The implementation of a hepatitis C testing service in community pharmacies: I-COPTIC consensus statement

OBJECTIVES

This aimed to develop a blueprint for an effective community pharmacy Hepatitis C virus (HCV) testing service by producing a consensus statement.

STUDY DESIGN

This was a modified Delphi process.

METHODS

We recruited a heterogenous panel of experts (who had been involved in the setup or delivery of a community pharmacy HCV testing service) by purposive and chain referral methods. We had three rounds of a modified Delphi process. The first was a series of questions with free text responses and was analysed using thematic analysis, and the second and third were statements for the respondents to rate using a 7-point Likert scale. Consensus was predefined in a published protocol, and the results were reviewed by a public and patient involvement panel before the statement was finalised.

RESULTS

We had 24 participants, including community and hospital-based pharmacists, local pharmaceutical committee members, charity representatives (Hepatitis C Trust), local clinical service lead, nurse specialists and doctors. The response rate of the first, second and third rounds were 100%, 96% and 88%, respectively. After the third round, we had 60 statements that reached consensus. We discussed the accepted statements with a patient and public involvement group. We used these statements to produce the I-COPTIC statement and a graphical summary.

CONCLUSIONS

We developed a blueprint for the design of a gold standard community pharmacy HCV testing service. We believe this will support the successful implementation of community pharmacy testing for HCV. Community pharmacy testing is an important service to help achieve and maintain HCV elimination.

A novel characterized multi-drug-resistant Pseudocitrobacter sp. isolated from a patient colonized while admitted to a tertiary teaching hospital

BACKGROUND

Reports of nosocomial infections typically describe recognised microorganisms. Here, a novel bacterial species was isolated, based on rectal swab screening for carbapenemases post-admission, then phenotypically and genetically characterized.

METHODS

Sensititre, Vitek and API kits, MALDI and Illumina MiSeq were employed before profiles and phylogeny were compared with other related species.

FINDINGS

Determined to be a possible Enterobacterales, the isolate was found to have 99.7% 16s rRNA identity to Pseudocitrobacter corydidari; an Asian cockroach-associated species. Given the highly conserved/low variability of 16S rRNA genes in Enterobacterales, average nucleotide identity (ANI) analysis compared the new isolate's genome with those of 18 Enterobacteriaceae species, including confirmed species of Pseudocitrobacter and unnamed Pseudocitrobacter species in the SILVA database. Of these, Pseudocitrobactercorydidari had the highest ANI at 0.9562. The published genome of the only known isolate of P.corydidari does not include Antimicrobial Resistance Genes (ARGs), with exception of potential drug efflux transporters. In contrast, our clinical isolate bears recognised antimicrobial resistance genes, including Klebsiella pneumoniae carbapenemase. The associated genome suggests resistance to carbapenems, β-lactams, sulfonamides, fluoroquinolones, macrolides, aminoglycosides and cephalosporins. Phenotypic antimicrobial resistance was confirmed.

CONCLUSION

Evident variations in ARG profiles, human colonization and origin in a clinically relevant niche that is geographically, physically and chemically disparate lend credibility for divergent evolution or, less likely, parallel evolution with P. corydidari. Genome data for this new species have been submitted to GENBANK using the proposed nomenclature Pseudocitrobacter limerickensis. The patient was colonized, rather than infected, and did not require antimicrobial treatment.

Evolutionary diversification reveals distinct somatic versus germline cytoskeletal functions of the Arp2 branched actin nucleator protein

Branched actin networks are critical in many cellular processes, including cell motility and division. Arp2, a protein within the seven-membered Arp2/3 complex, is responsible for generating branched actin. Given its essential roles, Arp2 evolves under stringent sequence conservation throughout eukaryotic evolution. We unexpectedly discovered recurrent evolutionary diversification of Arp2 in Drosophila, yielding independently arising paralogs Arp2D in obscura species and Arp2D2 in montium species. Both paralogs are unusually testis-enriched in expression relative to Arp2. We investigated whether their sequence divergence from canonical Arp2 led to functional specialization by replacing Arp2 in D. melanogaster with either Arp2D or Arp2D2. Despite their divergence, we surprisingly found that both complement Arp2's essential function in somatic tissue, suggesting they have preserved the ability to polymerize branched actin even in a non-native species. However, we found that Arp2D- and Arp2D2-expressing males display defects throughout sperm development, with Arp2D resulting in more pronounced deficiencies and subfertility, suggesting the Arp2 paralogs are cross-species incompatible in the testis. We focused on Arp2D and pinpointed two highly diverged structural regions-the D-loop and C terminus-and found that they contribute to germline defects in D. melanogaster sperm development. However, while the Arp2D C terminus is suboptimal in the D. melanogaster testis, it is essential for Arp2D somatic function. Testis cytology of the paralogs' native species revealed striking differences in germline actin structures, indicating unique cytoskeletal requirements. Our findings suggest canonical Arp2 function differs between somatic versus germline contexts, and Arp2 paralogs may have recurrently evolved for species-specialized actin branching in the testis.

Pooled prevalence of lymphopenia in all-cause hospitalisations and association with infection: a systematic review and meta-analysis

BACKGROUND

Lymphopenia is defined as a decrease below normal value (often 1.0 x 109 cells/L) of blood circulating lymphocyte count. In the general population, lymphopenia is associated with an increased risk of hospitalisation secondary to infection, independent of traditional clinical risk factors. In hospital, lymphopenia is associated with increased risk of healthcare-associated infection and mortality. By summarising lymphopenia's prevalence and impact on clinical outcomes, we can identify an at-risk population and inform future studies of immune dysfunction following severe illness.

