Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Gastric outlet obstruction secondary to a wandering spleen: systematic review and surgical management of a case

INTRODUCTION

A wandering spleen occurs when laxity or absence of the suspensory ligaments allows migration throughout the abdomen. Gastric outlet obstruction resulting from this abnormality is rare. We present a systematic literature search and a case that was managed successfully with surgical intervention at our centre.

METHODS

A systematic search of the PubMed, Embase™, Medline^® and Google Scholar™ databases was carried out employing the combined search terms "gastric outlet obstruction" AND "wandering spleen". Six results were included for final analysis.

RESULTS

All six search results described a single case each. Patients underwent surgical management (open or laparoscopic) after initial investigation utilising a range of modalities. There were no mortalities reported at 90 days. The single case we present was complicated by gastric perforation; the patient made a successful recovery following open splenopexy and stapled wedge resection of the stomach.

CONCLUSIONS

A wandering spleen is a rare diagnosis and there are only six reported cases of gastric outlet obstruction secondary to a wandering spleen in the literature. None report associated gastric perforation. There are a variety of presenting symptoms, intraoperative findings and operative techniques used to address the gastrosplenic abnormality. The case reported by our centre adds to this limited evidence base and demonstrates a successful outcome from definitive surgical management. We highlight the need to seek early gastro-oesophageal expertise if any gastric pathology is found together with anatomical abnormality of the spleen.

Herpes simplex oesophagitis leading to perforation and mediastinal collection: a case report and review of literature

Herpes simplex oesophagitis is rare, especially in immunocompetent patients. A 78-year-old man presented with sepsis on the background of several months of retrosternal chest pain and fatigue. Computed tomography of the chest abdomen and pelvis revealed a large mediastinal collection and an oesophago-gastro-duodenoscopy demonstrated a healed mucosal scar from a spontaneously healed perforation. The collection was successfully drained with an ultrasound-guided drain and the patient made a full recovery. Spontaneous oesophageal perforation from herpes simplex oesophagitis has been reported five times in the literature, with only two occurrences in immunocompetent individuals.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

What do I need to know? Essential educational concepts for complex regional pain syndrome

Background

Methods

Results

Conclusion

Significance

Investigation of healthcare-associated SARS-CoV-2 infection: Learning outcomes from an investigative process in the initial phase of the pandemic

Background

Healthcare-associated (HCA) SARS-CoV-2 infection is a significant contributor to the spread of the 2020 pandemic. Timely review of HCA cases is essential to identify learning to inform infection prevention and control (IPC) policies and organisational response.

Aim

To identify key areas for improvement through rapid investigation of HCA SARS-CoV-2 cases and to implement change.

Methods

Cases were identified based on date of first positive SARS-CoV-2 PCR sample in relation to date of hospital admission. Cases were reviewed using a structured gap analysis tool to identify key learning points. These were discussed in weekly multidisciplinary meetings to gain consensus on learning outcomes, level of harm incurred by the patient and required actions. Learning was then promptly fed back to individual teams and the organisation.

Findings

Of the 489 SARS-CoV-2 cases admitted between 10^th March and 23^rd June 2020, 114 suspected HCA cases (23.3%) were reviewed; 58/489 (11.8%) were ultimately deemed to be HCA. Five themes were identified: individual patient vulnerability, communication, IPC implementation, policy issues and organisational response. Adaptations to policies based on these reviews were completed within the course of the initial phase of the pandemic.

Conclusion

This approach enabled timely learning and implementation of control measures and policy development.

The barts heart attack centre early discharge pathway:- a novel protocol for next day discharge after primary pci for ST-elevation myocardiai infarction

Funding Acknowledgements

Type of funding sources: None.

