Author Correction: A transcriptomic analysis of the phylum Nematoda

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Process water recovery via forward osmosis: membrane and integrated process development

This work reports on efforts to develop an integrated continuous forward osmosis system for the recovery of water from wastewater streams, highlighting critical process parameters to minimize energy consumption. Forward osmosis experiments were performed using NaCl draw solutions of various concentrations and the intrinsic membrane parameters (water permeability, draw solution permeability, and structural parameter) were then determined via nonlinear regression using MATLAB. The experimental data were then used to validate a theoretical water flux model, which was subsequently applied to simulate the forward osmosis performance under different hydrodynamic conditions using both NaCl and TMA-CO₂-H₂O (TMA: trimethylamine) draw solutions. Analysis of the energy efficiency of the TMA-CO₂ draw solution regeneration stage revealed that the draw solution flow rate has a significant impact on energy consumption. Also, increasing the feed flow rate was found to slightly enhance the water flux up to 2.5%, while having a negligible impact on the downstream regeneration process energy consumption.

Mice infected with the hypervirulent Mycobacterium tuberculosis HN878 strain develop lung lesions resembling human tubercle granulomas

The aerosol infection of mice with lab-adapted Mycobacterium tuberculosis (Mtb) strains in not an ideal model to study the immune parameters crucial for structural organization of protective human tuberculosis (TB) granulomas. Since experimentation in larger animals that mimic human lung granulomatous responses is expensive, a cost-effective animal model recapitulating morphological aspects of human granulomas is needed. Here, we addressed whether the use of hypervirulent Mtb strains could be a better strategy to improve the mouse model of TB. Hence, we infected C57BL/6 mice with a low dose of aerosolized Mtb HN878 and histologically analyzed infected lung tissues at different time points after infection. We found that granulomas that developed early after Mtb HN878 infection resemble human and NHPs granulomas, except for the lack of multinucleated giant cells. These structures displayed a central core of macrophages surrounded by a lymphocyte cuff. Immunofluorescence analysis showed that the presence of Mtb within mouse human-like granulomas was restricted to the central core area where some macrophages also expressed iNOS. Furthermore, increased formation of B cell lymphoid follicles expressing CXCL13 and germinal center markers was observed at the peripheral lymphocyte cuffs of human-like granulomas. As B cell follicles are indicators of protective immunity in humans, we addressed whether their formation was crucial for Mtb control. In Ighm−/− B cell deficient mice, we found an increased susceptibility to Mtb HN878 infection and enhanced lung inflammation at 50 days post-infection as compared to wild-type mice. Thus, our data supports the use of Mtb HN878 infection to model human TB granuloma formation in mice.

Interventions to improve osteoporosis care: a systematic review and meta-analysis

Osteoporosis (OP) is a major public health concern, but still OP care does not meet guidelines. Interventions have been developed to improve appropriate OP management. The objective of the present study was to systematically review the current literature to ascertain the efficacy of interventions to improve OP care and characterize interventions taking into account elements related to their potential cost and feasibility. Studies published from 2003 to 2018 were retrieved from PubMed/MEDLINE, Science Direct, Web of Science, Cochrane, and Wiley Online Library databases. Screening of references and quality assessment were independently performed by two reviewers. We classified interventions into three types according to the target of the intervention: health system (structural interventions), healthcare professional (HCP), and patient. Meta-analysis was performed by type of intervention and their effect on two outcomes: prescription of BMD measurement and prescription of OP therapy. A total of 4268 records were screened; 32 studies were included in the qualitative analysis and 29 studies in the quantitative analysis. Structural interventions strongly and significantly improved prescription of BMD measurement (OR = 9.99, 95% CI 2.05; 48.59) and treatment prescription (OR = 3.82, 95% CI 2.16; 6.75). The impact of HCP-centered interventions on BMD measurement prescription did not reach statistical significance (OR = 2.19, 95% CI 0.84; 5.73) but significantly improved treatment prescription (OR = 3.82, 95% CI 2.16; 6.75). Interventions involving patients significantly improved the prescription of BMD measurement (OR = 2.16, 95% CI 1.62; 2.89) and treatment prescription (OR = 1.70, 95% CI 1.35; 2.14). Interventions to improve OP management had a significant positive impact on prescription of BMD measurement but a more limited impact on treatment prescription.

Improving Characterization of Understudied Human Microbiomes Using Targeted Phylogenetics