METHODS

Peer-reviewed search strategy was performed on three databases. Primary objective was to summarise the pooled prevalence of lymphopenia. Primary outcome was infection including pre-existing lymphopenia as a risk factor for admission with infection and as an in-hospital risk factor for healthcare-associated infection. Secondary outcomes were length of stay and mortality. Mortality data extracted included in-hospital, 28/30-day ('early'), and 90-day/1-year ('late') mortality. Meta-analysis was carried out using random-effects models for each outcome measure. Heterogeneity was assessed using I2 statistic. Joanna Briggs Institute checklist for cohort studies was used to assess risk of bias. The protocol was published on PROSPERO.

RESULTS

Fifteen observational studies were included. The pooled prevalence of lymphopenia in all-cause hospitalisations was 38% (CI 0.34-0.42, I2= 97%, p< 0.01). Lymphopenia was not associated with an infection diagnosis at hospital admission and healthcare associated infection (RR 1.03; 95% CI 0.26-3.99, p=0.97, I2 = 55% and RR 1.31; 95% CI 0.78-2.20, p=0.31, I2=97%, respectively), but was associated with septic shock (RR 2.72; 95% CI 1.02-7.21, p=0.04, I2 =98%). Lymphopenia was associated with higher in-hospital mortality and higher 'early' mortality rates (RR 2.44; 95% CI 1.71-3.47, p < 0.00001, I2 = 89% and RR 2.05; 95% CI 1.64-2.56, p < 0.00001, I2 = 29%, respectively). Lymphopenia was associated with higher 'late' mortality (RR 1.59; 1.33-1.90, p < 0.00001, I2 = 0%).

CONCLUSIONS

This meta-analysis demonstrates the high prevalence of lymphopenia across all-cause hospitalisations and associated increased risk of septic shock, early and late mortality. Lymphopenia is a readily available marker that may identify immune dysfunctional patients. Greater understanding of immune trajectories following survival may provide insights into longer-term poor clinical outcomes.

Large-scale characterization of hospital wastewater system microbiomes and clinical isolates from infected patients: profiling of multi-drug-resistant microbial species

BACKGROUND

Hospital-acquired infections (HAIs) and infectious agents exhibiting antimicrobial resistance (AMR) are challenges globally. Environmental patient-facing wastewater apparatus including handwashing sinks, showers and toilets are increasingly identified as sources of infectious agents and AMR genes.

AIM

To provide large-scale metagenomics analysis of wastewater systems in a large teaching hospital in the Republic of Ireland experiencing multi-drug-resistant HAI outbreaks.

METHODS

Wastewater pipe sections (N=20) were removed immediately prior to refurbishment of a medical ward where HAIs had been endemic. These comprised toilet U-bends, and sink and shower drains. Following DNA extraction, each pipe section underwent metagenomic analysis.

FINDINGS

Diverse taxonomic and resistome profiles were observed, with members of phyla Proteobacteria and Actinobacteria dominating (38.23 ± 5.68% and 15.78 ± 3.53%, respectively). Genomes of five clinical isolates were analysed. These AMR bacterial isolates were from patients >48 h post-admission to the ward. Genomic analysis determined that the isolates bore a high number of antimicrobial resistance genes (ARGs).

CONCLUSION

Comparison of resistome profiles of isolates and wastewater metagenomes revealed high degrees of similarity, with many identical ARGs shared, suggesting probable acquisition post-admission. The highest numbers of ARGs observed were those encoding resistance to clinically significant and commonly used antibiotic classes. Average nucleotide identity analysis confirmed the presence of highly similar or identical genomes in clinical isolates and wastewater pipes. These unique large-scale analyses reinforce the need for regular cleaning and decontamination of patient-facing hospital wastewater pipes and effective infection control policies to prevent transmission of nosocomial infection and emergence of AMR within potential wastewater reservoirs.

An angiotensin converting enzyme homolog is required for volatile pheromone detection, odorant binding protein secretion and normal courtship behavior in Drosophila melanogaster

In many arthropods, including insects responsible for transmission of human diseases, behaviors that include mating, aggregation, and aggression are triggered by detection of pheromones. Extracellular odorant binding proteins are critical for pheromone detection in many insects and are secreted into the fluid bathing the olfactory neuron dendrites. In Drosophila melanogaster, the odorant binding protein LUSH is essential for normal sensitivity to the volatile sex pheromone, 11-cis vaccenyl acetate (cVA). Using a genetic screen for cVA pheromone insensitivity, we identified ANCE-3, a homolog of human angiotensin converting enzyme that is required for detection of cVA pheromone. The mutants have normal dose-response curves for food odors, although olfactory neuron amplitudes are reduced in all olfactory neurons examined. ance-3 mutants have profound delays in mating, and the courtship defects are primarily but not exclusively due to loss of ance-3 function in males. We demonstrate that ANCE-3 is required in the sensillae support cells for normal reproductive behavior, and that localization of odorant binding proteins to the sensillum lymph is blocked in the mutants. Expression of an ance-3 cDNA in sensillae support cells completely rescues the cVA responses, LUSH localization, and courtship defects. We show the courtship latency defects are not due to effects on olfactory neurons in the antenna nor mediated through ORCO receptors, but instead stem from ANCE-3-dependent effects on chemosensory sensillae in other body parts. These findings reveal an unexpected factor critical for pheromone detection with profound influence on reproductive behaviors.

Optical mapping compendium of structural variants across global cattle breeds

Structural variants (SV) have been linked to important bovine disease phenotypes, but due to the difficulty of their accurate detection with standard sequencing approaches, their role in shaping important traits across cattle breeds is largely unexplored. Optical mapping is an alternative approach for mapping SVs that has been shown to have higher sensitivity than DNA sequencing approaches. The aim of this project was to use optical mapping to develop a high-quality database of structural variation across cattle breeds from different geographical regions, to enable further study of SVs in cattle. To do this we generated 100X Bionano optical mapping data for 18 cattle of nine different ancestries, three continents and both cattle sub-species. In total we identified 13,457 SVs, of which 1,200 putatively overlap coding regions. This resource provides a high-quality set of optical mapping-based SV calls that can be used across studies, from validating DNA sequencing-based SV calls to prioritising candidate functional variants in genetic association studies and expanding our understanding of the role of SVs in cattle evolution.

