Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Evaluation of a Mandatory Professional Development on Supporting Transgender, Nonbinary, and Gender-Nonconforming Students in Chicago Public Schools

To address the reality that LGBTQ+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, and others) students remain more likely to experience harm, harassment, and violence at school as well as miss school due to feeling unsafe and the fact that students identifying as transgender, nonbinary, and gender-nonconforming (TNBGNC) are at even greater risk of bullying, harassment, and significant mental health concerns, Chicago Public Schools' (CPS) Office of Student Health and Wellness (OSHW) created a novel professional development (PD) requirement in 2019, entitled "Supporting Transgender, Nonbinary, and Gender Nonconforming Students." The PD, a recorded webinar encouraging independent time for reflection and planning, takes an intersectional approach and is required of all CPS staff members across the entire district. A pre- and postevaluation of the PD, guided by the Kirkpatrick model, was completed by 19,503 staff members. The findings from this evaluation show that staff members significantly increased their knowledge, showed statistically significant gain in self-reported skills, and articulated key actions they could take toward sustaining an environment that fosters skill implementation and culture change more broadly. Findings reveal that a culture that supports staff members in learning from their mistakes can help to encourage staff members to employ gender-inclusive behaviors such as asking individuals for their pronouns and using gender-neutral pronouns. This districtwide mandatory PD approach shows value in influencing staff members' thinking and behaviors known to be supportive of TNBGNC students and may serve as a model for other school districts looking to build capacity to support TNBGNC students.

Evaluation of a dacitic (rhyolitic) tuff breccia use on performance, inflammatory, and antioxidant responses in broilers mildly challenged with Eimeria spp

The objective of the study was to investigate the effects of a dacitic tuff breccia (DTB) on Eimeria-infected broilers. A total of 600 one-day-old Cobb 500 male chickens were randomly assigned to 5 treatments with 10 replicates of 12 birds. Treatments were: an unchallenged control (UC), a challenged (CC) control (0% DTB), and 3 challenged groups with 0.125, 0.25, or 0.5% DTB. At d 14, birds in the CC and DTB groups were orally gavaged with mixed Eimeria spp., while the UC received water. Growth performance was evaluated during prechallenge, challenge, and postchallenge periods (0-14 d; 14-20 d; and 20-26 d, respectively). Gastrointestinal permeability was measured at 5 days postinfection (dpi). Intestinal histology and nutrient digestibility of dry matter (DM), crude protein (CP), and ileal digestible energy (IDE) were measured at 6 dpi. Liver activity of glutathione peroxidase (GSH-Px) was determined at 6 dpi, and concentrations of reduced (GSH) and oxidized glutathione (GSSG) were analyzed at 6 and 12 dpi. Data were analyzed using a linear mixed model analysis and Tukey's test (P ≤ 0.05). From 0 to 14 d, similar average daily gain (ADG) and average daily feed intake (ADFI, P > 0.05) were observed. Gain:feed ratio (GF) was higher in 0.125, 0.25, and 0.5% of DTB than the CC and UC (P < 0.001). From 14 to 20 d, the UC had the highest ADG, ADFI, and GF (P < 0.001). At 5 dpi, intestinal permeability was higher in the challenged groups than the UC. Additionally, the UC showed the highest apparent ileal digestibility of CP, whereas 0.125% DTB had higher CP digestibility than the CC and 0.5% DTB (P < 0.001). At 6 dpi, 0.125% DTB increased GSH-Px activity compared to the CC, 0.5% DTB, and UC (P < 0.001). At 12 dpi, 0.125% DTB showed increased GSH concentration compared to the CC, 0.25% DTB, and 0.5% DTB (P < 0.01). The mild coccidia infection negatively impacted growth performance, apparent ileal nutrient digestibility, intestinal histology, and gastrointestinal integrity in broilers. The use of 0.125% DTB exhibited potential in improving antioxidant responses, apparent ileal digestibility of CP, and growth performance.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Balance Right in Multiple Sclerosis (BRiMS): a feasibility randomised controlled trial of a falls prevention programme

Background

Balance, mobility impairments and falls are problematic for people with multiple sclerosis (MS). The “Balance Right in MS (BRiMS)” intervention, a 13-week home and group-based exercise and education programme, aims to improve balance and minimise falls. This study aimed to evaluate the feasibility of undertaking a multi-centre randomised controlled trial and to collect the necessary data to design a definitive trial.

