Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Incidence and risk factors of heat-related illness in dogs from New South Wales, Australia (1997-2017)

Heat Related Illness (HRI) in dogs is expected to increase as heatwaves surge due to global warming. The most severe form of HRI, heat stroke, is potentially fatal in dogs. The current study investigated the incidence and risk factors for HRI in dogs in NSW, Australia, from 1997 to 2017. We identified 119 HRI cases during this period, with a fatality rate of 23%. Dog breeds at elevated risk of HRI were Australian Stumpy Tail Cattle Dog, British Bulldog, French Bulldog, Maremma Sheepdog, Italian Greyhound, Chow Chow, Airedale Terrier, Pug, Samoyed, English Springer Spaniel, Labrador Retriever, Golden Retriever, Cavalier King Charles Spaniel, Border Collie, Staffordshire Bull Terrier, and pooled non-Australian National Kennel Council breeds (which included the American and Australian Bulldog) when compared with cross breeds (i.e., the reference variable). As expected, HRI cases were more likely in December and January, during the Australian summer and during hotter years (e.g., 2016). There were no differences in the risk of HRI between males and females nor between desexed or un-desexed dogs; but older dogs were at increased risk of HRI. These findings underscore the need for data collection that will enable the incidence of HRI in dogs to be monitored and to better understand canine risk factors particularly as temperatures will continue to rise due to global warming. The risk of mortality from HRI underpins the need for education programs focussed on prevention and early identification of HRI so that owners present affected dogs to their veterinarian as promptly as possible.

Effects of heat stress on markers of skeletal muscle proteolysis in dairy cattle

Heat stress (HS) markedly affects postabsorptive energetics and protein metabolism. Circulating urea nitrogen increases in multiple species during HS and it has been traditionally presumed to stem from increased skeletal muscle proteolysis; however, this has not been empirically established. We hypothesized HS would increase activation of the calpain and proteasome systems as well as increase degradation of autophagosomes in skeletal muscle. To test this hypothesis, lactating dairy cows (∼139 d in milk; parity ∼2.4) were exposed to thermal neutral (TN) or HS conditions for 7 d (8 cows/environment). To induce HS, cattle were fitted with electric blankets for the duration of the heating period and the semitendinosus was biopsied on d 7. Heat stress increased rectal temperature (1.3°C) and respiratory rate (38 breaths per minute) while it decreased dry matter intake (34%) and milk yield (32%). Plasma urea nitrogen (PUN) peaked following 3 d (46%) and milk urea nitrogen (MUN) peaked following 4 d of environmental treatment and while both decreased thereafter, PUN and MUN remained elevated compared with TN (PUN: 20%; MUN: 27%) on d 7 of HS. Contrary to expectations, calpain I and II abundance and activation and calpain activity were similar between groups. Likewise, relative protein abundance of E3 ligases, muscle atrophy F-box protein/atrogin-1 and muscle ring-finger protein-1, total ubiquitinated proteins, and proteasome activity were similar between environmental treatments. Finally, autophagosome degradation was also unaltered by HS. Counter to our hypothesis, these results suggest skeletal muscle proteolysis is not increased following 7 d of HS and call into question the presumed dogma that elevated skeletal muscle proteolysis, per se, drives increased AA mobilization.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Transcription shifts in gut bacteria shared between mothers and their infants

The infant gut microbiome contains a portion of bacteria that originate from the maternal gut. In the infant gut these bacteria encounter a new metabolic environment that differs from the adult gut, consequently requiring adjustments in their activities. We used pilot community RNA sequencing data (metatranscriptomes) from ten mother-infant dyads participating in the NiPPeR Study to characterize bacterial gene expression shifts following mother-to-infant transmission. Maternally-derived bacterial strains exhibited large scale gene expression shifts following the transmission to the infant gut, with 12,564 activated and 14,844 deactivated gene families. The implicated genes were most numerous and the magnitude shifts greatest in Bacteroides spp. This pilot study demonstrates environment-dependent, strain-specific shifts in gut bacteria function and underscores the importance of metatranscriptomic analysis in microbiome studies.

