitalization, antimicrobial use, pharmacy and laboratory costs. Facing problematic neonatal blood culture contamination (3.8%), we instigated a successful intervention combining skin antisepsis using sterile applicators with 2% chlorhexidine gluconate in 70% isopropanol prior to phlebotomy (replacing 70% isopropanol) and staff education. In the six months prior to intervention, 364 neonatal peripheral blood samples were collected. Fourteen (3.8%) were contaminated. In the post-intervention six months, 314 samples were collected. Three (0.96%) were contaminated, representing significant improvement (Fisher's exact test: P = 0.0259). No dermatological sequelae were observed. The improvement has been sustained.