[Open educational resources for otorhinolaryngology : A pilot study on needs assessment and implementation]

BACKGROUND

Open educational resources (OER) are educational materials licensed openly by authors, permitting usage, redistribution, and in some instances, modification. OER platforms thereby serve as a medium for distributing and advancing teaching materials and innovative educational methodologies.

OBJECTIVE

This study aims to determine the present state of OER in otorhinolaryngology and to examine the prerequisites for seamlessly integrating OER into the curricular teaching of medical schools, specifically through the design of two OER blended learning modules.

METHODS

OER content in the field of otorhinolaryngology was analyzed on OER platforms, ensuring its relevance to the German medical curriculum. Data protection concerns were addressed with legal counsel. The blended learning modules were developed in collaboration with medical students and subsequently published as OER.

RESULTS AND CONCLUSION

This project yielded the first OER from a German ENT department, tailored to the German medical curriculum. One significant barrier to OER use in medicine, more than in other fields, is data protection. This challenge can be navigated by obtaining consent to publish patient data as OER. OER hold the promise to play a pivotal role in fostering cooperation and collaboration among educators, aiding educators in lesson preparation, and simultaneously enhancing didactic quality.

Acute Exacerbation of Chronic Obstructive Pulmonary Disease Due to Carbapenem-Resistant Klebsiella pneumoniae-Induced Pneumonia: Clinical Features and Prognostic Factors

Purpose

Carbapenem-resistant Klebsiella pneumoniae (CRKP) is closely related to respiratory tract infection. The aim of this study was to investigate the clinical features and prognostic factors of CRKP-induced pneumonia in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients.

Methods

A single-centre, retrospective case-control study on COPD patients hospitalized for acute exacerbation and CRKP-induced pneumonia was conducted from January 1, 2016, to December 31, 2022. The mortality rate of acute exacerbation due to CRKP-induced pneumonia was investigated. The patients were divided into the CRKP-induced pneumonic acute exacerbation (CRKPpAE) group and the non-CRKP-induced pneumonic acute exacerbation (non-CRKPpAE) group, and the clinical characteristics and prognostic factors were compared using univariate analysis and multivariate analysis.

Results

A total of 65 AECOPD patients were included, composed of 26 patients with CRKPpAE and 39 patients with non-CRKPpAE. The mortality rate of CRKPpAE was 57.69%, while non-CRKPpAE was 7.69%. Compared with non-CRKPpAE, a history of acute exacerbation in the last year (OR=8.860, 95% CI: 1.360-57.722, p=0.023), ICU admission (OR=11.736, 95% CI: 2.112-65.207, p=0.005), higher NLR levels (OR=1.187, 95% CI: 1.037-1.359, p=0.013) and higher D-dimer levels (OR=1.385, 95% CI: 1.006-1.905, p=0.046) were independently related with CRKPpAE. CRKP isolates were all MDR strains (26/26, 100%), and MDR strains were also observed in non-CRKP isolates (5/39, 12.82%).

Conclusion

Compared with non-CRKPpAE, CRKPpAE affects the COPD patient's condition more seriously and significantly increases the risk of death.

Vagococcus fluvialis isolation from the urine of a bladder cancer patient: a case report

Vagococcus fluvialis infection is rare in humans, and there is limited research on the clinical manifestations and antimicrobial susceptibility testing of Vagococcus fluvialis infection. Here, We isolated Vagococcus fluvialis from the urine samples of bladder cancer patients at Hunan Provincial People's Hospital, and it is the first reported case of Vagococcus fluvialis isolated from the urine. The fully automated microbial identification system and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) identified the bacterium as Vagococcus fluvialis with a confidence level of 99.9%. The VITEK-2Compact fully automated microbial susceptibility analysis system indicated that it was most sensitive to tigecycline, vancomycin, quinupristin/dalfopristin, linezolid, and showed moderate sensitivity to erythromycin, levofloxacin, ciprofloxacin, ampicillin/sulbactam, and tetracycline. Additionally, it exhibited synergy when combined with high-level gentamicin and vancomycin, showing sensitivity. However, it displayed poor activity against penicillin and furanth. According to our knowledge, this is the first study to isolate and identify Vagococcus fluvialis from the urine of bladder cancer patients and the systematically reviewed other reported Vagococcus infections on human, which provide an experimental basis for guiding the rational use of drugs in the clinical treatment and diagnose of Vagococcus fluvialis infection and related pathogenic mechanism research. Meanwhile, we have systematically reviewed other reported.

[Thinking on ideological and political education in Medical Parasitology teaching]

With the deepening reform of ideological and political education, Medical Parasitology teaching needs to update the teaching concept, change the teaching ideas, as well as keep trying to combine ideological and political education with the curriculum content closely. In addition to teaching students' basic knowledge and practical skills, teachers are needed to cultivate their moral literacy and political awareness through course teaching, so as to provide the basis for students' subsequent adaptations to social environments and jobs. Currently, the study of ideological and political education in Medical Parasitology teaching is still in the exploratory stage. Therefore, colleges and universities need to carry out effective construction of ideological and political education in Medical Parasitology teaching, in order to achieve good teaching outcomes and provide insights into ideological and political education in teaching.