Methods

This randomised controlled feasibility study recruited from four United Kingdom NHS clinical neurology services. Patients ≥ 18 years with secondary progressive MS (Expanded Disability Status Scale 4 to 7) reporting more than two falls in the preceding 6 months were recruited. Participants were block-randomised to either a manualised 13-week education and exercise programme (BRiMS) plus usual care, or usual care alone.

Feasibility assessment evaluated recruitment and retention rates, adherence to group assignment and data completeness. Proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls) and economic data were collected at baseline, 13 and 27 weeks, and participants completed daily paper falls diaries.

Results

Fifty-six participants (mean age 59.7 years, 66% female, median EDSS 6.0) were recruited in 5 months; 30 randomised to the intervention group. Ten (18%) participants withdrew, 7 from the intervention group. Two additional participants were lost to follow up at the final assessment point. Completion rates were > 98% for all outcomes apart from the falls diary (return rate 62%).

After adjusting for baseline score, mean intervention—usual care between-group differences for the potential primary outcomes at week 27 were MS Walking Scale-12v2: − 7.7 (95% confidence interval [CI] − 17.2 to 1.8) and MS Impact Scale-29v2: physical 0.6 (CI − 7.8 to 9), psychological − 0.4 (CI − 9.9 to 9). In total, 715 falls were reported, rate ratio (intervention:usual care) for falls 0.81 (0.41 to 2.26) and injurious falls 0.44 (0.41 to 2.23).

Conclusions

Procedures were practical, and retention, programme engagement and outcome completion rates satisfied a priori progression criteria. Challenges were experienced in completion and return of daily falls diaries. Refinement of methods for reporting falls is therefore required, but we consider a full trial to be feasible.

Trial registration

ISRCTN13587999

Date of registration: 29 September 2016

Combined action observation and motor imagery facilitates visuomotor adaptation in children with developmental coordination disorder

The internal modelling deficit (IMD) hypothesis suggests that motor control issues associated with Developmental Coordination Disorder (DCD) are the result of impaired predictive motor control. In this study, we examined the benefits of a combined action observation and motor imagery (AO + MI) intervention designed to alleviate deficits in internal modelling and improve eye-hand coordination during a visuomotor rotation task. Twenty children with DCD were randomly assigned to either an AO + MI group (who watched a video of a performer completing the task whilst simultaneously imagining the kinaesthetic sensations associated with action execution) or a control group (who watched unrelated videos involving no motor content). Each group then attempted to learn a 90° visuomotor rotation while measurements of completion time, eye-movement behaviour and movement kinematics were recorded. As predicted, after training, the AO + MI group exhibited quicker completion times, more target-focused eye-movement behaviour and smoother movement kinematics compared to the control group. No significant after-effects were present. These results offer further support for the IMD hypothesis and suggest that AO + MI interventions may help to alleviate such deficits and improve motor performance in children with DCD.

Choroidal thickness in lupus nephritis

OBJECTIVE

This study aimed to compare choroidal thickness between patients with systemic lupus erythematosus (SLE) and lupus nephritis (LN) in complete renal remission to that of patients with SLE without LN.

METHODS

This was a retrospective case-control study of 23 SLE patients meeting either the American College of Rheumatology or Systemic Lupus International Collaborating Clinics classification criteria and followed at Washington University School of Medicine Rheumatology or Nephrology, and Ophthalmology outpatient clinics. The diagnosis of LN was based on renal pathology, and complete renal remission was defined as proteinuria <500 mg/daily and serum creatinine at baseline. Extra-renal flare status was determined using modified Fortin criteria. Choroidal thickness was measured using spectral-domain optical coherence tomography and read by blinded reviewers.

RESULTS

In SLE patients without extra-renal flare, choroidal thickness of LN patients was 281 ± 78 µm compared to 288 ± 70 µm in non-LN SLE patients (p = 0.766) at the fovea.

CONCLUSION

Choroidal thickness was not different in patients with LN in remission compared to non-LN SLE patients in remission. Additional studies are needed to examine choroidal thickness in patients with SLE with active LN.