Measurement(s)	Optical Mapping
Technology Type(s)	Optical Mapping
Factor Type(s)	Structural variants
Sample Characteristic - Organism	Bos taurus
Sample Characteristic - Location	United Kingdom • Kenya • Zambia • Uganda • Brazil • Nigeria

The relationship between residual limb health, motion within the socket, and prosthetic suspension

Residual limb health is critical for continued prosthesis use; however, many prosthesis users experience skin-related breakdown. The interface between the residual limb and the prosthetic socket sets the local mechanical environment and plays a role in skin stresses. Motion of the residual limb in the socket adds additional mechanical strain on the limb. This article explores the relationship between motion of the limb in the socket and residual limb health. We evaluated current methods for assessing residual limb health and motion of the residual limb in the socket and compared these evaluations across different prosthetic suspension systems. While few direct studies comparing residual limb health and motion exist, it has been shown that elevated vacuum suspension systems result in both improved residual limb health compared to passive suction and pin-lock systems and decreased motion compared to passive suction, pin-lock, knee sleeve, and anatomical suspension systems. While motion and health have not been directly linked, elevated vacuum suspension may demonstrate a relationship that reduced motion of the residual limb in the socket improves residual limb health. Further evaluation in this area is necessary to more completely and directly understand the relationship between residual limb motion and residual limb health.

Microbial epidemiology and clinical risk factors of carbapenemase-producing Enterobacterales amongst Irish patients from first detection in 2009 until 2020

Background

Carbapenemase producing Enterobacterales (CPE) are major public health threats.

Aim

To review microbial epidemiology of CPE, as well as clinical risk factors and infections, amongst CPE positive patients over 12 years in an Irish tertiary hospital.

Methods

Retrospective observational study of data extracted from a laboratory CPE database, electronic healthcare records and manual review of patient charts. Common risk factors, treatment regimens for all CPE related infections, and clinical outcomes were ascertained.

Findings

Among CPE strains isolated from 460 patients, Klebsiella pneumoniae carbapenemase (KPC) was the carbapenemase most frequently detected, accounting for 87.4% (459) of all CPE enzymes. Citrobacter species 177 (33.7%) were the most common species harbouring this enzyme. 428 CPE positive patients (93%) were identified in the acute hospital setting; the most common risk factor for CPE acquisition was history of hospitalisation, observed in 305 (66%) cases. Thirty patients (6.5%) had confirmed infections post-acquisition, of which four were bloodstream infections. There were 19 subsequent episodes of non CPE-related bacteraemia in this cohort. All causal mortality at 30 days was 41 patients (8.9%). However, clinical review determined that CPE was an indirect associative factor in 8 patient deaths.

Conclusions

In this tertiary hospital setting, microbial epidemiology is changing; with both OXA-48 enzymes and KPC-producing Citrobacter species becoming more prevalent. Whilst the burden of CPE related infections, especially bacteraemia, was low over the study period, it remains critical that basic infection prevention and control practices are adhered to lest the observed changes in epidemiology result in an increase in clinical manifestations.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Repeated transmission of SARS-CoV-2 in an overcrowded Irish emergency department elucidated by whole-genome sequencing

AIM

To provide a detailed genomic-epidemiological description of a complex multi-ward SARS-CoV-2 outbreak, which originated in the crowded emergency department (ED) in our hospital during the third wave of the COVID-19 pandemic, and was elucidated promptly by local whole-genome sequencing (WGS).

METHODS

SARS-CoV-2 was detected by reverse transcriptase real-time polymerase chain reaction on viral RNA extracted from nasopharyngeal swabs. WGS was performed using an Oxford MinION Mk1C instrument following the ARTIC v3 sequencing protocol. High-quality consensus genomes were assembled with the artic-ncov2019 bioinformatics pipeline and viral phylogenetic trees were built, inferred by maximum-likelihood. Clusters were defined using a threshold of 0-1 single nucleotide polymorphisms (SNPs) between epidemiologically linked sequences.

RESULTS

In April 2021, outbreaks of COVID-19 were declared on two wards at University Hospital Limerick after 4 healthcare-associated SARS-CoV-2 infections were detected by post-admission surveillance testing. Contact tracing identified 12 further connected cases; all with direct or indirect links to the ED 'COVID Zone'. All sequences were assigned to the Pangolin B.1.1.7 lineage by WGS, and SNP-level analysis revealed two distinct but simultaneous clusters of infections. Repeated transmission in the ED was demonstrated, involving patients accommodated on trolleys in crowded areas, resulting in multiple generations of infections across three inpatient hospital wards and subsequently to the local community. These findings informed mitigation efforts to prevent cross-transmission in the ED.

CONCLUSION

Cross-transmission of SARS-CoV-2 occurred repeatedly in an overcrowded emergency department. Viral WGS elucidated complex viral transmission networks in our hospital and informed infection, prevention and control practice.

Association between tocilizumab treatment of hyperinflammatory patients with COVID-19 in a critical care setting and elevated incidence of hospital-acquired bacterial and invasive fungal infections

Background

Tocilizumab is an interleukin-6 inhibitor that reduces mortality and the need for invasive mechanical ventilation, while increasing the possibility of successful hospital discharge for hyperinflammatory patients with severe coronavirus disease 2019 (COVID-19). No increase in adverse events or serious infections has been reported previously.

