Robotic-Assisted Surgery Training (RAST): Assessment of Surgeon Console Ergonomic Skills

OBJECTIVE

The aim of this study was to evaluate the responsiveness of postgraduate year (PGY) general surgery residents (GSRs) to surgeon console ergonomics within the robotic-assisted surgery training (RAST) program.

DESIGN

This was a prospective educational study. GSRs were prepared with a pretraining educational video. Faculty provided one-on-one resident hands-on training and testing. Nine proficiency criteria (emergency stop & recover; left side pod adjustments; touchpad controls; footswitch panel; energy control pedals; camera control & focus; arm swap; master & finger clutch; dual console settings control) were assessed with a 5-point Likert-scale. Responsiveness was defined as change in performance over time. The robotic platform was Da Vinci Xi (Intuitive Surgical, Sunnyvale, CA). The Dundee ready educational environment measure (DREEM) inventory was used by GSRs to assess the educational environment.

SETTING

Tertiary care academic teaching institution.

PARTICIPANTS

A total of 22 GSRs: 4 PGY 1, 4 PGY 2, 4 PGY 3, 5 PGY 4, 5 PGY 5.

RESULTS

From June 2022 to March 2023 the hands-on console time decreased at testing when compared to baseline: median 39.0 (range 37-41) vs 20.1 (range 19-22) minutes, respectively. There was no difference in mean hands-on testing scores stratified by PGY: 4.85±0.4 PGY1; 4.98 ± 0.3 PGY2; 4.86 ± 0.4 PGY3, 4.88 ± 0.2 PGY4, and 4.91 ± 0.1 PGY5 (ANOVA test; p = 0.095). The overall DREEM score was 167.1 ± 16.9 with CAC = 0.908 (excellent internal consistency).

CONCLUSIONS

Training in ergonomics on the surgeon console impacted the responsiveness of the GSRs with 51% console time reduction. There were no differences in hands-on testing scores among PGYs. Perception of the educational environment by the GSRs was high.

Rain triggers seasonal stratification in a temperate shelf sea

The North Atlantic Storm Track acts as a conveyor belt for extratropical cyclones that frequently deliver high winds and rainfall to northwest European shelf seas. Storms are primarily considered detrimental to shelf sea stratification due to wind-driven mixing countering thermal buoyancy, but their impact on shelf scale stratification cycles remains poorly understood. Here, we show that storms trigger stratification through enhanced surface buoyancy from rainfall. A multidecadal model confirms that rainfall contributed to triggering seasonal stratification 88% of the time from 1982 to 2015. Stratification could be further modulated by large-scale climate oscillations, such as the Atlantic Multidecadal Variability (AMV), with stratification onset dates being twice as variable during a positive AMV phase than a negative one. Further insights into how changing storm activity will impact shelf seas are discussed beyond the current view of increasing wind-driven mixing, with significant implications for marine productivity and ecosystem function.

Comparison of continuous versus intermittent enteral feeding in critically ill patients: a systematic review and meta-analysis

Background

The enteral route is commonly utilised to support the nutritional requirements of critically ill patients. However, there is paucity of data guiding clinicians regarding the appropriate method of delivering the prescribed dose. Continuous enteral feeding is commonly used; however, a bolus or intermittent method of administration may provide several advantages such as minimising interruptions. The purpose of this meta-analysis is to compare a continuous versus an intermittent or bolus enteral nutrition administration method.

Methods

A systematic review and meta-analysis were performed with studies identified from the PubMed, EMBASE, Cochrane Library and Web of Science databases. Studies were included if they compared a continuous with either an intermittent or bolus administration method of enteral nutrition in adult patients admitted to the intensive care unit. Study quality was assessed using the PEDro and Newcastle–Ottawa scoring systems. Review Manager was used for performing the random-effects meta-analysis on the outcomes of mortality, constipation, diarrhoea, increased gastric residuals, pneumonia, and bacterial colonisation.

Results

A total of 5546 articles were identified, and 133 were included for full text review. Fourteen were included in the final analysis. There was an increased risk of constipation with patients receiving continuous enteral nutrition (relative risk 2.24, 95% confidence interval 1.01–4.97, p = 0.05). No difference was identified in other outcome measures. No appreciable bias was identified.

Conclusion

The current meta-analysis has not identified any clinically relevant difference in most outcome measures relevant to the care of critically ill patients. However, there is a paucity of high-quality randomised controlled clinical trials to guide this decision. Therefore, clinicians may consider either dosing regimen in the context of the patient’s care requirements.