Implementation of influenza point-of-care testing and patient cohorting during a high-incidence season: a retrospective analysis of impact on infection prevention and control and clinical outcomes

BACKGROUND

During high-incidence influenza seasons, a robust infection prevention and control policy is imperative to reduce nosocomial transmission of influenza.

AIM

To assess the impact of influenza point-of-care testing (POCT) in an emergency department (ED) and patient cohorting on an influenza ward on infection prevention and control and clinical outcomes.

METHODS

Influenza POCT was operational in the study ED from 21^st January 2018 and patient cohorting was operational on an influenza ward from 25^th January 2018. A retrospective 'before-after' analysis was performed with pre-intervention defined as 1^st November 2017 to 20^th January 2018 and post-intervention defined as 21^st January 2018 to 30^th April 2018. The primary outcome was the rate of hospital-acquired influenza. Secondary outcomes included antiviral prescription and length of stay. The length of time that inpatients remained influenza-positive was estimated by polymerase chain reaction (PCR).

FINDINGS

There were 654 inpatients with confirmed influenza during the 2017/18 influenza season: 223 pre- and 431 post-intervention. Post-intervention, there were fewer cases of hospital-acquired influenza per day (0.66 vs 0.95, P < 0.0001), median length of stay was shorter (5.5 vs 7.5 days, P = 0.005) and antiviral prescription was more frequent (80% vs 64.1%, P < 0.0001). Cohorting released 779 single rooms for use elsewhere in the trust. The fixed probability of being PCR-negative by the next day (P) was 0.14 [95% confidence interval (CI) 0.12-0.16] for immunocompetent patients. This implies that half of immunocompetent patients are PCR-negative by five days post-diagnosis (95% CI 5-6).

CONCLUSION

Influenza POCT in an ED and patient cohorting on an influenza ward were associated with reduced nosocomial transmission of influenza and improved patient flow. A policy of retesting immunocompetent patients five days post-diagnosis could allow half of these patients to come out of respiratory isolation earlier.

Balance Right in Multiple Sclerosis (BRiMS): a guided self-management programme to reduce falls and improve quality of life, balance and mobility in people with secondary progressive multiple sclerosis: a protocol for a feasibility randomised controlled trial

BACKGROUND

Impaired mobility is a cardinal feature of multiple sclerosis (MS) and is rated by people with MS as their highest priority. By the secondary progressive phase, balance, mobility and physical activity levels are significantly compromised; an estimated 70% of people with secondary progressive MS fall regularly. Our ongoing research has systematically developed 'Balance Right in MS' (BRiMS), an innovative, manualised 13-week guided self-management programme tailored to the needs of people with MS, designed to improve safe mobility and minimise falls. Our eventual aim is to assess the clinical and cost effectiveness of BRiMS in people with secondary progressive MS by undertaking an appropriately statistically powered, multi-centre, assessor-blinded definitive, randomised controlled trial. This feasibility study will assess the acceptability of the intervention and test the achievability of running such a definitive trial.

METHODS/DESIGN

This is a pragmatic multi-centre feasibility randomised controlled trial with blinded outcome assessment. Sixty ambulant people with secondary progressive MS who self-report two or more falls in the previous 6 months will be randomly allocated (1:1) to either the BRiMS programme plus usual care or to usual care alone. All participants will be assessed at baseline and followed up at 15 weeks and 27 weeks post-randomisation. The outcomes of this feasibility trial include:Feasibility outcomes, including trial recruitment, retention and completionAssessment of the proposed outcome measures for the anticipated definitive trial (including measures of walking, quality of life, falls, balance and activity level)Measures of adherence to the BRiMS programmeData to inform the economic evaluation in a future trialProcess evaluation (assessment of treatment fidelity and qualitative evaluation of participant and treating therapist experience).

DISCUSSION

The BRiMS intervention aims to address a key concern for MS service users and providers. However, there are several uncertainties which need to be addressed prior to progressing to a full-scale trial, including acceptability of the BRiMS intervention and practicality of the trial procedures. This feasibility trial will provide important insights to resolve these uncertainties and will enable a protocol to be finalised for use in the definitive trial.