Fluviispira vulneris sp. nov., isolated from human wound secretions

Human infections by environmental bacteria is becoming an increasing problem and has become a matter of great concern due to the adverse effects worldwide. In this study, we reported a new environmental pathogen. Isolate GX5518T was a novel Gram-negative, aerobic, non-motile, pleomorphic and red-pigmented bacterium, was isolated from human wound secretions (GuangXi, People's Republic of China). Growth occurred at pH 6.0-8.0 (optimum, pH 7.0) and 10-37 °C (optimum, 28-32 °C) with 0-1.5% (w/v) NaCl in R2A agar. Comparative analysis of the 16S rRNA gene sequences revealed that isolate GX5518T was closely related to Fluviispira sanaruensis JCM 31447T (99.73%) and Fluviispira multicolorata 33A1-SZDPT (98.49%). However, the estimated ANI values of the isolate GX5518T compared to the F. sanaruensis JCM 31447T and F. multicolorata 33A1-SZDPT were 88.67% and 77.35%, respectively. The estimated dDDH, ANI and AAI values between isolate GX5518T and its closely related strains were below the threshold values generally considered for recognizing a new species. The genome size was 3.6 Mbp and the DNA G + C content was 33.1%. The predominant fatty acids (> 5%) in GX5518T cells were iso-C15:0, C16:0, C17:0, C17:1 ω8c and C16:1 ω7c/C16:1 ω6c. The major menaquinone was MK-8 (86.9%). The polar lipids were phosphatidylethanolamine (PE), phosphatidylglycerol (PG) and three unknown lipids (L1-3). The chemical composition was different from that of the F. sanaruensis JCM 31447T. Comparative genomics analysis between isolate GX5518T and its related strains revealed that there were a number of genes involved in resistance to antibiotics and toxic compounds in isolate GX5518T, which were responsible for the copper homeostasis, cobalt-zinc-cadmium resistance, resistance to fluoroquinolones, and zinc resistance. Based on the phenotypic, chemotaxonomic, and genomic analyses, isolate GX5518T (= CGMCC 1.18685T = KCTC 82149T) represents a novel species of the genus Fluviispira, for which the name Fluviispira vulneris sp. nov. is proposed.

Therapeutic potential of vasculogenic mimicry in urological tumors

Angiogenesis is an essential process in the growth and metastasis of cancer cells, which can be hampered by an anti-angiogenesis mechanism, thereby delaying the progression of tumors. However, the benefit of this treatment modality could be restricted, as most patients tend to develop acquired resistance during treatment. Vasculogenic mimicry (VM) is regarded as a critical alternative mechanism of tumor angiogenesis, where studies have demonstrated that patients with tumors supplemented with VM generally have a shorter survival period and a poorer prognosis. Inhibiting VM may be an effective therapeutic strategy to prevent cancer progression, which could prove helpful in impeding the limitations of lone use of anti-angiogenic therapy when performed concurrently with other anti-tumor therapies. This review summarizes the mechanism of VM signaling pathways in urological tumors, i.e., prostate cancer, clear cell renal cell carcinoma, and bladder cancer. Furthermore, it also summarizes the potential of VM as a therapeutic strategy for urological tumors.

Coexistence of Dirac points and nodal chains in photonic metacrystal

Gapless topological phases, i.e. topological semimetals, come in various forms such as Weyl/Dirac semimetals, nodal line/chain semimetals, and surface-node semimetals. However, the coexistence of two or more topological phases in a single system is still rare. Here, we propose the coexistence of Dirac points and nodal chain degeneracies in a judiciously designed photonic metacrystal. The designed metacrystal exhibits nodal line degeneracies lying in perpendicular planes, which are chained together at the Brillouin zone boundary. Interestingly, the Dirac points, which are protected by nonsymmorphic symmetries, are located right at the intersection points of nodal chains. The nontrivial Z₂ topology of the Dirac points is revealed by the surface states. The Dirac points and nodal chains are located in a clean frequency range. Our results provide a platform for studying the connection between different topological phases.

Dirac-Weyl semimetal in photonic metacrystals

Dirac-Weyl semimetal is a novel type of topological phase that features the coexistence of Dirac and Weyl points in momentum space. In this study, a photonic Dirac-Weyl semimetal is proposed by introducing screw rotation symmetries into a spatial inversion symmetry-lacking system. A realistic metacrystal structure is designed for experimental consideration. The screw rotation symmetries are crucial for the existence of Dirac points, whose Z₂ topology is revealed by the (010) surface states. Meanwhile, two pairs of ideal Weyl points at the same frequency are protected by D_2d point group symmetries. The Dirac points and Weyl points reside in a clean frequency interval. The proposed photonic Dirac-Weyl semimetal provides a versatile platform for exploring the interaction between Dirac and Weyl semimetals and exploiting possible photonic topological devices.

Catchment sourcing urban pesticide pollution using constructed wetlands in Melbourne, Australia

A survey of 111 urban constructed stormwater wetlands (median watershed area = 86.8 ha) was conducted to identify the major pesticides present and to determine their major catchment sources (residential, industrial, commercial, sporting ovals) and associations with catchment imperviousness. Melbourne, Australia, has separate stormwater and sewerage systems and these wetlands are designed to treat urban stormwater. To maximise the pesticides that could be detected, three types of passive samplers (POCIS, Chemcatcher® SDB-XC and Chemcatcher® C18) were deployed, along with collection of fine sediments. A total of 231 pesticides were screened using these methods. Pesticides that were detected in >5 % of wetlands were checked to determine their registered use in urban areas using an Australian government database (PubCris). Twenty-five pesticides were detected in >5 % of wetlands: 4 pesticides were associated with non-urban land uses (agriculture and forests), another 4 pesticides had no known registered use in urban areas and 17 were associated with urban areas. The pesticides associated with urban areas were the herbicides simazine, diuron, metolachlor, bromacil, propyzamide and paclobutrazol, the fungicides tebuconazole, propiconazole, metalaxyl, trifloxystrobin, iprodione and carbendazim and the insecticides fipronil, bifenthrin, chlorantraniliprole, thiamethoxam and permethrin. Atrazine was also detected in 59 % of wetlands but has not been registered for urban uses in Australia since 2010. It's presence in Melbourne may be due to legacy issues or aerial transportation from rural areas where it's still widely used in crop cultivation. Generally, the major urban catchment source of pesticides is from residential areas (particularly fipronil and simazine), most likely in wood preservatives, paints and from weed or insect control. Many of these widely used pesticides were correlated with increased catchment imperviousness. Some pesticides (bromacil and imidacloprid) were correlated with commercial premises and chlorantraniliprole was correlated with the presence of sporting ovals in the catchment. No pesticides were specifically correlated with industrial areas. The use of passive samplers and fine sediments, in conjunction with detailed land use mapping of stormwater wetland catchments is very effective and efficient in monitoring and sourcing pesticide contamination in urban environments.

