Parents on the Concept of Physical Literacy: What Do They Know, What Do They Do, and What Do They Want?

Physical literacy development in early childhood, viewed by many as the foundation for lifelong physical activity engagement, is significantly influenced by parents. Our aim was to explore parents' understanding of physical literacy and gain insight into their perspectives on physical literacy promotion. We recruited 18 parents of children between 5 and 8 years old in Australia. Using semistructured interviews and thematic analysis, we identified several key issues regarding parents' understanding and implementation of physical literacy. Parents expressed interest in improving their implementation of physical literacy practices and had (often unintentionally) provided support for physical literacy subcomponents in the past. However, they described difficulties prioritizing physical literacy above other parental demands and expressed conflicting perceptions regarding where the responsibility should lie for developing their child's physical literacy (e.g., at home or at school). To ensure that the physical literacy "message" reaches parents, we encourage physical literacy promoters to consider the target (e.g., responsibility, priorities, and awareness) of their promotional strategies. Further investigation into the influence of sociocultural and economic factors on parents' understanding and application of physical literacy is warranted.

Exploring NICU nurses' views of a novel genetic point-of-care test identifying neonates at risk of antibiotic-induced ototoxicity: A qualitative study

AIM

To explore the views of neonatal intensive care nursing staff on the deliverability of a novel genetic point-of-care test detecting a genetic variant associated with antibiotic-induced ototoxicity.

DESIGN

An interpretive, descriptive, qualitative interview study.

METHODS

Data were collected using semi-structured interviews undertaken between January and November 2020. Participants were neonatal intensive care nursing staff taking part in the Pharmacogenetics to Avoid Loss of Hearing trial.

RESULTS

Thematic analysis resulted in four themes: perceived clinical utility; the golden hour; point-of-care device; training and support. Recommendations were made to streamline the protocol and ongoing training and support were considered key to incorporating the test into routine care.

CONCLUSION

Exploring the views of nurses involved in the delivery of the point-of-care test was essential in its implementation. By the study endpoint, all participants could see the value of routine clinical introduction of the point-of care test.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurses are in a key position to support the delivery of point-of-care genetic testing into mainstream settings. This study has implications for the successful integration of other genetic point-of-care tests in acute healthcare settings.

IMPACT

The study will help to tailor the training and support required for routine deployment of the genetic point-of-care test. The study has relevance for nurses involved in the development and delivery of genetic point-of-care tests in other acute hospital settings.

REPORTING METHOD

This qualitative study adheres to the Standards for Reporting Qualitative Research EQUATOR guidelines and utilizes COREQ and SRQR checklists.

PATIENT OR PUBLIC CONTRIBUTION

All staff working on the participating neonatal intensive care units were trained to use the genetic point-of-care test. All inpatients on the participating units were eligible to have testing via the point-of-care test. The Pharmacogenetics to Avoid Loss of Hearing Patient and Public Involvement and Engagement group provided valuable feedback.

TRIAL AND PROTOCOL REGISTRATION

Registered within the University of Manchester. Ethics approval reference numbers: IRAS: 253102 REC reference: 19/NW/0400. Also registered with the ISRCTN ref: ISRCTN13704894.

Biomolecular characterization of 3500-year-old ancient Egyptian mummification balms from the Valley of the Kings

Ancient Egyptian mummification was practiced for nearly 4000 years as a key feature of some of the most complex mortuary practices documented in the archaeological record. Embalming, the preservation of the body and organs of the deceased for the afterlife, was a central component of the Egyptian mummification process. Here, we combine GC-MS, HT-GC-MS, and LC-MS/MS analyses to examine mummification balms excavated more than a century ago by Howard Carter from Tomb KV42 in the Valley of the Kings. Balm residues were scraped from now empty canopic jars that once contained the mummified organs of the noble lady Senetnay, dating to the 18th dynasty, ca. 1450 BCE. Our analysis revealed balms consisting of beeswax, plant oil, fats, bitumen, Pinaceae resins, a balsamic substance, and dammar or Pistacia tree resin. These are the richest, most complex balms yet identified for this early time period and they shed light on balm ingredients for which there is limited information in Egyptian textual sources. They highlight both the exceptional status of Senetnay and the myriad trade connections of the Egyptians in the 2nd millennium BCE. They further illustrate the excellent preservation possible even for organic remains long removed from their original archaeological context.

Becoming a podiatrist: an exploration of the practices and processes which underpin the acquisition of a professional identity

BACKGROUND

Undergraduate podiatry degrees are designed to enable students to become professional podiatrists. To be successful students must manage academic and practical activity to ultimately acquire a professional identity. Little is known about the practices and processes which underpin the acquisition of a professional podiatry identity. It is the aim of this paper to begin to address this absence of knowledge. Community of Practice theory, arguably the dominant contemporary learning theory, represents identity shift as an interaction of imagination, engagement and alignment which enables students to successfully participate in higher education, and ultimately, the professional context. This success is underpinned through assisting students to develop an enabling identity in their learning and doing.

METHODS

Here we present findings that emerged from a yearlong ethnography in a successful higher education podiatry department. The project followed students and staff in the classroom and the clinic and explored their experiences through interviews.

RESULTS

The findings suggest that the journey to professional identity is facilitated through meaningful learning relationships between staff and students and clarity around professional practices. Here we discuss how those relationships form and enable undergraduates to become podiatrists.

CONCLUSIONS

Our findings offer a model for the transition from student to professional and highlight the importance of relationship and experience in becoming a podiatrist. There is a paucity of research around not only podiatry but also other allied health professions around this topic and given the increasing emphasis around employability skills in HE, more research in a range of contexts is needed.

Gecko adhesion based sea star crawler robot

Over the years, efforts in bioinspired soft robotics have led to mobile systems that emulate features of natural animal locomotion. This includes combining mechanisms from multiple organisms to further improve movement. In this work, we seek to improve locomotion in soft, amphibious robots by combining two independent mechanisms: sea star locomotion gait and gecko adhesion. Specifically, we present a sea star-inspired robot with a gecko-inspired adhesive surface that is able to crawl on a variety of surfaces. It is composed of soft and stretchable elastomer and has five limbs that are powered with pneumatic actuation. The gecko-inspired adhesion provides additional grip on wet and dry surfaces, thus enabling the robot to climb on 25° slopes and hold on statically to 51° slopes.

Can interprofessional research enhance health care students' understanding and knowledge towards evidence based practice: A cross sectional study

AIM

To explore how inter-professional collaboration in the teaching and learning of research skills prepares undergraduate students for their professional roles in healthcare via an evaluation of inter-professional research modules from the student perspective.

PARTICIPANTS AND SETTINGS

Participants were selected from a university in the North of England where all undergraduate Healthcare students were taught Research and Evidence Based Practice (EBP) through interprofessional education (n = 400).

METHODS

Quantitative data was collected using an adapted Attitudes Towards Interprofessional Education Scale and internally-designed pilot instruments. Qualitative data was also collected via open comment to evaluate the taught research module.

RESULTS

50 students completed the survey pre-module and 49 students completed the survey post-module. The participants' views towards inter-professional education (IPE) are generally positive: the median responses of 4 single-item measures assessing inter-professional learning on 7-point Likert scales were 5 or above (where higher scores represented more positive perceptions). Scores on the Attitudes towards Interprofessional Education scale also generally represented positive opinions, with a mean post-test score of 58.8 on a scale from 5 to 75, with higher scores indicating greater levels of positivity. No evidence for a statistically significant improvement from the pre- to post- 3rd year experience of the IPE/research theme was revealed. Qualitative data identified six themes: promoting team working, developing awareness of other health care professional's roles, polarising research and practice, multidisciplinary team (MDT) working or not working, logistical issues and developing research skills.