Whole-genome bacterial sequences are required to better understand microbial functions, niche-specific bacterial metabolism, and disease states. Although genomic sequences are available for many of the human-associated bacteria from commonly tested body habitats (e.g., feces), as few as 13% of bacterium-derived reads from other sites such as the skin map to known bacterial genomes. To facilitate a better characterization of metagenomic shotgun reads from underrepresented body sites, we collected over 10,000 bacterial isolates originating from 14 human body habitats, identified novel taxonomic groups based on full-length 16S rRNA gene sequences, clustered the sequences to ensure that no individual taxonomic group was overselected for sequencing, prioritized bacteria from underrepresented body sites (such as skin and respiratory and urinary tracts), and sequenced and assembled genomes for 665 new bacterial strains. Here, we show that addition of these genomes improved read mapping rates of Human Microbiome Project (HMP) metagenomic samples by nearly 30% for the previously underrepresented phylum Fusobacteria, and 27.5% of the novel genomes generated here had high representation in at least one of the tested HMP samples, compared to 12.5% of the sequences in the public databases, indicating an enrichment of useful novel genomic sequences resulting from the prioritization procedure. As our understanding of the human microbiome continues to improve and to enter the realm of therapy developments, targeted approaches such as this to improve genomic databases will increase in importance from both an academic and a clinical perspective.IMPORTANCE The human microbiome plays a critically important role in health and disease, but current understanding of the mechanisms underlying the interactions between the varying microbiome and the different host environments is lacking. Having access to a database of fully sequenced bacterial genomes provides invaluable insights into microbial functions, but currently sequenced genomes for the human microbiome have largely come from a limited number of body sites (primarily feces), while other sites such as the skin, respiratory tract, and urinary tract are underrepresented, resulting in as little as 13% of bacterium-derived reads mapping to known bacterial genomes. Here, we sequenced and assembled 665 new bacterial genomes, prioritized from a larger database to select underrepresented body sites and bacterial taxa in the existing databases. As a result, we substantially improve mapping rates for samples from the Human Microbiome Project and provide an important contribution to human bacterial genomic databases for future studies.

Evaluation of Biodegradable Stent Graft Coatings in Pig and Rabbit Models

AIMS

Percutaneous coronary intervention is routinely performed to treat occlusive coronary artery disease. Coronary perforation is a potential complication and can be treated with a stent graft. Current stent grafts are associated with high restenosis rates. We tested the safety and feasibility of biodegradable stent grafts in pig and rabbit models.

METHODS AND RESULTS

Stent grafts were examined in pig coronaries with repeated OCT imaging for 42 days. Novel biodegradable coatings were applied on a bare metal stent by either an electrospinning (ES) or dip coating (DC) method. A completely biodegradable system was made by ES coating a magnesium-based stent. A commercially available stent graft served as a control. ES devices showed less restenosis (44.3 ± 8.8 vs. 59.1 ± 11.1% in controls, p < 0.05) and smaller reduction in minimum lumen area (44.3 ± 13.4 vs. 64.4 ± 13.6% in controls, p < 0.05) at day 42. DC devices occluded during follow-up. ES devices showed recanalization through the graft wall at day 42. Feasibility of the ES and DC devices was evaluated in pig coronary aneurysms and rabbit aortic perforation models and sealed aneurysms and perforations without complications.

CONCLUSIONS

Recanalization of the graft wall improves biocompatibility. Biodegradable stent grafts may present an alternative to permanent implants by showing reduced restenosis at day 42.

Impact of the Diabetes Inpatient Care and Education (DICE) project on length of stay and mortality

AIM

To determine whether the Diabetes Inpatient Care and Education (DICE) programme, a whole-systems approach to managing inpatient diabetes, reduces length of stay, in-hospital mortality and readmissions.

RESEARCH DESIGN AND METHODS

Diabetes Inpatient Care and Education initiatives included identification of all diabetes admissions, a novel DICE care-pathway, an online system for prioritizing referrals, use of web-linked glucose meters, an enhanced diabetes team, and novel diabetes training for doctors. Patient administration system data were extracted for people admitted to Ipswich Hospital from January 2008 to June 2016. Logistic regression was used to compare binary outcomes (mortality, 30-day readmissions) 6 months before and after the intervention; generalized estimating equations were used to compare lengths of stay. Interrupted time series analysis was performed over the full 7.5-year period to account for secular trends.

RESULTS

Before-and-after analysis revealed a significant reduction in lengths of stay for people with and without diabetes: relative ratios 0.89 (95% CI 0.83, 0.97) and 0.93 (95% CI 0.90, 0.96), respectively; however, in interrupted time series analysis the change in long-term trend for length of stay following the intervention was significant only for people with diabetes (P=0.017 vs P=0.48). Odds ratios for mortality were 0.63 (0.48, 0.82) and 0.81 (0.70, 0.93) in people with and without diabetes, respectively; however, the change in trend was not significant in people with diabetes, while there was an apparent increase in those without diabetes. There was no significant change in 30-day readmissions, but interrupted time series analysis showed a rising trend in both groups.

CONCLUSION

The DICE programme was associated with a shorter length of stay in inpatients with diabetes beyond that observed in people without diabetes.

Immune correlates of tuberculosis disease and risk translate across species

One quarter of the world's population is infected with Mycobacterium tuberculosis (Mtb), the causative agent of tuberculosis (TB). Although most infected individuals successfully control or clear the infection, some individuals will progress to TB disease. Immune correlates identified using animal models are not always effectively translated to human TB, thus resulting in a slow pace of translational discoveries from animal models to human TB for many platforms including vaccines, therapeutics, biomarkers, and diagnostic discovery. Therefore, it is critical to improve our poor understanding of immune correlates of disease and protection that are shared across animal TB models and human TB. In this study, we have provided an in-depth identification of the conserved and diversified gene/immune pathways in TB models of nonhuman primate and diversity outbred mouse and human TB. Our results show that prominent differentially expressed genes/pathways induced during TB disease progression are conserved in genetically diverse mice, macaques, and humans. In addition, using gene-deficient inbred mouse models, we have addressed the functional role of individual genes comprising the gene signature of disease progression seen in humans with Mtb infection. We show that genes representing specific immune pathways can be protective, detrimental, or redundant in controlling Mtb infection and translate into identifying immune pathways that mediate TB immunopathology in humans. Together, our cross-species findings provide insights into modeling TB disease and the immunological basis of TB disease progression.

