The metabolic effects of intermittent versus continuous feeding in critically ill patients

Intermittent (or bolus) feeding regimens in critically ill patients have been of increasing interest to clinicians and scientists. Changes in amino acid, fat and carbohydrate metabolites over time might yet deliver other benefits (e.g. modulation of the circadian rhythm and sleep, and impacts on ghrelin secretion, insulin resistance and autophagy). We set out to characterise these changes in metabolite concentration. The Intermittent versus Continuous Feeding in Critically Ill paitents study (NCT02358512) was an eight-centre single-blinded randomised controlled trial. Patients were randomised to received a continuous (control arm) or intermittent (6x/day, intervention arm) enteral feeding regimen. Blood samples were taken on trial days 1, 7 and 10 immediately before and 30 min after intermittent feeds, and at equivalent timepoints in the control arm. A pre-planned targeted metabolomic analysis was performend using Nuclear Resonance Spectroscopy. Five hundred and ninety four samples were analysed from 75 patients. A total of 24 amino acid-, 19 lipid based-, and 44 small molecule metabolite features. Across the main two axes of variation (40-60% and 6-8% of variance), no broad patterns distinguished between intermittent or continuous feeding arms, across intra-day sampling times or over the 10 days from initial ICU admission. Logfold decreases in abundance were seen in metabolites related to amino acids (Glutamine - 0.682; Alanine - 0.594), ketone body metabolism (Acetone - 0.64; 3-Hydroxybutyric Acid - 0.632; Acetonacetic Acid - 0.586), fatty acid (carnitine - 0.509) and carbohydrate metabolism ( Maltose - 0.510; Citric Acid - 0.485). 2-3 Butanediol, a by-product of sugar-fermenting microbial metabolism also decreased (- 0.489). No correlation was seen with change in quadriceps muscle mass for any of the 20 metabolites varying with time (all p > 0.05). Increasing severity of organ failure was related to increasing ketone body metabolism (3 Hydroxybutyric Acid-1 and - 3; p = 0.056 and p = 0.014), carnitine deficiency (p = 0.002) and alanine abundancy (p - 0.005). A 6-times a day intermittent feeding regimen did not alter metabolite patterns across time compared to continuous feeding in critically ill patients, either within a 24 h period or across 10 days of intervention. Future research on intermittent feeding regimens should focus on clinical process benefits, or extended gut rest and fasting.

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

INTRODUCTION

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

UK Research and Innovation and National Institute for Health Research.

Defining complexity in anaesthesia: description and validation of the Oxford Anaesthetic Complexity (OxAnCo) score

Increasing demand for surgery and anaesthesia has created an imperative to manage anaesthetic workforce and caseload. This may include changes to distribution of cases amongst anaesthetists of different grades, including non-physician anaesthetists. To achieve this safely, an assessment of case complexity is essential. We present a novel system for scoring complexity of cases in anaesthesia, the Oxford Anaesthetic Complexity score. This integrates patient, anaesthetic, surgical and systems factors, and is different from assessments of risk. We adopted an end-user development approach to the design of the score, and validated it using a dataset of anaesthetic cases. Across 688 cases, the median (IQR [range]) complexity score was 19 (17-22 [15-33]). Cases requiring a consultant anaesthetist had a significantly higher median (IQR [range]) score than those requiring a senior trainee at 22 (20-25 [15-33]) vs. 19(17-21 [15-28]), p < 0.001. Cases undertaken in a tertiary acute hospital had a significantly higher score than those in a district general hospital, the median (IQR [range]) scores being 20 (17-22 [15-33]) vs. 17 (16-19 [17-28]), p < 0.001. Receiver-operating characteristic analysis showed good prediction of complexity sufficient to require a consultant anaesthetist, with area under the curve of 0.84. Any rise in complexity above baseline (score > 15) was strongly predictive of a case too complex for a junior trainee (positive predictive value 0.93). The Oxford Anaesthetic Complexity score can be used to match cases to different grades of anaesthetist, and can help in defining cases appropriate for the expanding non-physician anaesthetist workforce.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

O-085 School-Age Outcomes Among IVF-Conceived Children: A Causal Inference Analysis Using Linked Population-Wide Data

Study question

To determine the causal effect of in-vitro fertilisation (IVF) on primary school-age childhood developmental and educational outcomes, compared with outcomes following spontaneous conception.

Summary answer

The school-age developmental and educational outcomes for children conceived by IVF are equivalent to those of spontaneously conceived peers.