Thoracic ultrasound for TB diagnosis in adults and children

Thoracic ultrasound is an appealing alternative to chest radiography for the diagnosis of TB. Based on research experience conducting thoracic ultrasound for adults and children in South Africa, three key considerations for potential scale-up were identified. First, thoracic ultrasound requires a comprehensive training programme for novice users; artificial intelligence may be used to simplify training and interpretation. Second, a robust ultrasound device is needed with good subpleural resolution and a probe suitable for children. Third, comprehensive scanning of the lungs is time-intensive, and shorter scanning protocols may be more feasible in clinical practice.

Treatment outcomes and safety in children with rifampicin-resistant TB

BACKGROUND: The treatment of rifampicin-resistant TB (RR-TB) in children is evolving rapidly. As newer regimens are introduced into routine care, it is vital to compare their outcome and safety with well-characterised clinical cohorts treated with historical regimens.METHODS: Study sample comprised a prospective observational cohort of children on routine RR-TB treatment, enrolled from 2011 to 2015 in Cape Town, South Africa. Children were followed for safety, treatment response and outcome.RESULTS: Of 136 children included, 27 (19.9%) were living with HIV and 48 (37.8%) had severe TB. The median time-to-culture conversion in children with bacteriological confirmation (n = 44) was 28.5 days (IQR 14.5-45). Overall, 118/129 (91.5%) had favourable TB treatment outcomes. Of 106 (77.9%) children who received an injectable drug, 9 (8.5%) developed hearing loss and 7/136 (5.1%) developed other Grade 3 or higher adverse events likely related to treatment.CONCLUSIONS: In this cohort with a substantial proportion of children with severe manifestations of TB and with HIV, TB treatment outcomes were excellent. Apart from hearing loss, few children developed severe adverse events related to treatment. This study provides robust reference data for future evaluation of shorter, injectable-sparing regimens.

High burden of viral respiratory co-infections in a cohort of children with suspected pulmonary tuberculosis

Background

The presentation of pulmonary tuberculosis (PTB) in young children is often clinically indistinguishable from other common respiratory illnesses, which are frequently infections of viral aetiology. As little is known about the role of viruses in children with PTB, we investigated the prevalence of respiratory viruses in children with suspected PTB at presentation and follow-up.

Methods

In an observational cohort study, children < 13 years were routinely investigated for suspected PTB in Cape Town, South Africa between December 2015 and September 2017 and followed up for 24 weeks. Nasopharyngeal aspirates (NPAs) were tested for respiratory viruses using multiplex PCR at enrolment, week 4 and 8.

Results

Seventy-three children were enrolled [median age 22.0 months; (interquartile range 10.0–48.0); 56.2% male and 17.8% HIV-infected. Anti-tuberculosis treatment was initiated in 54.8%; of these 50.0% had bacteriologically confirmed TB. At enrolment, ≥1 virus were detected in 95.9% (70/73) children; most commonly human rhinovirus (HRV) (74.0%). HRV was more frequently detected in TB cases (85%) compared to ill controls (60.6%) (p = 0.02). Multiple viruses were detected in 71.2% of all children; 80% of TB cases and 60.6% of ill controls (p = 0.07). At follow-up, ≥1 respiratory virus was detected in 92.2% (47/51) at week 4, and 94.2% (49/52) at week 8.

Conclusions

We found a high prevalence of viral respiratory co-infections in children investigated for PTB, irrespective of final PTB diagnosis, which remained high during follow up. Future work should include investigating the whole respiratory ecosystem in combination with pathogen- specific immune responses.

Human papillomavirus vaccine effectiveness within a cervical cancer screening programme: cohort study

OBJECTIVE

To assess the effectiveness of an HPV vaccination programme in reducing the risk of cervical abnormalities identified at subsequent screening.

DESIGN

Retrospective cohort study using administrative health data.

SETTING

General population of Ferrara Province, Italy.

POPULATION

Female residents born in 1986-1993 and participating in the organized cervical screening programme in 2011-2018, who were eligible for HPV vaccination in catch-up cohorts.

METHODS

Logistic regression to evaluate the potential association between abnormal cervical cytology and one, two, three or at least one dose of HPV vaccine.

MAIN OUTCOME MEASURES

Cervical abnormalities, as predicted by low-grade or high-grade cytology, by number of vaccine doses, stratified by age.

RESULTS

The sample consisted of 7785 women (mean age 27.5 years, SD 2.3). Overall, 391 (5.0%) were vaccinated with ≥1 dose and 893 (11.5%) had abnormal cytology. Women receiving at least one vaccine dose were significantly less likely to have an abnormal cytology (adjusted odds ratio 0.52; 95% confidence interval 0.34-0.79). Similar results were observed for women receiving a single dose, for both bivalent and quadrivalent vaccines, and applying buffer periods (excluding cytological outcomes within 1 month, 6 months and 1 year of the first dose).

CONCLUSIONS

In the context of an organised cervical screening programme in Italy, catch-up HPV vaccination almost halved the risk of cytological abnormalities.

