Improving the efficiency and effectiveness of an industrial SARS-CoV-2 diagnostic facility

On 11th March 2020, the UK government announced plans for the scaling of COVID-19 testing, and on 27th March 2020 it was announced that a new alliance of private sector and academic collaborative laboratories were being created to generate the testing capacity required. The Cambridge COVID-19 Testing Centre (CCTC) was established during April 2020 through collaboration between AstraZeneca, GlaxoSmithKline, and the University of Cambridge, with Charles River Laboratories joining the collaboration at the end of July 2020. The CCTC lab operation focussed on the optimised use of automation, introduction of novel technologies and process modelling to enable a testing capacity of 22,000 tests per day. Here we describe the optimisation of the laboratory process through the continued exploitation of internal performance metrics, while introducing new technologies including the Heat Inactivation of clinical samples upon receipt into the laboratory and a Direct to PCR protocol that removed the requirement for the RNA extraction step. We anticipate that these methods will have value in driving continued efficiency and effectiveness within all large scale viral diagnostic testing laboratories.

Can non-clinical community placements enhance medical students' understanding of the social determinants of ill health?

OBJECTIVES

Teaching the social determinants of health using classroom methods and medical settings is not effectual, yet few institutions require students to undertake placements in non-clinical settings. We sought to understand through qualitative investigation how non-clinical community placements contributed to students' understanding of health disparities.

STUDY DESIGN

Qualitative methods.

METHODS

Semistructured interviews with eight purposively selected students and a focus group were conducted by an independent, non-medical and non-religiously affiliated researcher. A thematic analysis elicited key themes and findings.

RESULTS

On analysis, students valued the placements, reporting a greater understanding of and empathy for the needs of people from marginalised socio-economic, cultural and ethnic groups. Some believed this was better gained in non-clinical settings where doctor-patient barriers were absent.

CONCLUSIONS

Non-clinical community placements may provide a special opportunity to teach health determinants and cultural competence to medical students.

Responding to the increased genetic risk associated with customary consanguineous marriage among minority ethnic populations: lessons from local innovations in England

Populations practising customary consanguineous marriage have a higher incidence of autosomal recessive genetic disorders than those in which reproductive partners are usually unrelated. In the absence of any national-level response, English service developments to address the additional needs of families living with or at risk of such disorders have been locally led. These interventions remain in their infancy here, as elsewhere in Europe, and important questions remain regarding how appropriate, effective and sustainable responses can be operationalised in practice. This formative service review employed four local case studies together with wider consultation exercises over a 4-year period (2011–2015) to document recent responses to this area of need, issues arising and lessons to inform future work. Service components included the following: enhancements to genetic services to provide family-centred, culturally competent approaches to counselling and testing; community genetic literacy approaches; and capacity development among health professionals. Local approaches were, however, very varied in their detail, scope, level of investment and longevity. The provisions of culturally competent genetic counselling services and community-level genetic literacy interventions were generally well received by those who accessed them. Coordinated action across all service components appeared important for an effective service, but healthcare professionals, particularly general practitioners, were often difficult to engage in this agenda. An evaluative culture and engagement in a wider community of practice had supported service development across sites. However, sustaining investment was challenging, particularly where new services were not well integrated into core provision and where commissioning was driven by expectations of short-term reductions in infant mortality and disability.

Developing a multidisciplinary approach within the ED towards domestic violence presentations

AIM

To improve the detection and quality of care of patients who attend the emergency department (ED) with confirmed or suspected domestic abuse (DA).

DESIGN

A quality improvement report on the design, implementation and evaluation of a specialised service and structured training programme to detect and manage DA presentations within an emergency medicine department.

SETTING

The study was set in the ED at the Northern General Hospital, Sheffield, UK.

KEY MEASURES FOR IMPROVEMENT

Key measures for improvement included introducing a service within the ED to help staff manage DA and coordinate responses; improve staff confidence in detecting DA; develop a structured and consistent process by which to manage DA presentations.