CONCLUSIONS

This study raised questions about the appropriateness of "unnatural" pairings for undertaking research projects. Whilst the students valued working together in the research process, they do not appear to have perceived a universal benefit to their inter-professional clinical practice.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Eligibility for subcutaneous implantable cardiac defibrillator utilising artificial intelligence and deep learning methods for prolonged screening: where is the cut-off?

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Main author is receiving an unrestricted grant by Boston Scientific

Background

S-ICD eligibility is determined by a single surface ECG analysis in which the suitability of an individual’s ECG vector morphology is assessed. A major predictor of eligibility is the T:R ratio. Current screening tools proposes T: R of 1:3 as a cut-off for eligibility. Inappropriate shocks due to T-wave oversensing (TWO) remains an issue despite screening. EFFORTLESS and PRAETORIAN trials reported inappropriate shock rates of 11.4% and 9.7% respectively, most frequently caused by cardiac oversensing.

Purpose

The cut-off T: R of 1:3 currently used incorporates a safety margin to accommodate for ECG signal amplitudes fluctuations without affecting S-ICD sensing. Prolonged screening using our tool accurately measures the T: R fluctuations. However, utilising a T: R of 1:3 for prolonged screening can unnecessarily exclude appropriate S-ICD candidates. The purpose of our study is to provide groundwork for future trials to find the optimal ratio that identifies patients at risk of TWO and inappropriate shocks while not excluding true S-ICD candidates after prolonged screening.

Methods

Patients were fitted with 24-hour Holter monitors with leads placed to correspond to the vectors of an S-ICD. We used our tool to assess T: R over the recordings utilising Phase Space Reconstruction matrices - to convert the ECG signal into compressed pixel images. A Convolutional Neural Network (CNN) model was trained to accurately predict the T: R from these images resulting in a T: R variation plot for each vector. We then applied multiple T:R ratio cut-offs on the recordings to identify patients at risk of inappropriate shocks due to TWO at each proposed value. A vector with a T: R above the cut-off for 20 consecutive seconds was deemed to have failed screening, the time determined by the current detection, charge, and redetection time of the current S-ICD system. A patient has to have at least one suitable vector to pass the screening at the selected threshold.

Results

37 patients (mean age 54.5 years,64.8% male) were included. 14 had Heart failure, 7 Hypertrophic cardiomyopathy, 7 normal hearts, 6 Adult congenital heart disease and 3 patients who received inappropriate S-ICD shocks due to TWO. Overall, 20 (54%) of patients passed prolonged screening using a 1:3 ratio. All of the patients passed screening with a T: R of 1:1. The only subgroup to wholly pass the screening for all the proposed ratios are the normal hearts group.

Conclusion

We propose adopting prolonged screening to select S-ICD eligible patients with low probability of TWO and inappropriate shocks. However, utilising T: R of 1:3 can unnecessarily exclude otherwise S-ICD eligible patients. The appropriate ratio likely lies between 1:3 - 1:1. Further studies are needed to identify the optimal screening thresholds, particularly in patients that have had inappropriate shocks due to TWO.

A leadless pacemaker matched with a vasovagal syncope: how long can it last?

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Dr.Mohamed ElRefai is receiving an unrestricted grant from Boston Scientific

Introduction

Although a benign condition, patients suffering from frequent vasovagal syncopal episodes need treatment to improve their quality of life. ESC Guidelines consider pacing for patients >40 years old with documented symptomatic asystolic pauses >3 seconds or asymptomatic pauses >6 seconds. Caution is advised with use of pacing in younger patients, due to long-term complications associated with transvenous pacemakers (TV-PPM). The ESC guidelines recommend that Leadless pacemakers (LP) should be considered as an alternative to TV-PPM when there is no appropriate venous access or if the risk of device infection is high, also on a case-by-case basis using shared decision making.

Studies on the use of LPs for cardioinhibitory vasovagal population specifically, concluded that the safety and efficacy of LPs are comparable with TV-PPM, demonstrating a high level of symptom improvement at follow up making them a reasonable option in these patients. In addition, observational studies demonstrated that LPs are associated with better quality of life than TV-PPM.

Purpose

Current practice is to implant another LP after the end of life of the old device without extracting it. There are concerns regards battery longevity specially with the paucity of data on device extraction and the number of concomitant LPs that can be implanted safely, a concern in younger patients’ population potentially requiring decades of pacing therapy. We aim to evaluate the performance of the LPs in the relatively younger vasovagal syncope patients with anticipated very low pacing dependency, with emphasis on battery longevity.

Methods

We conducted a retrospective analysis of the first 100 LP implanted at our tertiary referral centre for cardiac devices in the UK. Demographical data as well as devices parameters at implant and latest follow ups were obtained from the patients’ medical electronic records. We compared the performance of the LPs between patients with vasovagal syncope vs other pacing indications with emphasis on battery longevity in both groups.

Results

A total of 90 patients were included in our analysis after excluding 10 patients due to lack of follow-up data. 14 patients (15.6%) had vasovagal syncope as indication for pacing and 76 patients (84.4%) had other indications. Mean ages were 34±13 years and 62±20 years for the vasovagal and the other group, respectively. There were no complications in the vasovagal group. Pacing % at the last follow up was 1±1 in the vasovagal group and 37±43 for the other group. There was a significant difference in the estimated total battery life between both groups, 15.22±0.35 and 13.65±2.97 years in the vasovagal and the other group respectively.

Conclusion

LPs provide a safe and a reliable treatment for young patients with vasovagal syncope with promising battery performance at the short/intermediate term. Further longer-term follow up data is needed to identify the true battery potential in this patient cohort.

The use of artificial intelligence and deep learning methods in subcutaneous implantable cardioverter defibrillator screening to optimise selection in special patient populations

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Dr.Mohamed ElRefai is receiving an unrestricted grant from Boston Scientific.

Introduction

Adult congenital heart disease (ACHD) and hypertrophic cardiomyopathy (HCM) patients who require defibrillator therapy are often relatively young and may require several generator replacements in their lifetime. The increased risk of complications associated with transvenous ICDs make the subcutaneous (S-ICD) a valuable alternative. However, higher S-ICD ineligibility rates (20-40% in ACHD and 7-38% in HCM) and higher inappropriate shock rates (10.5% in ACHD and 12.5% in HCM) are observed in these populations. Unfavourable T:R ratios and dynamic changes in the R and T wave amplitudes are the primarily factors behind ineligibility and inappropriate shocks, which are most commonly caused by T wave over-sensing.

Purpose

We report a novel application of deep learning methods used to autonomously screen patients for S-ICD eligibility over a longer period than conventional screening. We hypothesise that this screening approach might achieve better patient selection and optimise S-ICD vector selection in challenging patient cohorts.

Methods

Adult patients with ACHD or HCM and a control group of normal subjects were fitted with a 24-hour ambulatory ECG with the leads placed to record their S-ICD vectors. T: R ratio throughout the recordings was analysed utilising phase space reconstruction matrices to convert the ECG signal into compressed pixel images. Whilst a convolutional neural network model was trained to provide an in-depth description of the T: R variation plot for each vector T: R variation was compared statistically using a one-way ANOVA test.