Towards high-quality peri-operative care: a global perspective

Article 25 of the United Nations' Universal Declaration of Human Rights enshrines the right to health and well-being for every individual. However, universal access to high-quality healthcare remains the purview of a handful of wealthy nations. This is no more apparent than in peri-operative care, where an estimated five billion individuals lack access to safe, affordable and timely surgical care. Delivery of surgery and anaesthesia in low-resource environments presents unique challenges that, when unaddressed, result in limited access to low-quality care. Current peri-operative research and clinical guidance often fail to acknowledge these system-level deficits and therefore have limited applicability in low-resource settings. In this manuscript, the authors priority-set the need for equitable access to high-quality peri-operative care and analyse the system-level contributors to excess peri-operative mortality rates, a key marker of quality of care. To provide examples of how research and investment may close the equity gap, a modified Delphi method was adopted to curate and appraise interventions which may, with subsequent research and evaluation, begin to address the barriers to high-quality peri-operative care in low- and middle-income countries.

High prevalence of asymptomatic COVID-19 in hemodialysis. Daily learning during first month of COVID-19 pandemic☆

Dialysis patients are a risk group for SARS-CoV2 infection and possibly further complications, but we have little information. The aim of this paper is to describe the experience of the first month of the SARS-Cov2 pandemic in a hospital haemodialysis (HD) unit serving the district of Madrid with the second highest incidence of COVID19 (almost 1000 patients in 100,000 h). In the form of a diary, we present the actions undertaken, the incidence of COVID19 in patients and health staff, some clinical characteristics and the results of screening all the patients in the unit.

We started with 90 patients on HD: 37 (41.1%) had COVID19, of whom 17 (45.9%) were diagnosed through symptoms detected in triage or during the session, and 15 (40.5%) through subsequent screening of those who, until that time, had not undergone SARS-CoV2 PCR testing. Fever was the most frequent symptom, 50% had lymphopenia and 18.4% <95% O₂ saturation. Sixteen (43.2%) patients required hospital admission and 6 (16.2%) died. We found a cluster of infection per shift and also among those using public transport. In terms of staff, of the 44 people involved, 15 (34%) had compatible symptoms, 4 (9%) were confirmed as SARS-Cov2 PCR cases by occupational health, 9 (20%) required some period of sick leave, temporary disability to work (ILT), and 5 were considered likely cases.

Conclusions

We detected a high prevalence of COVID19 with a high percentage detected by screening; hence the need for proactive diagnosis to stop the pandemic. Most cases are managed as outpatients, however severe symptoms are also appearing and mortality to date is 16.2%. In terms of staff, 20% have required sick leave in relation to COVID19.

Autologous Adipose Tissue-Derived Mesenchymal Stem Cells Introduced by Biliary Stents or Local Immersion in Porcine Bile Duct Anastomoses

Biliary complications (strictures and leaks) represent major limitations in living donor liver transplantation. Mesenchymal stem cells (MSCs) are a promising modality to prevent biliary complications because of immunosuppressive and angiogenic properties. Our goal was to evaluate the safety of adipose-derived MSC delivery to biliary anastomoses in a porcine model. Secondary objectives were defining the optimal method of delivery (intraluminal versus extraluminal) and to investigate MSC engraftment, angiogenesis, and fibrosis. Pigs were divided into 3 groups. Animals underwent adipose collection, MSC isolation, and expansion. Two weeks later, animals underwent bile duct transection, reanastomosis, and stent insertion. Group 1 received plastic stents wrapped in unseeded Vicryl mesh. Group 2 received stents wrapped in MSC-seeded mesh. Group 3 received unwrapped stents with the anastomosis immersed in an MSC suspension. Animals were killed 1 month after stent insertion when cholangiograms and biliary tissue were obtained. Serum was collected for liver biochemistries. Tissue was used for hematoxylin-eosin and trichrome staining and immunohistochemistry for MSC markers (CD44 and CD34) and for a marker of neoangiogenesis (CD31). There were no intraoperative complications. One pig died on postoperative day 3 due to acute cholangitis. All others recovered without complications. Cholangiography demonstrated no biliary leaks and minimal luminal narrowing. Surviving animals exhibited no symptoms, abnormal liver biochemistries, or clinically significant biliary stricturing. Group 3 showed significantly greater CD44 and CD34 staining, indicating MSC engraftment. Fibrosis was reduced at the anastomotic site in group 3 based on trichrome stain. CD31 staining of group 3 was more pronounced, supporting enhanced neoangiogenesis. In conclusion, adipose-derived MSCs were safely applied to biliary anastomoses. MSCs were locally engrafted within the bile duct and may have beneficial effects in terms of fibrosis and angiogenesis.

Challenging Europe: Technology, Environment, and the Quest for Resource Security

Since the nineteenth century, access to and the development of natural resources became an important element of national and international politics. Resource security emerged as an issue vital to national security; and resource competition and crises gave rise to international tensions as well as to technological innovation and new modes of transnational cooperation.