TRIAL REGISTRATION

ISRCTN13587999.

Campylobacter spp. Prevalence and Levels in Raw Milk: A Systematic Review and Meta-Analysis

Campylobacteriosis is the leading bacterial gastrointestinal disease internationally, contributing significantly to the enteric illness burden. Cases have been associated with the consumption of raw milk, a behavior that has garnered attention recently. Estimates of the prevalence and levels of Campylobacter spp. in raw milk are lacking, which hinders risk assessment attempts. This article is a systematic review and meta-analysis of reported prevalence and levels of zoonotic Campylobacter spp. in the raw milk of cows, goats, and sheep in Canada, the United States, Europe, Australia, and New Zealand. The relevant literature was reviewed, and trained reviewers examined the results for inclusion of articles in the meta-analysis. Relevant data (prevalence and/or level of Campylobacter in raw milk, country of origin, animal species, sample source, Campylobacter species identified, etc.) were extracted, and a meta-analysis was performed in Stata v. 12 (Metaprop command). The weighted mean prevalence of Campylobacter spp. in raw milk samples was 1.18%. Subgroup analyses were conducted to examine how prevalence varied by study characteristics, with the highest prevalence values in studies from the United Kingdom (by country, 6.4%), about cows (by animal species, 1.3%), and including samples taken from inline filters (by sample source, 1.75%) and in studies that included species that are not pathogenic to humans (by Campylobacter species, 1.14%). Two articles each included a single Campylobacter level, 0.16 ± 0.3 and approximately 0.047 most probable number per ml. Despite a relatively low prevalence, consumption of raw milk is inherently risky because no treatment has been used to inactivate pathogens. This potential risk further supports maintaining regulations to limit the sales of raw milk.

The Society of Thoracic Surgeons Lung Cancer Resection Risk Model: Higher Quality Data and Superior Outcomes

BACKGROUND

The Society of Thoracic Surgeons (STS) creates risk-adjustment models for common cardiothoracic operations for quality improvement purposes. Our aim was to update the lung cancer resection risk model utilizing the STS General Thoracic Surgery Database (GTSD) with a larger and more contemporary cohort.

METHODS

We queried the STS GTSD for all surgical resections of lung cancers from January 1, 2012, through December 31, 2014. Logistic regression was used to create three risk models for adverse events: operative mortality, major morbidity, and composite mortality and major morbidity.

RESULTS

In all, 27,844 lung cancer resections were performed at 231 centers; 62% (n = 17,153) were performed by thoracoscopy. The mortality rate was 1.4% (n = 401), major morbidity rate was 9.1% (n = 2,545), and the composite rate was 9.5% (n = 2,654). Predictors of mortality included age, being male, forced expiratory volume in 1 second, body mass index, cerebrovascular disease, steroids, coronary artery disease, peripheral vascular disease, renal dysfunction, Zubrod score, American Society of Anesthesiologists rating, thoracotomy approach, induction therapy, reoperation, tumor stage, and greater extent of resection (all p < 0.05). For major morbidity and the composite measure, cigarette smoking becomes a risk factor whereas stage, renal dysfunction, congestive heart failure, and cerebrovascular disease lose significance.

CONCLUSIONS

Operative mortality and complication rates are low for lung cancer resection among surgeons participating in the GTSD. Risk factors from the prior lung cancer resection model are refined, and new risk factors such as prior thoracic surgery are identified. The GTSD risk models continue to evolve as more centers report and data are audited for quality assurance.

Nursing students' experiences of ethical issues in clinical practice: A New Zealand study

Nursing students experience ethical problems in clinical practice in a different way from registered nurses. In order to develop ethical reasoning and competence in nursing students, nurse educators must recognise the unique issues students face. This research described the occurrence of ethical issues in clinical practice for 373 undergraduate nursing students who responded to a national questionnaire investigating the frequency of pre-determined ethical issues and the corresponding level of distress. Over two thirds of respondents experienced breaches of a patient's right to confidentiality, privacy, dignity or respect and 87% experienced unsafe working conditions. The most distressing issues were those that compromised patient safety, including unsafe healthcare practices, working conditions and suspected abuse or neglect. Themes that emerged from an open-ended question included lack of support and supervision, bullying and end of life issues. This research found the frequency at which ethical issues are experienced was highest in year three participants. However, the overall distress levels were lower for the majority of issues for those participants in the later part of their degree. Recommendations from this research include developing ethics education around the main concerns that students face in order to enhance students' understanding, resilience and ability to respond appropriately.