Results

20 patients (age 44.1 ±11.68, 60% male, 7 HCM, 6 ACHD and 7 control subjects) were enrolled. A significant difference was observed in the mean and median T: R values between the three groups (p<0.001). There was no difference observed in the standard deviation of T: R between the control subjects and HCM group. However, there was a statistically significant difference in the standard deviation of T: R between the control subjects and the ACHD group (p= 0.01). [see Figure].

Conclusions

T:R ratio, a main determinant for S-ICD eligibility, is significantly higher in ACHD and HCM when compared to normal hearts and it also has more tendency to fluctuate in ACHD patients when compared to HCM and normal hearts populations. We hypothesise that our novel model could be used to select S-ICD eligible patients by better characterisation of T:R ratio reducing the risk of T wave oversensing and inappropriate shocks particularly in the ACHD patients’ cohort.

Competing sexual-asexual generic names in Agaricomycotina (Basidiomycota) with recommendations for use

With the change to one scientific name for fungal taxa, generic names typified by species with sexual or asexual morph types are being evaluated to determine which names represent the same genus and thus compete for use. In this paper generic names of the Agaricomycotina (Basidiomycota) were evaluated to determine synonymy based on their type. Forty-seven sets of sexually and asexually typified names were determined to be congeneric and recommendations are made for which generic name to use. In most cases the principle of priority is followed. However, 16 generic names are recommended for use that do not have priority and thus need to be protected: Aleurocystis over Matula; Armillaria over Acurtis and Rhizomorpha; Asterophora over Ugola; Botryobasidium over Acladium, Allescheriella, Alysidium, Haplotrichum, Physospora, and Sporocephalium; Coprinellus over Ozonium; Coprinopsis over Rhacophyllus; Dendrocollybia over Sclerostilbum and Tilachlidiopsis; Diacanthodes over Bornetina; Echinoporia over Echinodia; Neolentinus over Digitellus; Postia over Ptychogaster; Riopa over Sporotrichum; Scytinostroma over Artocreas, Michenera, and Stereofomes; Tulasnella over Hormomyces; Typhula over Sclerotium; and Wolfiporia over Gemmularia and Pachyma. Nine species names are proposed for protection: Botryobasidium aureum, B. conspersum, B. croceum, B. simile, Pellicularia lembosporum (syn. B. lembosporum), Phanerochaete chrysosporium, Polyporus metamorphosus (syn. Riopa metamorphosa), Polyporus mylittae (syn. Laccocephalum mylittae), and Polyporus ptychogaster (syn. Postia ptychogaster). Two families are proposed for protection: Psathyrellaceae and Typhulaceae. Three new species names and 30 new combinations are established, and one lectotype is designated.

Pharmacogenetics to Avoid Loss of Hearing (PALOH) trial: a protocol for a prospective observational implementation trial

INTRODUCTION

In conjunction with a beta-lactam, aminoglycosides are the first-choice antibiotic for empirical treatment of sepsis in the neonatal period. The m.1555A>G variant predisposes to ototoxicity after aminoglycoside administration and has a prevalence of 1 in 500. Current genetic testing can take over 24 hours, an unacceptable delay in the acute setting. This prospective-observational trial will implement a rapid point of care test (POCT), facilitating tailored antibiotic prescribing to avoid hearing loss.

METHODS AND ANALYSIS

The genedrive POCT can detect the m.1555A>G variant in 26 min from buccal swab. This system will be integrated into the clinical pathways at two large UK neonatal centres over a minimum 6-month period. The primary outcome is the number of neonates successfully tested for the variant out of all babies prescribed antibiotics. As a secondary outcome, clinical timings will be compared with data collected prior to implementation, measuring the impact on routine practice.

ETHICS AND DISSEMINATION

Approval for the trial was granted by the Research Ethics Committee (REC) and Human Research Authority in August 2019. Results will be published in full on completion of the study.

TRIAL REGISTRATION NUMBER

ISRCTN13704894.

PROTOCOL VERSION

V 1.3.

Leadless pacemakers: where is the device?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Leadless pacemakers (LPs) were designed to avoid lead-related complications associated with transvenous pacing. To minimise the risk of complications, there is preference towards implanting LPs into the septal aspect of the right ventricle rather than the apex or free wall. The Transcatheter Pacing Study (TPS) and the international post-approval registry demonstrated the safety and reliability of the LP systems in real-world settings. The registry demonstrated that more than half of the LPs were implanted into the septum and most required <2 attempts at deployment. We report a radiological method of defining LP position.

Methods

We reviewed the first 100 LPs implanted at our centre. Two independent observers who didn’t implant LPs reviewed the patients’ post-implant fluoroscopy images and/or post-implant CXRs when available. The reviewers assessed the devices’ positions in postero-anterior (PA) and/or right anterior oblique (RAO) views based on conventional fluoroscopic criteria for lead position. We used the proposed criteria interchangeably on fluoroscopic images and post implant CXRs (Figure). Differences in classification of device position were resolved by consensus.

Results

Three experienced operators implanted 100 LPs at our centre. Patients (61% male) 56.6 ± 22.2 years had normal hearts (74%), ischaemic cardiomyopathies (12%), congenital heart diseases (6%), valvular pathologies (5%) and dilated cardiomyopathies (3%). Indications for pacing were symptomatic sinus node dysfunction (36%), followed by high grade atrio-ventricular block (33%), bradyarrhythmia associated with atrial tachyarrhythmias (27%) and other indications for pacing (4%). We had a 100% successful implant rate, 88% required ≤2 attempts and 70% required one attempt. There were no major complications.

We were able to classify the site of the LPs implants in a total of 90 patients who had fluoroscopic projections or chest x-rays that would allow us to classify the implant sites. A total of 32 implants were in the apex (35.6%). 28 were in mid-septum (31.1 %), 15 in the apical septum (16.7%), 14 on the septal aspect of the right ventricular inflow (15.5%) and 1 implant (1.1%) in the septum of the RV outflow tract.

Conclusion

Our proposed method of defining LP position demonstrated that the rate of implants into the true apex at our centre was highly comparable to that of the international registry. It also showed that we had lower rates of implants into the mid-septum in favour of apical septum. There were no pericardial effusions or cardiac perforations resulting from our implant procedures regardless of the site of the implant. We utilised widely used fluoroscopic and chest x-ray criteria for categorisation of the LPs implantation sites. However, a recognised limitation to our analysis is that our findings were not validated using other imaging modalities such as echocardiogram or cardiac computerised tomography (CT). Abstract Figure. Criteria to classify device position

Leadless pacemakers: does location matter?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Leadless pacemakers (LPs) provide a viable alternative for patients who have an indication for pacing where transvenous pacing is not desirable or possible. Registries have demonstrated stable performance associated with LPs. There is preference towards implanting LPs into the trabeculated septum rather than the apex or free wall. We report our experience with the impact of the implantation site on acute and long-term electrical performance of LPs.

Methods

We ran a retrospective analysis on the first 100 LPS implanted at our centre. Two independent observers reviewed the fluoroscopic images and post-implant chest x-rays to classify the LPs’ positions.  We obtained the recorded pacing threshold , R-wave amplitude and impedance of the devices at the time of implant and at the latest available routine device follow-up. We used one-way ANOVA testing to compare the acute and long-term electrical performance of the LPs between different implantation sites.