De novo Assembly of the Brugia malayi Genome Using Long Reads from a Single MinION Flowcell

Filarial nematode infections cause a substantial global disease burden. Genomic studies of filarial worms can improve our understanding of their biology and epidemiology. However, genomic information from field isolates is limited and available reference genomes are often discontinuous. Single molecule sequencing technologies can reduce the cost of genome sequencing and long reads produced from these devices can improve the contiguity and completeness of genome assemblies. In addition, these new technologies can make generation and analysis of large numbers of field isolates feasible. In this study, we assessed the performance of the Oxford Nanopore Technologies MinION for sequencing and assembling the genome of Brugia malayi, a human parasite widely used in filariasis research. Using data from a single MinION flowcell, a 90.3 Mb nuclear genome was assembled into 202 contigs with an N50 of 2.4 Mb. This assembly covered 96.9% of the well-defined B. malayi reference genome with 99.2% identity. The complete mitochondrial genome was obtained with individual reads and the nearly complete genome of the endosymbiotic bacteria Wolbachia was assembled alongside the nuclear genome. Long-read data from the MinION produced an assembly that approached the quality of a well-established reference genome using comparably fewer resources.

Refining the Definition of Polypharmacy and Its Link to Disability in Older Adults: Conceptualizing Necessary Polypharmacy, Unnecessary Polypharmacy, and Polypharmacy of Unclear Benefit

The term polypharmacy in older adults is generally used in a pejorative context in the medical literature. Because of its link to geriatric syndromes and disability, the avoidance of polypharmacy is usually recommended in older adults as a strategy to optimize functional status. However, there are many polypharmacy regimens based on high-quality trials that clearly reduce the risk of disability in older adults. Other guidelines for older adults recommend the use of additional medications that may or may not be evidence based and that may or may not reduce disability. Therefore, we propose that, in the geriatric literature, polypharmacy now be categorized as "necessary polypharmacy," "unnecessary polypharmacy," or "polypharmacy of unclear benefit." In this article, we discuss the 3 categories of polypharmacy and give examples on each polypharmacy regimen and its potential relationship to disability in older adults.

Utilizing Microbiome and Bioinformatic Tools to Reduce Food Waste in Poultry

ObjectivesIn chicken harvest, the post-harvest chilling process is a crucial step for food safety. Most facilities use either water immersion chilling (WC) or air chilling (AC) to rapidly cool the chicken. A holistic assessment of the consequences of each method to meat quality and shelf life is necessary to determine the impacts of each method. To address this knowledge gap, a multi-faceted project was conducted to determine how the chilling system influenced the microbial ecology and subsequent deterioration of chicken breasts.Materials and MethodsThe study was conducted using a 2 × 2 × 2 factorial design to evaluate the impacts of chilling method (AC vs. WC), fabrication method (bone-in vs. boneless; BI vs. BL), and cold storage period (7 vs. 14 d) on the microbial ecology of chicken breasts. A total of 256 chicken carcasses were used for this study. Carcasses were obtained from a commercial processing plant following dressing and a single antimicrobial treatment. Twenty carcasses were removed for sampling as warm carcasses, and the remaining 236 were divided into eight groups for processing (AC-BI, AC-BL, WC-BI, WC-BL tray-wrapped for 7- and 14-d storage). Collection time-points included: warm, post-chilling, post-fabrication, post-storage, and after 3-d retail display. Microbiome samples were collected at each sampling using a PBS rinsate. Then, samples were further processed for microbiome analysis following standard methods, sequenced for the V4 region of the 16S rRNA gene, and analyzed using the QIIME2 pipeline.ResultsThere were significant differences in microbial diversity between different chilling methods, fabrications methods, and cold storage times. Both chilling methods were different from the warm carcasses based on α diversity metrics, though the two chilling methods were not different from each other. However, there were differences in the β diversity between all three groups. Storage day significantly altered the faith’s phylogenetic α diversity but had no impact on Shannon’s α diversity. By both metrics, the diversity was reduced with increased length of storage, suggesting that a few organisms begin to dominate the product during dark storage. The fabrication methods also resulted in significantly different diversities when phylogenetic metrics (Faith’s, unweighted UniFrac) were used. The products that were sampled prior to dark storage, regardless of chilling method, were dominated by Enterobacteriaceae, while those that were subjected to cold storage were dominated by Pseudomonadaceae. In the stored samples, AC samples tended to have a greater abundance of Moraxellaceae and Enterobacteriaceae than WC.ConclusionThese results suggest that different treatments of chicken breasts, including chilling, fabrication, and storage time, all correspond with changes to the product microbiome. These data will be combined with microbiology, physiochemical, nutritive, and taste and color data as well as a techno-economic analysis to provide a deeper understanding of impacts of processing methods on poultry quality and shelf life.

