Novel discovery of Extended Spectrum β-lactamase (ESBL) Pluralibacter gergoviae in acute urinary tract infection and urolithiasis

Introduction/Objective

This case study describes the diagnosis, treatment, whole genome sequencing (WGS) and antibiotic resistance characterization from the ESBL-producing Pluralibacter gergoviae, a multi-drug resistant organism (MDRO) with a previously-documented presence in foodstuffs and cosmetics.

Methods/Case Report

A 39-year-old Hispanic American woman was admitted to the emergency department (ED) for fever, suprapubic tenderness, and pyuria. Three days prior to admission, patient underwent elective bilateral lithotripsy for retained nephrolithiasis. Seven days prior to ED admission, patient had an “Orgasm Shot” (O-Shot) which consists of platelet rich plasma that is drawn from the patient and injected into her vulvar area and around her clitoris to increase stimulation potential during orgasm. The patient was started on broad spectrum antibiotics, receiving Vancomycin and Ceftriaxone 1 gram 1 gram IV every 12 hours, intravenously. Urine cultures yielded two organisms, including a lactose fermenting as well as a non-lactose fermenting Gram negative rod. Mass spectrometry-based identification was successful in identifying the non-lactose fermenting colony as Pseudomonas aeruginosa, which also identified from a blood culture collected from the patient upon presentation to the ED. The lactose fermenting colony resulted in no identification by mass spectrometry but was identified using biochemical methods as Pluralibacter gergoviae, a recently-reclassified taxonomy previously identified as Enterobacter gergoviae. The P. gergoviae isolate was submitted to the Multidrug-Resistant Organism Repository (MRSN) at Walter Reed Army Institute of Research (WARIR) for WGS on Illumina Miseq. Sequencing and phenotypic/ genotypic data on isolate confirmed this as an ESBL P. gergoviae organism.

Results (if a Case Study enter NA)

NA

Conclusion

Summary data on possible epidemiological associations, antibiotic susceptibility testing, antibiotic resistance genes identified, and information on the antibiotic resistance plasmids will be presented. These findings from the WGS data, antibiotic susceptibilities will provide a lessons-learned for other clinical microbiology labs on how to identify unusual organisms such as P. gergoviae.

Characterising the outcomes, impacts and implementation challenges of advanced clinical practice roles in the UK: a scoping review

OBJECTIVES

In response to demographic and health system pressures, the development of non-medical advanced clinical practice (ACP) roles is a key component of National Health Service workforce transformation policy in the UK. This review was undertaken to establish a baseline of evidence on ACP roles and their outcomes, impacts and implementation challenges across the UK.

DESIGN

A scoping review was undertaken following JBI methodological guidance.

METHODS

13 online databases (Medline, CINAHL, ASSIA, Embase, HMIC, AMED, Amber, OT seeker, PsycINFO, PEDro, SportDiscus, Osteopathic Research and PenNutrition) and grey literature sources were searched from 2005 to 2020. Data extraction, charting and summary was guided by the PEPPA-Plus framework. The review was undertaken by a multi-professional team that included an expert lay representative.

RESULTS

191 papers met the inclusion criteria (any type of UK evidence, any sector/setting and any profession meeting the Health Education England definition of ACP). Most papers were small-scale descriptive studies, service evaluations or audits. The papers reported mainly on clinical aspects of the ACP role. Most papers related to nursing, pharmacy, physiotherapy and radiography roles and these were referred to by a plethora of different titles. ACP roles were reported to be achieving beneficial impacts across a range of clinical and health system outcomes. They were highly acceptable to patients and staff. No significant adverse events were reported. There was a lack of cost-effectiveness evidence. Implementation challenges included a lack of role clarity and an ambivalent role identity, lack of mentorship, lack of continuing professional development and an unclear career pathway.

CONCLUSION

This review suggests a need for educational and role standardisation and a supported career pathway for advanced clinical practitioners (ACPs) in the UK. Future research should: (i) adopt more robust study designs, (ii) investigate the full scope of the ACP role and (iii) include a wider range of professions and sectors.