Results

We were able to classify the site of the LPs implants in a total of 90 patient. 84 Patients (60% male) 57.3± 22.16 years were included .23.8% of the patients presented with syncope.  Indications for pacing were symptomatic sinus node dysfunction (33.3%), high grade AV block (34.5%), bradyarrhythmia associated with atrial tachyarrhythmias (28.6%) and other indications (3.6%). We had a 100% successful implant rate, 85.7% required ≤2 attempts and 71.4% required one attempt. A total of 32 implants were in the apex (38.1%), 26 in mid-septum (30.9 %), 13 in the apical septum (15.5%), 12 on the septal aspect of the right ventricular inflow (14.3%) and 1 implant (1.2%) in the septum of the RV outflow tract.

The follow up period of the 84 patients was 3.09 ± 1.97 years. 100% of the LPs had the pacing thresholds <2.0 V @0.24 ms at the time of implant. Pacing threshold, R-wave amplitude, and impedance averaged at 0.67 ± 0.41 V, 10.86 ± 5.41 mV, and 775 ± 193.28 Ohms respectively at the time of implantation and 0.66 ± 0.39 V, 14.08 ± 6.14 mV, and 564.29 ± 96.76 Ohms at the last device check. There was no statistically significant difference in either the pacing thresholds or the impedance between implant sites. Post hocTukey’s analysis (excluding the outflow tract case) demonstrated significant statistical difference in the R-wave amplitudes between implants at the apex and the mid-septum both at the time of implantation (12.9 ± 6.1 mV and 8.53 ± 2.84 mV; p = 0.0196) and at follow up (15.97 ± 5.35 mV and 11.52 ± 5.01 mV; p = 0.0415). There were no differences between other sites

Conclusions

Our analysis demonstrated that aside from the difference between the sensed R wave amplitudes between LPs implanted at the apex and those implanted at mid-septum , there was no statistically significant difference in the acute or the long term electrical performance of implanted LPs regardless of the implantation site. A limitation to our analysis is the relatively low number of LP implants included in our analysis. Abstract Figure. Mean of parameters by validated position

ACE inhibitors, angiotensin receptor blockers and endothelial injury in COVID-19

BACKGROUND

COVID-19 is caused by the coronavirus SARS-CoV-2, which uses angiotensin-converting enzyme 2 (ACE-2) as a receptor for cellular entry. It is theorized that ACE inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) may increase vulnerability to SARS-CoV-2 by upregulating ACE-2 expression, but ACE-I/ARB discontinuation is associated with clinical deterioration.

OBJECTIVE

To determine whether ACE-I and ARB use is associated with acute kidney injury (AKI), macrovascular thrombosis and in-hospital mortality.

METHODS

A retrospective, single-centre study of 558 hospital inpatients with confirmed COVID-19 admitted from 1 March to 30 April 2020, followed up until 24 May 2020. AKI and macrovascular thrombosis were primary end-points, and in-hospital mortality was a secondary end-point.

RESULTS

AKI occurred in 126 (23.1%) patients, 34 (6.1%) developed macrovascular thrombi, and 200 (35.9%) died. Overlap propensity score-weighted analysis showed no significant effect of ACE-I/ARB use on the risk of occurrence of the specified end-points. On exploratory analysis, severe chronic kidney disease (CKD) increases odds of macrovascular thrombi (OR: 8.237, 95% CI: 1.689-40.181, P = 0.009). The risk of AKI increased with advancing age (OR: 1.028, 95% CI: 1.011-1.044, P = 0.001) and diabetes (OR: 1.675, 95% CI: 1.065-2.633, P = 0.025). Immunosuppression was associated with lower risk of AKI (OR: 0.160, 95% CI: 0.029-0.886, P = 0.036). Advancing age, dependence on care, male gender and eGFR < 60 mL min^-1 /1.73 m² increased odds of in-hospital mortality.

CONCLUSION

We did not identify an association between ACE-I/ARB use and AKI, macrovascular thrombi or mortality. This supports the recommendations of the European and American Societies of Cardiology that ACE-Is and ARBs should not be discontinued during the COVID-19 pandemic.

N-glycosylation profiling of Type 2 diabetes mellitus from baseline to follow-up: an observational study in a Ghanaian population

Aim: The study sought to determine the patterns of N-glycan profiles among Type 2 diabetes mellitus (T2DM) patients over a 6-month period. Materials & methods: Biochemical and clinical data were obtained from 253 T2DM patients at baseline and follow-up. Ultra-performance liquid chromatography and statistical methods were applied for N-glycan profiling. Results: The coefficients of variation were 28% and 29% at baseline and follow-up, respectively, whereas the range of N-glycan variability was from 11% to 56%. Apart from GP1 (FA2) and GP29 (FA3G3S [3,3,3]3), the intra-individual variations of N-glycan peaks were not statistically significant. Conclusion: N-glycan profiles were stable over 6-month period in T2DM patients and could be used to monitor biochemical changes in relation with T2DM comorbidities.

Pseudomonas aeruginosa infection in augmented care: the molecular ecology and transmission dynamics in four large UK hospitals

BACKGROUND

Pseudomonas aeruginosa is a common opportunistic pathogen and molecular typing in outbreaks has linked patient acquisition to contaminated hospital water systems.

AIM

To elucidate the role of P. aeruginosa transmission rates in non-outbreak augmented care settings in the UK.

METHODS

Over a 16-week period, all water outlets in augmented care units of four hospitals were sampled for P. aeruginosa and clinical isolates were collected. Outlet and clinical P. aeruginosa isolates underwent whole-genome sequencing (WGS), which with epidemiological data identified acquisition from water as definite (level 1), probable (level 2), possible (level 3), and no evidence (level 4).

FINDINGS

Outlets were positive in each hospital on all three occasions: W (16%), X (2.5%), Y (0.9%) and Z (2%); and there were 51 persistently positive outlets in total. WGS identified likely transmission (at levels 1, 2 and 3) from outlets to patients in three hospitals for P. aeruginosa positive patients: W (63%), X (54.5%) and Z (26%). According to the criteria (intimate epidemiological link and no phylogenetic distance), approximately 5% of patients in the study 'definitely' acquired their P. aeruginosa from their water outlets in the intensive care unit. This study found extensive evidence of transmission from the outlet to the patients particularly in the newest hospital (W), which had the highest rate of positive outlets.

CONCLUSIONS

The overall findings suggest that water outlets are the most likely source of P. aeruginosa nosocomial infections in some settings, and that widespread introduction of control measures would have a substantial impact on infections.

Rare complication after pericardial window: symptomatic diaphragmatic hernia containing bowel and liver

A 37-year-old woman presented to her local district general hospital with a cough, pleuritic chest pain and intermittent cyanosis. Eight months prior, she underwent a successful pericardial window for recurrent, symptomatic pericardial effusions. On presentation she was hypoxic but haemodynamically stable. Her chest radiograph raised the suspicion of a diaphragmatic hernia, confirmed by CT imaging. This identified herniation through the diaphragm of the transverse colon and left lobe of the liver resulting in cardiac compression and right ventricular dysfunction. She continued to deteriorate and required emergency intubation to allow safe transfer to a tertiary upper gastrointestinal unit. She underwent a laparotomy and repair of the diaphragmatic hernia with an uneventful inpatient recovery. In the literature, diaphragmatic liver herniation is a recognised complication secondary to trauma or congenital defects, however, to our knowledge, there are currently no cases described following pericardial windowing.

Nanofiltration as a robust method contributing to viral safety of plasma-derived therapeutics: 20 years' experience of the plasma protein manufacturers

Background

Nanofiltration entails the filtering of protein solutions through membranes with pores of nanometric sizes that have the capability to effectively retain a wide range of viruses.