Fluctuations in the Microbial Community and the Volatile Organic Acids Created During Aerobic Storage of Ground Beef

ObjectivesDegradation due to microbial and chemical mechanisms occurs throughout the storage life of ground beef. These pathways are intertwined and the microbial community and the volatile organic acids (VOCs) that evolve in ground beef are dynamic. Evaluation of microbial growth using traditional culture-dependent techniques can be misleading due to the presence of unculturable organisms. Therefore, utilizing culture-independent techniques allows for a more thorough understanding of the microbial community within a meat matrix during storage life. The objective of this study was to employ 16s rRNA amplicon sequencing and VOC identification using GC–MS to explore diversity and changes of the microbial community and VOC production during shelf-life of ground beef.Materials and MethodsFinely ground beef (80/20) was procured from beef processing facilities in the West (one lot) and Midwest (two lots). The lots were separated into three physically separate replicates. Ground beef lots were transported in chub packaging to Colorado State University (Fort Collins, CO), and the chubs were stored in the dark at 2°C for either 16/17 d or 23/24 d. After dark storage, chubs were reground, and 454 g fluff-packs were placed on polystyrene trays before overwrapping with polyvinyl chloride film. The trays were placed in retail display cases maintained at 2–4°C for 5 d. Samples were collected every day of retail display for evaluation of the microbial community and VOC development. Following standardized extraction, 16S rRNA amplicon sequencing was used to explore microbial communities. Sequencing data were analyzed using the programs in the QIIME2 (version 2018.4) pipeline. Similarly, volatile organic compounds were extracted prior to analysis of targeted VOCs using a GC–MS. The project was designed as a split-plot design and was analyzed using R packages (version 3.4.3), lme4, lmerTest, and emmeans. Least squares means were separated using an α of 0.05.ResultsThe top orders of bacteria found in the meat samples were from Enterobacteriales, Lactobacillales, and Pseudomonadales. No differences (P ≥ 0.05) in Faith’s Phylogenetic Diversity Index, or a measure of diversity of the bacterial species within a sample, were observed between Days 0, 2, and 4 of retail case display. A targeted analysis identified eighteen VOCs associated with ground beef spoilage. In previous studies, the presence of hexanal, acetoin and acetic acid are identified as spoilage indicators. Hexanal, Acetoin and acetic acid increased (P ≤ 0.05) over the 5 d of retail display.ConclusionThe use of 16s rRNA amplicon sequencing technology is a relatively recent tool that has rapidly advanced the study of microbial deterioration during beef storage and shelf-life. Moreover, the combination of 16s rRNA amplicon sequencing and identification of VOCs in this study, afforded an exploration of the relationship between chemical and biological changes which occur during ground beef storage. These analytical technologies, when used in unison, can highlight the dynamic relationships and evolution of chemical and biological constituents in ground beef. Further research in ground beef shelf-life should incorporate such measures.

Conservation and global distribution of non-canonical antigens in Enterotoxigenic Escherichia coli

BACKGROUND

Enterotoxigenic Escherichia coli (ETEC) cause significant diarrheal morbidity and mortality in children of resource-limited regions, warranting development of effective vaccine strategies. Genetic diversity of the ETEC pathovar has impeded development of broadly protective vaccines centered on the classical canonical antigens, the colonization factors and heat-labile toxin. Two non-canonical ETEC antigens, the EtpA adhesin, and the EatA mucinase are immunogenic in humans and protective in animal models. To foster rational vaccine design that complements existing strategies, we examined the distribution and molecular conservation of these antigens in a diverse population of ETEC isolates.

METHODS

Geographically diverse ETEC isolates (n = 1159) were interrogated by PCR, immunoblotting, and/or whole genome sequencing (n = 46) to examine antigen conservation. The most divergent proteins were purified and their core functions assessed in vitro.

RESULTS

EatA and EtpA or their coding sequences were present in 57.0% and 51.5% of the ETEC isolates overall, respectively; and were globally dispersed without significant regional differences in antigen distribution. These antigens also exhibited >93% amino acid sequence identity with even the most divergent proteins retaining the core adhesin and mucinase activity assigned to the prototype molecules.

CONCLUSIONS

EtpA and EatA are well-conserved molecules in the ETEC pathovar, suggesting that they serve important roles in virulence and that they could be exploited for rational vaccine design.

Microbiological Assay-Trienzyme Procedure for Total Folates in Cereals and Cereal Foods: Collaborative Study

In 1996, U.S. Food and Drug Administration regulations mandated the fortification of enriched cereal-grain products with folic acid, thereby emphasizing the need for validated methods for total folates in foods, particularly cereal products. The AOAC Official Methods (944.12, 960.46) currently used for the analysis of folate in foods for compliance purposes are microbiological methods. When the fortification regulations were finalized, no Official AOAC or Approved AACC methods for folate in cereal-grain products were in place. The AOAC Official Method (992.05) for folic acid in infant formula does not incorporate important improvements in the extraction procedure and was not considered suitable for the analysis of folates in foods in general. Amicrobiological assay protocol using a trienzyme extraction procedure was prepared and submitted for comments to 40 laboratories with recognized experience in folate analysis. On the basis of comments, the method was revised to have the conjugase (gamma-glutamyl-carboxy-peptidase) treatment follow a protease treatment, to include the use of cryoprotected inoculum, and to include the spectroscopic standardization of the standard and optional use of microtiter plates. Thirteen laboratories participated in a collaborative study of 10 required and 10 optional cereal-grain products, including flour, bread, cookies, baking mixes, and ready-to-eat breakfast cereals. The majority of the participating laboratories performed the assay by the standard test tube method; others used the microtiter plate modification for endpoint quantitation with equal success. For the required products, the relative standard deviation between laboratories (RSDR) ranged from 7.4 to 21.6% for 8 fortified (or enriched) products compared with expected (Horwitz equation-based) values of 11–20%. RSDR values were higher (22.7–52.9%) for 2 unfortified cereal-grain products. For the optional products, the RSDR ranged from 1.8 to 11.2% for 8 fortified products. RSDR values were higher (27.9–28.7%) for 2 unfortified cereal-grain products. Based on the results of the collaborative study, the microbiological assay with trienzyme extraction is recommended for adoption as Official First Action.