What is known already

More than 8 million children have been conceived globally with the assistance of in-vitro fertilization (IVF). Large cohort studies have suggested an increase in the frequency of congenital abnormalities, autism spectrum disorder, developmental-delay and intellectual disability in children conceived via IVF. Educational and cognitive outcomes following IVF conception have not yet been adequately established. Two large Scandinavian studies (Norrman et al 2018 and Wienecke et al 2020) found poorer educational outcomes in children born after IVF-conception.

Study design, size, duration

Causal inference methods (based on the potential outcomes approach) were used to analyse observation data in a way that emulates the results of a target randomised clinical trial. The study cohort comprised state-wide linked maternal and childhood administrative data from Victoria, Australia.

Participants/materials, setting, methods

The study included singleton infants conceived spontaneously or via IVF and born between 2005-2014. The exposure of interest was conception via IVF, with those born after spontaneous conception as the control group. Two separate measures of childhood outcome were examined: The Australian Early Developmental Consensus (AEDC), (age 4-6); and the National Assessment Program – Literacy and Numeracy (NAPLAN) at age 7-9. We combined inverse probability weighting with regression adjustment to estimate population average causal effects.

Main results and the role of chance

The final cohort included 412,713 children across the two outcome cohorts. Linked records were available for 4,697 IVF-conceived cases and 168,503 controls for AEDC outcome data, and 8,976 cases and 333,335 controls for NAPLAN data. The mothers of IVF-conceived children were older, more highly educated mothers, who lived in more socio-economic advantaged areas and were less likely to be from non-English speaking backgrounds. There was no causal effect of IVF-conception on the on the risk of developmental vulnerability at school-entry compared to spontaneously conceived children, as defined by AEDC metrics; with an adjusted risk difference of -0.3% (95% CI -3.7% to 3.1%) and an adjusted risk ratio of 0.97 (95% CI 0.77 to 1.25). At age 7-9 years, there was no causal effect of IVF-conception on the NAPLAN overall z-score, adjusted mean difference of 0.030 (95% CI -0.018 to 0.077) between IVF-conceived and spontaneously conceived children.

Given the use of observational data, there were missing data and inherent differences in the covariate profile of the exposure cohorts. Multiple imputation and doubly robust inverse probability weighting regression adjustment modelling was utilised to allow a causal interpretation of results.

Limitations, reasons for caution

Children who did not attend school due to severe disability were not included, possibly leading to selection bias. It is possible that unmeasured common cause confounders could have led to bias in estimating the average treatment effects.

Wider implications of the findings

This study, in contrast to previous evidence, suggests that conception via IVF does not affect early childhood developmental and educational outcomes. These findings provide important reassurance for current and prospective parents, and clinicians alike.

Trial registration number

Not applicable

Circulation des variants du SARS-CoV-2 en milieu insulaire ultra-marin

Introduction

Dans cette région d'Outre-Mer, les premiers cas de COVID-19 ont été détectés le 11 mars 2020 chez un groupe de personnes de retour de voyage. En réponse, une surveillance épidémiologique régionale basée sur le « contact-tracing » et l'identification de clusters a rapidement été mise en place. De mars à juillet 2020, les cas ont été importés ou autochtones sporadiques, puis la circulation virale s'est intensifiée sur l'île à partir d'août 2020 à la fin des vacances scolaires. En janvier 2021, une surveillance génomique locale a été mise en place suite à l'émergence de variants du SARS-CoV-2.

Matériels et méthodes

Du 04 janvier 2021 au 06 juin 2021, 1 528 génomes ont été séquencés, soit 8,3 % des cas de COVID-19 sur la période. La sélection de prélèvements à séquencer était pseudo-aléatoire, avec une sélection ciblée en fonction de caractéristiques épidémiologiques ou cliniques atypiques (ex : cas importés, cas graves). Les distributions de lignages génétiques dans l'Océan indien et dans certains pays d'Afrique ont été extraites de la base de données GISAID (Global Initiative on Sharing All Influenza Data).

Résultats

Au total, 22 lignages du SARS-CoV-2 ont été identifiés et 71 % des observations étaient attribuées au variant Beta (B.1.351 et B.1.351.2). Ce variant a été détecté pour la première fois la première semaine de janvier 2021, dès le lancement des activités de séquençage. Pendant les six premières semaines de l'année 2021, la majorité des lignages détectés correspondait à des variants circulant activement en Europe (ex : B.1.160, B.1.177), illustrant l'impact des flux de voyageurs sur la dynamique de la COVID-19 sur l'île. Selon les données GISAID, le lignage B.1.622 serait spécifique à l'île car aucun autre territoire n'a identifié de séquences de ce variant.