Effects of fluoroquinolone restriction (from 2007 to 2012) on resistance in Enterobacteriaceae: interrupted time-series analysis

BACKGROUND

Antibiotic stewardship is a key component in the effort to reduce healthcare-associated infections.

AIM

To describe the implementation and analyse the impact of fluoroquinolone restriction on resistance in Enterobacteriaceae, focusing on urinary isolates of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli, which were historically almost universally resistant to fluoroquinolones.

METHODS

ESBL-producing E. coli hospital and community isolates, obtained between April 2009 and March 2012 from consecutive non-duplicate urine samples, were included in an interrupted time-series analysis based on a Poisson distribution model. Periods before and after fluoroquinolone restriction were compared. The trend in fluoroquinolone resistance in all urinary isolates of Enterobacteriaceae (N ≈ 20,000 per year) and blood culture isolates of E. coli (N ≈ 350) between 2009 and 2013 were also analysed.

FINDINGS

A large decline in the percentage of ciprofloxacin-resistant ESBL-producing urinary E. coli isolates was observed in both hospital (risk ratio: 0.473; 95% confidence interval: 0.315-0.712) and community settings (0.098; 0.062-0.157). The decline was also marked in all urinary isolates of Enterobacteriaceae and E. coli isolates from blood cultures.

CONCLUSION

We conclude that reducing fluoroquinolone usage to a level of ≤2 defined daily doses per 100 occupied bed-days in hospital sufficiently removed selection pressure to allow resistant Enterobacteriaceae – specifically, the UK endemic strains of ESBL-producing E. coli – to revert back to fluoroquinolone susceptibility within a short span of four months. This was accompanied with a concomitant reduction in overall ESBL burden.

Experiences and attitudes towards evidence-informed policy-making among research and policy stakeholders in the Canadian agri-food public health sector

Policy-makers working at the interface of agri-food and public health often deal with complex and cross-cutting issues that have broad health impacts and socio-economic implications. They have a responsibility to ensure that policy-making based on these issues is accountable and informed by the best available scientific evidence. We conducted a qualitative descriptive study of agri-food public health policy-makers and research and policy analysts in Ontario, Canada, to understand their perspectives on how the policy-making process is currently informed by scientific evidence and how to facilitate this process. Five focus groups of 3-7 participants and five-one-to-one interviews were held in 2012 with participants from federal and provincial government departments and industry organizations in the agri-food public health sector. We conducted a thematic analysis of the focus group and interview transcripts to identify overarching themes. Participants indicated that the following six key principles are necessary to enable and demonstrate evidence-informed policy-making (EIPM) in this sector: (i) establish and clarify the policy objectives and context; (ii) support policy-making with credible scientific evidence from different sources; (iii) integrate scientific evidence with other diverse policy inputs (e.g. economics, local applicability and stakeholder interests); (iv) ensure that scientific evidence is communicated by research and policy stakeholders in relevant and user-friendly formats; (V) create and foster interdisciplinary relationships and networks across research and policy communities; and (VI) enhance organizational capacity and individual skills for EIPM. Ongoing and planned efforts in these areas, a supportive culture, and additional education and training in both research and policy realms are important to facilitate evidence-informed policy-making in this sector. Future research should explore these findings further in other countries and contexts.

Time series evaluation of an intervention to increase statin tablet splitting by general practitioners

BACKGROUND

Tablet splitting, in which a higher-dose tablet is split to get 2 doses, reduces patients' drug costs. Statins can be split safely. General practitioners (GPs) may not direct their patients to split statins because of safety concerns or unawareness of costs. Medical chart inserts provide cost-effective education to physicians.

OBJECTIVE

The aim of this study was to assess whether providing GPs with statin-splitting chart inserts would increase splitting rates, and to identify predictors of splitting.