TWEETABLE ABSTRACT

Among Ferrara women, vaccination against human papillomavirus halved the risk of screening cervical abnormalities.

The logistical management of tertiary urethral disease in the United Kingdom: Implications from an online audit of male reconstructive urethral surgery

Objective:

To determine those patient groupings, based on volume and risk, whose optimal urethral reconstructive management might be provided by a reorganisation of UK reconstructive surgeons.

Methods:

Between 2010 and 2017, ~689 men/year were enrolled onto an online audit platform collecting data about urethral reconstruction in the UK; this accrual was compared against hospital episode statistics (HES). The available workforce, and where this was based, was collected. Individual and institutional incumbent patient volumes, pathology, surgical complexity and outcomes from treatment were collated to stratify volume/risk groups.

Results:

More than 90% of all HES-recorded data were accrued, being provided by 50 surgeons at 39 operative sites. Most reconstructive surgery was provided at 10 centres performing >20 procedures/year. More than 50% of all interventions were of a high-volume low-risk type. Of activity, 32.3% was intermediate volume or moderate risk, and 12.5% of men presented for lower-volume or higher-risk procedures.

Conclusion:

Correlation of detailed volume/outcome data allows the definition of patient populations presenting for urethral reconstruction. Stratification of each group’s management, to optimise the surgical outcome, may be applied to a hierarchical service delivery model based on the complexity of the patient’s presenting urethral pathology.

Level of evidence:

Level IV

THU0540 A PHASE 2B STUDY OF INTRAVENOUSLY (IV) ADMINISTERED TC 99M TILMANOCEPT TO DETERMINE DIFFERENTIAL UPTAKE, REPRODUCIBILITY OVER TIME AND IMAGE STABILITY IN HEALTHY SUBJECTS AND IN PATIENTS WITH RHEUMATOID ARTHRITIS (RA) ON STABLE TREATMENT

Background:

At present, there are no reliable noninvasive means to directly monitor disease activity in RA patients. Activated macrophages are a critical component of the inflammatory etiology of RA due to their role in prolonged RA joint inflammation and destruction through the release of pro-inflammatory cytokines and chemokines. Tc 99m tilmanocept is a radiopharmaceutical imaging agent that binds with high affinity to the macrophage mannose receptor CD206 that resides on activated macrophages. Previous clinical trials demonstrated safety and tolerability of Tc 99m tilmanocept, as well as a determination of optimal clinical dose and timeframe for RA imaging.

Objectives:

The current phase 2b study aims to evaluate reproducibility and stability of imaging and will assess quantitative Tc 99m tilmanocept uptake cut points that reliably enable discrimination between joints of healthy people and RA patients.

Methods:

The analysis cohort contained 18 healthy controls (HC) clinically free of inflammatory joint disease and 12 subjects with clinically diagnosed RA who are on stable anti-inflammatory and/or anti-rheumatic therapy. Each subject received a 150-mcg dose of tilmanocept radiolabeled with 10 mCi of Tc 99m in a 3mL IV injection. Injection was followed by planar imaging at 60 and 180 minutes for both HC and RA subjects on study Day 0 and repeated in RA subjects on Day 8. Images were quantitatively assessed to detect localization within synovial spaces of bilateral hands and wrists by determining average pixel intensity in each region of interest relative to average pixel intensity in a joint-specific reference region.

Results:

Data obtained from the interim analysis support the hypothesis that Tc 99m tilmanocept imaging can provide robust quantitative imaging in HC and RA subjects. Repeat images within and between days demonstrate root mean squared differences that are approximately 10% or less of the observed localization of Tc 99m tilmanocept. Qualitatively, images of HC indicated no disease-related site-specific localization, whereas localization is present in RA subjects at levels expected given the difference in macrophage number and density in different pathotypes of RA. Notably, images from patients with active RA exhibit the same localization patterns on images taken in a test-retest fashion on the same day as well as in subjects with images acquired on Day 0 and Day 8 (see Figure 1). These results show low imaging readout variability, enabling reliable quantification of joints with RA-involved macrophage-mediated inflammation. Analysis of the HC and RA images was used to determine initial quantitative “cut-points” to differentiate between joints with and without the inflammation typically seen in RA.

Figure 1.

Tilmanocept consistently localizes in areas of macrophage-driven inflammation, demonstrating low variability. RA patients exhibit reproducible localization over a 1-week period. Typical of healthy subjects, no evidence of inflammation-related Tc 99m tilmanocept uptake was observed in the healthy control. Images on the right show same patient imaged on 2 different days.

Conclusion:

Tc 99m tilmanocept imaging of the joints in healthy subjects as well as in patients with active RA under stable treatment is reproducible and stable over time. The results confirmed that the signal in joints of healthy subjects and RA patients can be quantified and used to establish cut points to distinguish inflamed and non-inflamed joints on a joint-by-joint basis. These results provide the foundation for a noninvasive, objective method to monitor activity in macrophage-driven inflammation in joints of patients with RA.