Aim

To describe the characteristics and outcomes of patients with severe COVID-19 in critical care who received tocilizumab, and to compare mortality and length of hospital stay for patients who received tocilizumab (N=41) with those who did not (N=33).

Methods

Retrospective review of data related to patients with COVID-19 who received tocilizumab in a critical care setting from 1^st January to 31^st December 2021.

Findings

Amongst COVID-19 survivors, those who had received tocilizumab had longer intensive care unit (ICU) stays (median length 21 vs 9 days) and hospital stays (45 vs 34 days) compared with those who had not received tocilizumab. Thirty-day mortality (29% vs 36%; P=0.5196) and 60-day mortality (37% and 42%; P=0.6138) were not significantly lower in patients who received tocilizumab. Serious bacterial and fungal infections occurred at higher frequency amongst patients who received tocilizumab [odds ratio (OR) 2.67, 95% confidence interval (CI) 1.04–6.86; P=0.042], and at significantly higher frequency than in non-COVID-19 ICU admissions (OR 5.26, 95% CI 3.08–9.00; P<0.0001).

Conclusions

In this single-centre study, patients in critical care with severe COVID-19 who received tocilizumab had a greater number of serious bacterial and fungal infections, but this may not have been a direct effect of tocilizumab treatment.

Metallosis following hip arthroplasty: two case reports

Background

There has been increasing recognition of local and systemic adverse events associated with the release of metal ions and nanoparticles from hip arthroplasty components. Adverse local tissue reactions to metal ion debris can include periprosthetic solid and cystic masses known as pseudotumors. These masses can result in pain, swelling, extensive destruction to surrounding hip soft-tissues, and compression syndromes on neurovascular, gastrointestinal, and genitourinary structures. As reports of pseudotumors requiring multidisciplinary excision are limited, we present two pseudotumor cases that were excised through a combined approach.

Case presentations

The first case involves a 60-year-old Caucasian female with a large pseudotumor with intrapelvic and vascular involvement associated with a metal-on-polyethylene total hip arthroplasty, excised with contributions from general surgery, vascular surgery, and orthopedic surgery. Pseudotumor excision was followed by a revision total hip reconstruction in addition to an abductor mechanism reconstruction with tendo-Achilles allograft. The second case is that of a 64-year-old Caucasian female with a pseudotumor in close relationship to the femoral vessels following a metal-on-metal hip resurfacing, excised with a combination of vascular surgery and orthopedic surgery, with subsequent revision total hip reconstruction.

Conclusions

There remains a lack of literature to support the extensiveness of pseudotumor excision required in complex cases with significant intrapelvic or vascular involvement. Given the potential for significant adverse effects of large masses, the authors’ preference is to involve a multidisciplinary team to achieve a more comprehensive excision while minimizing the risk of potential complications.

717 FLUSHI- AN INTERVENTION TO IMPROVE CATHETER CARE AND REDUCE UNNECESSARY CATHETERISATION DAYS

Introduction

Catheter-Associated Urinary Tract Infections (CAUTIs) are a common and preventable healthcare-associated infection that cost NHS hospitals an estimated £54.4 M per year. The risk of developing a CAUTI is intrinsically linked to the duration of an indwelling catheter. Our project was created in response to a clinical incident where a patient was mislabelled as having a long-term catheter (LTC) and discharged, subsequently enduring several unnecessary catheter days. We have created interventions with the primary aim of reducing the number of Short-term Catheters (STC) mislabelled as LTCs by 100%, and secondary aims of reducing the number of unnecessary catheter days, increasing the number of discharge summaries with correct catheter information and reducing the number of inappropriate catheterisations.

Method

All patients admitted to one Care of the Elderly from August 2020 with a new STC were included in this project. We designed the FLUSHI sticker as a tool for recording catheter care which specifically delineated between LTCs and STCs. In addition, it allowed space for recording essential catheter care and simplified the approach to indications for ongoing catheters. This was implemented alongside a Catheter Training Programme. Finally, specific catheter prompts were integrated into the discharge summary software to encourage the correct recording of catheter care on discharge. These data were compared with pre-intervention data to assess progression towards our aims.

Results

Provisional results have demonstrated a significant reduction in the proportion of patients with an STC mislabelled as having an LTC. In addition, we have seen a significant reduction in the number of unnecessary catheter days within inpatients.

Conclusions

The FLUSHI sticker is a valid intervention that allows for the delineation between STCs and LTCs, which in turn has reduced unnecessary catheter days, decreased the number of patients being mislabelled as having an LTC, and improved catheter communication on discharge.

Hyperhidrosis of the residual limb: a narrative review of the measurement and treatment of excess perspiration affecting individuals with amputation

BACKGROUND

Hyperhidrosis (HH) is a relatively common disorder involving excessive sweating, typically of the palms or axilla. HH can also frequently occur after limb amputation, where the remaining residual limb excessively perspires, leading to an increased risk of dermatological disorders and functional limitations, such as the inability to comfortably or safely wear a prosthesis. Although many treatments have been proposed to treat HH within the dermatology community, they are not widely known by healthcare providers typically involved in caring for individuals with acquired limb loss.

OBJECTIVES

To appraise the current state of quantitative and qualitative assessment of HH within the residual limb and examine existing and future treatment strategies for this problem.

STUDY DESIGN

Narrative Literature Review.

METHODS

A literature review focused on the assessment and treatment of excessive sweating of residual limbs.

RESULTS

There is currently no objective or subjective standard to assess or diagnose HH of the residual limb. Conventional therapies for HH do not always translate to the population of individuals with limb loss. Emerging modalities for treating HH show promise toward a permanent resolution of excess perspiration but require additional studies within people with amputation.

CONCLUSIONS

Further research is needed to quantify standard values to objectively and subjectively assess and diagnose hyperhidrosis of the residual limb. New and developing treatments for hyperhidrosis require additional studies to assess efficacy and safety in the residual limb.