Study Design and Methods

Data were collected from 754 virus validation studies (individual data points) by Plasma Protein Therapeutics Association member companies and analyzed for the capacity of a range of nanofilters to remove viruses with different physicochemical properties and sizes. Different plasma product intermediates were spiked with viruses and filtered through nanofilters with different pore sizes using either tangential or dead‐end mode under constant pressure or constant flow. Filtration was performed according to validated scaled‐down laboratory conditions reflecting manufacturing processes. Effectiveness of viral removal was assessed using cell culture infectivity assays or polymerase chain reaction (PCR).

Results

The nanofiltration process demonstrated a high efficacy and robustness for virus removal. The main factors affecting nanofiltration efficacy are nanofilter pore size and virus size. The capacity of nanofilters to remove smaller, nonenveloped viruses was dependent on filter pore size and whether the nanofiltration process was integrated and designed with the intention to provide effective parvovirus retention. Volume filtered, operating pressure, and total protein concentration did not have a significant impact on the effectiveness of virus removal capacity within the investigated ranges.

Conclusions

The largest and most diverse nanofiltration data collection to date substantiates the effectiveness and robustness of nanofiltration in virus removal under manufacturing conditions of different plasma‐derived proteins. Nanofiltration can enhance product safety by providing very high removal capacity of viruses including small non‐enveloped viruses.

Prevalence and lifestyle-related risk factors of obesity and unrecognized hypertension among bus drivers in Ghana

Obesity and hypertension are public health problems associated with cardiovascular events worldwide. Bus drivers, whose lifestyle is primarily sedentary and characterized by poor eating habits are at increased risk. This study determined the prevalence and lifestyle-related risk factors of obesity and hypertension among Inter-Regional Metromass Bus Drivers (IRMBDs) in Ghana. This cross-sectional study recruited 527 professional drivers from Metromass Bus stations in Accra and Kumasi Metropolis, Ghana. Structured questionnaires were administered to obtain socio-demographic and lifestyle characteristics from all participants. Anthropometric measurements including body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) and blood pressure (BP) were determined. The prevalence of unrecognized hypertension was 38.7%. The prevalence of obesity using BMI, WC, and WHR as obesity indices were 19.0%, 19.9%, and 19.4%, respectively. Use of sleep inhibitors, long-duration sitting and eating late at night were independent risk factors for obesity, regardless of the obesity index used (p < 0.05). Physical inactivity, high caloric intake and eating at stressful periods were independent risk factors for obesity based on WC and WHR measurements (p < 0.05). Ageing, smoking history, alcoholic beverage intake, sleep inhibitor drug use, high calorie intake, long-duration sitting, eating late and under stressful conditions were independent risk factors for hypertension (p < 0.05). There is a high prevalence of unrecognized hypertension and obesity among IRMBDs which were associated with individual lifestyle and behaviours. Increased awareness through educational and screening programs will trigger lifestyle modifications that will reduce cardio-metabolic disease onset and offer clues for better disease predictive, preventive and personalized medicine.

Suboptimal health pregnant women are associated with increased oxidative stress and unbalanced pro- and antiangiogenic growth mediators: a cross-sectional study in a Ghanaian population

Optimal oxidative stress (OS) is important throughout pregnancy; however, an increased OS may alter placental angiogenesis culminating in an imbalanced of angiogenic growth mediators (AGMs). Suboptimal Health Status (SHS), a physical state between health and disease, may be associated with increased OS and unbalanced AGMs. In this study, we explored the association between SHS, biomarkers of OS (BOS) and AGMs among normotensive pregnant women (NTN-PW) in a Ghanaian Suboptimal Health Cohort Study (GHOACS). This comparative GHOACS recruited 593 NTN-PW from the Komfo Anokye Teaching Hospital, Ghana. SHS was measured using a Suboptimal Health Status Questionnaire-25 (SHSQ-25). Along with the subjective SHS measure, objective BOS: 8-hydroxy-2-deoxyguanosine (8-OHdG), 8-epiprostaglandinF2 alpha (8-epi-PGF2α), total antioxidant capacity (TAC), and AGMs: vascular endothelial growth factor-A (VEGF-A), soluble fms-like tyrosine kinase receptor 1 (sFlt-1), placental growth factor (PIGF) and soluble endoglin (sEng) were evaluated. Compared to optimal health NTN-PW, levels of PlGF, VEGF-A and TAC were significantly (p < 0.05) reduced and negatively associated with SHS whilst sEng, sFlt-1, 8-epiPGF2α, 8-OHdG, and combined ratios of sFlt-1/PlGF, 8-epiPGF2α/PlGF, 8-OHdG/PlGF, and sEng/PlGF were significantly increased and positively associated with SHS. The first quartile for PIGF (2.79-fold) and VEGF-A (5.35-fold), and the fourth quartile for sEng (4.31-fold), sFlt-1 (1.84-fold), 8-epiPGF2α (2.23-fold), 8-OHdG (1.90-fold) and urinary 8-OHdG (1.95-fold) were independently associated with SHS (p < 0.05). SHS is associated with increased OS and unbalanced AGMs. Early identification of SHS-related OS and unbalanced AGMs may inform clinicians of the need for therapeutic options.

Type 2 Diabetes Mellitus is Associated with the Immunoglobulin G N-Glycome through Putative Proinflammatory Mechanisms in an Australian Population

Type 2 diabetes mellitus (T2DM) is a common complex trait arising from interactions among multiple environmental, genomic, and postgenomic factors. We report here the first attempt to investigate the association between immunoglobulin G (IgG) N-glycan patterns, T2DM, and their clinical risk factors in an Australian population. N-glycosylation of proteins is one of the most frequently observed co- and post-translational modifications, reflecting, importantly, the real-time status of the interplay between the genomic and postgenomic factors. In a community-based case-control study, 849 participants (217 cases and 632 controls) were recruited from an urban community in Busselton, Western Australia. We applied the ultraperformance liquid chromatography method to analyze the composition of IgG N-glycans. We then conducted Spearman's correlation analyses to explore the association between glycan biomarker candidates and clinical risk factors. We performed area under the curve (AUC) analysis of the receiver operating characteristic curves by fivefold cross-validation for clinical risk factors, IgG glycans, and their combination. Two directly measured and four derived glycan peaks were significantly associated with T2DM, after correction for extensive clinical confounders and false discovery rate, thus suggesting that IgG N-glycan traits are highly correlated with T2DM clinical risk factors. Moreover, adding the IgG glycan profiles to fasting blood glucose in the logistic regression model increased the AUC from 0.799 to 0.859. The AUC for IgG glycans alone was 0.623 with a 95% confidence interval 0.580-0.666. In addition, our study provided new evidence of diversity in T2DM complex trait by IgG N-glycan stratification. Six IgG glycan traits were firmly associated with T2DM, which reflects an increased proinflammatory and biological aging status. In summary, our study reports novel associations between the IgG N-glycome and T2DM in an Australian population and the putative role of proinflammatory mechanisms. Furthermore, IgG N-glycomic alterations offer future prospects as inflammatory biomarker candidates for T2DM diagnosis, and monitoring of T2DM progression to cardiovascular disease or renal failure.

P577Early experience with the first pacemakers to directly connect with smart devices for remote monitoring

Background

Remote monitoring is associated with improved patient outcomes; however, adoption and adherence to remote monitoring via home-based consoles remains suboptimal. BlueSync technology in new generation pacemaker and CRT-P models enables the implanted device to communicate directly with patient-owned, Bluetooth-equipped smartphones/tablets and an app (MyCareLink Heart). The app can automatically retrieve information from the cardiac device and transmit the data to the remote network, eliminating the need for traditional remote monitoring consoles.