Disclosure of Interests:

Ayah Hussein Employee of: Currently employed by Navidea Biopharmaceuticals, David Ralph Consultant of: Previous consultant for Navidea Biopharmaceuticals, Employee of: Currently employed by Navidea Biopharmaceuticals, Beth Potter Employee of: Currently employed by Navidea Biopharmaceuticals, Bonnie Abbruzzese Employee of: Currently employed by Navidea Biopharmaceuticals, Rachael Hershey Employee of: Currently employed by Navidea Biopharmaceuticals, Katherine Repp Employee of: Previously employed by Navidea Biopharmaceuticals, Haya Shakhtra Employee of: Currently employed by Navidea Biopharmaceuticals, Mehak Goel Employee of: Currently employed by Navidea Biopharmaceuticals, Madison Palmer Employee of: Currently employed by Navidea Biopharmaceuticals, Allison Kissling Employee of: Previously employed by Navidea Biopharmaceuticals, Carley Hartings Employee of: Previously employed by Navidea Biopharmaceuticals, Michael Blue Employee of: Currently employed by Navidea Biopharmaceuticals, Michael Rosol Employee of: Currently employed by Navidea Biopharmaceuticals

High-resolution ion mobility spectrometry-mass spectrometry of isomeric/isobaric ribonucleotide variants

In this report, we explored the benefits of cyclic ion mobility (cIM) mass spectrometry in the analysis of isomeric post-transcriptional modifications of RNA. Standard methyl-cytidine samples were initially utilized to test the ability to correctly distinguish different structures sharing the same elemental composition and thus molecular mass. Analyzed individually, the analytes displayed characteristic arrival times (tD ) determined by the different positions of the modifying methyl groups onto the common cytidine scaffold. Analyzed in mixture, the widths of the respective signals resulted in significant overlap that initially prevented their resolution on the tD scale. The separation of the four isomers was achieved by increasing the number of passes through the cIM device, which enabled to fully differentiate the characteristic ion mobility behaviors associated with very subtle structural variations. The placement of the cIM device between the mass-selective quadrupole and the time-of-flight analyzer allowed us to perform gas-phase activation of each of these ion populations, which had been first isolated according to a common mass-to-charge ratio and then separated on the basis of different ion mobility behaviors. The observed fragmentation patterns confirmed the structures of the various isomers thus substantiating the benefits of complementing unique tD information with specific fragmentation data to reach more stringent analyte identification. These capabilities were further tested by analyzing natural mono-nucleotide mixtures obtained by exonuclease digestion of total RNA extracts. In particular, the combination of cIM separation and post-mobility dissociation allowed us to establish the composition of methyl-cytidine and methyl-adenine components present in the entire transcriptome of HeLa cells. For this reason, we expect that this technique will benefit not only epitranscriptomic studies requiring the determination of identity and expression levels of RNA modifications, but also metabolomics investigations involving the analysis of natural extracts that may possibly contain subsets of isomeric/isobaric species.

Acceptability of a first-line anti-tuberculosis formulation for children: qualitative data from the SHINE trial

SETTING: We conducted a qualitative exploration into the palatability and acceptability of a novel fixed-dose combination (FDC) anti-tuberculosis drug. This study was nested in the SHINE (Shorter treatment for minimal TB in children) trial, which compares the safety and efficacy of treating non-severe drug-susceptible tuberculosis (TB) with a 6 vs. 4 months anti-tuberculosis regimen in children aged 0-16 years. Participants were recruited in Cape Town, South Africa.OBJECTIVE: To describe the palatability and acceptability of a FDC of rifampicin, isoniazid and pyrazinamide among South African children and their caregivers in the SHINE trial.METHODS: We conducted 20 clinic observations of treatment administration, during which we conducted 16 semi-structured interviews with children and their caregivers. Data were organised thematically to report on experiences with administering and ingesting the FDC.RESULTS: Children and caregivers' experiences varied from delight to disgust. In general, participants said that the FDC compared favourably to other formulations. Pragmatic challenges such as dissolving the FDC and the time required to administer the FDC impeded caregivers' ability to integrate treatment into their daily routines. Drug manipulation was common among caregivers to improve TB treatment administration.CONCLUSION: This novel FDC appears acceptable for children, albeit with practical challenges to administration. Scale-up of FDC use should include supplementary intervention components to support caregivers.