Impact of Dance Movement Psychotherapy on the wellbeing of caregivers of children with Autism Spectrum Disorder

OBJECTIVES

Sustaining the wellbeing of caregivers of children with Autism Spectrum Disorder (ASD) can be highly demanding. This study explored the impact of Dance Movement Psychotherapy (DMP) intervention on the wellbeing of caregivers in comparison with their standard care routine.

STUDY DESIGN

This pilot evaluation study used a quasi-experimental design.

METHODS

Thirty-seven caregivers of children with ASD were recruited from two special educational needs settings and were allocated to the DMP intervention or the control group depending on their availability to attend the sessions. The participants in the intervention group received five DMP sessions lasting 90 min each. Adult Wellbeing Scale (AWS) and Parenting Stress Index-Short Form (PSI-SF) were the two outcome measures administered before and after DMP to measure the impact of DMP intervention on caregivers' wellbeing and parental stress.

RESULTS

The retention rates were poor, with only 50% of participants in the DMP intervention arm attending at least 70% of the sessions until its end. The Minimal Clinically Important Difference (MCID) was achieved for a small effect size in both outcome measures in the DMP intervention group but not in the control group. Results from the Analyses of Covariance (ANCOVAs) showed a significant difference in post-intervention scores between the DMP intervention and the control group for AWS (F_1,33 = 106.474, P < 0.001) but not for PSI-SF. In addition, a significant association was found between pre-intervention scores and the number of sessions attended with the postintervention scores of both AWS and PSI-SF.

CONCLUSIONS

The results of this pilot DMP study are promising. However, before running a larger randomised controlled trial, strategies to support caregivers to attend the intervention need to be considered carefully.

EP.FRI.16 Use of Pulsed Lavage Reduces the Rate of Surgical Site Infection After Laparotomy

Aims

Surgical site infections (SSIs) are a preventable and common post-operative complication within general surgery. Intra-operative irrigation of surgical incisions is an inexpensive method to reduce post-operative SSI rates, however its use is currently limited to orthopaedic surgery. We aimed to assess the effects of pulsed lavage (PL) irrigation on SSI rates following elective and emergency laparotomies.

Methods

Elective and emergency patients who underwent a laparotomy between 2018 and 2019 were included. Relevant demographic and peri-operative risk factors collected retrospectively, following STROBE criteria. The primary outcome was rate of superficial SSIs within 30 days of the operation. Independent risk factors were assessed via multivariate logistic regression analysis.

Results

176 patients were identified, with an average age of 60.7 ±19.1 years. 82.4% (145/176) were emergencies and the mean ASA grade was 2.8. Fifty two patients (29.5%) had PL used during their operation. Thirty seven patients (29.8%, 37/124) in the control group developed a SSI, compared to seven patients (13.5%, 7/52) in the PL group (p = 0.022). At multi-variate analysis, the use PL conferring an Odds Ratio 0.36 (CI 0.12-0.94, p = 0.047) for developing a SSI.

Conclusions

PL appears to significantly reduced the rate of SSI following laparotomy. There remains scope to reduce the incidence of this common and expensive post-operative complication, and PL could provide a potential cost-effective means to deliver improved outcomes. Future prospective randomised trials are essential to fully assess its benefits and wider use within general surgery.

Analysis of body condition indices reveals different ecotypes of the Antillean manatee

Assessing the body condition of wild animals is necessary to monitor the health of the population and is critical to defining a framework for conservation actions. Body condition indices (BCIs) are a non-invasive and relatively simple means to assess the health of individual animals, useful for addressing a wide variety of ecological, behavioral, and management questions. The Antillean manatee (Trichechus manatus manatus) is an endangered subspecies of the West Indian manatee, facing a wide variety of threats from mostly human-related origins. Our objective was to define specific BCIs for the subspecies that, coupled with additional health, genetic and demographic information, can be valuable to guide management decisions. Biometric measurements of 380 wild Antillean manatees captured in seven different locations within their range of distribution were obtained. From this information, we developed three BCIs (BCI₁ = UG/SL, BCI₂ = W/SL³, BCI₃ = W/(SL*UG²)). Linear models and two-way ANCOVA tests showed significant differences of the BCIs among sexes and locations. Although our three BCIs are suitable for Antillean manatees, BCI₁ is more practical as it does not require information about weight, which can be a metric logistically difficult to collect under particular circumstances. BCI₁ was significantly different among environments, revealing that the phenotypic plasticity of the subspecies have originated at least two ecotypes-coastal marine and riverine-of Antillean manatees.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Peri-operative derangement in liver function tests in older patients with neck of femur fracture

Neck of femur fracture is a common consequence of falls in the elderly with a large burden of morbidity and mortality. Derangement in liver function tests (LFTs) is frequently seen in elderly people with neck of femur (NOF) fracture in the peri-operative period and can indicate serious and treatable underlying pathology as well as prognosis.On admission, raised alkaline phosphatase (ALP) levels with normal gamma-glutamyl transferase (GGT) suggest underlying bone pathology such as osteomalacia or Paget's disease but do not confirm or exclude osteoporosis. ALP can also be raised by non-bone pathology such as congestive cardiac failure and chronic kidney disease. LFT derangement in cardiac failure is associated with poorer prognosis. Post-operatively, ALP levels rise after the first week with a peak at 3-4 weeks and then fall thereafter. The rate at which they fall may help indicate bone healing in trochanteric fractures. Derangement in other LFTs is commonly due to hepatic injury; causes include trauma, alcohol, and viral hepatitis. There are also iatrogenic causes including surgery and commonly prescribed medication such as beta-lactam antibiotics, non-steroidal anti-inflammatories, and paracetamol.The differential diagnosis for deranged LFTs in the elderly peri-operatively is wide; however, most causes can be elicited through careful history and examination with occasional need for further investigations.