Impact of Removing Race Adjustment When Estimating GFR on Chronic Kidney Disease Staging

Introduction/Objective

Determination of glomerular filtration rate (GFR) is essential in assessment of kidney function, particularly in patients with chronic kidney disease (CKD). Formulas were developed to calculate estimated GFR (eGFR), as direct measurement is cumbersome and not amenable to routine monitoring. CKD-EPI is the most widely used formula for eGFR, using parameters of serum creatinine, gender, race, and age. A race adjustment was added from an unfounded assumption that Black patients have more muscle mass, increasing their eGFR by about 16%. There is concern on the impact of “correcting” for Black race on patient management, utility of eGFR, and its possible contribution to healthcare disparities. This study examined the impact of eliminating race adjustment from the CKD- EPI formula on CKD staging in patients at a large safety-net hospital in an academic medical center.

Methods/Case Report

80090 serum creatinine values from 56676 adult patients (31.4% Black, 67.5% female, median age 51 yrs) were collected from the electronic medical record (Epic, Verona, WI) over a 16-month timeframe. Values were excluded if they lacked age, gender, self-identified race, or serum creatinine. eGFR was calculated using the CKD-EPI equation with and without race modifier, and CKD staging was performed using 2012 Kidney Disease: Improving Global Outcomes guidelines.

Results (if a Case Study enter NA)

In our cohort, only 50.8% of Black patients are in CKD1, indicative of no CKD, compared to 67.9% of non-Black patients. Given that these two cohorts are demographically similar, this shows a discrepancy in kidney function even before removing the race adjustment. After removal of the race modifier, 28.1% of Black patients were reclassified into a more severe CKD stage. The most restaging occurred from CKD3A to 3B (39%).

Conclusion

Many Black patients in our study were reclassified to a more severe CKD stage, with the highest percentage of patients restaged to CKD3B, which would have attracted clinical attention for nephrology referral. We recommend removal of the race adjustment in eGFR, given its basis in the incorrect belief in biological differences between races. It perpetuates systemic racism and discrimination in healthcare, and its removal will provide more equitable care and reduce healthcare disparities. Future studies should examine the increase in resources required to provide adequate medical care to patients who will be placed into a more severe CKD stage.

1703 The Walking Thread – What Happens to Fistula-In-Ano Patients Who Are Lost to Follow Up? A Service Improvement Study

Aim

1/3 of idiopathic cryptoglandular abscesses can result in fistula-in-ano. Current practice is to incise and drain primary abscesses and safety net for patients to return as necessary. Known fistula patients will be appointed for Examination Under Anaesthetic at 6-12 weeks.Is this best management or do they become “elective emergencies”?

Method

We performed a retrospective audit of management of fistula-in-ano over 4 years. We used a precollected data set of Cryptoglandular abscesses, excluding inflammatory, radiation or malignant causes and collected data for patients lost to follow up, including presentation, fistula diagnosed at first or subsequent attendance, number of operations, number of attendances and seton placement.

Results

512 patients were operated on for cryptoglandular abscess causing fistula-in-ano between 2013 and 2017. 10% (N = 50) were lost to follow up. 32 had documented follow up plans, that were not fulfilled (eg elective theatre not booked). Of these, 18 were elective attendances, 14 emergency. 24 of the 32 had a Seton sited prior to being lost to follow up

Conclusions

The various presentations (emergency, elective, clinic or day surgery) and long waiting lists mean many of these patients are presenting as emergencies still awaiting follow up. Many are lost to follow-up, with Setons in situ. We propose a fortnightly hot-clinic system, registrar led to assess and manage these patients. This would provide an elective clinic to allow single point of access to fistula-in-ano patients ensuring prompt follow up and reduction in unnecessary EUA, as well as improving senior colorectal trainees exposure to perianal disease and its management.

400 A Comparative Study of Intracapsular & Extracapsular Coblation Paediatric Tonsillectomy in A Tertiary Centre

Background

Intracapsular tonsillectomy has emerged as a novel alternative to traditional tonsillectomy where the tonsillar capsule is left intact with a small amount of overlying tonsillar tissue. There is growing evidence to suggest that intracapsular tonsillectomy is associated with reduced post-operative pain, haemorrhage and readmission rates. The aim of this study was to assess the reported benefits of intracapsular tonsillectomy within the ENT department at a tertiary paediatric hospital.

Method

Retrospective analysis comparing two cohorts of 72 consecutive paediatric patients undergoing coblation intracapsular and extracapsular tonsillectomy between March-2019 and November-2020. Patient age at procedure, removal of adenoids, indication, surgeon grade, and discharge time were recorded. Post-tonsillectomy bleeding and 30-day readmission rates were used as the main outcome measures.