Successful development of methodology for detection of hapten-specific contact hypersensitivity (CHS) memory in swine

Hapten contact hypersensitivity (CHS) elicits a well-documented inflammation response that can be used to illustrate training of immune cells through hapten-specific CHS memory. The education of hapten-specific memory T cells has been well-established, recent research in mice has expanded the “adaptive” characteristic of a memory response from solely a function of the adaptive immune system, to innate cells as well. To test whether similar responses are seen in a non-rodent model, we used hapten-specific CHS to measure the ear inflammation response of outbred pigs to dinitrofluorobenzene (DNFB), oxazolone (OXA), or vehicle controls. We adapted mouse innate memory literature protocols to the domestic pig model. Animals were challenged up to 32 days post initial sensitization exposure to the hapten, and specific ear swelling responses to this challenge were significant for 7, 21, and 32 days post-sensitization. We established hapten-specific CHS memory exists in a non-rodent model. We also developed a successful protocol for demonstrating these CHS responses in a porcine system.

An inverse free electron laser acceleration-driven Compton scattering X-ray source

The generation of X-rays and γ-rays based on synchrotron radiation from free electrons, emitted in magnet arrays such as undulators, forms the basis of much of modern X-ray science. This approach has the drawback of requiring very high energy, up to the multi-GeV-scale, electron beams, to obtain the required photon energy. Due to the limit in accelerating gradients in conventional particle accelerators, reaching high energy typically demands use of instruments exceeding 100’s of meters in length. Compact, less costly, monochromatic X-ray sources based on very high field acceleration and very short period undulators, however, may enable diverse, paradigm-changing X-ray applications ranging from novel X-ray therapy techniques to active interrogation of sensitive materials, by making them accessible in energy reach, cost and size. Such compactness and enhanced energy reach may be obtained by an all-optical approach, which employs a laser-driven high gradient accelerator based on inverse free electron laser (IFEL), followed by a collision point for inverse Compton scattering (ICS), a scheme where a laser is used to provide undulator fields. We present an experimental proof-of-principle of this approach, where a TW-class CO₂ laser pulse is split in two, with half used to accelerate a high quality electron beam up to 84 MeV through the IFEL interaction, and the other half acts as an electromagnetic undulator to generate up to 13 keV X-rays via ICS. These results demonstrate the feasibility of this scheme, which can be joined with other techniques such as laser recirculation to yield very compact photon sources, with both high peak and average brilliance, and with energies extending from the keV to MeV scale. Further, use of the IFEL acceleration with the ICS interaction produces a train of high intensity X-ray pulses, thus enabling a unique tool synchronized with a laser pulse for ultra-fast strobe, pump-probe experimental scenarios.

Do stroke patients screened as lower-nutritional-risk still receive dietitian assessment if indicated? A retrospective evaluation of two dietetic models of care for adult stroke patients

BACKGROUND

Dietetic models of care at Logan Hospital changed from all patients with a confirmed stroke receiving dietitian assessment (Old pathway) to only those patients screened as high-nutritional-risk (Modified pathway). However, it was unknown whether all low-nutritional-risk patients who were indicated for dietitian assessment for nutrition support actually received assessment. This pre-post retrospective study evaluated whether the Old pathway and the Modified pathway were equally effective in identifying low-nutritional-risk stroke patients who were indicated for dietitian assessment and compared the time spent providing Dietetic care.

METHODS

For both pathways, medical charts were reviewed for low-nutritional-risk patients admitted between December 2012 and November 2017 with a confirmed stroke, who were given a standard food and fluid diet code and scored MST < 2 (Malnutrition Screening Tool) on admission. Data collected included demographics, anthropometrics, malnutrition assessment, dietetic intervention and time spent caring for patients. Malnutrition-related clinical indicators were used to classify patients as either Dietitian Assessment for Nutrition Support Indicated or Not Indicated.

RESULTS

Low-nutritional-risk patients were similar on the Old (n = 180) and Modified (n = 206) pathways [mean (SD) 66 (13) years, 63% male, 4% malnutrition]. Those classified as Dietitian Assessment for Nutrition Support Indicated (n = 61 of 180) were older, had a longer length of stay (P < 0.05), and were all identified by the Dietitian on both pathways. Ten minutes less dietetic time per patient was required on the Modified pathway (P < 0.001).

CONCLUSIONS

The Modified Nutrition Stroke pathway performed more efficiently than the Old pathway and was equally effective at ensuring that stroke patients who were determined as being low-nutritional-risk received dietitian assessment during admission if indicated.

Demonstration of Cascaded Modulator-Chicane Microbunching of a Relativistic Electron Beam

We present results of an experiment showing the first successful demonstration of a cascaded microbunching scheme. Two modulator-chicane prebunchers arranged in series and a high power mid-IR laser seed are used to modulate a 52 MeV electron beam into a train of sharp microbunches phase locked to the external drive laser. This configuration is shown to greatly improve matching of the beam into the small longitudinal phase space acceptance of short-wavelength accelerators. We demonstrate trapping of nearly all (96%) of the electrons in a strongly tapered inverse free-electron laser accelerator, with an order-of-magnitude reduction in injection losses compared to the classical single-buncher scheme. These results represent a critical advance in laser-based longitudinal phase space manipulations and find application in high gradient advanced acceleration as well as in high peak and average power coherent radiation sources.