Impact of the COVID-19 pandemic on maternal mental heath

Introduction

As countries adopt strict quarantines and lockdowns, increasing attention has been given to the impact on mental wellbeing. The influence of this on perinatal mental health and service provision is important to consider, as these women may be particularly vulnerable to the negative effects already seen in general and psychiatric populations.

Objectives

The impact on global mental health of Covid-19, and the isolation measures used to combat it’s spread, is increasingly acknowledged. We were interested in the effect the pandemic has had specifically on the mental health of women in the peripartum period. By reflecting on our experiences, we hope to generate ideas to improve services.

Methods

We considered the effects of the pandemic in this high-risk population during each stage of contact with services. This included pre-conception, antenatal and postnatal periods, as well as the potential longitudinal and service effects. Recent case examples were identified and described from our busy and diverse South London perinatal psychiatry service.

Results

Recent referrals to our service suggest the current crisis has been a key trigger for the deterioration of many women’s mental health. This includes women who have been impacted by various factors related to the pandemic, at all stages of the perinatal period.

Conclusions

It is vital to maintain equality of access to perinatal services and to continue to consider how to deliver best care. This will involve adapting to the new working environment, and optimising care delivery using remote technologies where appropriate, in a way that is safe, accessible and acceptable to service users.

GW190521: A Binary Black Hole Merger with a Total Mass of 150 M_{⊙}

On May 21, 2019 at 03:02:29 UTC Advanced LIGO and Advanced Virgo observed a short duration gravitational-wave signal, GW190521, with a three-detector network signal-to-noise ratio of 14.7, and an estimated false-alarm rate of 1 in 4900 yr using a search sensitive to generic transients. If GW190521 is from a quasicircular binary inspiral, then the detected signal is consistent with the merger of two black holes with masses of 85_{-14}^{+21}  M_{⊙} and 66_{-18}^{+17}  M_{⊙} (90% credible intervals). We infer that the primary black hole mass lies within the gap produced by (pulsational) pair-instability supernova processes, with only a 0.32% probability of being below 65  M_{⊙}. We calculate the mass of the remnant to be 142_{-16}^{+28}  M_{⊙}, which can be considered an intermediate mass black hole (IMBH). The luminosity distance of the source is 5.3_{-2.6}^{+2.4}  Gpc, corresponding to a redshift of 0.82_{-0.34}^{+0.28}. The inferred rate of mergers similar to GW190521 is 0.13_{-0.11}^{+0.30}  Gpc^{-3} yr^{-1}.

Minimally Invasive Therapies for Osteoarthritic Hip Pain: a Comprehensive Review

PURPOSE OF REVIEW

Osteoarthritis (OA) is a highly prevalent cause of chronic hip pain, affecting 27% of adults aged over 45 years and 42% of adults aged over 75 years. Though OA has traditionally been described as a disorder of "wear-and-tear," recent studies have expanded on this understanding to include a possible inflammatory etiology as well, damage to articular cartilage produces debris in the joint that is phagocytosed by synovial cells which leads to inflammation.

RECENT FINDINGS

Patients with OA of the hip frequently have decreased quality of life due to pain and limited mobility though additional comorbidities of diabetes, cardiovascular disease, poor sleep quality, and obesity have been correlated. Initial treatment with conservative medical management can provide effective symptomatic relief. Physical therapy and exercise are important components of a multimodal approach to osteoarthritic hip pain. Patients with persistent pain may benefit from minimally invasive therapeutic approaches prior to consideration of undergoing total hip arthroplasty. The objective of this review is to provide an update of current minimally invasive therapies for the treatment of pain stemming from hip osteoarthritis; these include intra-articular injection of medication, regenerative therapies, and radiofrequency ablation.

First reported cases of actinic folliculitis treated successfully with topical retinoid

Actinic folliculitis (AF) is a rare recurrent seasonal photodermatosis, relatively newly characterized by nonpruritic, monomorphic pustules and papules appearing 4-24 h after exposure to sunlight. Lesions usually affect the face but also appear on the upper chest and arms. Resolution normally occurs within 7-10 days with cessation of sunlight exposure. AF is resistant to standard treatments used for acne vulgaris and acne rosacea, with only oral retinoids previously being reported as effective. We report the first two cases, to our knowledge, of AF responding extremely effectively to a topical retinoid.

The single-cell eQTLGen consortium

In recent years, functional genomics approaches combining genetic information with bulk RNA-sequencing data have identified the downstream expression effects of disease-associated genetic risk factors through so-called expression quantitative trait locus (eQTL) analysis. Single-cell RNA-sequencing creates enormous opportunities for mapping eQTLs across different cell types and in dynamic processes, many of which are obscured when using bulk methods. Rapid increase in throughput and reduction in cost per cell now allow this technology to be applied to large-scale population genetics studies. To fully leverage these emerging data resources, we have founded the single-cell eQTLGen consortium (sc-eQTLGen), aimed at pinpointing the cellular contexts in which disease-causing genetic variants affect gene expression. Here, we outline the goals, approach and potential utility of the sc-eQTLGen consortium. We also provide a set of study design considerations for future single-cell eQTL studies.