Results

The median age in both groups was 5 years. The intracapsular cohort demonstrated a lower 30-day readmission rate (8.3% vs. 15.3%), lower primary (<24 hours) post-op bleed rate (0% vs. 2.78%) and lower secondary (>24hours) post-op bleed rate (4.2% vs. 12.5%) when compared to the extracapsular cohort. Eight cases were conducted as day cases in total, all Intracapsular, with none of these patients requiring readmission within 30 days.

Discussion

Coblation Intracapsular tonsillectomy is an effective and low-risk alternative to extracapsular techniques. It is hoped with the reduced associated risks and morbidity associated with the procedure, the department can move towards day case tonsillectomy procedures resulting in a reduction in overall healthcare costs and improved patient experience.

O-105 High prevalence of obesity and polycystic ovary syndrome in an online community seeking assistance with fertility

Study question

What are the characteristics of a large online community of women trying to conceive and what are the factors that predict infertility in this group?

Summary answer

The cohort was not characterized by increased age, though age, obesity and PCOS strongly correlated with fertility. PCOS may be under-recognized within some ethnic groups.

What is known already

Obesity, polycystic ovary syndrome (PCOS), and age are among the primary predictors of infertility in women. However, most studies assessing reproductive health employ populations who have sought medical assistance for infertility or associated disorders, potentially leading to populations more likely to exhibit disorders such as PCOS or to be of increased age. Characterization of factors affecting fertility in a general population may highlight epidemiological influences that should be better addressed to aid women trying to conceive.

Study design, size, duration

This study employed users of the mobile application, FertilityAnswers, for people searching for answers to fertility problems. Users answered a short survey describing themselves, their fertility history and goals. Recruitment for this study began in March 2017 and ended in January 2021. 61814 participants downloaded the application during this period, and 56878 at least provided their age. The primary inclusion criteria were that study participants be US females over eighteen years of age.

Participants/materials, setting, methods

Regression models estimated beta coefficients and corresponding confidence intervals. Multivariable models determined independence of variables. To model PCOS, the available data in January 2020 was split randomly into discovery and validation subsets. Missing value imputation using random forests was performed in the discovery dataset. Minimal feature selection used a linear regression model penalized with a lasso and elastic net. The model was then validated on samples collected after the model was trained and tested.

Main results and the role of chance

Age was a significant predictor of fertility in this study (p < 1x10-10). However, the distribution of age in the cohort was very similar to that of women at first birth in the United States, therefore we did not observe the majority of study participants to be of an age where in a typical clinical setting age-related concerns would be addressed (i.e., approaching 35 years). Using National Center for Health Statistics data, the mean age of 1,433,604 women at first birth in 2018 in the US was younger than the study population (restricted to those without children) by only one month. Obesity was of increased prevalence in this cohort, with 55% being obese, compared to 37% in an age-matched US population. Participants reported a variety of fertility-related disorders, with polycystic ovary syndrome (PCOS) being most prevalent (19.0%), followed by endometriosis (6.0%). Prediction of PCOS, performed by modeling on training and test sets (10476 and 5312 participants) and then validating with an additional 21097 participants collected after the model creation, found that African-Americans and Latino members of this cohort had a lower self-reported rate of the disorder than was anticipated by the model, in contrast to those of Asian or European descent.

Limitations, reasons for caution

All health data was self-reported. Additionally, as this is the initial survey of this population, no a priori hypotheses were made as to the expected relationships to be observed. Instead, all associations were examined, and measurements of false discovery rate were estimated.

Wider implications of the findings

We found that women were seeking answers about infertility at ages coincident with that of their peers achieving first pregnancies. ART is often not a first-line treatment for women of this age, but there may be a disconnect between traditional clinical response to this group and their desire for assistance.