Beyond Zar: the use and abuse of classification statistics for otolith chemistry

Classification method performance was evaluated using otolith chemistry of juvenile Atlantic menhaden Brevoortia tyrannus when assumptions of data normality were met and were violated. Four methods were tested [linear discriminant function analysis (LDFA), quadratic discriminant function analysis (QDFA), random forest (RF) and artificial neural networks (ANN)] using computer simulation to determine their performance when variable-group means ranged from small to large and their performance under conditions of typical skewness to double the amount of skewness typically observed. Using the kappa index, the parametric methods performed best after applying appropriate data transformation, gaining 2% better performance with LDFA performing slightly better than QDFA. RF performed as well as QDFA and showed no difference in performance between raw and transformed data while the performance of ANN was the poorest and worse with raw data. All methods performed well when group differences were large, but parametric methods outperformed machine-learning methods. When data were skewed the performance of all methods declined and worsened with greater skewness, but RF performed consistently as well or better than the other methods in the presence of skewness. The parametric methods were found to be more powerful when assumptions of normality can be met and can be used confidently when skewness and kurtosis are minimized. When these assumptions cannot be minimized, then machine-algorithm methods should also be tried.

Kidney Transplantation From a Donor With Sickle Cell Disease

In the United States, >100 000 patients are waiting for a kidney transplant. Given the paucity of organs available for transplant, expansion of eligibility criteria for deceased donation is of substantial interest. Sickle cell disease (SCD) is viewed as a contraindication to kidney donation, perhaps because SCD substantially alters renal structure and function and thus has the potential to adversely affect multiple physiological processes of the kidney. To our knowledge, transplantation from a donor with SCD has never been described in the literature. In this paper, we report the successful transplantation of two kidneys from a 37-year-old woman with SCD who died from an intracranial hemorrhage. Nearly 4 mo after transplant, both recipients are doing well and are off dialysis. The extent to which kidneys from donors with SCD can be safely transplanted with acceptable outcomes is unknown; however, this report should provide support for the careful expansion of kidneys from donors with SCD without evidence of renal dysfunction and with normal tissue architecture on preimplantation biopsies.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Trends in the use of emergency contraception in Britain: evidence from the second and third National Surveys of Sexual Attitudes and Lifestyles

OBJECTIVE

To examine the changes in the prevalence of, and the factors associated with, the use of emergency contraception (EC) in Britain between 2000 and 2010, spanning the period of deregulation and increase in pharmacy supply.

DESIGN

Cross-sectional probability sample surveys.

SETTING AND POPULATION

British general population.

METHODS

Data were analysed from the second and third British National Surveys of Sexual Attitudes and Lifestyles (Natsal), undertaken in 1999-2001 and 2010-12. Univariate and logistic regression analyses were used to measure change in EC use amongst sexually active women aged 16-44 years not intending pregnancy.

MAIN OUTCOME MEASURES

Prevalence of EC use and factors associated with use.

RESULTS

Of the 5430 women surveyed in 1999-2001 and the 4825 women surveyed in 2010-12, 2.3 and 3.6%, respectively, reported using EC in the year prior to interview (P = 0.0019 for change over time). The prevalence of EC use increased amongst single women and those with higher educational attainment (adjusted odds ratio, aOR 1.51; 95% confidence interval, 95% CI 1.04-2.20; P = 0.0308). Increases in EC use were generally greater among women without behavioural risk factors, such as those with no history of abortion within 5 years (aOR 1.57; 95% CI 1.17-2.12; P = 0.0029), or those whose first heterosexual intercourse occurred after the age of 16 years (aOR 1.68; 95% CI 1.21-2.35; P = 0.0021). The increase in EC use was also more marked among women usually accessing contraception from retail sources than among those doing so from healthcare sources, which may reflect a use of condoms amongst EC users.

CONCLUSION

The increase in EC use among women in Britain in the first decade of the 21st century was associated with some, but not all, risk factors for unplanned pregnancy. Advice and provision may need to be targeted at those at highest risk of unplanned pregnancy.

TWEETABLE ABSTRACT

Despite pharmacy access, only a small rise in emergency contraception use has been seen in Britain over 10 years.

Reduction of the 28-Day Readmission Rate for Children with Sickle Cell Disease

BACKGROUND: Failure to provide coordinated care may lead to inefficiencies and negatively impact the quality of patient care provided. For children with sickle cell disease (SCD) at our tertiary care children’s hospital, traditionally hematology has provided ambulatory and consultative care, and general paediatrics has provided inpatient management. We fostered collaboration and used quality improvement (QI) methods to improve patient care, using hospital readmission rates as our primary QI measure.