1088 A QUALITY IMPROVEMENT PROJECT TO IMPROVE END OF LIFE CARE DOCUMENTATION ON A CARE OF THE ELDERLY WARD

Introduction

The National End of Life Care Strategy highlighted the need for individualised care plans accessible to the multi-disciplinary team. Care planning tools have been shown to improve documentation, with proformas providing a systematic approach to recording EOL discussions. Our initial staff survey highlighted a lack of familiarity with required EOLC documentation. We aimed to increase awareness of existing documentation proformas and to improve EOLC documentation on an elderly care ward.

Methods

A Driver Diagram increased understanding of the principles underlying excellent EOLC and aided development of change ideas. The Model for Improvement allowed identification of measurable aims. 20 patient notes were reviewed fortnightly, including patients who had died since the previous intervention.

Results

Three PDSA cycles were completed, changes were measured by evaluating patient documentation. The first PDSA cycle involved providing training to nursing colleagues. Step-by-step teaching on the use of Cerner EOL documentation demonstrated a 15% increase in completed care plans. The second cycle (placing posters around the ward) - detailing how to access and document care plans resulted in a 5% increase. The third cycle (25% improvement) involved education sessions for ward doctors.

Conclusions

Comprehensive documentation is key to ensuring good EOLC, as it enables continuity of care and improves MDT communication. Withdrawal of the Liverpool Care Pathway resulted in a need for individualised care plans. Active interventions including face-to-face teaching were more effective than passive (posters) in improving documentation. Limitations included small sample sizing, likely due to a lack of engagement with questionnaires and inclusion criteria. Only documentation of deceased patients was analysed, excluding patients discharged home or transferred to hospice. We aim to extend to other elderly care wards and to integrate documentation training into junior doctor induction. A review of existing EOL proformas and their ease of access may also be considered.

95 EXPLORING HIP FRACTURE OUTCOMES IN POST-ACUTE REHABILITATION: A MULTI-SITE AUDIT

Background

In 2020, 28% of all hip fractures in Ireland were discharged to off-site rehabilitation. The annual Irish Hip Fracture Database (IHFD) report captures patient outcomes at the point of acute discharge however patient outcomes at discharge from offsite rehabilitation are unknown.

Methods

A multi-site retrospective audit was completed examining hip fracture outcomes for patients admitted to four post-acute rehabilitation hospitals during 2021, using IHFD HIPE portals as well as local databases. Descriptive statistics including demographics, pre-fracture mobility as well as outcomes measured including acute length of stay, rehabilitation length of stay, discharge destination and independence with mobility on discharge from rehabilitation. A comparison analysis between sites was completed.

Results

A total of 445 patients were admitted post hip fracture to the four rehabilitation hospitals in 2021. Most were female (69%, n=307), mean age 82.5, 49% lived alone and most (55%) had low pre-fracture mobility as measured by New Mobility Score of 0-6. The mean acute length of stay was 11.8 days and rehabilitation stay 37.6 days. Most (90.2% of complete data, n=333) discharged home, 4.5% (n=17) were transferred to hospital, 3.2% (n=12) were newly admitted to nursing home and 1% (n=4) died. Most (82.2% of complete data, n=256) were independently mobile (CAS 6) at discharge from rehabilitation. There was no significant difference in patient profile between sites however there were significant difference in both acute length of stay (median range 8-13days) as well as rehabilitation length of stay (median range 16-39days).

Conclusion

The findings of this audit provide a new perspective on recovery post hip fracture and insight into longer term hip fracture outcomes. It shows that data collection is feasible in off-site rehabilitation units and should be considered for inclusion in the IHFD. Further work could explore the establishment of standards of care in the post-acute phase of hip fracture rehabilitation.

The effectiveness of passive sumps and static cowls in reducing radon levels in new build Irish dwellings

The most cost-effective way of protecting the population from radon is to ensure that new dwellings are built to prevent the entry of this gas from the ground below the building. One of the most common methods used to protect buildings from radon is the installation of a system to depressurize the subsoil below the building, reducing the ingress of the gas indoors. Laboratory based research has shown that the use of a wind-driven passive radon sump and static cowl has significant potential to protect new buildings in Ireland through depressurization. A field trial of this system was carried out in a sample of new Irish dwellings built to the requirements of Irish Building Regulations. The study focused on six unoccupied, adjacent, south-east facing dwellings of identical construction. The variables of occupancy, geology, building type, building material and weather were all controlled for, consequently, the study was carried out under highly controlled conditions. The radon levels in each of the dwellings were measured over a 6-week period under three test conditions: the passive sump closed, the passive sump open and the passive sump open with a static cowl installed. The results show an average reduction of 65% in radon levels due to the installation of a wind-driven passive sump. The cumulative effect of the installation of a passive sump plus a static cowl was an average reduction in radon levels of 75%. The number of observations that exceed the Government's Reference Level for dwellings of 200 Bq/m³ was reduced from 38% with the passive sump closed to 9% when the passive radon sump was in operation and 0% when both the passive radon sump and static cowl were installed. These results are statistically significant, and the cost is estimated at €100 per dwelling. The study concludes that the installation of a passive sump fitted with a static cowl in new dwellings is a low cost, effective method of reducing radon exposure in new Irish dwellings.