Trial registration number

not applicable

Marine mammal conservation: over the horizon

Marine mammals can play important ecological roles in aquatic ecosystems, and their presence can be key to community structure and function. Consequently, marine mammals are often considered indicators of ecosystem health and flagship species. Yet, historical population declines caused by exploitation, and additional current threats, such as climate change, fisheries bycatch, pollution and maritime development, continue to impact many marine mammal species, and at least 25% are classified as threatened (Critically Endangered, Endangered or Vulnerable) on the IUCN Red List. Conversely, some species have experienced population increases/recoveries in recent decades, reflecting management interventions, and are heralded as conservation successes. To continue these successes and reverse the downward trajectories of at-risk species, it is necessary to evaluate the threats faced by marine mammals and the conservation mechanisms available to address them. Additionally, there is a need to identify evidence-based priorities of both research and conservation needs across a range of settings and taxa. To that effect we: (1) outline the key threats to marine mammals and their impacts, identify the associated knowledge gaps and recommend actions needed; (2) discuss the merits and downfalls of established and emerging conservation mechanisms; (3) outline the application of research and monitoring techniques; and (4) highlight particular taxa/populations that are in urgent need of focus.

Exiting Medicine Faculty Want the Organizational Culture and Climate to Change

National data indicate about 50% of junior faculty leave a School of Medicine (SOM) within eight years of hire. The long-term goal of the study was to determine innovative strategies for promoting SOM faculty retention. The study objective was to determine factors influencing SOM faculty to exit, and what would encourage them to stay or return. All faculty exiting the University of New Mexico (UNM) SOM were surveyed and their responses analyzed to the following items: (a) If something could have been done differently that might have resulted in staying at UNM, what would it have been? (b) What would need to change at UNM SOM for you to return? and (c) general comments offered. Qualitative analysis of open-ended responses used an iterative process and systematic thematic approach and NVivo software. 173 faculty respondents surveyed between July 2017 and June 2019 included 86 women, 33 non-Caucasians, and 14 Hispanics. A total of 110 faculty reported an MD degree and 117 were assistant professors. Seventy-eight faculty were on clinician educator track. The 367 responses to the three questions were categorized into 10 themes. The most common themes included (a) people (leadership and others) and workplace culture (25.1% of responses); (b) extent of career support and resources (15.3%); (c) organizational systems and administration (13.6%); and (d) faculty feelings of autonomy and value (10.9%). Exiting faculty frequently discussed the need for a change of leadership and changes in organizational climate and culture, which may have influenced their willingness to stay or to return to UNM SOM. To retain faculty, SOM leaders need to strengthen and/or modify organizational climate and culture components. Innovative strategies for this purpose may include organizational interventions followed by evidence-based leadership training programs, and the use of exit surveys for monitoring interventions.

Factors Related to Faculty Retention in a School of Medicine: A Time to Event Analysis

National data indicate that 50% of assistant professors leave a School of Medicine (SOM) within eight years of hire. At-risk for attrition in some studies are women, racial/ethnic underrepresented minorities (URM), and clinical faculty. Retention of faculty is not adequately studied in the Southwestern US, where at-risk faculty constitute the majority group. The study hypothesized that at-risk faculty have lower retention rates than those not at-risk. Identification of factors predicting retention of at-risk faculty may help institutions devise novel and targeted retention strategies. Prospective time to event analyses studied assistant professors hired at the University of New Mexico's (UNM) SOM from 2008-2019. Eight factors, measured at the time of hire, included: rank, race/ethnicity, gender, MD degree, academic track, department type, salary, and fiscal year of hire. Univariate analyses included graphical analysis of Kaplan-Meier analysis and Cox proportional hazard ratios with years to departure measuring the main event to resignation. 844 full-time junior faculty included 50% women, 81% physicians, 42% clinician educators, and 18% racial/ethnic URM. Compared to non-Hispanic Whites, Black faculty (HR = 2.24, 1.25-4.03) and faculty with non-US degree (1.53, 1.19-1.94) had a higher risk of leaving. Faculty in clinician educator (2.01, 1.06-3.82) or visiting research tracks (2.41, 1.20-4.84) both had higher risk of leaving than tenure track faculty. Although URM faculty did not have an overall higher risk of departure, male faculty had higher risk of leaving than women when they are URM or unknown-URM status. In our analysis of junior faculty, we showed that faculty who were Black, had an international education, and in clinician educator or visiting research tracks were at greater risk of leaving, but women and Hispanic faculty had similar retention rates as their respective counterparts at UNM SOM. The differential retention rates among several at-risk subgroups of junior faculty may indicate the need to refocus the existing diversity and faculty development programs at UNM SOM.