OBJECTIVES: To reduce the 28-day readmission rate for pediatric patients with SCD from current levels (18.5%) to 14% over a 12-month period.

DESIGN/METHODS: An interdisciplinary team diagnosed and developed strategies to address gaps in care coordination. A chart audit was conducted and a process map of the hospital journey was created to identify opportunities for improvement. Based on impact and effort, the following strategies were prioritized and implemented: standardization of pain management, support for patients at highest risk of readmission, streamlining the discharge process, and increased use of hydroxyurea. Quarterly data were abstracted via Health Records from the Discharge Abstract Database (DAD). The measure of interest was the percentage of patients (0-18 years of age) with SCD and crisis readmitted with the same or related diagnosis within 28 days. Patients were identified using the ICD10 code D57.0; “crisis” includes vaso-occlusive crisis, acute chest syndrome, and splenic sequestration. Individual process measures reflecting our multiple improvement strategies were also collected.

RESULTS: From fiscal year 2013-14 to 2014-15, the total number of patient admissions for SCD decreased from 173 to 166. The readmission rate, as defined above, decreased from 18.5% to 10.8%. Other measures specifically reflecting our improvement strategies continue to be followed with ongoing process improvement.

CONCLUSION: A multi-modal strategy approach aimed at coordinating care has led to a decrease in rate of readmission for children with SCD below the established target. Ongoing monitoring will be required to ensure sustainability of this result. Further opportunities for standardization of care for this patient population include updating relevant clinical practice guidelines and order sets; implementing “pain plans” for transition home; and optimizing outpatient follow-up.

Leptospirosis acquisition following the reintroduction of wildlife

Potential risks posed to domestic animals and human beings by zoonotic diseases in reintroduced animals can reduce the acceptability of reintroductions. The authors investigated the role of endangered water voles, Arvicola amphibius, as a host for leptospirosis, a waterborne zoonosis affecting a range of mammals. Based on samples from 112 individuals from across the UK, a 6.2 per cent exposure rate was found (7 animals were microscopic agglutination test (MAT) positive for serum antibodies), with 4 of 11 sites having positive animals. No individual was actively excreting leptospires in urine (PCR urine test, 0 per cent positive). The acquisition of Leptospira species by a cohort of 'clean' captive-bred voles reintroduced to one site in the wild was then examined. By four months postrelease the maximum exposure prevalence (by either MAT or culture) was 42.9 per cent. Thirty-five per cent were actively excreting leptospires. The rapidity of leptospire acquisition and comparatively high prevalence of infectious individuals is notable, exceeding expectation based on wild voles. One possible explanation is a lack of immunocompetence in reintroduced voles. Analyses of haematological parameters from reintroduced voles suggest a link between prior condition and disease acquisition. There may be potential to select the fittest animals before release to maximise reintroduction success.

Aspects of protected mealtimes are associated with improved mealtime energy and protein intakes in hospitalized adult patients on medical and surgical wards over 2 years

BACKGROUND/OBJECTIVES

Protected mealtimes programs aim to improve inpatient intakes. Yet its efficacy has not yet been established. We aimed to determine which patient-related factors and aspects of protected mealtimes, for example, mealtime assistance and meal within reach, were associated with energy and protein intakes of adult inpatients on medical and surgical wards.

SUBJECTS/METHODS

Patient characteristics and dietary intake data were collected at main meals over 2 years. Proportions of individual foods and drinks consumed were visually estimated and converted to nutrients using averaged ready reckoner data. Mealtime factors associated with energy and protein intakes were determined using multivariate linear hierarchical regression analyses.

RESULTS

Over 2 years, mealtime nutrient intakes of 798 inpatients were calculated ((63 ± 19) years, 52% male). Average intakes at main meals were 1419 ± 614 kJ and 15 ± 7 g protein. Inpatient intakes were significantly associated with gender, age, season, stopping or refusing a meal, time until discharge and eating at dinner (B = -829-222 kJ, B = -8.8 to 2.2 g protein, P = 0.000-0.032). Protected mealtimes program implementation was not associated with inpatient intake (P=0.094-0.157). However, aspects of protected mealtimes were associated with intake. This included requiring and documenting the need for mealtime assistance, introduction of mealtime volunteers, time to eat and appropriate positioning during mealtimes (B = 177-296 kJ, B = 0.07-3.9 g protein, P=0.000-0.014, R(2) = 0.148-0.154). In those specifically requiring mealtime assistance, inpatient protein intake was associated with mealtime volunteers and appropriate positioning (B = 4.1-4.4 g protein, P = 0.013-0.026, R(2) = 0.197).

CONCLUSIONS

Aspects of protected mealtimes were associated with improved intake. Identifying these achievable aspects during planning and ensuring successful implementation of protected mealtimes may be critical for optimizing acute inpatient intake.