Le variant Beta est devenu dominant à partir de mi-février 2021, malgré une circulation à bas-bruit du variant Alpha (B.1.1.7) qui était alors dominant en métropole. En plus de sa transmissibilité accrue, d'autres facteurs génétiques et épidémiologiques auraient pu expliquer la dominance du variant Beta, dont une fréquence d'introduction plus importante (flux de voyageurs) et les contextes locaux et régionaux. En effet, la proximité géographique et les mouvements de population avec d'autres îles de la région relient indirectement l'île au pays d'où serait originaire le variant Beta.

Deux sous-lignages du variant Beta ont été détectés. B.1.351.2 représentait trois fois plus de séquences que B.1.351. Les données disponibles dans GISAID suggèrent qu'il aurait été importé depuis son pays d'origine vers d'autres îles de l'Océan indien avant d'être introduit sur l'île, compte tenu des flux de voyageurs entre les régions concernées et l'importante épidémie liée variant Beta ayant eu lieu sur une île voisine de janvier à mi-mars 2021.

Conclusion

Cette étude permet de mieux comprendre les interactions entre les variants du SARS-CoV-2 sur l'île, qui représente un système fermé avec contrôle des entrées. L'étude illustre aussi l'impact des flux de voyageurs sur la dynamique de la COVID-19 en milieu insulaire, et ouvre des perspectives de travaux en épidémiologie génomique pour mieux comprendre les mécanismes d'émergence de variants dominants.

Aucun lien d'intérêt

Quality assurance of VMAT on flattened and flattening filter-free accelerators using a high spatial resolution detector

PURPOSE

This study investigated the use of high spatial resolution solid-state detectors (DUO and Octa) combined with an inclinometer for machine-based quality assurance (QA) of Volumetric Modulated Arc Therapy (VMAT) with flattened and flattening filter-free beams.

METHOD

The proposed system was inserted in the accessory tray of the gantry head of a Varian 21iX Clinac and a Truebeam linear accelerator. Mutual dependence of the dose rate (DR) and gantry speed (GS) was assessed using the standard Varian customer acceptance plan (CAP). The multi-leaf collimator (MLC) leaf speed was evaluated under static gantry conditions in directions parallel and orthogonal to gravity as well as under dynamic gantry conditions. Measurements were compared to machine log files.

RESULTS

DR and GS as a function of gantry angle were reconstructed using the DUO/inclinometer and in agreement to within 1% with the machine log files in the sectors of constant DR and GS. The MLC leaf speeds agreed with the nominal speeds and those extracted from the machine log files to within 0.03 cm s-1 . The effect of gravity on the leaf motion was only observed when the leaves traveled faster than the nominal maximum velocity stated by the vendor. Under dynamic gantry conditions, MLC leaf speeds ranging between 0.33 and 1.42 cm s-1 were evaluated. Comparing the average MLC leaf speeds with the machine log files found differences between 0.9% and 5.7%, with the largest discrepancy occurring under conditions of fastest leaf velocity, lowest DR and lowest detector signal.

CONCLUSIONS

The investigation on the use of solid-state detectors in combination with an inclinometer has demonstrated the capability to provide efficient and independent verification of DR, GS, and MLC leaf speed during dynamic VMAT delivery. Good agreement with machine log files suggests the detector/inclinometer system is a useful tool for machine-specific VMAT QA.

Zoledronate in the prevention of Paget's (ZiPP): protocol for a randomised trial of genetic testing and targeted zoledronic acid therapy to prevent SQSTM1-mediated Paget's disease of bone

INTRODUCTION

Paget's disease of bone (PDB) is characterised by increased and disorganised bone remodelling affecting one or more skeletal sites. Complications include bone pain, deformity, deafness and pathological fractures. Mutations in sequestosome-1 (SQSTM1) are strongly associated with the development of PDB. Bisphosphonate therapy can improve bone pain in PDB, but there is no evidence that treatment alters the natural history of PDB or prevents complications. The Zoledronate in the Prevention of Paget's disease trial (ZiPP) will determine if prophylactic therapy with the bisphosphonate zoledronic acid (ZA) can delay or prevent the development of PDB in people who carry SQSTM1 mutations.