Simultaneous Determination of Multiple Tetracycline Residues in Milk by Metal Chelate Affinity Chromatography: Collaborative Study

To meet federal and state regulatory needs, a liquid chromatographic (LC) method with ultraviolet (UV) detection was developed for determination of 7 tetracyclines at 30 ng/mL in milk. Raw milk samples are defatted, acidified, and centrifuged to remove proteins, and tetracyclines are specifically absorbed from the milk by chelation with metal ions bound to small Chelating Sepharose Fast Flow columns. Tetracyclines are removed from these columns with EDTA-containing buffer, and extracts are further cleaned by ultrafiltration. Finally, extracts are concentrated and analyzed simultane ously by using on-line concentration. This method was validated in a collaborative study that involved 11 laboratories, including the authors’ laboratory. Each laboratory was asked to prepare and analyze known control and fortified milk samples, as well as 18 coded blind samples. Eight laboratories completed all analyses. Average interlaboratory recoveries for the known fortified samples ranged from 59% (methacycline at 15 ng/mL) to 78% (oxytetracy cline at 60 ng/mL). Average recovery for each of 7 residues at 30 ng/mL were between 60 and 110%, meeting single-residue guidelines for accuracy set by the U.S. Food and Drug Administration. Reproducibility relative standard deviation (RSDR) for the known fortified samples varied from 11 to 39%, with 6 of 7 residues at the 30 ng/mL level having RSDR values at or below 20%. Seven of 8 laboratories correctly identified blind control milk samples and all 28 residues present in blind samples. The metal chelate affinity—LC method for determination of multiple tetracycline residues in milk has been adopted first action by AOAC INTERNATIONAL.

Assigning mentors for new HSC faculty hires: A preliminary policy evaluation

Effective practices for selecting mentors for new faculty at academic health centers (AHC) are currently unknown. The University of New Mexico's School of Medicine assigns a mentor to all new faculty at the time of hire. The effectiveness of this policy measure has not been previously evaluated. The research question was to determine the proportion of new faculty mentees who meet with their assigned mentors before their mandatory orientation held within their first year of hire. At the orientation, faculty are surveyed about their response to the institutional policy of assigning mentors upon their hire. The proportion of new faculty mentees who met their assigned mentors prior to the orientation event constituted the primary study outcome. Of the 289 new faculty surveyed, 79.9% met their assigned mentors prior to the orientation - most meetings were weekly (48.8%) or monthly (27.9%). Among those who had not yet met their mentors, 65% planned to meet them within the month of the survey. 5.5% of all faculty reported a change of mentor from their initial assignment and 2.8% stated that they needed a different mentor. Physicians were less likely to meet with their assigned mentors than non-physician faculty (p=0.02). The preliminary policy evaluation demonstrates that most new faculty either meet or plan to meet their assigned mentors. Most participants stated that they did not need to be assigned a different mentor. Assigning mentors for new faculty hires may be considered a best practice at an AHC.

Diffuse osteosclerosis as a presentation of recurrent breast cancer: role of endothelin 1

We report a 46-yr-old woman with a history of breast cancer who presented with diffuse myalgias, bone pain, and osteosclerosis. She was found to have recurrent breast cancer producing endothelin-1.

INTRODUCTION

Acquired osteosclerosis can be caused by various disorders. Endothelin -1 is believed to contribute to osteosclerosis caused by breast cancer.

METHODS

Although the bone marrow biopsy did not reveal breast cancer, she developed skin lesions consistent with metastatic breast cancer. She ultimately died from progressive disease. At autopsy immunohistochemistry for endothelin-1 was performed on a section from the L5 vertebral body.

RESULTS

The section from the L5 vertebral body showed small foci of cells consistent with metastatic carcinoma and a prominent sclerotic response. Immunohistochemistry for endothelin-1 was strongly positive.

CONCLUSIONS

Recurrent breast cancer may present with diffuse osteosclerosis. Endothelin-1 may be a paracrine factor responsible for increased bone formation and osteosclerosis.

Combined total hip and knee arthroplasty during the same hospital admission: is it safe?

AIMS

The purpose of this study was to compare outcomes of combined total joint arthroplasty (TJA) (total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed during the same admission) versus bilateral THA, bilateral TKA, single THA, and single TKA. Combined TJAs performed on the same day were compared with those staged within the same admission episode.