Pesticide use and risk of systemic autoimmune diseases in the Agricultural Health Study

BACKGROUND

Systemic lupus erythematosus (SLE) risk has been associated with pesticide use, but evidence on specific pesticides or other agricultural exposures is lacking. We investigated history of pesticide use and risk of SLE and a related disease, Sjögren's syndrome (SS), in the Agricultural Health Study.

METHODS

The study sample (N = 54,419, 52% male, enrolled in 1993-1997) included licensed pesticide applicators from North Carolina and Iowa and spouses who completed any of the follow-up questionnaires (1999-2003, 2005-2010, 2013-2015). Self-reported cases were confirmed by medical records or medication use (total: 107 incident SLE or SS, 79% female). We examined ever use of 31 pesticides and farm tasks and exposures reported at enrollment in association with SLE/SS, using Cox regression to estimate hazard ratios (HR) and 95% confidence intervals (CI), with age as the timescale and adjusting for gender, state, and correlated pesticides.

RESULTS

In older participants (>62 years), SLE/SS was associated with ever use of the herbicide metribuzin (HR 5.33; 95%CI 2.19, 12.96) and applying pesticides 20+ days per year (2.97; 1.20, 7.33). Inverse associations were seen for petroleum oil/distillates (0.39; 0.18, 0.87) and the insecticide carbaryl (0.56; 0.36, 0.87). SLE/SS was inversely associated with having a childhood farm residence (0.59; 0.39, 0.91), but was not associated with other farm tasks/exposures (except welding, HR 2.65; 95%CI 0.96, 7.35).

CONCLUSIONS

These findings suggest that some agricultural pesticides may be associated with higher or lower risk of SLE/SS. However, the overall risk associated with farming appears complex, involving other factors and childhood exposures.

817 AVOIDING THAT SINKING FEELING: A QIP TO IMPROVE THE IDENTIFICATION OF POSTURAL HYPOTENSION ON A MEDICINE FOR THE ELDERLY WARD

Background

Postural hypotension contributes significantly to falls in frail older people. The RCP recommend that all inpatients >65 years have a lying and standing blood pressure (L&SBP) performed early. We recognised that there was a need to improve the understanding, measurement and consistency of documentation for L&SBP on our ward, a 20-bedded acute MFE ward with many patients at risk of falls.

Methods

This project incorporates two PDSA cycles with three data collection points. We began with baseline measurements of the proportion of patients with: 1) L&SBP recorded within two working days of arrival 2) BP recorded at 1 and 3 minutes, and 3) documentation of associated symptoms. Patients were excluded where it was not possible or appropriate to perform L&SBP. We then carried out a qualitative questionnaire to understand the barriers for staff performing L&SBPs and potential solutions. Our first intervention was to design and deliver a teaching session to all nurses and health care assistants. After re-audit, we created a poster highlighting guidelines for measuring and documenting L&SBPs, and reinforced the learning at MDMs We reviewed the notes of all eligible patients on the ward before and after each intervention.

Results

Our questionnaire revealed useful insights including time constraints and uncertainty of where to document results—these findings allowed us to develop bespoke training for our team.

Discussion

This project demonstrates that junior doctor-led teaching and working with MDT colleagues improves the identification of postural hypotension on a ward. Reinforcement of learning is important.

702 COMMUNICATION CHALLENGES BETWEEN DOCTORS & RELATIVES DURING THE COVID-19 PANDEMIC: SIMPLE INTERVENTIONS WITH MEANINGFUL IMPACT

Background

& Aims Visiting restrictions during the COVID-19 pandemic resulted in reduced and inconsistent communication with the next-of-kin of elderly inpatients. This project aimed to improve communication between doctors and patients’ relatives in accordance with the GMC Good Medical Practice guidelines which outline that doctors ‘must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.

Methods

We created a virtual whiteboard on an elderly care ward in an inner London hospital documenting patient demographics, details of named next-of-kin and when they had been contacted. We aimed to update next-of-kin within 48-hours of ward admission and subsequently twice weekly. The outcome was measured via identical ‘pre- and post-intervention’ questionnaires recording the next-of-kin’s satisfaction with communication from the doctors. Questionnaires included 11 questions utilising a 5-point Likert scale for satisfaction. Results were anonymised and analysed using Microsoft Excel.

Results

Satisfaction with communication improved in 10 of the 11 domains of the questionnaire following intervention. Cumulative satisfaction scores post-intervention (N = 13) in comparison to pre-intervention (N = 25) were closer to the total possible satisfaction score per question for these 10 domains. The mean cumulative satisfaction score across all domains was 60% post-intervention compared with 44% pre-intervention. Satisfaction following intervention was particularly improved in the domains of frequency of communication (60% post-intervention.

32.8% pre-intervention) and how adequately questions and concerns were addressed (69.2% post-intervention; 45.6% pre-intervention).

Conclusion

During the COVID-19 pandemic healthcare professionals have had to adapt in communicating with patients’ next-of-kin. Our Introduction of robust standards and a virtual whiteboard to track communication resulted in improved satisfaction and proved useful in adapting to remote communication. We propose that similar practice and standards are extended across additional wards to encourage widespread optimal and consistent communication between doctors and patients’ relatives, an integral part of patient care.