METHODS AND ANALYSIS

People with a family history of PDB aged >30 years who test positive for SQSTM1 mutations are eligible to take part. At the baseline visit, participants will be screened for the presence of bone lesions by radionuclide bone scan. Biochemical markers of bone turnover will be measured and questionnaires completed to assess pain, health-related quality of life (HRQoL), anxiety and depression. Participants will be randomised to receive a single intravenous infusion of 5 mg ZA or placebo and followed up annually for between 4 and 8 years at which point baseline assessments will be repeated. The primary endpoint will be new bone lesions assessed by radionuclide bone scan. Secondary endpoints will include changes in biochemical markers of bone turnover, pain, HRQoL, anxiety, depression and PDB-related skeletal events.

ETHICS AND DISSEMINATION

The study was approved by the Fife and Forth Valley Research Ethics Committee on 22 December 2008 (08/S0501/84). Following completion of the trial, a manuscript will be submitted to a peer-reviewed journal. The results of this trial will inform clinical practice by determining if early intervention with ZA in presymptomatic individuals with SQSTM1 mutations can prevent or slow the development of bone lesions with an adverse event profile that is acceptable.

TRIAL REGISTRATION NUMBER

ISRCTN11616770.

Diagnosis and Management of Paget's Disease of Bone in Adults: A Clinical Guideline

An evidence-based clinical guideline for the diagnosis and management of Paget's disease of bone (PDB) was developed using GRADE methodology, by a Guideline Development Group (GDG) led by the Paget's Association (UK). A systematic review of diagnostic tests and pharmacological and nonpharmacological treatment options was conducted that sought to address several key questions of clinical relevance. Twelve recommendations and five conditional recommendations were made, but there was insufficient evidence to address eight of the questions posed. The following recommendations were identified as the most important: 1) Radionuclide bone scans, in addition to targeted radiographs, are recommended as a means of fully and accurately defining the extent of metabolically active disease in patients with PDB. 2) Serum total alkaline phosphatase (ALP) is recommended as a first-line biochemical screening test in combination with liver function tests in screening for the presence of metabolically active PDB. 3) Bisphosphonates are recommended for the treatment of bone pain associated with PDB. Zoledronic acid is recommended as the bisphosphonate most likely to give a favorable pain response. 4) Treatment aimed at improving symptoms is recommended over a treat-to-target strategy aimed at normalizing total ALP in PDB. 5) Total hip or knee replacements are recommended for patients with PDB who develop osteoarthritis in whom medical treatment is inadequate. There is insufficient information to recommend one type of surgical approach over another. The guideline was endorsed by the European Calcified Tissues Society, the International Osteoporosis Foundation, the American Society of Bone and Mineral Research, the Bone Research Society (UK), and the British Geriatric Society. The GDG noted that there had been a lack of research on patient-focused clinical outcomes in PDB and identified several areas where further research was needed. © 2019 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals Inc.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Patient values informing medical treatment: a pilot community and advance care planning survey

Medicine regards the prevention of death as an important priority. Yet patients may have a range of priorities of equal or greater importance. These other priorities are often not discussed or appreciated by treating doctors.

OBJECTIVES

We sought to identify priorities of care for patients attending an advance care planning (ACP) clinic and among the general population, and to identify factors associated with priorities other than prolonging life.

METHODS

We used a locally developed survey tool 'What Matters Most' to identify values. Choices presented were: maintaining dignity, avoiding pain and suffering, living as long as possible, and remaining independent. Participants rated the importance of each and then selected a main priority for their doctor. Participant groups were a purposive sample of 382 lay people from the general population and 100 attendees at an ACP clinic.

RESULTS

Living as long as possible was considered to be less important than other values for ACP patients and for the general population. Only 4% of ACP patients surveyed and 2.6% of our general population sample selected 'living as long as possible' as their top priority for medical treatment.

CONCLUSIONS

'Living as long as possible' was not the most important value for ACP patients, or for a younger general population. Prioritisation of other goals appeared to be independent of extreme age or illness. When end of life treatment is being discussed with patients, priorities other than merely prolonging life should be considered.

Patient values informing medical treatment: a pilot community and advance care planning survey

Medicine regards the prevention of death as an important priority. Yet patients may have a range of priorities of equal or greater importance. These other priorities are often not discussed or appreciated by treating doctors.