PATIENTS AND METHODS

Data from the National (Nationwide) Inpatient Sample recorded between 2005 and 2014 were used for this retrospective cohort study. Postoperative in-hospital complications, total costs, and discharge destination were reviewed. Logistic and linear regression were used to perform the statistical analyses. p-values less than 0.05 were considered statistically significant.

RESULTS

Combined TJA was associated with increased risk of deep vein thrombosis, prosthetic joint infection, irrigation and debridement procedures, revision arthroplasty, length of stay (LOS), and in-hospital costs compared with bilateral THA, bilateral TKA, single THA, and single TKA. Combined TJA performed on separate days of the same admission showed no statistically significant differences when compared with same-day combined TJA, but trended towards decreased total costs and total complications despite increased LOS.

CONCLUSION

Combined TJA is associated with increased in-hospital complications, LOS, and costs. We do not recommend performing combined TJA during the same hospital stay. Cite this article: Bone Joint J 2019;101-B:573-581.

Mapping widespread and increasing underwater noise pollution from acoustic deterrent devices

Acoustic deterrent devices (ADDs) are used in attempts to mitigate pinniped depredation on aquaculture sites through the emission of loud and pervasive noise. This study quantified spatio-temporal changes in underwater ADD noise detections along western Scotland over 11 years. Acoustic point data ('listening events') collected during cetacean line-transect surveys were used to map ADD presence between 2006 and 2016. A total of 19,601 listening events occurred along the Scottish west coast, and ADD presence was recorded during 1371 listening events. Results indicated a steady increase in ADD detections from 2006 (0.05%) to 2016 (6.8%), with the highest number of detections in 2013 (12.6%), as well as substantial geographic expansion. This study demonstrates that ADDs are a significant and chronic source of underwater noise on the Scottish west coast with potential adverse impacts on target (pinniped) and non-target (e.g. cetaceans) species, which requires further study and improved monitoring and regulatory strategies.

Improving pneumococcal vaccine uptake in veterans with chronic lymphocytic leukemia through a virtual clinic

Through a "virtual clinic," we used the electronic medical record to identify and intervene upon patients with chronic lymphocytic leukemia (cll) who were not current for pneumococcal vaccines. Within 180 days, 100/160 patients (62%) received the recommended pneumococcal vaccine. A virtual clinic may improve vaccination rates among high-risk patient populations.

Current and future treatment options for community-associated MRSA infection

INTRODUCTION

Community-associated MRSA (CA-MRSA) represents a global epidemic which beautifully encapsulates the fascinating ability of bacterial organisms to adapt quickly on an evolutionary basis to the extreme selective pressure of antibiotic exposure. In stark contrast to Healthcare-associated MRSA (HA-MRSA), it has become apparent that CA-MRSA is less straight forward of a challenge in terms of controlling its transmission, and has forced clinicians to adjust empiric management of clinical syndromes such as skin and soft tissue infection (SSTI) as well as pneumonia.

AREAS COVERED

This review details the history and epidemiology of CA-MRSA, while covering both current and future treatment options that are and may be available to clinicians. The authors reviewed both historic and more recent literature on this ever-evolving topic.

EXPERT OPINION

While development of new anti-MRSA agents should be encouraged, the importance of antimicrobial stewardship in the battle to stay ahead of the curve with regards to the ongoing control of the MRSA epidemic should be emphasised.

Towards quantifying the role of hydrogen bonding within amphiphile self-association and resultant aggregate formation

The role of hydrogen bonding within aggregate formation and CMC: can these properties be predicted by low level computational modelling?

Herein, we present a series of five tetrabutylammonium (TBA) sulfonate–urea amphiphilic salts. In solution these amphiphilic salts have been shown to form a variety of self-associated species. The proportion and type of which are both solvent and concentration dependent. In DMSO-d₆ a variety of NMR experiments provide evidence towards the formation of mainly dimeric over larger aggregate species. Increasing the percentage of water was shown to increase the concentration of the larger aggregates over dimers in solution. A correlation was established between critical micelle concentration (CMC) values obtained in a 1 : 19 EtOH : H₂O mixture, dimeric self-association constants obtained in a DMSO-d₆ – 0.5% H₂O and the results of simple semi-empirical PM6 computational modelling methods. This approach begins to quantify the role of hydrogen bonding in amphiphile self-association and the effects it imparts on surfactant properties. This consequently provides preliminary evidence that these properties maybe predicted by simple low level computational modelling techniques.