STRATEGIES FOR CHANGE

An Independent Domestic Violence Advocate service was introduced into the department in July 2011 through a multiagency agreement. A structured training and education programme was delivered to ED staff. A 'communications form' was developed for DA risk assessment and case management. The process was reviewed quarterly.

RESULTS

One hundred and seventy-two referrals were made to the service (121 distinct clients) over a 12-month period. Staff reported greater confidence in detecting DA, and community partners highlighted the role the service had in improving DA detection and care quality within the city.

CONCLUSIONS

Strong leadership and prioritising the issue within the department has facilitated the development of the process and contributed substantially to its success. Support from community partners has been invaluable in tailoring the service and education programme to the needs of staff and patients within the department.

Screening older patients for obstructive airways disease in a semi-rural practice

BACKGROUND

Obstructive airways disease in older patients is reported to be not only common, but frequently overlooked and untreated by general practitioners. This study examines the value of screening elderly patients in a large semi-rural general practice for potentially treatable asthma and chronic obstructive pulmonary disease (COPD).

METHODS

A random sample of 353 patients aged 60-75 years attended a nurse run screening clinic for pulmonary function testing, serial peak flow recording, and completion of a symptom questionnaire. Patients with a low forced expiratory volume in one second (below the fifth centile of their predicted value) or >15% mean diurnal variation in peak flow were referred to a doctor's clinic for further diagnostic assessment and/or to discuss possible treatment where appropriate.

RESULTS

Fifty eight patients (16.4%) had obstructive airways disease, the prevalence of asthma being 6.5% and that of COPD 9.9%. Of these, 30 had no previous diagnosis of airways disease and were not on treatment; eight of them had significant airways reversibility and 10 were current smokers. No newly diagnosed patients had severe disease as measured by pulmonary function or quality of life assessment, and six patients accepted treatment.

CONCLUSION

Few older patients benefited from a screening programme for obstructive airways disease in a semi-rural general practice.

A new fossil fern assignable to Gleicheniaceae from Late Cretaceous sediments of New Jersey

The recent discovery of well-preserved charcoalified rhizomes, petioles. pinnules, sori, and spores from the Upper Cretaceous of New Jersey provides the basis for the description of a new gleicheniaceous fern, Boodlepteris turoniana. The fossils were collected from unconsolidated sediments of Turonian age (~90 MYBP million years before present; Raritan/ Lower Magothy Formation, Potomac Group). These deposits are rich in angiosperms, but also have a limited representation of fern and gymnosperm remains. Fossil specimens from this locality are particularly remarkable in that minute detail, including anatomical features, are often preserved. Some Boodlepteris specimens have cell by cell preservation that reveals the nature and structure of the stele in rhizomes and petioles, and others show minute details of the sori borne on fertile pinnae. Although these specimens are not in organic connection, there are sufficient structural and anatomical details preserved to confidently suggest that they belong to the same taxon. Cladistic analysis of the fossils, both separately and as a reconstruction, support assignment of Boodlepteris to the extant family Gleicheniaceae.

Advantages of an increased dose of MRI contrast agent for enhancing inflammatory synovium

MRI intravenous contrast enhancement of inflammatory synovium has been studied at two different doses to determine to what extent enhancement is dose dependent. 19 patients with clinically active rheumatoid arthritis involving a knee were scanned twice, one week apart, using 0.1 mmol/kg of gadoteridol (ProHance) on the first occasion and 0.3 mmol/kg on the second. Static pre-and post-contrast images together with dynamic images immediately following injection were obtained on a 1.0T scanner. On subjective assessment, 84% of patients showed improved enhancement. 47% showed more enhancing tissue, a clearer delineation of enhancing tissue or both. Objectively, enhancement was increased significantly at the higher dose, as judged by the percentage increase in mean signal intensity within regions of interest plotted over the suprapatellar pouch (1723% v. 1005% enhancement P < 0.05). In practical terms the better visualization of enhancing tissue achieved with higher doses is likely to reduce margins of error in attempts at quantification from MRI scans, particularly of synovial volume, but emphasizes also the need for care and consistency to be exercised in calculating the exact dose of contrast medium to be administered.