The Intensive Care Lifeboat: a survey of lay attitudes to rationing dilemmas in neonatal intensive care

BACKGROUND

Resuscitation and treatment of critically ill newborn infants is associated with relatively high mortality, morbidity and cost. Guidelines relating to resuscitation have traditionally focused on the best interests of infants. There are, however, limited resources available in the neonatal intensive care unit (NICU), meaning that difficult decisions sometimes need to be made. This study explores the intuitions of lay people (non-health professionals) regarding resource allocation decisions in the NICU.

METHODS

The study design was a cross-sectional quantitative survey, consisting of 20 hypothetical rationing scenarios. There were 119 respondents who entered the questionnaire, and 109 who completed it. The respondents were adult US and Indian participants of the online crowdsourcing platform Mechanical Turk. Respondents were asked to decide which of two infants to treat in a situation of scarce resources. Demographic characteristics, personality traits and political views were recorded. Respondents were also asked to respond to a widely cited thought experiment involving rationing.

RESULTS

The majority of respondents, in all except one scenario, chose the utilitarian option of directing treatment to the infant with the higher chance of survival, higher life expectancy, less severe disability, and less expensive treatment. As discrepancy between outcomes decreased, however, there was a statistically significant increase in egalitarian responses and decrease in utilitarian responses in scenarios involving chance of survival (P = 0.001), life expectancy (P = 0.0001), and cost of treatment (P = 0.01). In the classic 'lifeboat' scenario, all but two respondents were utilitarian.

CONCLUSIONS

This survey suggests that in situations of scarcity and equal clinical need, non-health professionals support rationing of life-saving treatment based on probability of survival, duration of survival, cost of treatment or quality of life. However, where the difference in prognosis or cost is very small, non-health professionals preferred to give infants an equal chance of receiving treatment.

Detection of T-Cadherin Expression in Mouse Embryos

The aim of the present study was to evaluate T-cadherin expression at the early developmental stages of the mouse embryo. Using in situ hybridization and immunofluorescent staining of whole embryos in combination with confocal microscopy, we found that T-cadherin expression is detected in the developing brain, starting with the E8.75 stage, and in the heart, starting with the E11.5 stage. These data suggest a possible involvement of T-cadherin in the formation of blood vessels during embryogenesis.

Detection of T-Cadherin Expression in Mouse Embryos

The aim of the present study was to evaluate T-cadherin expression at the early developmental stages of the mouse embryo. Using in situ hybridization and immunofluorescent staining of whole embryos in combination with confocal microscopy, we found that T-cadherin expression is detected in the developing brain, starting with the E8.75 stage, and in the heart, starting with the E11.5 stage. These data suggest a possible involvement of T-cadherin in the formation of blood vessels during embryogenesis.

ToxML, a data exchange standard with content controlled vocabulary used to build better (Q)SAR models

Development of accurate quantitative structure-activity relationship (QSAR) models requires the availability of high quality validated data. International regulations such as REACH in Europe will now accept (Q)SAR-based evaluations for risk assessment. The number of toxicity datasets available for those wishing to share knowledge, or to use for data mining and modelling, is continually expanding. The challenge is the current use of a multitude of different data formats. The issues of comparing or combining disparate data apply both to public and proprietary sources. The ToxML project addresses the need for a common data exchange standard that allows the representation and communication of these data in a well-structured electronic format. It is an open standard based on Extensible Markup Language (XML). Supporting information for overall toxicity endpoint data can be included within ToxML files. This makes it possible to assess the quality and detail of the data used in a model. The data file model allows the aggregation of experimental data to the compound level in the detail needed to support (Q)SAR work. The standard is published on a website together with tools to view, edit and download it.

Corrupted cultures in mental health inpatient settings. Is restraint reduction the answer?

The early years of the 21st century have seen successful efforts in a number of countries to reduce the use of restraint in services for people with mental health problems. An underlying emphasis on 'cultural change' is characteristic of such initiatives reflecting, it appears, the re-emergence of interest in the therapeutic milieu. Such efforts have though lacked a comprehensive explanation of how organizational culture plays a role in the development of the excessive use of restraint, which seems to respond to such initiatives. This paper seeks to address that deficit and draws in particular on the concepts of corrupted culture, institutional violence, trauma, parallel processing and contemporary research on restraint and seclusion reduction. In doing so it examines whether restraint reduction initiatives represent part of the solution to the problem of corruption, which is intrinsically associated with the legitimatization of coercion.