Introduction

To respond to the challenges of COVID-19 and based on evidence confirming low rates of Major Adverse Cardiac Events (MACE) occurring between 24- and 48-hours post AMI (Acute Myocardial Infarction), we sought to design and implement a novel Early Hospital Discharge (EHD) pathway

Aim

The goal of the EHD protocol is to accurately and efficiently identify low-risk AMI patients who can be safely discharged between 24 and 48 hours after successful primary PCI, aiming to provide a  safe discharge for low risk patients, reduce length of stay  enhance the follow up of patients post AMI

Methodology :

Project was designed a QI project and patients were discharged with a structured follow up at 48 hours , 2 weeks and 8 weeks and with a interventional cardiologist at 3 months 

Virtual follow up was conducted using a bespoke application enable a 2 way messaging and video consultation

Patients with AMI are taken for primary PCI in an unselected manner which includes post cardiac arrest, intubated and ventilated patients

Results :The median follow-up was 201 days (OQR: 98-268 days). In the early discharge group, there were 2 deaths (0.5%), both due to COVID-19 (both >30 days after d/c) with 0% cardiovascular mortality (comparator group 5% mortality, 2.5% cardiovascular

 Overall, this resulted in a significant reduction in the overall length of stay for all patients presenting with STEMI undergoing primary PCI over the time period. The median length of stay was 3 days (IQR 2-5 days) from October 2019 to March 2020 before the pathway was introduced. Following the pathway introduction, from April 2020 to February 2021 the median length of stay was 2 days (1-4 days) (p < 0.0001), significantly reduced from pre pathway introduction

Conclusion :Driven by the necessity to adapt to the pandemic, we report the safe and successful implementation of an early post MI discharge pathway with an integrated and structural multidisciplinary virtual follow up schedule.  This has shortened hospital admission times, decreasing the risk of nosocomial infections and optimised resource utilization, while at the same time enhancing the quality of post discharge care with high levels of patient satisfaction.

Defining Combat-Relevant Endpoints for Early Trauma Resuscitation Research in a Resource-Constrained Civilian Setting

INTRODUCTION

Studies assessing early trauma resuscitation have used long-term endpoints, such as 28- or 30-day mortality or Glasgow Outcomes Scores at 6-months. These endpoints are convenient but may not accurately reflect the effect of early resuscitation. We sought expert opinion and consensus on endpoints and definitions of variables needed to conduct a Department of Defense- (DoD) funded study to epidemiologically assess combat-relevant mortality and morbidity due to timeliness of resuscitation among critically injured civilians internationally.

METHODS

We conducted an online modified Delphi process with an international panel of civilian and US military experts. In several iterative rounds, experts reviewed background information, appraised relevant scientific evidence, provided comments, and rendered a vote on each variable. A-priori, we set consensus at ≥80% concordant votes.

RESULTS

Twenty panelists participated with a 100% response rate. Eight items were presented, with the following outputs for the epidemiologic study: Assess mortality within 7-days of injury; assess multi-organ failure using SOFA scores measured early (at day 3) and late (at day 7); assess traumatic brain injury mortality early (≤7-days) and late (28-days); hybrid (anatomic and physiologic) injury severity scoring is optimal; capture comorbidities per the US National Trauma Data Standard list with specific additions; assign resuscitative interventions to one of five standardized phases of trauma care; and, use a novel trauma death categorization system.

CONCLUSIONS

A modified Delphi process yielded expert-ratified definitions and endpoints of variables necessary to conduct a combat-relevant epidemiologic study assessing outcomes due to early trauma resuscitation. Outputs may also benefit other groups conducting trauma resuscitation research.

535 Private Trauma Lists: A Pragmatic Panacea During This Pandemic

Introduction

COVID-19 has disrupted the efficiency of hospitals nationwide. Ambulant trauma surgery was minimised to reduce risk of contracting COVID-19. Operating capacity significantly reduced and surgical training dramatically curtailed. Locally, a private hospital has been utilised as a green site with consultant-lead trauma lists. Our aim is to review the safety and efficiency of this service.

Method

Patients underwent pre-assessment, COVID-19 swabs and 7 days isolation pre and post-op. Staff also underwent swabbing. Prospectively data was gathered for all patients operated on at this site from 12/05/2020 to 20/08/2020. Records reviewed for readmission, complications and COVID status. A satisfaction questionnaire was sent to trainees who operated at this site.