Embryonal tumors in Canadian children less than 36 months of age: results from the Canadian Pediatric Brain Tumor Consortium (CPBTC)

Embryonal tumors are a heterogeneous group of central nervous system (CNS) tumors whose subgroups have varying incidence and outcome. Despite these differences, they are often grouped as a single entity for study purposes. To date, there are no Canadian multi-institutional studies examining the incidence and outcome of all embryonal subtypes. The current study is an observational study reviewing embryonal tumors in all patients less than 36 months of age diagnosed with a CNS tumor in Canada from 1990 to 2005. Embryonal tumors accounted for 26.9% of all CNS tumors. Medulloblastomas were the highest proportion of the embryonal tumors at 61.5%. Atypical teratoid/rhabdoid tumors (AT/RT) had the second highest proportion of embryonal tumors at 18%. The proportion of primitive neuroectodermal tumors (PNET) was 16%, with 2.6 and 1.9% for congenital medulloepithelioma and ependymoblastoma tumors, respectively. AT/RT and PNET were more common in younger age groups. Medulloblastoma became more prevalent with increasing age, with its highest prevalence in the 25 to 36 month age group. Survival rates for our Canadian population at 18 and 24 months were 0.74 and 0.68 for medulloblastoma, 0.64 and 0.60 for PNET, and 0.36 and 0.29 for AT/RT, respectively. Overall, our data are comparable with published international rates for embryonal tumors. These incidence and outcome figures can guide future research into these rare tumors.

dc conductivity of two-temperature warm dense gold

Using recently obtained ac conductivity data we have derived dc conductivity together with free electron density and electron momentum relaxation time in two-temperature warm dense gold with energy density up to 4.1 MJ/kg (0.8×10^{11}J/m^{3}). The derivation is based on a Drude interpretation of the dielectric function that takes into account contributions of intraband and interband transitions as well as atomic polarizability. The results provide valuable benchmarks for assessing the extended Ziman formula for electrical resistivity and an accompanying average atom model.

Impact of concomitant medication use on belimumab efficacy and safety in patients with systemic lupus erythematosus

Practicing physicians have requested efficacy and safety data for belimumab, when used with specific systemic lupus erythematosus (SLE) medications. This was a post hoc analysis of pooled efficacy and safety data from patients who received belimumab 10 mg/kg plus standard of care (SoC) or placebo (SoC) in two Phase III, randomized trials, BLISS-52 and BLISS-76. Patients were categorized into four groups based on baseline concomitant medication usage: steroids only; antimalarials (AM) only; steroids + AM; or steroids + AM + immunosuppressants (IS). The primary endpoint was the SLE Responder Index (SRI) at Week 52. SRI over time and individual SRI components were secondary endpoints. Time to first flare and changes in concomitant medications were exploratory endpoints. Safety was assessed using adverse event (AE) reporting. Across 834 patients, steroids + AM was the largest group (n = 346, 41.5%) and AM only was the smallest (n = 77, 9.2%). Disease duration was shortest in the steroids + AM group (5.7 years vs 6.4–7.1 years); SELENA-SLEDAI scores were similar across groups. At Week 52, the percentage of SRI responders was greatest in the steroids + AM group for belimumab 10 mg/kg (59%) compared with placebo (44%); treatment response and SRI component improvements were also observed across other groups. The probability of experiencing an SLE flare was reduced in the steroids-only group for patients who received belimumab 10 mg/kg compared with placebo (64.3% vs 78.1%; hazard ratio 0.64; 95% confidence interval: 0.42–0.96). There was little or no change in daily AM or IS dose in any group. For all groups, there was a general decrease in steroid dose over time; a quarter to a third of patients experienced decreased steroid doses at Week 52. The overall safety profile was similar across treatment arms and concomitant medication groups, with the exception of serious AEs in the steroids + AM group (belimumab 10 mg/kg 16%, placebo 8%). The efficacy and safety of belimumab in combination with SoC was demonstrated for various groupings of steroids, AM and IS. These findings may improve the understanding of the safety and efficacy of adding belimumab to different treatments.