Prospects for observing and localizing gravitational-wave transients with Advanced LIGO, Advanced Virgo and KAGRA

We present our current best estimate of the plausible observing scenarios for the Advanced LIGO, Advanced Virgo and KAGRA gravitational-wave detectors over the next several years, with the intention of providing information to facilitate planning for multi-messenger astronomy with gravitational waves. We estimate the sensitivity of the network to transient gravitational-wave signals for the third (O3), fourth (O4) and fifth observing (O5) runs, including the planned upgrades of the Advanced LIGO and Advanced Virgo detectors. We study the capability of the network to determine the sky location of the source for gravitational-wave signals from the inspiral of binary systems of compact objects, that is binary neutron star, neutron star-black hole, and binary black hole systems. The ability to localize the sources is given as a sky-area probability, luminosity distance, and comoving volume. The median sky localization area (90% credible region) is expected to be a few hundreds of square degrees for all types of binary systems during O3 with the Advanced LIGO and Virgo (HLV) network. The median sky localization area will improve to a few tens of square degrees during O4 with the Advanced LIGO, Virgo, and KAGRA (HLVK) network. During O3, the median localization volume (90% credible region) is expected to be on the order of 10 5 , 10 6 , 10 7 Mpc 3 for binary neutron star, neutron star-black hole, and binary black hole systems, respectively. The localization volume in O4 is expected to be about a factor two smaller than in O3. We predict a detection count of 1 - 1 + 12 ( 10 - 10 + 52 ) for binary neutron star mergers, of 0 - 0 + 19 ( 1 - 1 + 91 ) for neutron star-black hole mergers, and 17 - 11 + 22 ( 79 - 44 + 89 ) for binary black hole mergers in a one-calendar-year observing run of the HLV network during O3 (HLVK network during O4). We evaluate sensitivity and localization expectations for unmodeled signal searches, including the search for intermediate mass black hole binary mergers.

Search for Subsolar Mass Ultracompact Binaries in Advanced LIGO's Second Observing Run

We present a search for subsolar mass ultracompact objects in data obtained during Advanced LIGO's second observing run. In contrast to a previous search of Advanced LIGO data from the first observing run, this search includes the effects of component spin on the gravitational waveform. We identify no viable gravitational-wave candidates consistent with subsolar mass ultracompact binaries with at least one component between 0.2  M_{⊙}-1.0  M_{⊙}. We use the null result to constrain the binary merger rate of (0.2  M_{⊙}, 0.2  M_{⊙}) binaries to be less than 3.7×10^{5}  Gpc^{-3} yr^{-1} and the binary merger rate of (1.0  M_{⊙}, 1.0  M_{⊙}) binaries to be less than 5.2×10^{3}  Gpc^{-3} yr^{-1}. Subsolar mass ultracompact objects are not expected to form via known stellar evolution channels, though it has been suggested that primordial density fluctuations or particle dark matter with cooling mechanisms and/or nuclear interactions could form black holes with subsolar masses. Assuming a particular primordial black hole (PBH) formation model, we constrain a population of merging 0.2  M_{⊙} black holes to account for less than 16% of the dark matter density and a population of merging 1.0  M_{⊙} black holes to account for less than 2% of the dark matter density. We discuss how constraints on the merger rate and dark matter fraction may be extended to arbitrary black hole population models that predict subsolar mass binaries.

C-66 Limited Access to Pediatric Neuropsychological Evaluations for Non-English Speakers

Objective

The aim of this empirical study was to examine the accessibility of pediatric neuropsychological evaluations in the state of Arizona for non-English speaking children. To date, there is very limited research that analyzes the accessibility of neuropsychological evaluations. Diversity variables, such as primary language, can negatively impact assessment scores (Norbury & Sparks, 2013), leaving diverse individuals at risk of misdiagnosis when an assessment is not conducted in one’s primary language, nor normed on similar individuals (Mindt et al., 2008). The Center for Immigration Studies (2017) found 28% of school-age children in Arizona speak a foreign language, warranting a need for culturally-appropriate evaluations.

Method

Arizona pediatric neuropsychologists in non-hospital settings were identified via electronic resources: AzNS, AAPdN, AzPA, CSN, and AACN provider lists; LinkedIn; Google search. Participants met criteria for inclusion if “pediatric neuropsychological” evaluations were provided by a neuropsychologist on staff. “Pediatrics” is defined as 0-17. Neuropsychologists were contacted directly via phone for survey participation; verbal informed consent was obtained.

Results

Seventeen pediatric neuropsychologists were found in the state of Arizona, and 52.9% consented to participate in the survey (n = 9). All participants (100%, n = 9) stated they provide evaluations in English only, and refer-out for non-English evaluations.

Conclusions

There is a severe disparity in the access to care with respect to availability of culturally-appropriate evaluations in Arizona: a state with a large population of non-English speakers. The current study adds to the limited literature in this area, and sets the stage for continued professional advocacy efforts. Goals for future national research is critically discussed.

Time to positivity (TTP) of neonatal blood cultures: a trend analysis over a decade from Ireland