Results

79 operations were completed during this period. 50 male and 29 female, average age 49, average ASA 2. No complications or COVID-19 infections were recorded. Mean time to theatre was 18 days. Delays to theatre led to 2 complications. 87% of trainees felt training was maintained.

Conclusions

Establishing a green site enabled efficient and safe management whilst still facilitating surgical training. This requires clear guidelines for staff and patients. We believe this model can help trauma service provision as the pandemic evolves.

Comparative Study of Dissolution for Cannabidiol in EU and US Hemp Oil Products by HPLC

For the first time, a simple and robust HPLC method has been developed for dissolution studies for cannabidiol (CBD) in hemp oil products. An isocratic elution of samples performed on SOLAS™ C18 150 mm x 4.6 mm, 5 μm column with a mobile phase consisting of 75:25 acetonitrile-water v/v, delivered at a flow rate 1.5 mL/minutes to variable wavelength detector using 214 nm. An in-house validated assay test was executed for calculating the purity of hemp oil products and also for considering the dissolution medium to be used. For dissolution studies, equivalent of 5 mg and/or 10 mg of the active was introduced into 500 mL of simulated gastric and intestinal fluids separately, and dissolution was performed at 50 rpm using paddles for 180 min. Dissolution profiles for hemp oil products purchased from the United States and Europe were compared. Additionally, dissolution testing was conducted to study the effect of percentage CBD release on increased agitation speed of 75 and 100 rpm and also, on extended dissolution runtime of 240 min.

Admission COVID-19 clinical risk assessment for guiding patient placement and diagnostic testing strategy

INTRODUCTION

Without universal access to point-of-care SARS-CoV-2 testing, many hospitals rely on clinical judgement alone for identifying cases of COVID-19 early.

METHODS

Cambridge University Hospitals NHS Foundation Trust introduced a 'traffic light' clinical judgement aid to the COVID-19 admissions unit in mid-March 2020. Ability to accurately predict COVID-19 was audited retrospectively across different stages of the epidemic.

RESULTS

One SARS-CoV-2 PCR positive patient (1/41, 2%) was misallocated to a 'green' (non-COVID-19) area during the first period of observation, and no patients (0/32, 0%) were mislabelled 'green' during the second period. 33 of 62 (53%) labelled 'red' (high risk) tested SARS-CoV-2 PCR positive during the first period, while 5 of 22 (23%) 'red' patients were PCR positive in the second.

CONCLUSION

COVID-19 clinical risk stratification on initial assessment effectively identifies non-COVID-19 patients. However, diagnosing COVID-19 is challenging and risk of overcalling COVID-19 should be recognised, especially when background prevalence is low.

Characterization of a bovine intestinal myofibroblast cell line and stimulation using phytoglycogen-based nanoparticles bound to inosine monophosphate

The goal of the present study was to characterize a novel bovine intestinal myofibroblast (BT-IMF) cell line isolated from a fetal bovine intestine. This cell type is of importance as intestinal myofibroblasts play a key role in controlling intestinal epithelial cell proliferation, intestinal regulation, wound healing, epithelial cell turnover, and structural support. The present work demonstrates that BT-IMF cells could be successfully cryopreserved and thawed and cultured past 25 passages. Immunocytochemical staining of the BT-IMF cell line was positive for vimentin and smooth muscle actin (α-SMA) and negative for pancytokeratin, suggesting that the cells are myofibroblastic in type. Growth kinetic experiments demonstrate that hydrocortisone negatively impacts BT-IMF growth and non-essential amino acids enhance its proliferation. Inosine monophosphate (IMP) is a dietary nucleotide and is essential for supporting animal health. Stimulation with IMP bound to a novel phytoglycogen-based nanocarrier (IMP-NP) showed enhanced cell proliferation. BT-IMF provides a new tool for studying bovine cells in vitro and may be of particular interest for cultured meat manufacturing in the future.