Objectives

To characterize the communication process between implanted pacemakers and smart device remote monitoring apps by assessing the success of prescheduled remote transmissions in the first month of follow-up. Additionally, to assess the feedback of both patients and clinicians about the process of device pairing.

Methods

Enrollment in the BlueSync Field Evaluation began in April 2018 and was completed November 2018. Follow-up is ongoing. Prior to enrollment in the evaluation, patients completed the device pairing process with the app using their own compatible smartphone or tablet. Patient and clinician questionnaires were completed at the time of the device pairing process. After enrollment, successful completion of scheduled transmissions occurring in the first month were analyzed.

Results

Preliminary data includes 241 enrolled patients with mean age of 64.7±15.5 yrs (min 20, max 90 yrs), who completed device pairing between their implanted device and their smart device app. Of enrolled patients, 79% felt that the device paring was easy to do, 85% were satisfied with the amount of time it took to complete it, and 93% felt that they would be comfortable using the app. Clinicians reported that 67% of the device pairings took less than 20 minutes and 78% felt patients would be able to use the app independently. At the time of analysis 174 patients had at least one scheduled transmission within the first month, and collectively had a total of 322 scheduled transmissions. Out of these, 309 (96%, 95% CI: 93%-98%) were successfully completed.

MyCareLink Heart App

Conclusions

Initial experience with the world's first app based remote monitoring system for Bluetooth enabled pacemakers demonstrated success to scheduled transmissions in the first month across a wide range of patient ages. Patients and clinicians reported high satisfaction with this novel technology.

Acknowledgement/Funding

Medtronic PLC

Utilization of N-glycosylation profiles as risk stratification biomarkers for suboptimal health status and metabolic syndrome in a Ghanaian population

Aim: The study sought to apply N-glycosylation profiles to understand the interplay between suboptimal health status (SHS) and metabolic syndrome (MetS). Materials & methods: In this study, 262 Ghanaians were recruited from May to July 2016. After completing a health survey, plasma samples were collected for clinical assessments while ultra performance liquid chromatography was used to measure plasma N-glycans. Results: Four glycan peaks were found to predict case status (MetS and SHS) using a step-wise Akaike’s information criterion logistic regression model selection. This model yielded an area under the curve of MetS: 83.1% (95% CI: 78.0–88.1%) and SHS: 67.1% (60.6–73.7%). Conclusion: Our results show that SHS is a significant, albeit modest, risk factor for MetS and N-glycan complexity was associated with MetS.

Integration of suboptimal health status evaluation as a criterion for prediction of preeclampsia is strongly recommended for healthcare management in pregnancy: a prospective cohort study in a Ghanaian population

Background

Normotensive pregnancy may develop into preeclampsia (PE) and other adverse pregnancy complications (APCs), for which the causes are still unknown. Suboptimal health status (SHS), a physical state between health and disease, might contribute to the development and progression of PE. By integration of a routine health measure in this Ghanaian Suboptimal Health Cohort Study, we explored the usefulness of a 25-question item SHS questionnaire (SHSQ-25) for early screening and prediction of normotensive pregnant women (NTN-PW) likely to develop PE.

Methods

We assessed the overall health status among a cohort of 593 NTN-PW at baseline (10-20 weeks gestation) and followed them at 21-31 weeks until 32-42 weeks. After an average of 20 weeks follow-up, 498 participants returned and were included in the final analysis. Hematobiochemical, clinical and sociodemographic data were obtained.

Results

Of the 498 participants, 49.8% (248/498) had 'high SHS' at baseline (61.7% (153/248) later developed PE) and 38.3% (95/248) were NTN-PW, whereas 50.2% (250/498) had 'optimal health' (17.6% (44/250) later developed PE) and 82.4% (206/250) were NTN-PW. At baseline, high SHS score yielded a significantly (p < 0.05) increased adjusted odds ratio, a wider area under the curve (AUC) and a higher sensitivity and specificity for the prediction of PE (3.67; 0.898; 91.9% and 87.8%), PE coexisting with intrauterine growth restriction (2.86, 0.838; 91.5% and 75.9%), stillbirth (2.52; 0.783; 96.6% and 60.0%), hemolysis elevated liver enzymes and low platelet count (HELLP) syndrome (2.08; 0.800; 97.2% and 63.8%), acute kidney injury (2.20; 0.825; 95.3% and 70.0%) and dyslipidaemia (2.80; 0.8205; 95.7% and 68.4%) at 32-42 weeks gestation.

Conclusions

High SHS score is associated with increased incidence of PE; hence, SHSQ-25 can be used independently as a risk stratification tool for adverse pregnancy outcomes thereby creating an opportunity for predictive, preventive and personalized medicine.

HIV/HCV/HBV testing in the emergency department: a feasibility and seroprevalence study

OBJECTIVES

The aims of this study were to to assess the feasibility of simultaneous testing for the blood-borne viruses (BBV), HIV, hepatitis C (HCV) and hepatitis B (HBV), in the Emergency Department (ED) and ascertain the seroprevalence for these three viruses in this setting.

METHODS

A pilot BBV testing program was undertaken as part of routine clinical care in the ED. All ED attendees aged between 16 and 65 years old who were able to consent were tested over a 55 week period on an opt out basis. Patients with positive test results were linked to clinical services. Interventions aimed at improving testing rates were implemented and evaluated by quality improvement (QI) methodology.

RESULTS

Of 25,520 age-eligible ED attendees, 6108 (24%) underwent BBV testing; an additional 1160 (4.5%) underwent a standalone HIV test (total of 7268 (28%) individuals).There were 83/7268 (1.1%) non-negative (ie reactive or equivocal) results for HIV and 103/6108 (1.7%) and 32/6108 (0.52%) for anti-HCV IgG and HBsAg, respectively. Of these, 12 (0.17%), 16 (0.26%) and 8 (0.13%) were new reactive tests for HIV, HCV and HBV, respectively, which were able to be confirmed on a second test. Specific QI interventions led to temporary increases in testing rates.

CONCLUSIONS

An opt out BBV testing program in the ED is feasible and effective at finding new cases. However, the testing rate was low at 24%. Although QI interventions led to some improvement in testing rates, further studies are required to identify ways to achieve sustained increases in testing in this setting.

Compassionate Use of Cefiderocol as Adjunctive Treatment of Native Aortic Valve Endocarditis Due to Extremely Drug-resistant Pseudomonas aeruginosa

Serious infections such as endocarditis due to extremely drug-resistance gram-negative bacteria are an increasing challenge. Here, we present successful adjunctive use of cefiderocol for a patient with persistently bacteremic healthcare-associated native aortic valve endocarditis due to an extended-spectrum beta-lactamase-positive Pseudomonas aeruginosa susceptible in vitro only to colistin, following failure of conventional therapeutic options.

Improving patient outcomes with inguinal hernioplasty-local anaesthesia versus local anaesthesia and conscious sedation: a randomized controlled trial

PURPOSE

Conscious sedation is regularly used in ambulatory surgery to improve patient outcomes, in particular patient satisfaction. We hypothesized that the addition of conscious sedation would provide greater patient satisfaction with inguinal hernioplasty compared to local anesthesia alone.

METHODS

This trial was a single-centre, randomized, placebo-controlled, double-blinded trial where patients undergoing inguinal hernioplasty using local anaesthesia were randomized to receive local anaesthesia alone versus local anaesthesia and conscious sedation. The primary outcome of patient satisfaction was assessed using the Iowa Satisfaction with Anesthesia Scale (ISAS). The study was powered to detect a significant difference in ISAS scores between groups. Comparisons were made using T test and Chi square tests. A p value of less than 0.05 was considered significant.