Round Cells in Diagnostic Semen Analysis: A Guide for Laboratories and Clinicians

Round cells in seminal fluid are defined as either leucocytes or immature germ cells. Laboratories undertaking semen analysis often report these combined as a concentration, with no further review, comment or direction for clinician action or review. Although numerous publications discuss the possible clinical relevance of these cells (particularly leucocytes) in infertility, the methods employed to differentiate them are often beyond the scope of most diagnostic laboratories. This paper aims to support healthcare scientists in understanding the clinical significance of round cells and aid their identification, differentiation and interpretation. This will support the quality of care the patient receives and direct clinicians to further considerations that may be appropriate for their patient and should consequently reduce indiscriminate and unnecessary use of antibiotics.

Estimating population lung cancer risk from radon using a resource efficient stratified population weighted sample survey protocol - Lessons and results from Ireland

A 2018 estimate indicates that there were 226,057 radon-attributable lung cancer deaths in 66 countries that had representative radon surveys. This is a shocking figure, and as it comes from only 66 countries it underestimates the worldwide death toll. Any research that enables countries to conduct representative radon surveys and to understand better the risk to citizens from radon is surely welcome. We hope this paper provides a useful methodology for estimating population risk. The estimation of population weighted average indoor radon levels requires statistically valid sampling methodologies that use a representative sample of occupied homes throughout the country. A literature review indicates that in many population weighted surveys, the sampling methodology may not have been designed to do this. This paper describes a simple, resource efficient methodology which produces statistically valid and reliable estimates based on a small scale sample that is representative of the population distribution. The resource efficient design of this study enables it to be repeated at frequent intervals providing for a longitudinal analysis of the population risk from indoor radon. This survey was conducted in Ireland using 653 measurements and a representative sampling strategy to provide a baseline population weighted radon exposure for future comparisons. This study estimates the average population weighted indoor radon concentration in Ireland to be 97.83 Bq m^-3 (95% Confidence Interval 90.69 Bq m^-3 to 105.53 Bq m^-3), and that there are an estimated 350 lung cancer cases and 255 deaths per year due to radon exposure. The mortality rate of 5.3 per 100,000 due to indoor radon, demonstrates that radon remains one of the highest preventable causes of death in Ireland.

115 Multi-Disciplinary Simulation Training on Delirium

Introduction

Delirium is still perceived as a “geriatric medicine competency”, despite its high prevalence across most specialties. Collective multi-disciplinary team performance in implementation of multi-component interventions is key. Simulation training incorporates the complex interplay of non-technical factors, specifically, role recognition and empowerment, inter-personal skills and teamwork that are pivotal in delivering effective delirium care.

Methods

Funding was approved by Health Education England. 2 pilot teaching sessions were arranged in the simulation ward. 3 scenarios were developed, each requiring a facilitator, an actor and three participants- a foundation-year doctor, a nurse/healthcare assistant and a therapist. Scenario 1 dealt with a patient with hypoactive delirium with focus on identification and multidisciplinary optimisation. Scenario 2 challenged participants with management of an agitated patient. Scenario 3 involved discharging a patient with resolving delirium and a reluctant relative, with emphasis on mental capacity assessment. Communication, patient risk assessment and challenging perceived role barriers were global themes. Participant feedback was captured using unstructured interviews and pre- and post-session 5-point Likert confidence scale in various learning outcomes.

Results

16 participants were included- 4 foundation year doctors, 3 therapists, 2 healthcare assistants and 7 nurses. There was an average improvement in Likert confidence scales in all measured learning outcomes. All participants would recommend the course to their colleagues (average Likert scale 4.9). Qualitative feedback appraised the course for demonstration of de-escalation communication strategies, the application of mental capacity and recognition of early discharge planning.

Conclusion

Simulation training targeted at multi-disciplinary groups is an effective way to deliver teaching on delirium. It contextualises synergistic operation of different skills and personal accountability in influencing patient management. The challenge to its potential remains its adoption as mandatory training for various disciplines involved in care of older adults and its implementation at a wider-scale, to assure cost effectiveness.

Adverse childhood experiences during childhood and academic attainment at age 7 and 11 years: an electronic birth cohort study

OBJECTIVES

Adverse childhood experiences (ACEs) have a negative impact on childhood health, but their impact on education outcomes is less well known. We investigated whether or not ACEs were associated with reduced educational attainment at age 7 and 11 years.

STUDY DESIGN

The study design used in the study is a population-based electronic cohort study.

METHODS

We analysed data from a total population electronic child cohort in Wales, UK. ACEs (exposures) were living with an adult household member with any of (i) serious mental illness, (ii) common mental disorder (CMD), (iii) an alcohol problem; (iv) child victimisation, (v) death of a household member and (vi) low family income. We used multilevel logistic regression to model exposure to these ACEs and not attaining the expected level at statutory education assessments, Key Stage (KS) 1 and KS2 separately, adjusted for known confounders including perinatal, socio-economic and school factors.

RESULTS

There were 107,479 and 43,648 children included in the analysis, with follow-up to 6-7 years (KS1) and 10-11 years (KS2), respectively. An increased risk of not attaining the expected level at KS1 was associated with living with adult household members with CMD (adjusted odds ratio [aOR]: 1.13 [95% confidence interval [CI]: 1.09-1.17]) or an alcohol problem (adjusted odds ratio [aOR]: 1.16 [95% confidence interval [CI]: 1.10-1.22]), childhood victimisation (adjusted odds ratio [aOR]: 1.58 [95% confidence interval [CI]: 1.37-1.82]), death of a household member (adjusted odds ratio [aOR]: 1.14 [95% confidence interval [CI]: 1.04-1.25]) and low family income (adjusted odds ratio [aOR]: 1.92 [95% confidence interval [CI]: 1.84-2.01]). Similar results were observed for KS2. Children with multiple adversities had substantially increased odds of not attaining the expected level at each educational assessment.