METHODS

In 2005 and 2006, we faxed a statin chart insert to British Columbia GPs with a request for a telephone interview. Consenting GPs were mailed 3 statin chart inserts and interviewed by phone (the intervention). In an interrupted time series, we compared monthly rates of statin-splitting prescriptions among intervention and nonintervention GPs before, during, and after the intervention. In multivariate logistic regressions accounting for patient clustering, predictors of splitting included physician and patient demographics and the specific statin prescribed.

RESULTS

Of 5051 GPs reached, 282 (6%) agreed to the intervention. Before the intervention, GPs' splitting rate was 2.6%; after intervention, GPs' splitting rate was 7.5%. The rate for the nonintervention GPs was 4.4%. Intervention GPs were 1.68 (95% CI, 1.12-2.53) times more likely to prescribe splitting after the intervention than were nonintervention GPs. Other predictors were a patient's female sex (odds ratio [OR] = 1.26; 95% CI, 1.18-1.34), lower patient income (OR = 1.33; 95% CI, 1.18-1.34), and a lack of drug insurance (OR = 1.89; 95% CI, 1.69-2.04).

CONCLUSIONS

An inexpensive intervention was effective in producing a sustained increase in GPs' splitting rate during 22 months of observed follow-up. Expanding statin-splitting education to all GPs might reduce prescription costs for many patients and payors.

Thirty-day mortality of Clostridium difficile infection in a UK National Health Service Foundation Trust between 2002 and 2008

Few standardised data are available on mortality rates in patients with Clostridium difficile infection (CDI). The literature often reports 'attributable' mortality or cannot be universally applied. We aimed to investigate the pattern and trends in all-cause mortality in a large unselected cohort of patients affected by CDI. This was done by means of a retrospective cohort study between 2002 and 2008 of all patients with positive stool toxin tests indicating CDI in one National Health Service (NHS) Trust, comprising three general hospitals and seven community hospitals. Vital status of the patients was determined from two sources. In total, 2571 patients with a first episode of CDI were identified (1638 females; median age 82.1 years). Cumulative mortality at 7 days, 14 days, 30 days and 1 year was 13.4%, 20.8%, 32.5% and 58.7%, respectively. There was no significant difference in mortality between sex, year of diagnosis or hospital site. Mortality at 30 days increased incrementally from 3.4% in those aged <40 years to 41% in those >90 years. Mortality rates were significantly higher than reported by previous studies but were remarkably consistent over the time period and between different hospitals within the Trust. Prognosis falls with increasing age, and the age of this cohort may explain the high 30-day absolute mortality. CDI infection is associated with high early mortality. To reduce mortality, new interventions need to be introduced soon after diagnosis. There is a need for standardised outcome data for CDI.

Anatomic changes in multiple brainstem nuclei after incremental, near-complete neurotoxic destruction of the pre-Bötzinger Complex in adult goats

Abrupt, bilateral destruction of the pre-Bötzinger Complex (preBötC) leads to terminal apnea in unanesthetized goats and rats. In contrast, respiratory rhythm and pattern and arterial blood gases in goats during wakefulness and sleep are normal after incremental (over a month) destruction of > 90% of the preBötC. Here, we tested the hypothesis that the difference in effects between abrupt and incremental destruction of the preBötC are a result of time-dependent plasticity, which manifests as anatomic changes at sites within the respiratory network. Accordingly, we report data from histological analyses comparing the brainstems of control goats, and goats that had undergone bilateral, incremental, ibotenic acid (IA)-induced preBötC lesioning. A major focus was on the parafacial respiratory group/retrotrapezoid nucleus (pFRG/RTN) and the pontine respiratory group (PRG), which are sites thought to contribute to respiratory rhythmogenesis. We also studied the facial (FN), rostral nucleus ambiguus (NA), medullary raphé (MRN), hypoglossal (HN), and the dorsal motor vagal (DMV) nuclei. Neuronal counts, count region area (mm²), and neuronal densities were calculated using computer-assisted analyses and/or manual microscopy to compare control and preBötC-lesioned animals. We found that within the ventral and lateral medulla 2mm rostral to the caudal pole of the FN (presumed pFRG/RTN), there were 25% and 65% more (P < 0.001) neurons, respectively, in preBötC-lesioned compared to control goats. Lesioned goats also showed 14% and 13% more (P < 0.001) neurons in the HN and medial parabrachialis nucleus, but 46%, 28%, 7%, and 17% fewer (P < 0.001) neurons in the FN, NA, DMV, and Kölliker-Fuse nuclei, respectively. In the remaining sites analyzed, there were no differences between groups. We conclude that anatomic changes at multiple sites within the respiratory network may contribute to the time-dependent plasticity in breathing following incremental and near-complete destruction of the preBötC.