Family History-Taking in Paediatrics: It’s Much More Than Just A Checklist

BACKGROUND: Family history (FH) is a risk factor for many conditions in pediatric practice; interest has increased in supporting systematic FH taking in this area by identifying core conditions for enquiry and developing point of care tools. There is little published about current practice to inform implementing such changes.

OBJECTIVES: To inform future FH taking interventions by identifying pediatricians' perceptions, attitudes, beliefs, and current practices.

DESIGN/METHODS: The Theoretical Domains Framework (TDF) was used to develop a comprehensive interview scheme. Semi-structured interviews were conducted with community and hospital-based pediatricians Analysis was by the constant comparison method, using a thematic approach. This study was funded by the Canadian Institutes of Health Research.

RESULTS: The data revealed FH taking to be a firmly embedded, but complex aspect of pediatric practice. Participants described FH as part of regular, holistic care, extending to social and interpersonal, as well as clinical purposes; in addition to disease risk assessment, FH information helped clarify diagnosis, and select medication; tailor the overall patient management based on family circumstances; and provide psychosocial support for parents. It was also used as a method to build a relationship with parents/carers. FH and social history information were inextricably linked and often appeared to be the same concept in participants’ minds. Participating pediatricians generally expressed confidence in their FH skills and reported tailoring their approach according to experience, after initial training early in their career. While acknowledging some challenges in ensuring accuracy, they were attuned to nuances in their interactions with parents and children which would affect whether, and what, they were told about illness in the family. Most were not concerned about formal evidence, and would not change their practice except for “good reason”.

CONCLUSION: The use of the TDF helped ensure a comprehensive approach to FH taking in pediatric practice. The findings suggest that FH taking in this setting is a complex activity, embedded in routine care. Recommendations for systematic enquiry about specific conditions cannot be seen as a simple additional activity to current practice. Efforts to make FH taking more systematic may founder if they fail to take into account pediatricians’ attitudes, perspectives, and practices. Further studies should explore and seek to confirm and expand our observations.

Long-term organ damage accrual and safety in patients with SLE treated with belimumab plus standard of care

Objective

To examine long-term organ damage and safety following treatment with belimumab plus standard of care (SoC) in patients with systemic lupus erythematosus (SLE).

Methods

Pooled data were examined from two ongoing open-label studies that enrolled patients who completed BLISS-52 or BLISS-76. Patients received belimumab every four weeks plus SoC. SLICC Damage Index (SDI) values were assessed every 48 weeks (study years) following belimumab initiation (baseline). The primary endpoint was change in SDI from baseline at study years 5–6. Incidences of adverse events (AEs) were reported for the entire study period.

Results

The modified intent-to-treat (MITT) population comprised 998 patients. At baseline, 940 (94.2%) were female, mean (SD) age was 38.7 (11.49) years, and disease duration was 6.7 (6.24) years. The mean (SD) SELENA-SLEDAI and SDI scores were 8.2 (4.18) and 0.7 (1.19), respectively; 411 (41.2%) patients had organ damage (SDI = 1: 235 (23.5%); SDI ≥ 2: 176 (17.6%)) prior to belimumab. A total of 427 (42.8%) patients withdrew overall; the most common reasons were patient request (16.8%) and AEs (8.5%).

The mean (SD) change in SDI was +0.2 (0.48) at study years 5–6 (n = 403); 343 (85.1%) patients had no change from baseline in SDI score (SDI +1: 46 (11.4%), SDI +2: 13 (3.2%), SDI +3: 1 (0.2%)). Of patients without organ damage at baseline, 211/241 (87.6%) had no change in SDI and the mean change (SD) in SDI was +0.2 (0.44). Of patients with organ damage at baseline, 132/162 (81.5%) had no change in SDI and the mean (SD) change in SDI was +0.2 (0.53). The probability of not having a worsening in SDI score was 0.88 (95% CI: 0.85, 0.91) and 0.75 (0.67, 0.81) in those without and with baseline damage, respectively (post hoc analysis).

Drug-related AEs were reported for 433 (43.4%) patients; infections/infestations (282, 28.3%) and gastrointestinal disorders (139, 13.9%) were the most common.

Conclusion

Patients with SLE treated with long-term belimumab plus SoC had a low incidence of organ damage accrual and no unexpected AEs. High-risk patients with pre-existing organ damage also had low accrual, suggesting a favorable effect on future damage development.