First-dose ChAdOx1 and BNT162b2 COVID-19 vaccines and thrombocytopenic, thromboembolic and hemorrhagic events in Scotland

Reports of ChAdOx1 vaccine-associated thrombocytopenia and vascular adverse events have led to some countries restricting its use. Using a national prospective cohort, we estimated associations between exposure to first-dose ChAdOx1 or BNT162b2 vaccination and hematological and vascular adverse events using a nested incident-matched case-control study and a confirmatory self-controlled case series (SCCS) analysis. An association was found between ChAdOx1 vaccination and idiopathic thrombocytopenic purpura (ITP) (0-27 d after vaccination; adjusted rate ratio (aRR) = 5.77, 95% confidence interval (CI), 2.41-13.83), with an estimated incidence of 1.13 (0.62-1.63) cases per 100,000 doses. An SCCS analysis confirmed that this was unlikely due to bias (RR = 1.98 (1.29-3.02)). There was also an increased risk for arterial thromboembolic events (aRR = 1.22, 1.12-1.34) 0-27 d after vaccination, with an SCCS RR of 0.97 (0.93-1.02). For hemorrhagic events 0-27 d after vaccination, the aRR was 1.48 (1.12-1.96), with an SCCS RR of 0.95 (0.82-1.11). A first dose of ChAdOx1 was found to be associated with small increased risks of ITP, with suggestive evidence of an increased risk of arterial thromboembolic and hemorrhagic events. The attenuation of effect found in the SCCS analysis means that there is the potential for overestimation of the reported results, which might indicate the presence of some residual confounding or confounding by indication. Public health authorities should inform their jurisdictions of these relatively small increased risks associated with ChAdOx1. No positive associations were seen between BNT162b2 and thrombocytopenic, thromboembolic and hemorrhagic events.

Rapid implementation of SARS-CoV-2 sequencing to investigate cases of health-care associated COVID-19: a prospective genomic surveillance study

BACKGROUND

The burden and influence of health-care associated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections is unknown. We aimed to examine the use of rapid SARS-CoV-2 sequencing combined with detailed epidemiological analysis to investigate health-care associated SARS-CoV-2 infections and inform infection control measures.

METHODS

In this prospective surveillance study, we set up rapid SARS-CoV-2 nanopore sequencing from PCR-positive diagnostic samples collected from our hospital (Cambridge, UK) and a random selection from hospitals in the East of England, enabling sample-to-sequence in less than 24 h. We established a weekly review and reporting system with integration of genomic and epidemiological data to investigate suspected health-care associated COVID-19 cases.

FINDINGS

Between March 13 and April 24, 2020, we collected clinical data and samples from 5613 patients with COVID-19 from across the East of England. We sequenced 1000 samples producing 747 high-quality genomes. We combined epidemiological and genomic analysis of the 299 patients from our hospital and identified 35 clusters of identical viruses involving 159 patients. 92 (58%) of 159 patients had strong epidemiological links and 32 (20%) patients had plausible epidemiological links. These results were fed back to clinical, infection control, and hospital management teams, leading to infection-control interventions and informing patient safety reporting.

INTERPRETATION

We established real-time genomic surveillance of SARS-CoV-2 in a UK hospital and showed the benefit of combined genomic and epidemiological analysis for the investigation of health-care associated COVID-19. This approach enabled us to detect cryptic transmission events and identify opportunities to target infection-control interventions to further reduce health-care associated infections. Our findings have important implications for national public health policy as they enable rapid tracking and investigation of infections in hospital and community settings.

FUNDING

COVID-19 Genomics UK funded by the Department of Health and Social Care, UK Research and Innovation, and the Wellcome Sanger Institute.

Rebooting medical education with virtual grand rounds during the COVID-19 pandemic

Social distancing during the coronavirus disease 2019 (COVID-19) pandemic has necessitated drastic changes in the practice of hospital medicine, including the cancellation of many educational activities. At the same time, the emergence of a new disease with a rapidly evolving knowledge base has mandated timely educational updates. To resolve this conflict in our hospital, we substituted 'traditional' grand rounds with 'virtual' grand rounds delivered over Zoom, consisting of a local situation report and operational update, followed by a specialty-specific clinical presentation on management of COVID-19. Attendance was greatly increased (mean 384 attendees) compared to traditional grand rounds (mean 44 attendees) and included a diverse audience of medical professionals. Feedback was overwhelmingly positive, with >80% of responders stating that the sessions would or might inform their clinical practice. COVID-19 has therefore provided an opportunity to modernise grand rounds, and develop a new model matching the needs of medical education beyond the pandemic.