Exploring historical Canadian foodborne outbreak data sets for human illness attribution

Human illness attribution has been recently recognized as an important tool to better inform food safety decisions. Analysis of outbreak data sets has been used for that purpose. This study was conducted to explore the usefulness of three comprehensive Canadian foodborne outbreak data sets covering 30 years for estimating food attribution in cases of gastrointestinal illness, providing Canadian food attribution estimates from a historical perspective. Information concerning the microbiological etiology and food vehicles recorded for each outbreak was standardized between the data sets. The agent-food vehicle combinations were described and analyzed for changes over time by using multiple correspondence analysis. Overall, 6,908 foodborne outbreaks were available for three decades (1976 through 2005), but the agent and the food vehicle were identified in only 2,107 of these outbreaks. Differences between the data sets were found in the distribution of the cause, the vehicle, and the location or size of the outbreaks. Multiple correspondence analysis revealed an association between Clostridium botulinum and wild meat and between C. botulinum and seafood. This analysis also highlighted changes in food attribution over time and generated the most up-to-date food attribution values for salmonellosis (29% of cases associated with produce, 15% with poultry, and 15% with meat other than poultry, pork, and beef), campylobacteriosis (56% of cases associated with poultry and 22% with dairy products other than fluid milk), and Escherichia coli infection (37% of cases associated with beef, 23% with cooked multi-ingredient dishes, and 11% with meat other than beef, poultry, and pork). Because of the inherent limitations of this approach, only the main findings should be considered for policy making. The use of other human illness attribution approaches may provide further clarification.

Does knowledge of medication prices predict physicians' support for cost effective prescribing policies

BACKGROUND

British Columbia implemented a generic substitution (GS) and Reference Drug Program (RDP) to contain drug expenditures without negatively affecting health outcomes. Years after implementation, these policies remain controversial among physicians.

OBJECTIVE

To assess British Columbia general practitioners' (GPs) opinions of RDP and GS stratified by knowledge of drug costs.

METHODS

In telephone interviews, GPs ranked the economic and clinical appropriateness of drug policy options on a 5-point Likert scale. Responses to economic questions were stratified and compared according to the accuracy (+ $10 of the actual cost) of GPs' cost estimates for a 30-day supply of atorvastatin and omeprazole.

RESULTS

The majority of 210 interviewed GPs rated the economic appropriateness of GS and RDP positively (79% and 65%) but fewer rated them clinically appropriate (60% and 43%). Ratings for GS were more favorable than RDP, economically (mean=4.3 vs. 3.8, p=0.0005) and clinically (mean=3.7 vs. 3.1, p=0.006). GP's assessment of the therapeutic equivalence among ACE inhibitors and among CCBs correlated with their ratings of the respective RDPs (I=0.3, p=0.03, and I=0.4, p=0.02). GPs underestimated the price for omeprazole by C$28 (33%) and atorvastatin by C$28 (34%). GPs with accurate cost estimates were equally as likely to favorably rank the economic appropriateness of RDP as those with inaccurate estimates (mean = 3.7 vs. 4.0, p=0.0847). GS was assessed similarly (mean = 4.2 vs. 4.5, p=0.0712).

CONCLUSIONS

In British Columbia, the majority of GPs hold favorable opinions of GS and RDP; but, simply educating physicians about drug prices will not make them more supportive of cost-containment policies.

Rapid diagnosis of Mycobacterium tuberculosis meningitis by enumeration of cerebrospinal fluid antigen-specific T-cells

SETTING

Hospital in-patients with suspected tuberculous meningitis (TBM), predominantly in India.

OBJECTIVE

To determine whether interferon-gamma (IFN-gamma) secreting Mycobacterium tuberculosis antigen-specific T-cells are present in the cerebrospinal fluid (CSF) of patients with TBM and to evaluate the feasibility of CSF enzyme-linked immunospot (ELISpot) for the diagnosis of active TBM.