RESULTS

There were 149 patients randomized: 78 to the local anesthesia (LA) group and 71 to the local anaesthesia and conscious sedation (LACS) group. For the primary outcome measure of patient satisfaction, the mean ISAS score was significantly greater in the LACS group (p = 0.009). The experience of pain and pain severity was greater in the LA group (p = 0.016; p = 0.0162 respectively). No statistically significant difference was found between groups with respect to operative time, time to discharge or postoperative complications.

CONCLUSION

The use of conscious sedation with local anesthesia for inguinal hernioplasty is safe, results in less pain experience and severity and is associated with better patient satisfaction. The use of conscious sedation does not delay patient discharge.

Extensive elemental mapping unlocks Mg/Ca ratios as climate proxy in seasonal records of Mediterranean limpets

Elemental analysis of biogeochemical archives is an established technique used to study climate in a range of applications, including ocean circulation, glacial/interglacial climates, and anthropogenic climate change. Data from mollusc archives are especially important because of their global abundance and sub-annual resolution. Despite this potential, they are underrepresented among palaeoclimate studies, due to enigmatic physiological influences skewing the elemental record. Understanding the patterns behind these influences will improve data interpretation and lead to the development of new climate proxies. Here, we show for the first time that extensive spatial mapping of multiple mollusc specimens using Laser Induced Breakdown Spectroscopy (LIBS) across a wider region can resolve enigmatic patterns within the elemental record caused by physiological influences. 2D elemental (Mg/Ca) maps of whole limpet shells (Patella caerulea) from across the Mediterranean revealed patterns of variability within individual mollusc records as well as within isochronous parts of specimens. By registering and quantifying these patterns, we established previously uninterpretable correlations with temperature (R² > 0.8, p < 0.01). This outcome redefines the possibilities of accessing sub-annual climate proxies and presents the means to assess annual temperature ranges using oxygen isotope analysis requiring only 2 samples per shell.

Zoonotic Transfer of Clostridium difficile Harboring Antimicrobial Resistance between Farm Animals and Humans

The emergence of Clostridium difficile as a significant human diarrheal pathogen is associated with the production of highly transmissible spores and the acquisition of antimicrobial resistance genes (ARGs) and virulence factors. Unlike the hospital-associated C. difficile RT027 lineage, the community-associated C. difficile RT078 lineage is isolated from both humans and farm animals; however, the geographical population structure and transmission networks remain unknown. Here, we applied whole-genome phylogenetic analysis of 248 C. difficile RT078 strains from 22 countries. Our results demonstrate limited geographical clustering for C. difficile RT078 and extensive coclustering of human and animal strains, thereby revealing a highly linked intercontinental transmission network between humans and animals. Comparative whole-genome analysis reveals indistinguishable accessory genomes between human and animal strains and a variety of antimicrobial resistance genes in the pangenome of C. difficile RT078. Thus, bidirectional spread of C. difficile RT078 between farm animals and humans may represent an unappreciated route disseminating antimicrobial resistance genes between humans and animals. These results highlight the importance of the "One Health" concept to monitor infectious disease emergence and the dissemination of antimicrobial resistance genes.

'VIOLET': a fluorescence-based simulation exercise for training healthcare workers in the use of personal protective equipment

Background

Healthcare workers caring for patients with high-consequence infectious diseases (HCIDs) require protection from pathogen exposure, for example by wearing personal protective equipment (PPE). Protection is acquired through the inherent safety of the PPE components, but also their safe and correct use, supported by adequate training and user familiarity. However, the evidence base for HCID PPE ensembles and any associated training is lacking, with subsequent variation between healthcare providers.

Aim

To develop an evidence-based assessment and training tool for evaluating PPE ensembles and doffing protocols, in the assessment of patients with suspected HCIDs.

Methods

VIOLET (Visualising Infection with Optimised Light for Education and Training) comprises a healthcare mannequin adapted to deliver simulated bodily fluids containing UV-fluorescent tracers. On demand and remotely operated, the mannequin projectile vomits (blue), coughs (red), has diarrhoea (yellow) and is covered in sweat (orange). Wearing PPE, healthcare staff participate in an HCID risk assessment and examination of the ‘patient’, thereby becoming exposed to these bodily fluids. Contamination of PPE is visualized and body-mapped under UV light before and after removal. Observational findings and participant feedback, around its use as a training exercise, is also recorded.

Findings

Significant contamination from different exposure events was seen, enabling evaluation of PPE and doffing procedures used. Observational data and participant feedback demonstrated its strengths and success as a training technique.

Conclusion

Simulation exercises using VIOLET provide evidence-based assessment of PPE ensembles, and are a valuable resource for training of healthcare staff in wearing and safe doffing of PPE.

Analysing the impacts of air quality policies on ecosystem services; a case study for Telemark, Norway

There is an increasing interest in considering the effects of air pollution on ecosystem services supply in order to enhance cost-benefit analyses of air pollution policies. This paper presents a generic, conceptual approach that can be used to link atmospheric deposition of air pollutants to ecosystem services supply and societal benefits. The approach is applied in a case study in the Telemark county of Norway. First, we examine the potential effects of four European air quality policy scenarios on N deposition in the ecosystems of this county. Second, we analyse the subsequent impacts on the supply of three ecosystem services: carbon sequestration, timber production and biodiversity. Changes in the supply of the first two services are analysed in both physical and monetary units, biodiversity effects are only analysed in physical terms. The scenarios derive from work conducted in the context of the European National Emissions Ceilings Directive. In the 2010 base case the benefits of carbon sequestration are estimated at 13 million euro per year and the value of timber harvesting at 2.9 million euro per year. Under the examined policy scenarios aiming to reduce nitrogen emissions the societal benefits resulting from these two ecosystem services in Telemark are found to be reduced; the scenarios have little effect on terrestrial biodiversity. Such results cannot be scaled up, individual ecosystem services respond differently to changes in air pollution depending upon type of pollutant, type of ecosystem, type of service, and the magnitude of change. The paper further presents an analysis of the uncertainties that need to be considered in linking air pollution and ecosystem services including those in deposition rates, ecosystem responses, human responses and in the values of ecosystem services. Our conceptual approach is also useful for larger scale analysis of air pollution effects on ecosystem services, for example at national or potentially European scale.

Use of ultraviolet-fluorescence-based simulation in evaluation of personal protective equipment worn for first assessment and care of a patient with suspected high-consequence infectious disease

BACKGROUND

Variations currently exist across the UK in the choice of personal protective equipment (PPE) used by healthcare workers when caring for patients with suspected high-consequence infectious diseases (HCIDs).

AIM

To test the protection afforded to healthcare workers by current PPE ensembles during assessment of a suspected HCID case, and to provide an evidence base to justify proposal of a unified PPE ensemble for healthcare workers across the UK.

METHODS

One 'basic level' (enhanced precautions) PPE ensemble and five 'suspected case' PPE ensembles were evaluated in volunteer trials using 'Violet'; an ultraviolet-fluorescence-based simulation exercise to visualize exposure/contamination events. Contamination was photographed and mapped.

FINDINGS

There were 147 post-simulation and 31 post-doffing contamination events, from a maximum of 980, when evaluating the basic level of PPE. Therefore, this PPE ensemble did not afford adequate protection, primarily due to direct contamination of exposed areas of the skin. For the five suspected case ensembles, 1584 post-simulation contamination events were recorded, from a maximum of 5110. Twelve post-doffing contamination events were also observed (face, two events; neck, one event; forearm, one event; lower legs, eight events).