Oral versus intravenous antibiotics for bone and joint infections: the OVIVA non-inferiority RCT

BACKGROUND

Management of bone and joint infection commonly includes 4-6 weeks of intravenous (IV) antibiotics, but there is little evidence to suggest that oral (PO) therapy results in worse outcomes.

OBJECTIVE

To determine whether or not PO antibiotics are non-inferior to IV antibiotics in treating bone and joint infection.

DESIGN

Parallel-group, randomised (1 : 1), open-label, non-inferiority trial. The non-inferiority margin was 7.5%.

SETTING

Twenty-six NHS hospitals.

PARTICIPANTS

Adults with a clinical diagnosis of bone, joint or orthopaedic metalware-associated infection who would ordinarily receive at least 6 weeks of antibiotics, and who had received ≤ 7 days of IV therapy from definitive surgery (or start of planned curative treatment in patients managed non-operatively).

INTERVENTIONS

Participants were centrally computer-randomised to PO or IV antibiotics to complete the first 6 weeks of therapy. Follow-on PO therapy was permitted in either arm.

MAIN OUTCOME MEASURE

The primary outcome was the proportion of participants experiencing treatment failure within 1 year. An associated cost-effectiveness evaluation assessed health resource use and quality-of-life data.

RESULTS

Out of 1054 participants (527 in each arm), end-point data were available for 1015 (96.30%) participants. Treatment failure was identified in 141 out of 1015 (13.89%) participants: 74 out of 506 (14.62%) and 67 out of 509 (13.16%) of those participants randomised to IV and PO therapy, respectively. In the intention-to-treat analysis, using multiple imputation to include all participants, the imputed risk difference between PO and IV therapy for definitive treatment failure was -1.38% (90% confidence interval -4.94% to 2.19%), thus meeting the non-inferiority criterion. A complete-case analysis, a per-protocol analysis and sensitivity analyses for missing data each confirmed this result. With the exception of IV catheter complications [49/523 (9.37%) in the IV arm vs. 5/523 (0.96%) in the PO arm)], there was no significant difference between the two arms in the incidence of serious adverse events. PO therapy was highly cost-effective, yielding a saving of £2740 per patient without any significant difference in quality-adjusted life-years between the two arms of the trial.

LIMITATIONS

The OVIVA (Oral Versus IntraVenous Antibiotics) trial was an open-label trial, but bias was limited by assessing all potential end points by a blinded adjudication committee. The population was heterogenous, which facilitated generalisability but limited the statistical power of subgroup analyses. Participants were only followed up for 1 year so differences in late recurrence cannot be excluded.

CONCLUSIONS

PO antibiotic therapy is non-inferior to IV therapy when used during the first 6 weeks in the treatment for bone and joint infection, as assessed by definitive treatment failure within 1 year of randomisation. These findings challenge the current standard of care and provide an opportunity to realise significant benefits for patients, antimicrobial stewardship and the health economy.

FUTURE WORK

Further work is required to define the optimal total duration of therapy for bone and joint infection in the context of specific surgical interventions. Currently, wide variation in clinical practice suggests significant redundancy that likely contributes to the excess and unnecessary use of antibiotics.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN91566927.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 38. See the NIHR Journals Library website for further project information.

Diabetes care in remote Australia: the antenatal, postpartum and inter-pregnancy period

BACKGROUND

Aboriginal and Torres Strait Islander women experience high rates of diabetes in pregnancy (DIP), contributing to health risks for mother and infant, and the intergenerational cycle of diabetes. By enhancing diabetes management during pregnancy, postpartum and the interval between pregnancies, the DIP Partnership aims to improve health outcomes and reduce risks early in the life-course. We describe a mixed methods formative study of health professional's perspectives of antenatal and post-partum diabetes screening and management, including enablers and barriers to care.