Background and aims: Blood culture (BC) remains gold standard for the evaluation and diagnosis of neonatal sepsis. Time when BC becomes positive and the type of microorganism isolated are crucial in deciding the antimicrobial management. Likely pathogenicity of organisms growing in BC could potentially be predicted based on the "time to positivity" (TTP). We aimed to estimate the predictive value of isolating a likely pathogenic organism depending on TTP; evaluate the aetiological trend and neonatal mortality rate due to culture-proven neonatal sepsis for over a decade and verify whether the application of a "36 hour rule" to discontinue empiric antibiotics in well newborn infants with negative BC would be safe.Methods: Retrospective review of BC results over a 14-year period from a regional neonatal unit in Ireland. Laboratory data were independently extracted in relation to BC results from the laboratory information management system (LIMS-iLAB). Neonatal mortality data were collected from multiple sources. Statistical analysis included logistic regression, chi-square, and Mann-Whitney U-test.Results: Over a 14-year period 11,432 neonatal BC specimens were incubated of which 605 (5.3%) turned positive. Overall, the commonest organism grown was coagulase-negative Staphylococcus (CoNS), 416 (68.8%). Main pathogenic organisms were Staphylococcus aureus 23 (3.8%), Enterococcus spp. 22 (3.6%), E.coli 21 (3.5%), group B Streptococcus (GBS) 18 (3.0%), and Klebsiella species 9 (1.5%). Gram-negative organisms had the shortest TTP, with Klebsiella spp. having a median TTP of 10 h and E. coli 11 h. For Gram-positives, GBS had a median TTP of 12 h, Enterococcus species 14 h, with S. aureus growing at a median time of 15 h. All of the Klebsiella spp. and other Coliforms were detected within 24 h, with, 95.2% of E.coli, 94.4% of GBS, 95.5% of Enterococci, and 95.7% of S. aureus, flagging positive in 24 h. Using logistic regression the omnibus test of the coefficients in the resulting model was significant (p < .001). Our observed coefficient (β) for TTP was 0.144; shorter the TTP higher was the likelihood of isolating a pathogenic organism, with an odds ratio (OR) of 1.155. We also report a relatively low blood culture proven sepsis-specific neonatal mortality rate of 0.403/1000 live births and in all such instances observed TTP was less than 24 h.Conclusion: Duration of this study exceeds that of most of the neonatal blood culture TTP analysis published to-date. A shorter TTP is an important adjunct to suggest the growth of a pathogenic organism while managing suspected neonatal sepsis. TTP if < 24 h per se would not necessarily confirm the growth of a highly pathogenic organism; however, if a positive growth is likely to happen for a significant neonatal pathogen, in more than 98% the TTP would be within 24 h. This offers the clinician more of negative predictive value than a positive one; when there is no growth in BC. Our observation on TTP reiterate the National Institute of Health and Care Excellence (NICE) guideline of discontinuation of empiric antibiotics after 36 h in and clinically well and BC negative newborn infants.

Tests of General Relativity with GW170817

The recent discovery by Advanced LIGO and Advanced Virgo of a gravitational wave signal from a binary neutron star inspiral has enabled tests of general relativity (GR) with this new type of source. This source, for the first time, permits tests of strong-field dynamics of compact binaries in the presence of matter. In this Letter, we place constraints on the dipole radiation and possible deviations from GR in the post-Newtonian coefficients that govern the inspiral regime. Bounds on modified dispersion of gravitational waves are obtained; in combination with information from the observed electromagnetic counterpart we can also constrain effects due to large extra dimensions. Finally, the polarization content of the gravitational wave signal is studied. The results of all tests performed here show good agreement with GR.

Breast infections - Microbiology and treatment in an era of antibiotic resistance

INTRODUCTION

Primary breast abscesses occur in <1% of non-lactating women, rising to 11% in women with lactational mastitis. In patients undergoing breast cancer surgery, the inflammatory response to post-operative surgical site infection (SSI) has been implicated in recurrence. Anti-microbial resistance increasingly hampers treatment in each group.

AIMS

Describe the demographic and predisposing characteristics of patients with primary breast abscesses and secondary infections, identify the microbial and antimicrobial patterns and formulate an evidence-based protocol for treating breast infections.

METHODS

Retrospective cohort study of all breast infections (primary and post-operative) treated at UHL from 2014 to 2017. Data collected from microbiology databases and patient records was analysed using Minitab V18.

RESULTS

537 cultures from 108 patients were analysed. 47 (43.5%) had primary abscesses, 12 (11.1%) were lactational and 49 (45.4%) were post-operative SSI. For primary infections, the mean age was 41.9 (±12.2) and reinfection rate 33%. For SSIs the mean age was 51.8 (±14.52) and reinfection rate 11.8%. Overall, 29.3% were smokers, 6.4% diabetic and 2.9% pregnant. 60 (43%) patients required radiological drainage and 2 (1%) surgical drainage. 57.5% had mixed growth. The most common isolate was Staphylococcus aureus; cultured in 16.7% of primary abscesses and 24% of SSIs. 13 empiric antibiotic regimes were prescribed before 26.4% of patients changed to 12 different targeted regimes.

CONCLUSION

Breast infections are frequently polymicrobial with a wide variety of organisms isolated, suggesting the need for broad spectrum coverage until culture results become available. Based on our local culture results, the addition of clindamycin to flucloxacillin would provide excellent empiric coverage for all categories of breast infection. An evidence-based treatment guideline is required and should be formulated in close collaboration with microbiology specialists.

Constraining the p-Mode-g-Mode Tidal Instability with GW170817

We analyze the impact of a proposed tidal instability coupling p modes and g modes within neutron stars on GW170817. This nonresonant instability transfers energy from the orbit of the binary to internal modes of the stars, accelerating the gravitational-wave driven inspiral. We model the impact of this instability on the phasing of the gravitational wave signal using three parameters per star: an overall amplitude, a saturation frequency, and a spectral index. Incorporating these additional parameters, we compute the Bayes factor (lnB_{!pg}^{pg}) comparing our p-g model to a standard one. We find that the observed signal is consistent with waveform models that neglect p-g effects, with lnB_{!pg}^{pg}=0.03_{-0.58}^{+0.70} (maximum a posteriori and 90% credible region). By injecting simulated signals that do not include p-g effects and recovering them with the p-g model, we show that there is a ≃50% probability of obtaining similar lnB_{!pg}^{pg} even when p-g effects are absent. We find that the p-g amplitude for 1.4  M_{⊙} neutron stars is constrained to less than a few tenths of the theoretical maximum, with maxima a posteriori near one-tenth this maximum and p-g saturation frequency ∼70  Hz. This suggests that there are less than a few hundred excited modes, assuming they all saturate by wave breaking. For comparison, theoretical upper bounds suggest ≲10^{3} modes saturate by wave breaking. Thus, the measured constraints only rule out extreme values of the p-g parameters. They also imply that the instability dissipates ≲10^{51}  erg over the entire inspiral, i.e., less than a few percent of the energy radiated as gravitational waves.