CONCLUSION

The educational potential of many children may not be achieved due to exposure to adversity in childhood. Affected children who come in to contact with services should have relevant information shared between health and care services, and schools to initiate and facilitate a coordinated approach towards providing additional support and help for them to fulfil their educational potential, and subsequent economic and social participation.

A Low Vision Reading Comprehension Test

The Low Vision Reading Comprehension Assessment (LVRCA) uses an 18-sentence cloze format in two equivalent forms to measure understanding of print reading by persons with macular degeneration. It requires nine minutes to administer and thus can be used in clinical settings. This article describes its development and a study of the reliability and validity of the LVRCA tested on 50 persons with macular degeneration.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Domesticated equine species and their derived hybrids differ in their fecal microbiota

BACKGROUND

Compared to horses and ponies, donkeys have increased degradation of dietary fiber. The longer total mean retention time of feed in the donkey gut has been proposed to be the basis of this, because of the increased time available for feed to be acted upon by enzymes and the gut microbiota. However, differences in terms of microbial concentrations and/or community composition in the hindgut may also underpin the increased degradation of fiber in donkeys. Therefore, a study was conducted to assess if differences existed between the fecal microbiota of pony, donkey and hybrids derived from them (i.e. pony × donkey) when fed the same forage diet.

RESULTS

Fecal community composition of prokaryotes and anaerobic fungi significantly differed between equine types. The relative abundance of two bacterial genera was significantly higher in donkey compared to both pony and pony x donkey: Lachnoclostridium 10 and 'probable genus 10' from the Lachnospiraceae family. The relative abundance of Piromyces was significantly lower in donkey compared to pony × donkey, with pony not significantly differing from either of the other equine types. In contrast, the uncultivated genus SK3 was only found in donkey (4 of the 8 animals). The number of anaerobic fungal OTUs was also significantly higher in donkey than in the other two equine types, with no significant differences found between pony and pony × donkey. Equine types did not significantly differ with respect to prokaryotic alpha diversity, fecal dry matter content or fecal concentrations of bacteria, archaea and anaerobic fungi.

CONCLUSIONS

Donkey fecal microbiota differed from that of both pony and pony × donkey. These differences related to a higher relative abundance and diversity of taxa with known, or speculated, roles in plant material degradation. These findings are consistent with the previously reported increased fiber degradation in donkeys compared to ponies, and suggest that the hindgut microbiota plays a role. This offers novel opportunities for pony and pony × donkey to extract more energy from dietary fiber via microbial mediated strategies. This could potentially decrease the need for energy dense feeds which are a risk factor for gut-mediated disease.

Cyclosporiasis Epidemiologically Linked to Consumption of Green Onions: Houston Metropolitan Area, August 2017

ABSTRACT

During July 2017, Texas public health officials noted an increase in the number of reported cyclosporiasis cases. They detected a cluster in the Houston metropolitan area that involved four locations of a Mediterranean restaurant chain, restaurant A. A case-control study was conducted among patrons of restaurant A to identify a common food vehicle among items containing fresh produce. In matched case-control ingredient-level analyses that included both probable and confirmed cases, consumption of green onions, red onions, tomatoes, and cabbage was significantly associated with illness. A substantial percentage of case patients reported consumption of green onions, and only green onions remained statistically significantly associated with illness, whether probable and confirmed cases were included in analyses (matched odds ratio: 11.3; 95% confidence interval: 2.5 to 104.7), or only confirmed cases were included in analyses (matched odds ratio: 17.6; 95% confidence interval: 2.5 to 775.7). These results provide evidence that green onions were the likely vehicle of infection. It was not possible to trace the green onions to their source due to the need to redirect public health resources to Hurricane Harvey response efforts in Texas.

HIGHLIGHTS

Seasonal abundance of the stable fly Stomoxys calcitrans in southwest England

The stable fly Stomoxys calcitrans (L.) is a cosmopolitan biting fly of both economic and welfare concern, primarily as a result of its painful bite, which can cause blood loss, discomfort and loss of productivity in livestock. Between June and November in 2016 and May and December in 2017, Alsynite sticky-traps were deployed at four Donkey Sanctuary sites in southwest England, which experience recurrent seasonal biting fly problems. The aim was to evaluate the seasonal dynamics of the stable fly populations and the risk factors associated with abundance. In total, 19 835 S. calcitrans were trapped during the study period. In both years, abundance increased gradually over summer months, peaking in late August/September. There were no relationships between seasonally detrended abundance and any climatic factors. Fly abundance was significantly different between sites and population size was consistent between years at three of the four sites. The median chronological age, as determined by pteridine analysis of flies caught live when blood-feeding, was 4.67 days (interquartile range 3.8-6.2 days) in males and 6.79 days (interquartile range 4.8-10.4 days) in females; there was no significant, consistent change in age or age structure over time, suggesting that adult flies emerge continuously over the summer, rather than in discrete age-related cohorts. The data suggest that flies are more abundant in the vicinity of active animal facilities, although the strong behavioural association between flies and their hosts means that they are less likely to be caught on traps where host availability is high. The implications of these results for fly management are discussed.

Development and validation of a nomogram to predict the risk of occult cervical lymph node metastases in cN0 squamous cell carcinoma of the tongue

We have explored the relations between clinicopathological features and cervical lymph node metastases (LNM) in patients with cN0 squamous cell carcinoma (SCC) of the tongue, and developed and validated a nomogram for predicting the risk of their development. Clinical data on 230 patients with cN0 SCC of the tongue who had had primary extended excision and lymph node dissection of the neck were collected retrospectively. They were divided into a development cohort and a validation cohort in a 4:1 ratio. Logistic regression analysis was used to assess the risk factors of cervical LNM in patients in the development cohort, and a nomogram was established to predict the risk of such nodes. In the validation cohort, the predictive performance and compliance of the model were evaluated using the consistency index (C-index) and calibration curve, and the clinical value was evaluated by decision curve analysis. Of the 230 patients, 60 had cervical LNM, of which 60 were invaded (26%). Analysis of the development cohort showed that the site of the primary lesion, depth of invasion, size of the tumour, and histopathological grade were included in the prediction model, which was validated in the validation cohort. Consistency was high (C-index=0.846), calibration good, and it was clinically valuable. The nomogram could be used to predict the probability of occult cervical LNM before operation in patients with stage cN0 SCC of the tongue. It could also be used as a reference tool for dissection of cervical nodes and a communication tool between the doctor and the patient.