METHODS

Health professionals involved in providing diabetes care in pregnancy, from a range of health services across the Northern Territory, completed the survey (n = 82) and/or took part in interviews and/or focus groups (n = 62).

RESULTS

Qualitative findings highlighted factors influencing the delivery of care as reported by health professionals, including: whose responsibility it is, access to care, the baby is the focus and pre-conception care. The main challenges were related to: disjointed systems and confusion around whose role it is to provide follow-up care beyond six weeks post-partum. Quantitative findings indicated that the majority of health professionals reported confidence in their own skills to manage women in the antenatal period (62%, 40/79) and slightly lower rates of confidence in the postpartum interval (57%, 33/58).

CONCLUSION

These findings regarding whose role it is to provide postpartum care, along with opportunities to improve communication pathways and follow up care have informed the design of a complex health intervention to improve health systems and the provision of DIP related care.

Oral versus Intravenous Antibiotics for Bone and Joint Infection

BACKGROUND

The management of complex orthopedic infections usually includes a prolonged course of intravenous antibiotic agents. We investigated whether oral antibiotic therapy is noninferior to intravenous antibiotic therapy for this indication.

METHODS

We enrolled adults who were being treated for bone or joint infection at 26 U.K. centers. Within 7 days after surgery (or, if the infection was being managed without surgery, within 7 days after the start of antibiotic treatment), participants were randomly assigned to receive either intravenous or oral antibiotics to complete the first 6 weeks of therapy. Follow-on oral antibiotics were permitted in both groups. The primary end point was definitive treatment failure within 1 year after randomization. In the analysis of the risk of the primary end point, the noninferiority margin was 7.5 percentage points.

RESULTS

Among the 1054 participants (527 in each group), end-point data were available for 1015 (96.3%). Treatment failure occurred in 74 of 506 participants (14.6%) in the intravenous group and 67 of 509 participants (13.2%) in the oral group. Missing end-point data (39 participants, 3.7%) were imputed. The intention-to-treat analysis showed a difference in the risk of definitive treatment failure (oral group vs. intravenous group) of -1.4 percentage points (90% confidence interval [CI], -4.9 to 2.2; 95% CI, -5.6 to 2.9), indicating noninferiority. Complete-case, per-protocol, and sensitivity analyses supported this result. The between-group difference in the incidence of serious adverse events was not significant (146 of 527 participants [27.7%] in the intravenous group and 138 of 527 [26.2%] in the oral group; P=0.58). Catheter complications, analyzed as a secondary end point, were more common in the intravenous group (9.4% vs. 1.0%).

CONCLUSIONS

Oral antibiotic therapy was noninferior to intravenous antibiotic therapy when used during the first 6 weeks for complex orthopedic infection, as assessed by treatment failure at 1 year. (Funded by the National Institute for Health Research; OVIVA Current Controlled Trials number, ISRCTN91566927 .).

Dietary Patterns and Retinal Vessel Caliber in the Irish Nun Eye Study

BACKGROUND

Retinal vessel abnormalities are associated with cardiovascular disease risk. Widening of retinal venules is associated with increased risk of stroke while narrowing of retinal arterioles independently predicts incident hypertension, coronary heart disease and diabetes. Dietary factors are known to play an important role in cardiovascular health. However, few studies have examined the association between dietary patterns (DPs) and retinal microvascular health.

OBJECTIVE

To examine the association between 'a posteriori'-derived DPs and retinal vascular caliber (RVC) in older women with a restricted lifestyle.

METHODS

This was a cross-sectional study of 1233 participants (mean age: 76.3 years) from the Irish Nun Eye Study (INES). Computer-assisted software was used to measure RVC from digital eye images using standardized protocols. Dietary intake was assessed using a food frequency questionnaire (FFQ). DP analysis was performed using principal component analysis from completed FFQs. Regression models were used to assess associations between DPs and retinal vessel diameters, adjusting for age, body mass index, refraction, hypertension, diabetes mellitus, ischemic heart disease, cerebrovascular accident and fellow eye RVC.