Characterising the evidence base for advanced clinical practice in the UK: a scoping review protocol

INTRODUCTION

A global health workforce crisis, coupled with ageing populations, wars and the rise of non-communicable diseases is prompting all countries to consider the optimal skill mix within their health workforce. The development of advanced clinical practice (ACP) roles for existing non-medical cadres is one potential strategy that is being pursued. In the UK, National Health Service (NHS) workforce transformation programmes are actively promoting the development of ACP roles across a wide range of non-medical professions. These efforts are currently hampered by a high level of variation in ACP role development, deployment, nomenclature, definition, governance and educational preparation across the professions and across different settings. This scoping review aims to support a more consistent approach to workforce development in the UK, by identifying and mapping the current evidence base underpinning multiprofessional advanced level practice in the UK from a workforce, clinical, service and patient perspective.

METHODS AND ANALYSIS

This scoping review is registered with the Open Science Framework (https://osf.io/tzpe5). The review will follow Joanna Briggs Institute guidance and involves a multidisciplinary and multiprofessional team, including a public representative. A wide range of electronic databases and grey literature sources will be searched from 2005 to the present. The review will include primary data from any relevant research, audit or evaluation studies. All review steps will involve two or more reviewers. Data extraction, charting and summary will be guided by a template derived from an established framework used internationally to evaluate ACP (the Participatory Evidence-Informed Patient-Centred Process-Plus framework).

DISSEMINATION

The review will produce important new information on existing activity, outcomes, implementation challenges and key areas for future research around ACP in the UK, which, in the context of global workforce transformations, will be of international, as well as local, significance. The findings will be disseminated through professional and NHS bodies, employer organisations, conferences and research papers.

Musculoskeletal (MSK) practitioners in primary care: an evaluation of a MSK core capabilities framework and review process

The General Practice Contract 2019/20 established first contact musculoskeletal (MSK) physiotherapists in primary care. This paper describes an evaluation exploring the feasibility of using the MSK Core Capabilities Framework and a peer review process to evidence capability. It discusses how this process may be developed to ensure MSK practitioners are able to evidence the level of practice required within the complex environment of primary care. MSK practitioners were supported to evidence their capabilities against the MSK Framework. Twenty-two participants took part in the evaluation of this intervention via semi-structured interviews. A robust and iterative process of qualitative data analysis was undertaken. The findings are framed in terms of Davis' Technology Acceptance Model of evaluation (i.e. user perceptions).There were a range of perceived benefits of the Framework including as a means of quality assurance, career progression, the promotion of knowledge consolidation and reflective practice. There were however, a number of 'translation into practice' issues. Given the newness of the MSK Framework, it is perhaps not surprising there is a need for refinement. This evaluation highlights key enablers for reviewing capabilities of MSK practitioners: a curriculum; educational supervision; and accreditation. Learning also applies more widely to other emerging role opportunities.

Developing a national musculoskeletal core capabilities framework for first point of contact practitioners

Objective

We aimed to support service transformation by developing a core capabilities framework for first contact practitioners working with people who have musculoskeletal conditions.

Methods

We conducted a modified three-round Delphi study with a multi-professional panel of 41 experts nominated through 18 national professional and patient organizations. Qualitative data from an open-ended question in round one were analysed using a thematic approach and combined with existing literature to shape a draft framework. Participants rated their agreement with each of the proposed 142 outcomes within 14 capabilities on a 10-point Likert scale in round two. The final round combined round two results with a wider online survey.

Results

Rounds two and three of the Delphi survey were completed by 37 and 27 participants, respectively. Ninety practitioners responded to the wider online survey. The final framework contains 105 outcomes within 14 capabilities, separated into four domains (person-centred approaches; assessment, investigation and diagnosis; condition management, intervention and prevention; and service and professional development). The median agreement for all 105 outcomes was at least nine on the 10-point Likert scale in the final round.