Evaluation of the VIDAS® Listeria (LIS) Immunoassay for the Detection of Listeria in Foods Using Demi-Fraser and Fraser Enrichment Broths, as Modification of AOAC Official Method 999.06 (AOAC Official Method 2004.06)

A multilaboratory study was conducted to compare the VIDAS® LIS immunoassay with the standard cultural methods for the detection of Listeria in foods using an enrichment modification of AOAC Official Method 999.06. The modified enrichment protocol was implemented to harmonize the VIDAS LIS assay with the VIDAS LMO2 assay. Five food types—brie cheese, vanilla ice cream, frozen green beans, frozen raw tilapia fish, and cooked roast beef—at 3 inoculation levels, were analyzed by each method. A total of 15 laboratories representing government and industry participated. In this study, 1206 test portions were tested, of which 1170 were used in the statistical analysis. There were 433 positive by the VIDAS LIS assay and 396 positive by the standard culture methods. A Chi-square analysis of each of the 5 food types, at the 3 inoculation levels tested, was performed. The resulting average Chi square analysis, 0.42, indicated that, overall, there are no statistical differences between the VIDAS LIS assay and the standard methods at the 5% level of significance.

Evaluation of the BAX® System for Detection of Listeria monocytogenes in Foods: Collaborative Study

A multilaboratory study was conducted to compare the automated BAX® system and the standard cultural methods for detection of Listeria monocytogenes in foods. Six food types (frankfurters, soft cheese, smoked salmon, raw, ground beef, fresh radishes, and frozen peas) were analyzed by each method. For each food type, 3 inoculation levels were tested: high (average of 2 CFU/g), low (average of 0.2 CFU/g) and uninoculated controls. A total of 25 laboratories representing government and industry participated. Of the 2335 samples analyzed, 1109 were positive by the BAX system and 1115 were positive by the standard method. A Chi square analysis of each of the 6 food types, at the 3 inoculation levels tested, was performed. For all foods, except radishes, the BAX system performed as well as or better than the standard reference methods based on the Chi square results.

Evaluation of the BAX® System for Detection of Salmonella in Selected Foods: Collaborative Study

A multilaboratory study was conducted to compare the automated BAX® System to the standard cultural methods for detection of Salmonella in selected foods. Five food types—frankfurters, raw ground beef, mozzarella cheese, raw frozen tilapia fish, and orange juice—at 3 inoculation levels, were analyzed by each method. A sixth food type, raw ground chicken, was tested using 3 naturally contaminated lots. A total of 16 laboratories representing government and industry participated. In this study, 1386 samples were analyzed, of which 1188 were paired samples and 198 were unpaired samples. Of the 1188 paired samples, 461 were positive by both methods and 404 were negative by both methods. Thirty-seven samples were positive by the BAX System but negative by the standard reference method, and 11 samples were positive by standard cultural method and negative by the BAX System. Of the 198 unpaired samples, 106 were positive by the BAX System and 60 were positive by the standard cultural method. A Chi square analysis of each of the 6 food types, at the 3 inoculation levels tested, was performed. For all foods, the BAX System demonstrated results comparable to those of the standard reference methods based on the Chi square results.

Predictors of in-hospital mortality post hip fracture in Ireland 2013-2017

Background

Hip fractures are associated with considerable mortality, morbidity and healthcare expenditure. There are approximately 3,500 hip fractures in Ireland per annum with this figure set to increase considerably over the coming years due to the ageing population. Internationally, mortality following hip fracture is approximately 10% at 1 month and 30% at 1 year, with less than half of survivors regaining their preoperative level of function. The authors aimed to identify the determinants of in-hospital mortality post hip fracture in the Republic of Ireland 2013-2017, with specific reference to the Irish Hip Fracture Standards.

Methods

A secondary analysis of 15,603 patients in the Irish hip fracture database was conducted.

Results

31% (n = 4,769) were male and 69% (n = 10,807) were female. Mean age for males was 75 years (SD 13.5) and 79 years for females (SD 10.5). The largest proportion of hip fractures occurred in the 80-89 age category, with 72.3% (n = 4,600) of these being female. Median in-hospital mortality was 4.7% (n = 711) (Range 2.7-6.2). Univariate logistic regression revealed 11 statistically significant predictors of in-hospital mortality; however, only 4 remained statistically significant on multivariate analysis [mobilised day of/after surgery (OR 1.46, 95% CI 1.25-1.70, p &lt; 0.000), pre-fracture mobility (OR 0.84, 95% CI 0.79-0.89, p &lt; 0.000), gender (OR 0.56, 95% CI 0.41-0.76, p &lt; 0.000) and age (OR 1.05, 95% CI 1.03-1.06, p &lt; 0.000)].