RESULTS

Two DPs were identified: a 'healthy' pattern with high factor loadings for fruit, vegetables, wholegrains and oily fish and an 'unhealthy' pattern with high factor loadings for sugar and sweets, chips, high fat dairy products and French fries. Adjusted linear regression analysis revealed that those who adhered most closely to the unhealthy DP had wider central retinal venular equivalent (CRVE) (p=0.03) and narrower central retinal arteriolar equivalent (CRAE) (p=0.01) compared to the least unhealthy DP. No independent relationship was observed between the healthy DP and RVC.

CONCLUSION

In this cohort of older women with a restricted lifestyle, an unhealthy DP was independently associated with an unfavorable retinal profile, namely a widening of retinal venules and narrowing of retinal arterioles.

A retrospective study of seven-day consultant working: reductions in mortality and length of stay

Weekend admission is associated with higher in-hospital mortality than weekday admission. Whether providing enhanced weekend staffing for acute medical inpatient services reduces mortality or length of stay is unknown.

METHODS

This paper describes a retrospective analysis of in-hospital mortality and length of stay before and after introduction of an enhanced, consultant-led weekend service in acute medicine in November 2012. In-hospital mortality was compared for matching admission calendar months before and after introduction of the new service, adjusted for case volume. Length of stay and 30-day postdischarge mortality were also compared; illness severity of patients admitted was assessed by cross-sectional acuity audits.

RESULTS

Admission numbers increased from 6,304 (November 2011-July 2012) to 7,382 (November 2012-July 2013), with no change in acuity score in elderly medical patients but a small fall in younger patients. At the same time, however, a 57% increase in early-warning score triggered calls was seen in 2013 (410 calls vs 262 calls in 2012; p<0.01). Seven-day consultant working was associated with a reduction in in-hospital mortality from 11.4% to 8.8% (p<0.001). Mortality within 30 days of discharge fell from 2.4% to 2.0% (p=0.12). Length of stay fell by 1.9 days (95% CI 1.1-2.7; p=0.004) for elderly medicine wards and by 1.7 days (95% CI 0.8-2.6; p=0.008) for medical wards. Weekend discharges increased from general medical wards (from 13.6% to 18.8%, p<0.001) but did not increase from elderly medicine wards.

CONCLUSIONS

Introduction of an enhanced, consultant-led model of working at weekends was associated with reduced in-hospital and 30-day post discharge mortality rates as well as reduced length of stay. These results require confirmation in rigorously designed prospective studies.

Management of the Infected Total Hip Arthroplasty

In the United Kingdom approximately 80,000 total hip arthroplasties are undertaken on an average each year. The popularity and demand for this operation are continually increasing. Our understanding of arthroplasty surgery and its complications has evolved greatly, and as a result infection rates are undeniably at an all-time low. The increasing volume of operations being performed does, however, mean that we still continue to see an increased number of cases of infection. There is no doubt that periprosthetic joint infection (PJI) poses a complex clinical and diagnostic predicament to clinicians. Delay in the diagnosis and treatment of PJI can not only be detrimental in terms of patient morbidity, but it also poses a significant financial burden to health care institutions. It is therefore in the best interest of the patient, surgeon, and institution to optimize the diagnosis and treatment of this devastating complication. There remains considerable variability in terms of approach to diagnosis and treatment of PJI among orthopedic surgeons. In this review, we will, therefore, examine in detail the current body of evidence available on PJI. We will discuss the most robust and up-to-date methods of diagnosis and offer a comparison of management strategies.

Nerve localization techniques for peripheral nerve block and possible future directions

BACKGROUND

Ultrasound guidance is now a standard nerve localization technique for peripheral nerve block (PNB). Ultrasonography allows simultaneous visualization of the target nerve, needle, local anesthetic injectate, and surrounding anatomical structures. Accurate deposition of local anesthetic next to the nerve is essential to the success of the nerve block procedure. Due to limitations in the visibility of both needle tip and nerve surface, the precise relationship between needle tip and target nerve is unknown at the moment of injection. Importantly, nerve injury may result both from an inappropriately placed needle tip and inappropriately placed local anesthetic. The relationship between the block needle tip and target nerve is of paramount importance to the safe conduct of peripheral nerve block.