CONCLUSION

All suspected case PPE ensembles either had post-doffing contamination events or other significant disadvantages to their use. This identified the need to design a unified PPE ensemble and doffing procedure, incorporating the most protective PPE considered for each body area. This work has been presented to, and reviewed by, key stakeholders to decide on a proposed unified ensemble, subject to further evaluation.

Team based learning in nursing and midwifery higher education; a systematic review of the evidence for change

REVIEW AIM

The aim of this study is to review the evidence in relation to the experiences and outcomes of students on nursing and/or midwifery higher education programmes, who experience team based learning.

REVIEW OBJECTIVES

To examine the relationship between team based learning and attainment for nursing and midwifery students in professional higher education. To examine the relationship between team based learning and student satisfaction for nurses and midwifery students in higher education. To identify and report examples of good practice in the implementation of team based learning in Nursing and Midwifery higher education.

DESIGN

A systematic Review of the literature was undertaken. The population were nurses and midwives studying on higher education pre and post registration professional programmes. The intervention was learning and teaching activities based on a team-based learning approach. Data sources included CINAHL and MEDLINE. ERIC and Index to Theses were also searched.

REVIEW METHODS

International research papers published in English between 2011 and 2017 that met the inclusion criteria were included in the study. Papers that met the criteria were subjected to quality appraisal and agreement amongst authors for inclusion in the review.

RESULTS

A total of sixteen papers were reviewed and four themes emerged for discussion. These were Student Engagement, Student Satisfaction, Attainment and Practice Development and Transformational Teaching and Learning.

CONCLUSIONS

There is a tentative, though growing body of evidence to support TBL as a strategy that can impact on student engagement, student satisfaction, attainment, practice development and transformative teaching and learning. The literature indicates that implementing TBL within the curriculum is not without challenge and requires a sustained and structured approach. Staff and students need to understand the processes involved, and why they should be adhered to, in the pursuit of enhanced student experiences and outcomes for nurses and midwives in Higher Education.

Incorporation of suboptimal health status as a potential risk assessment for type II diabetes mellitus: a case-control study in a Ghanaian population

Due to a paradigm shift in lifestyles, there is growing concern that type 2 diabetes mellitus (T2DM) will reach epidemic proportions in Ghana. However, specific characteristics of the disease are under explored in this region. More challenging are those yet to be diagnosed or who complain of poor health in the absence of a diagnosed disease-suboptimal health status (SHS). We conducted a study to examine various factors that characterise SHS and T2DM. Using a cross-sectional design, we recruited 264 people as controls and 241 T2DM patients from January to June 2016. The controls were categorised into high and low SHS based on how they rated on an SHS questionnaire-25 (SHSQ-25). Anthropometric and biochemical parameters: body mass index (BMI); blood pressure (BP); fasting plasma glucose (FPG); glycated haemoglobin (HbA1c); serum lipids [(total cholesterol, triglycerides (TG), high- and low-density lipoprotein-cholesterol (HDL-c and LDL-c)] were measured. The male to female ratio for T2DM and controls were 99:142 and 98:166, respectively, whilst the mean ages were 55.89 and 51.52 years. Compared to controls, T2DM patients had higher FPG (8.96 ± 4.18 vs. 6.08 ± 1.79; p < 0.0001) and HbA1c (8.23 ± 2.09 vs. 5.45 ± 1.00; p < 0.0001). Primarily sedentary [adjusted odds ratio (aOR) = 2.97 (1.38-6.39); p = 0.034)], systolic blood pressure (SBP) (p = 0.001) and diastolic blood pressure (DBP) (p = 0.001) significantly correlated with high SHS. After adjusting for age and gender, central adiposity [aOR = 1.74 (1.06-2.83); p = 0.027)], underweight [aOR = 5.82 (1.23-27.52); p = 0.018)], high SBP [aOR = 1.86 (1.14-3.05); p = 0.012)], high DBP [aOR = 2.39 (1.40-4.07); p = 0.001)] and high TG [aOR = 2.17 (1.09-4.33); p = 0.029)] were found to be independent risk factors associated with high SHS. The management of T2DM in Ghana is suboptimal and undiagnosed risk factors remain prevalent. The SHSQ-25 can be translated and applied as a practical tool to screen at-risk individuals and hence prove useful for the purpose of predictive, preventive and personalised medicine.

Profiling of cardio-metabolic risk factors and medication utilisation among Type II diabetes patients in Ghana: a prospective cohort study

BACKGROUND

Type II diabetes mellitus (T2DM) is complicated by multiple cardio-metabolic risk factors. Controlling these factors requires lifestyle modifications alongside utilisation of anti-diabetic medications. Different glucose lowering [(biguanides (BIGs), sulfonylureas (SUAs), thiazolidinediones (TNZ)], lipid lowering (statins), and anti-hypertensive medicines [angiotensin converting enzyme inhibitors (ACEIs), calcium channel blockers (CCBs), angiotensin II receptor blockers (ARBs) and central acting drugs (CADs)] have been approved for controlling hyperglycaemia, dyslipidaemia and hypertension respectively. Here, we examined factors that characterise T2DM and explored the response to medication therapy among T2DM patients.

METHODS

This prospective cohort study recruited 241 T2DM patients reporting at a clinic in Ghana, from January through to August, 2016. Each patient's demographic, medications and anthropometric data was obtained while information on medication adherence was captured using Morisky adherence scale-8 (MMAS-8). Fasting blood samples were collected for biochemical analysis.

RESULTS

The mean age of participants was 57.82 years for baseline and six-month follow-up. Physical activity differed at baseline and follow up (p < 0.05) but not body mass index (BMI). BIG alone, or in combination with SUA and TNZ did not improve glycaemic status at follow up (p > 0.05). Many participants using either ACEI or ARB were able to control their blood pressures. Among dyslipidaemia patients under statin treatment, there was an improved lipid profile at follow-up.

CONCLUSIONS

Statin medications are effective for reducing dyslipidaemia in T2DM patients. However, control of modifiable risk factors, particularly blood glucose and to a lesser degree blood pressure is suboptimal. Addressing these will require concomitant interventions including education on medication adherence and correct dietary plans, lifestyle modifications and physical activity.

A survey of scientists' awareness of and attitudes to the use of human blood products and alternatives in human assisted reproductive technology

Scientists working in assisted reproduction [members of Scientists in Reproductive Technology (SIRT) Australia, and subscribers of the online forums EmbryoMail and Quartec] were invited to complete an online questionnaire on the use of human blood products in assisted reproductive technologies (ART). A total of 260 started the questionnaire, with 208 (80%) completing it. A total of 62% of respondents had worked in human ART ≥8 years and 68% had post-graduate qualifications. The majority (82%) reported using products of animal or human origin, with 75% knowing why protein was added to culture media and 41% not worried by this. Almost half (49%) of respondents were unaware of regulations surrounding the use of human blood products in health care and 70% were unaware of adverse events involving human blood products in human ART. Most respondents (70%) indicated that they were not concerned about infections such as hepatitis, but agents such as prions were a cause for concern (57%). A total of 57% of respondents were unaware of alternatives, but 77% would use a suitable alternative. Using blood products in human ART is surrounded by a lack of awareness, often independent of respondents' qualifications or experience. A better understanding of these products and possible alternatives is required if informed decisions about their suitability are to be made.