Agreement between student dietitians' identification of refeeding syndrome risk with refeeding guidelines, electrolytes and other dietitians: a pilot study

BACKGROUND

Limited research exists concerning how consistently and accurately student and newly-graduated dietitians are identifying refeeding syndrome risk in hospitalised patients. The present study aimed to determine the consistency of students' and newly-graduated dietitians' classification of refeeding syndrome risk, as well as agreement with the application of comparison tools such as the National Institute for Health and Care Excellence guidelines, patients' electrolytes and supplementation, and clinical dietitians previously surveyed.

METHODS

Recently-graduated and final-year Griffith University dietetics students were invited to complete an online survey. The survey questioned demographics and asked respondents to classify the level of refeeding syndrome risk (i.e. none, some, high, unsure) in 13 case studies. Electrolytes and supplementation data were sourced from electronic patient records. Chi-squared tests, t-tests and linear regression analyses were conducted.

RESULTS

Fifty-three eligible people responded [n = 53 of 112, mean (SD) age 26 (4) years, 89% female, 34% graduates]. Respondents' answers were generally more consistent and more likely to agree with comparison tools when two tools showed the same level of refeeding syndrome risk (49-98%, β = 0.626-1.0994, P < 0.001) than when they differed (11-49%). Respondents' level of agreement with refeeding identification guidelines, electrolyte levels, supplementation and dietitians previously surveyed did not differ by graduate status, degree level, clinical placement status or having read refeeding syndrome guidelines recently (P > 0.05).

CONCLUSIONS

Students' and new graduates' identification of refeeding syndrome risk improved when there was consistency between guidelines, electrolytes and dietitians' responses. More research is needed to improve the evidence behind refeeding guidelines, with the aim of enhancing the accuracy and consistency of assessment.

Adapting to the wild: the case of aquaculture-produced and released meagres Argyrosomus regius

The performance of juvenile Argyrosomus regius released off the coast of Mallorca Island (Balearic Islands, Spain) was assessed by comparing the body condition, stable isotope signature and stomach contents of aquaculture-produced A. regius that had been released, fished and returned by fishermen after spending from a few days to >1 year at liberty with A. regius reared under controlled conditions on two contrasting diets (well-fed and unfed). During the first 40 days of the experiment, the condition index (K(R)) of the returned A. regius and the unfed A. regius followed the same decreasing trend. Thereafter, the K(R) values of the returned A. regius were significantly higher than those of the unfed A. regius but never reached the values of well-fed A. regius. The δ¹³C signal of the returned A. regius clearly increased (in comparison with the well-fed A. regius) after they had spent a few months at liberty. The temporal pattern depicted by the stable isotopes and the most likely prey composition inferred from this pattern strongly suggest a shift in diet. The stomach contents of the returned A. regius that had spent <100 days at liberty consisted almost exclusively of decapods. The diet of the few returned A. regius that had spent >100 days at liberty consisted entirely of fishes. Wild A. regius from the remaining fishery on the Spanish coast exhibited the same ontogenetic diet shift from invertebrates to fishes, but at a smaller size threshold. Overall, the results demonstrated that culture-reared A. regius experience adverse conditions during the first days after release into the wild but that at least some A. regius are able to adapt to the natural environment after a few months at liberty.

Measurement of transmission efficiency for 400 MeV proton beam through collimator at Fermilab MuCool Test Area using Chromox-6 scintillation screen

The MuCool Test Area (MTA) at Fermilab is a facility to develop the technology required for ionization cooling for a future Muon Collider and∕or Neutrino Factory. As part of this research program, feasibility studies of various types of RF cavities in a high magnetic field environment are in progress. As a unique approach, we have tested a RF cavity filled with a high pressure hydrogen gas with a 400 MeV proton beam in an external magnetic field (B = 3 T). Quantitative information about the number of protons passing through this cavity is an essential requirement of the beam test. The MTA is a flammable gas (hydrogen) hazard zone. Due to safety reasons, no active (energized) beam diagnostic instrument can be used. Moreover, when the magnetic field is on, current transformers (toroids) used for beam intensity measurements do not work due to the saturation of the ferrite material of the transformer. Based on these requirements, we have developed a passive beam diagnostic instrumentation using a combination of a Chromox-6 scintillation screen and CCD camera. This paper describes details of the beam profile and position obtained from the CCD image with B = 0 T and B = 3 T, and for high and low intensity proton beams. A comparison is made with beam size obtained from multi-wires detector. Beam transmission efficiency through a collimator with a 4 mm diameter hole is measured by the toroids and CCD image of the scintillation screen. Results show that the transmission efficiency estimated from the CCD image is consistent with the toroid measurement, which enables us to monitor the beam transmission efficiency even in a high magnetic field environment.