Determining the probability of locating peaks using computerized peak-location methods in gamma-ray spectra as a function of the relative peak-area uncertainty

The probabilities of locating peaks with a high relative peak-area uncertainty were determined empirically with nine types of peak-location software used in laboratories engaged in gamma-ray spectrometry measurements. It was found that it is not possible to locate peaks with a probability of 0.95, when they have a relative peak-area uncertainty in excess of 50%. Locating peaks at these relatively high peak-area uncertainties with a probability greater than 0.95 is only possible in the library-driven mode, where the peak positions are supposed a-priori. The deficiencies of the library-driven mode and the possibilities to improve the probabilities of locating peaks are briefly discussed.

Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea

BACKGROUND

The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking.

AIM

To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards.

METHODS

A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted ≥72 h were screened for HOD (definition: ≥2 episodes of Bristol Stool Type 5-7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively.

FINDINGS

Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9-5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1-6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1-3.5%; odds ratio 2.2, 95% CI 1.7-3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset.

CONCLUSION

HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.

[Epidemiological characteristics of Pneumocystis jirovecii infection and colonization in non-AIDS patients]

Objective: To analyze the epidemiological characteristics of Pneumocystis jirovecii infection and colonization in non-AIDS patients. Methods: From January 2010 to December 2017, bronchoalveolar lavage fluid (BALF) was detected by Grocott's methenamine silver (GMS) staining and real-time fluorescence quantitative PCR (qPCR) in non-AIDS patients with bronchoscopic alveolar lavage at Peking University First Hospital. At the same time, Pneumocystis jirovecii was detected in the environment of the hospital. Results: Within 8 years, Pneumocystis jirovecii were detected in BALF of a total of 1 407 non-AIDS patients. GMS staining was performed in all these 1 407 cases, of which 114 (8.10%) cases were with Pneumocystis jirovecii infection and 3 (0.21%) cases with colonization. There were totally 946 non-AIDS immunocompromised patients, of which 113 (11.95%) cases were infected and 2 (0.21%) cases with colonization; there were 461 non-AIDS immunocompetent patients, of which only 1 (0.22%) case was infected and 1 (0.22%) case with colonization. GMS staining and qPCR were both performed in 196 cases, of which 36 (18.37%) cases were infected and 33 (16.84%) cases with colonization. There were totally 175 non-AIDS immunocompromised patients, of which 36 (20.57%) cases were infected and 30 (17.14%) cases with colonization; there were 21 non-AIDS immunocompetent patients, of which no one was infected and 3 (14.29%) cases with colonization. By means of GMS staining and qPCR, no Pneumocystis jiroveci were detected in the environment of Peking University First Hospital. Conclusions:Pneumocystis pneumonia is rare in immunocompetent patients, but not in non-AIDS immunocompromised patients. And colonization is rare in both of them. There may be no Pneumocystis jiroveci in the environment.

Sperm toxicity testing: UK best practice guideline from the Association of Biomedical Andrologists

In order to ensure the quality and integrity of diagnostic semen analysis results, materials used should be tested to ensure that they do not interfere with sperm function. As a toxicity test, complex sperm function testing may be considered controversial, since the fertilizing capacity of single sperm can never be assured. In preference, sperm motility offers a unique means of assessing the toxicity of reagents and materials before they are used in routine practice. Motility is the semen parameter most likely to be influenced by the external environment. Indeed, it is the main reason that laboratories insist on supplying their own approved specimen containers and ensuring that patients, as far as possible, adhere to strict conditions for sample collection and transport prior to testing. This differs to other indirect tests of toxicity such as the mouse embryo assay, whereby the rate of mouse pre-implantation embryo development to the blastocyst stage is compared. This guideline is aimed at health care scientists who deal with andrology in both general pathology and specialised fertility laboratories, and provides a model approach to sperm toxicity testing. For assisted reproduction clinics, the same methodology can be used to test any consumables that are used for sperm processing, and as an indirect guide for any consumables that come into direct contact with oocytes and pre-implantation embryos.

Logistic regression model for detecting radon prone areas in Ireland

A new high spatial resolution radon risk map of Ireland has been developed, based on a combination of indoor radon measurements (n=31,910) and relevant geological information (i.e. Bedrock Geology, Quaternary Geology, soil permeability and aquifer type). Logistic regression was used to predict the probability of having an indoor radon concentration above the national reference level of 200Bqm^-3 in Ireland. The four geological datasets evaluated were found to be statistically significant, and, based on combinations of these four variables, the predicted probabilities ranged from 0.57% to 75.5%. Results show that the Republic of Ireland may be divided in three main radon risk categories: High (HR), Medium (MR) and Low (LR). The probability of having an indoor radon concentration above 200Bqm^-3 in each area was found to be 19%, 8% and 3%; respectively. In the Republic of Ireland, the population affected by radon concentrations above 200Bqm^-3 is estimated at ca. 460k (about 10% of the total population). Of these, 57% (265k), 35% (160k) and 8% (35k) are in High, Medium and Low Risk Areas, respectively. Our results provide a high spatial resolution utility which permit customised radon-awareness information to be targeted at specific geographic areas.