Conclusions

Older males with poor pre-fracture mobility who were not mobilised the day of/after surgery had the highest risk of in-hospital mortality. The ability to be mobilised on the day of/after surgery is a good composite measure of both patient and organisational factors in hip fracture care. This research supports the inclusion of mobilisation on the day of/after surgery as a new formal best practice standard.

Key messages

Patients not mobilised on the day of/after surgery are 46% more likely to die in hospital. In-hospital mortality of 4.7% in Ireland is comparable internationally. None of the IHFSs significantly influenced in-hospital mortality after multivariate analysis, but may well affect other outcomes such as ability to return home.

C-reactive protein kinetics post elective cranial surgery. A prospective observational study

Introduction: Post cranial surgery readmission, largely caused by surgical site infection (SSI), is a marker of patient-care quality requiring comprehensive discharge planning. Currently, discharge assessment is based on clinical recovery and basic laboratory tests, including C-reactive protein (CRP). Although CRP kinetics have been examined postoperatively in a handful of papers, the validity of CRP as a standalone test to predict SSI is yet to be explored.Methods: A prospective observational study was performed on adult patients undergoing elective cranial surgery over a 3-month period. Laboratory data; CRP, white cell count (WCC), neutrophil cell count (NCC), and clinical data were assessed pre and post-operatively and were evaluated as predictors for safe discharge. Readmission rates within 1 month were recorded.Results: In this study, 68 patients were included. About 8.6% were readmitted due to SSI. A postoperativepeak in CRP was seen on day 2 with a value of 57 in the non-readmitted group, and 115 in the readmitted group. CRP dropped gradually to normal levels by day 5 in the non-readmitted group. A secondary CRP rise at day 5 was noted in the readmitted group with a sensitivity, specificity, and negative predictive value of 71%, 90%, and 96%, respectively. Interestingly, our ROC analysis indicates that a CRP value of less than 65 predicts safe discharge with a sensitivity of 86%, specificity of 89% and negative predictive value of 98% of safe discharge (area under the curve, AUC: 0.782). No significant difference in other inflammatory markers was found between both groups.Conclusions: CRP increases postoperatively for 4-5 d which could be a physiological response to surgery, however, prolonged elevation or a secondary increase in CRP may indicate an ongoing infection. Our data validate the potential use of CRP levels to predict SSI. A multicentre study is warranted to investigate the role of CRP in predicting SSI.

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.

Water safety plans for water supply utilities in China, Cuba, France, Morocco and Spain: costs, benefits, and enabling environment elements

Water Safety Plans (WSPs) are a management tool to identify and prioritize risks and implement appropriate control measures throughout the water supply chain, from catchment to consumer. WSPs have been implemented in over 90 countries; yet, costs, benefits and the enabling environment elements necessary for WSP implementation are under-studied. To better understand these factors, we conducted interviews with WSP implementation management teams from 20 private urban water utilities in China, Cuba, France, Morocco and Spain in 2014. Collectively, these utilities serve 10.6 million consumers and supply over 2.2 million m3/day of water to consumers. Time for WSP implementation to achieve certification averaged 13 months. The main startup cost was staff time, averaging 16.2 full-time equivalent person-months. Additional costs, averaging €16,777, were for training staff, hiring consultants, purchasing equipment, and certifying WSPs. Benefits commonly reported included improved hazard control, treatment practices, record keeping, and client and health agency confidence.

249 Is Our Diabetic Control Too Tight? An Audit of Management of Type II Diabetes in a Long Term Care Setting

Background

Recent guidelines on diabetes management recommend individualisation of management particularly in those with frailty or significant co-morbidities.

The aim of our audit was to assess diabetic control of residents in a long term care setting. Studies have shown that intensive control in an older population increases the risk of hypoglycaemia and does not necessarily improve clinical outcomes. There is also evidence that increased pill burden and hypoglycaemic events negatively affect quality of life among older people.

Methods

176 nursing home residents were assessed. Detailed chart review was carried out on the 47 residents with a diagnosis of type 2 diabetes. Information collated included age, sex, diabetes type, frequency of blood sugar monitoring, weight, BMI, Clinical Frailty Scale, allocation of diabetic diet and treatments including insulin and oral hypoglycaemic agents. Diabetic control was assessed by HbA1c. Evidence of hypoglycaemia in the preceding four weeks was documented.

Results

Of 47 patients (33 female), average age was 79.8 years and median BMI was 25. 41/47 residents had a Clinical Frailty Score of 6 or greater. The median HbA1c overall was 44mmol/l (range was 29-116mmol/l). All patients were on a diabetic diet. 23/47 residents on oral hypoglycaemic agents and the median HbA1c of this group was 51mmol/l. 6/47 were on insulin. Sugars were checked weekly (daily in those on insulin) and HbA1c was checked in the previous 6 months in 36/47.There was 1 recorded hypoglycaemic episode.