'Targeted' molecular diversity: design and development of non-peptide antagonists for cholecystokinin and tachykinin receptors

A drug design strategy to non-peptide small molecule antagonists of neuropeptides is described that targets the molecular diversity which exists in the 'privileged' data set of the physico-chemical properties represented by the side-chains of the 20 genetically encoded amino acids. The strategy is exemplified by the design of a selective and high affinity cholecystokinin CCK-A antagonist PD 140548, CCK-B antagonist CI-988 (formerly PD 134308) tachykinin NK-1 antagonist PD 154075 and NK-2 antagonist Cam-2291. The NK-3 antagonists, PD 157672 and the non-peptide PD 161182, were developed from an information-rich dipeptide library constructed from 256 N-protected dipeptides and 64 hydrophobic biased dipeptides.

Atrio-ventricular dissociation in meningococcal meningitis

A case is presented of meningococcal meningitis, without septicaemia, which was associated with a transient atrio-ventricular dissociation. The need for cardiac monitoring in similar cases is discussed.

P NMR Observations on the Effect of the External pH on the Intracellular pH Values in Plant Cell Suspension Cultures

(31)P nuclear magnetic resonance (NMR) spectroscopy was used to monitor the response of oil palm (Elaeis guineensis) and carrot (Daucus carota) cell suspensions to changes in the external pH. An airlift system was used to oxygenate the cells during the NMR measurements and a protocol was developed to enable a constant external pH to be maintained in the suspension when required. Phosphonoacetic acid was used as an external pH marker and the intracellular pH values were measured from the chemical shifts of the cytoplasmic and vacuolar orthophosphate resonances. In contrast to earlier studies the cytoplasmic pH was independent of the external pH over the range 5.5 to 8.0 and it was only below pH 5.5 that the cytoplasmic pH varied, falling at a rate of 0.12 pH unit per external unit. Loss of pH control was observed in response to sudden increases in external pH with the response of the cells depending on the conditions imposed. A notable feature of the recovery from these treatments was the transient acidification of the cytoplasm that occurred in a fraction of the cells and overshoot phenomena of this kind provided direct evidence for the time dependence of the regulatory mechanisms.

Abnormal pancreatic electrolyte secretion in cystic fibrosis. Reliability as a diagnostic marker

We performed pancreatic function tests on sixty-five cystic fibrosis (CF), and eleven control children. The technique used continuous IV infusion of cholecystokinin and secretin, with duodenal juice collection over a 90 min period, and was made quantitative by continuous duodenal infusion and distal collection of an unabsorbable marker (bromosulphthalein). Some CF patients had near normal pancreatic enzyme outputs, some had impaired but measurable levels, but most (79%) had almost absent trypsin secretion. CF children with better pancreatic function, were younger and more likely to be male. All controls showed a large increase in bicarbonate concentration and secretion rate per kilogram body weight during the test, but most children with CF (96.5%) did not. Because two of our CF patients had water and bicarbonate secretion within the control range, this finding does not exclude the diagnosis of CF. Sodium, potassium and chloride ion secretion in CF patients was lower than controls but overlap occurred. We found a linear correlation between acinar and tubular secretion in CF patients which indicates that there is probably not a primary genetic defect in pancreatic bicarbonate secretion in CF.

Nuclear-magnetic-resonance studies of 5'-ribonucleotide and 5'-deoxyribonucleotide conformations in solution using the lanthanide probe method

The conformations of the metal-bound 5'-ribonucleotides and 5'-deoxyribonucleotides in aqueous solution at different pH values have been studied using the lanthanide probe method. The conformational analysis, based on mixing different conformations in fast exchange within the nuclear magnetic resonance time scale, agrees well with the results from coupling constants, nuclear Over-hauser effects and spin-lattice relaxation times, obtained for the metal-fixed systems. The equilibrium between the two basic conformational combinations for the 5'-nucleotides, anti-(N in equalibrium S)-gg-g'g' and syn-(N in equalibrium S)-gt-g'g' depends on the nature of the furanose ring, the base and also on the state of base protonation and phosphate ionization. The effect of base protonation is particularly strong for the guanine nucleotides.