METHODS

This review summarizes the evolution of nerve localization in regional anesthesia, characterizes a problem faced by clinicians in performing ultrasound-guided nerve block, and explores the potential technological solutions to this problem.

RESULTS

To date, technology newly applied to PNB includes real-time 3D imaging, multi-planar magnetic needle guidance, and in-line injection pressure monitoring. This review postulates that optical reflectance spectroscopy and bioimpedance may allow for accurate identification of the relationship between needle tip and target nerve, currently a high priority deficit in PNB techniques.

CONCLUSIONS

Until it is known how best to define the relationship between needle and nerve at the moment of injection, some common sense principles are suggested.

Intellectual disability in young people in custody in New South Wales, Australia - prevalence and markers

BACKGROUND

Intellectual disability (ID) is known to be more common in incarcerated groups, especially incarcerated youth. Aboriginal young people have higher rates of ID, and make up half of all youth in juvenile custody in New South Wales (NSW), Australia. We aimed to describe the prevalence of possible ID and borderline intellectual functioning (BIF) in young people in NSW custody, and to describe the association between possible ID and Aboriginality after adjusting for the inequalities in social disadvantage.

METHODS

Baseline study of all youth in NSW Custodial Centres between August and October 2009, with 18-month follow-up. Using Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV) and Wechsler Adult Intelligence Scale - Fourth Edition (WAIS-IV) cognitive assessments, possible ID was defined as Extremely Low Intellectual Quotient range (Full Scale Intellectual Quotient, FSIQ < 70), and possible BIF was defined as Borderline IQ range (FSIQ < 80). Risk factors for possible ID and BIF included age, gender, Aboriginality, socio-economic disadvantage, offending history and psychological disorders.

RESULTS

N = 295 (65%) of all young people in NSW custody completed cognitive and psychological assessments (87% male, 50% Aboriginal, average age 17 years). Almost one half (45.8%) of young people had borderline or lower intellectual functioning (by IQ assessment), and 14% had an IQ in the extremely low range (FSIQ < 70), indicating a possible ID. Aboriginal participants were three times more likely than non-Aboriginal participants to have a possible ID, but after accounting for the excess disadvantage in the Aboriginal group, Aboriginality was no longer a marker of ID. Incarceration from a young age and psychosis were significantly associated with possible ID in Aboriginal participants, compared with Aboriginal participants first incarcerated at a later age, and Aboriginal participants without psychosis.

CONCLUSION

The inequalities in criminal justice between Aboriginal and non-Aboriginal youth may exacerbate or contribute to the intellectual impairment of those incarcerated from a young age. Aboriginal young people with psychosis are also at high risk of cognitive impairments that might indicate a possible co-morbid ID, and these patients should be diverted at court into community assessment services, rather than incarcerated. These results highlight a need for better and earlier identification of young people (particularly Aboriginal youth) at risk of ID and other co-morbidities in the juvenile justice system.

Glycaemic control in insulin requiring diabetes patients receiving exclusive enteral tube feeding in an acute hospital setting

AIMS

Optimising glycaemic control for insulin requiring individuals during enteral feeding is important but difficult. We compare 3 insulin regimens with the aim of improving glucose control and reducing hypoglycaemia.

METHODS

Comparison of 3 insulin/feed regimens: (1) A 20 h feed using a 30:70 premixed insulin (2) Three bolus (4 h) feeds combined with short acting analogue insulin and a basal long acting insulin. (3) A 24 h feed combined with a long acting analogue insulin. The study combined a retrospective analysis of regimen (1) with consecutive prospective analyses of (2) and (3).

RESULTS

Glucose concentrations were suboptimal with higher values during the feeds (12.6 mmol/L ± 4.4 vs 10.3 ± 4.1 p<0.001). Although there was no overall difference in glucose control between groups there was a reduction in hypoglycaemia during the feed in the bolus group (no hypoglycaemia during intermittent feeds p<0.001).

CONCLUSIONS

Glucose concentrations were relatively high overall. Short bolus feeding appears to reduce the frequency of hypoglycaemia. This is of clinical significance for this patient group.