Hair coat properties of donkeys, mules and horses in a temperate climate

BACKGROUND

There are clear differences between donkeys and horses in their evolutionary history, physiology, behaviour and husbandry needs. Donkeys are often kept in climates that they are not adapted to and as such may suffer impaired welfare unless protection from the elements is provided.

OBJECTIVES

To compare some of the hair coat properties of donkeys, mules and horses living outside, throughout the year, in the temperate climate of the UK.

STUDY DESIGN

Longitudinal study.

METHODS

Hair samples were taken from 42 animals: 18 donkeys (4 females, 14 males), 16 horses (6 females, 10 males) and eight mules (5 females, 3 males), in March, June, September and December. The weight, length and width of hair were measured, across the four seasons, as indicators of the hair coat insulation properties.

RESULTS

Donkeys' hair coats do not significantly differ across the seasons. All three measurements of the insulation properties of the hair samples indicate that donkeys do not grow a winter coat and that their hair coat was significantly lighter, shorter and thinner than that of horses and mules in winter. In contrast, the hair coats of horses changed significantly between seasons, growing thicker in winter.

MAIN LIMITATIONS

The measurements cover only a limited range of features that contribute to the thermoregulation of an animal. Further research is needed to assess shelter preferences by behavioural measures, and absolute heat loss via thermoimaging.

CONCLUSIONS

Donkeys, and to a lesser extent mules, appear not to be as adapted to colder, wet climates as horses, and may therefore require additional protection from the elements, such as access to a wind and waterproof shelter, in order for their welfare needs to be met.

Testing headings for communicating the personal health record: comparison from the recipients’ perspective

In the spring of 1998, 16 general practitioners and 16 community psychiatric nurses participated in a study to test a draft set of headings for communicating clinical summaries. Eight anonymized psychiatric discharge summaries were used to assess the impact of the presentational format on the time taken by professionals to read the summaries and to answer a series of standard questions about each of them. Respondents also completed a questionnaire on their opinions of the headings. There was considerable variation between individuals in the times taken to read the summaries and answer the questions, but no evidence that any of the formats was associated with decreased reading time or with improvement in retrieving information. Most respondents preferred information structured using the headings rather than the original semi-structured discharge summaries, and information on paper rather than on computer screen.

Respondents were guardedly supportive of the particular draft headings presented. A weak preference was expressed for locally defined headings, with some recognition of advantages in widely agreed headings. There was a view that there were too many headings, and there was overlap between specific heading pairs (for example, ‘aim’ and ‘goal’). Concerns were expressed about specific headings, particularly the ‘softer’ headings, such as ‘informing’ and ‘communicating’.

Loss of TACSTD2 contributed to squamous cell carcinoma progression through attenuating TAp63-dependent apoptosis

Tumor-associated calcium signal transducer 2 (TACSTD2), a calcium signal transducer, is universally expressed in stratified squamous epithelia of many organs, including skin, esophagus and cervix. Although TACSTD2, was reported to be overexpressed in many epithelial tumors, which has increased interest in using it as a molecular target for cancer therapy, the role of TACSTD2 in carcinogenesis of squamous cell carcinoma (SCC) is largely unclear and controversial. To explore the role of TACSTD2, temporal-spatial expression of TACSTD2 was analyzed in both normal and SCC tissues. Our data demonstrate that Tacstd2 expression and membrane localization are tightly associated with stratified epithelial homeostasis, while loss of TACSTD2 was identified in poorly differentiated SCC tissues collected from cervix, esophagus, head and neck. Gradual loss of TACSTD2 was correlated with stepwise progression of SCC. Consistent with these in vivo observations, our data show that inhibition of Tacstd2 expression significantly inhibited chemotherapeutic reagent-induced apoptosis, and TACSTD2 regulated apoptotic gene expression through P63 containing the transactivation domain (TAp63). These findings indicated that loss of TACSTD2 could promote SCC progression and treatment resistance through attenuating chemotherapeutic reagent-induced apoptosis through TAp63, and TACSTD2 could be used as a marker for pathological grading of SCC.

Placement of deep brain electrodes in the dog using the Brainsight frameless stereotactic system: a pilot feasibility study

Background

Deep brain stimulation (DBS) together with concurrent EEG recording has shown promise in the treatment of epilepsy. A novel device is capable of combining these 2 functions and may prove valuable in the treatment of epilepsy in dogs. However, stereotactic implantation of electrodes in dogs has not yet been evaluated.

Objective

To evaluate the feasibility and safety of implanting stimulating and recording electrodes in the brain of normal dogs using the Brainsight system and to evaluate the function of a novel DBS and recording device.

Animals

Four male intact Greyhounds, confirmed to be normal by clinical and neurologic examinations and hematology and biochemistry testing.

Methods

MRI imaging of the brain was performed after attachment of fiducial markers. MRI scans were used to calculate trajectories for electrode placement in the thalamus and hippocampus, which was performed via burr hole craniotomy. Postoperative CT scanning was performed to evaluate electrode location and accuracy of placement was calculated. Serial neurologic examinations were performed to evaluate neurologic deficits and EEG recordings obtained to evaluate the effects of stimulation.

Results

Electrodes were successfully placed in 3 of 4 dogs with a mean accuracy of 4.6 ± 1.5 mm. EEG recordings showed evoked potentials in response to stimulation with a circadian variation in time‐to‐maximal amplitude. No neurologic deficits were seen in any dog.

Conclusions and Clinical Importance

Stereotactic placement of electrodes is safe and feasible in the dog. The development of a novel device capable of providing simultaneous neurostimulation and EEG recording potentially represents a major advance in the treatment of epilepsy.