DESIGN

Prospective blinded hospital-based study.

RESULTS

The overnight ELISpot assay detected M. tuberculosis antigen-specific IFN-gamma secreting T-cells in CSF from nine of 10 prospectively recruited patients with TBM, and zero of seven control patients with meningitis of other aetiology. This corresponds to a diagnostic sensitivity of 90% (95%CI 56-100) and specificity of 100% (95%CI 59-100).

CONCLUSION

This pilot study demonstrates proof-of-principle for a new T-cell-based diagnostic test for TBM which is rapid, sensitive and specific.

Thermographic investigation of the heating effect of high intensity focused ultrasound

The purpose of this study was to use thermal imaging camera to investigate the localised heating effect of High intensity focused ultrasound (HIFU), to monitor temperature rise in real time and accurately. In order to visualise thermally induced protein coagulation, a phantom of Polyacrylamide (PAA) gel containing fresh egg albumin was used as tissue mimicking material. A high resolution thermal camera was positioned directly over the samples to record thermal fluctuations. Two modes of ultrasound were investigated, i.e. continuous wave and pulsed wave. Through imaging processing and thermal analysis, the temperature profile of the phantoms during HIFU heating was obtained, and the optimised parameters for protein coagulation were identified. The experiments have shown that thermal imaging is an effective way to measure the bioheating effect of HIFU.

Complications of Thoracic Computed Tomography–Guided Fiducial Placement for the Purpose of Stereotactic Body Radiation Therapy

PURPOSE

This study examined the complication rates associated with percutaneous fiducial placement for the purpose of stereotactic body radiation therapy of primary and metastatic lung neoplasms.

PATIENTS AND METHODS

This is a retrospective review of computed tomography (CT) scans and follow-up chest radiographs of 48 consecutive patients who underwent CT-guided percutaneous fiducial placement. The effect of age, sex, number of fiducials placed, and performance of a concomitant biopsy on the complication rates were assessed.

RESULTS

Of 48 patients with a total of 221 fiducials placed, 16 (33%) had a procedure-related pneumothorax. There was no significant difference in pneumothorax rate based on age (P = 0.16), sex (P > 0.99), and number of fiducials placed (P = 0.21). Overall, 6 of 48 patients (12.5%) required a thoracostomy tube. Performance of a concomitant core needle biopsy at the time of fiducial placement was associated with pneumothorax rates of 64% compared with 26% without biopsies (P = 0.03). Postprocedural CT demonstrated hemorrhage in 9 patients (19%). Two patients had hemoptysis; one required admission. Patients' age, sex, number of fiducials placed, and performance of concomitant biopsy had no statistically significant implications on parenchymal hemorrhage incidence.

CONCLUSION

Approximately one third of the patients develop a pneumothorax during CT-guided fiducial placement. Most are asymptomatic and do not require a thoracostomy. A concurrent biopsy at the time of fiducial placement is associated with an increased risk of pneumothorax. Hemorrhage occurs but is usually clinically insignificant.

TGF-beta signaling pathway inactivation and cell cycle deregulation in the development of gastric cancer: role of the beta-spectrin, ELF

We have shown that loss of ELF, a stem cell adaptor protein, disrupts TGF-beta signaling through Smad3 and Smad4 localization. Notably elf(+/-)/smad4(+/-) mice develop gastric cancer presenting this as an important model for analyzing molecular event in gastric carcinogenesis. To gain further insight into the functional role of ELF in gastric cancer suppression, we carried out a detailed characterization of cell cycle events leading to gastric tumorigenesis. elf(-/-) cells and elf(+/-)/smad4(+/-) mice demonstrate a marked alteration of cell cycle regulators, such as Cdk4, K-Ras, and p21. Levels of Cdk4 increased compared to normal controls, suggesting loss of ELF results in functional abnormalities in cell cycle regulation. We further demonstrate that the elf(-/-) MEFs show a disruption of G1/S cell cycle transition and a significant reduction in senescence. Thus, in response to ELF deficiency, the abnormalities of G1/S checkpoint and senescence contribute their increment of susceptibility to malignant transformation.