Conclusion

Our data showed that long stay residents continue to have tight diabetic control despite low BMI, evidence of frailty, significant co morbidities and dependency. HbA1c can also decrease due to renal disease, weight loss and poor oral intake. In line with recent guidelines our data shows there is scope to rationalise diabetic treatment regimens with reduction in polypharmacy and improvement in quality of life.

Delay of transfer from the intensive care unit: a prospective observational analysis on economic effects of delayed in-house transfer

Background

Intensive care unit (ICU) capacity is a scant and precious resource in hospitals. Therefore, an optimal occupancy rate as well as detailed occupation planning is of great importance. Most literature deals with admission to the ICU, while only few discuss discharge from the ICU. Specifically, a delay of transfer from the ICU can cause a shortness of beds, jeopardize urgent patient treatment and lead to a decrease in treatment quality as well as economic downsides. This study examined the incidence, costs and reasons for delayed discharge from the ICU and analyzed the influence of the department the patient was admitted to.

Methods

Over the course of 12 months, the discharges of all 1643 patients of two surgical intensive care units of a large academic medical center were analyzed. Delay in minutes and reasons were recorded and translated into financial figures. A univariate logistic regression model was developed to evaluate the impact of length of stay at the ICU, age, gender, subspecialty and specific ICU on the delay of transfer. In a next step, significant factors of the univariate logistic regression were incorporated into a multivariate regression model.

Results

In 326 out of 1312 patients ready for discharge (24.8%), the transfer to the floor was delayed. Time of delay for all patients added up to a total of 265,691 min in 1 year. The application of the internal cost allocation, in which 1 min corresponds to 0.75 Euro cents, led to costs of 199,268 Euros (~ $240,000) for the study period. In 91.7% of the cases, the reason for the delay was the lack of an available or appropriate bed on the regular ward. Multivariate regression analysis revealed that the type of department the patient is admitted to poses a significantly influencing factor for delayed discharge from the ICU.

Conclusion

Delay in discharge from the ICU is a common problem of economic relevance. The main reason is a lack of appropriate floor beds. Patients from certain specific departments are at a higher risk to be discharged with delay. A solution to this problem lies in the focus on the downstream units. A proper use of the scarce resources is to be pursued because of ethical as well as economic reasons in an increasingly aging population.

The genus Rhabdomastix Skuse in Australia (Diptera: Tipuloidea: Limoniidae)

The crane fly genus Rhabdomastix Skuse, 1890 is briefly introduced, the four species hitherto known from Australia are reviewed. The male of R. tonnoirana Alexander, 1934 and the female of R. wilsoniana Alexander, 1934 are described for the first time and R. minima Alexander, 1926 is considered as nomen dubium. A further eight Australian species are described as new, their affinities and distributions are discussed. They are R. borroloola sp. nov., R. dobrotworskyi sp. nov., R. dooragana sp. nov., R. hirsuta sp. nov., R. nivalis sp. nov., R. ponticulus sp. nov., R. collessiana sp. nov., R. rosae sp. nov.  A key to the males of Australian Rhabdomastix is presented.

V1 and V2 Domains of HIV Envelope Contribute to CCR5 Antagonist Resistance

Vicriviroc (VCV) is a CCR5 antagonist that blocks the viral entry of CCR5-tropic (R5) virions by binding to and inducing a conformational change in the chemokine receptor. Clinical resistance to CCR5 antagonists occurs in two phases, competitive and noncompetitive stages. In this study, we analyzed two subjects, from a phase 2b VCV clinical trial, whose quasispecies contained R5 and dual-mixed virions at the earliest recorded time of virological failure (VF). Genotypic analysis of R5-tropic patient-derived envelope genes revealed significant changes in the V1/V2 coding domain and convergence toward a more homogenous sequence under VCV therapy. Additionally, a small population of baseline clones sharing similar V1/V2 and V3 domains with the predominant VF isolate was observed. These clones were denoted preresistant based on their genotype. Preresistant clones and chimeric clones containing V1/V2 regions isolated during VF displayed high 50% inhibitory concentration (IC50) values relative to those at baseline, consistent with early competitive resistance. Genotypic analysis of the dual-tropic clones also showed significant changes in the V1/V2 region, different from the resistant R5-tropic viruses. Our findings suggest that the V1/V2 domain plays a key role in the initial step of development of drug resistance.IMPORTANCE It is believed that each CCR5 antagonist-resistant isolate will develop its own unique set of mutations, making it difficult to identify a signature mutation that can effectively predict CCR5 antagonist resistance. This may explain why we do not observe shared mutations among clinical studies. The present study examined the earliest events in the development of drug resistance with viral quasispecies that continued the use of CCR5 for entry. Genotypic and phenotypic assays demonstrated a distinct role of the variable domain V1/V2 in competitive resistance to CCR5 antagonist therapy. Thus, future studies analyzing the development of clinical resistance should focus on the relationship between the V1/V2 and V3 domains.

Early recognition and management of fetal head trauma with massive subgaleal hemorrhage

Non-obstetrical fetal head injury is an unusual clinical event. While multiple case reports describe motor vehicle collisions resulting in intrauterine fetal skull fractures, management of these injuries has not been emphasized. We report a case of a depressed fetal skull fracture with massive subgaleal and subperiosteal hemorrhage requiring neurosurgical intervention with good clinical outcomes for both mother and infant dyad.