Conclusion

The framework outlines the core capabilities required for practitioners working as the first point of contact for people with musculoskeletal conditions. It provides a standard structure and language across professions, with greater consistency and portability of musculoskeletal core capabilities. Agreement on each of the 105 outcomes was universally high amongst the expert panel, and the framework is now being disseminated by Health Education England, NHS England and Skills for Health.

The TspanC8 subgroup of tetraspanins interacts with A disintegrin and metalloprotease 10 (ADAM10) and regulates its maturation and cell surface expression

A disintegrin and metalloprotease 10 (ADAM10) is a ubiquitous transmembrane metalloprotease that cleaves the extracellular regions from over 40 different transmembrane target proteins, including Notch and amyloid precursor protein. ADAM10 is essential for embryonic development and is also important in inflammation, cancer, and Alzheimer disease. However, ADAM10 regulation remains poorly understood. ADAM10 is compartmentalized into membrane microdomains formed by tetraspanins, which are a superfamily of 33 transmembrane proteins in humans that regulate clustering and trafficking of certain other transmembrane "partner" proteins. This is achieved by specific tetraspanin-partner interactions, but it is not clear which tetraspanins specifically interact with ADAM10. The aims of this study were to identify which tetraspanins interact with ADAM10 and how they regulate this metalloprotease. Co-immunoprecipitation identified specific ADAM10 interactions with Tspan5, Tspan10, Tspan14, Tspan15, Tspan17, and Tspan33/Penumbra. These are members of the largely unstudied TspanC8 subgroup of tetraspanins, all six of which promoted ADAM10 maturation. Different cell types express distinct repertoires of TspanC8 tetraspanins. Human umbilical vein endothelial cells express relatively high levels of Tspan14, the knockdown of which reduced ADAM10 surface expression and activity. Mouse erythrocytes express predominantly Tspan33, and ADAM10 expression was substantially reduced in the absence of this tetraspanin. In contrast, ADAM10 expression was normal on Tspan33-deficient mouse platelets in which Tspan14 is the major TspanC8 tetraspanin. These results define TspanC8 tetraspanins as essential regulators of ADAM10 maturation and trafficking to the cell surface. This finding has therapeutic implications because focusing on specific TspanC8-ADAM10 complexes may allow cell type- and/or substrate-specific ADAM10 targeting.

Generic, symptom based, exercise rehabilitation; integrating patients with COPD and heart failure

BACKGROUND

Patients with Chronic Heart Failure (CHF) develop similar symptoms of exertional breathlessness and fatigue as patients with COPD. Although pulmonary (exercise based) rehabilitation (PR) is an integral part of the management of COPD, the potential for exercise rehabilitation (ER) to assist patients with CHF may not be as readily appreciated. We investigated whether combined ER for patients with CHF and COPD was feasible and effective using the model of PR.

METHODS

57 patients with CHF were randomized 2:1 to 7 weeks ER (CHF-ER) or 7 weeks of usual care (CHF-UC). As a comparator 55 patients with COPD were simultaneously recruited to the same ER program (COPD-ER). The primary outcome measure was the Incremental Shuttle Walk Test (ISWT) and the secondary outcome measures were the Endurance Shuttle Walk Test (ESWT), isometric quadriceps strength and health status.

RESULTS

27 CHF and 44 COPD patients completed ER and 17 patients with CHF completed UC. The CHF-ER group made significant improvements, compared to CHF-UC, in the mean (95%CI) ISWT distance; 62(35-89)m vs -6(-11 to 33)m p < 0.001. The CHF-ER group also made statistically significant improvements in health status. The improvements in exercise performance and health status were similar between patients with CHF and COPD, treated with ER.

CONCLUSION

Patients with CHF who undergo ER improve similarly in their exercise performance and health status to COPD. Combined training programs for COPD and CHF are effective and feasible, such that service provision could be targeted around common disability rather than the primary organ disease.