Linking communities and health facilities to improve child health in low resource settings: a systematic review

Community-facility linkage interventions are gaining popularity as a way to improve community health in low-income settings. Their aim is to create/strengthen a relationship between community members and local healthcare providers. Representatives from both groups can address health issues together, overcome trust problems, potentially leading to participants' empowerment to be responsible for their own health. This can be achieved via different approaches. We conducted a systematic literature review to explore how this type of intervention has been implemented in rural and low or lower-middle income countries, its various features and how/if it has helped to improve child health in these settings. Publications from three electronic databases (Web of Science, PubMed, Embase) up to 03/02/2022 were screened, with 14 papers meeting the inclusion criteria (rural setting in low/lower-middle income countries, presence of a community-facility linkage component, outcomes of interest related to under-five children's health, peer-reviewed articles containing original data written in English). We used Rosato's integrated conceptual framework for community participation to assess the transformative and community empowering capacities of the interventions, and realist principles to synthesize the outcomes. The results of this analysis highlight which conditions can lead to success of this type of intervention: active inclusion of hard-to-reach groups, involvement of community members in implementation's decisions, activities tailored to the actual needs of interventions' contexts, and usage of mixed methods for a comprehensive evaluation. These lessons informed the design of a community-facility linkage intervention and offer a framework to inform the development of monitor and evaluation plans for future implementations.

Concussion injury management, perception, and knowledge in amateur field hockey

Background

Field hockey has a high risk for sports-related concussion (SRC) injuries due to the speed and intensity of the game, current rules, field surfaces and equipment composition. Head injuries are the second most common reported injury and up to 75% of SRCs go unreported or undetected. This increases the subsequent injury risk, long-term health consequences and prolonged injury recovery.

Objectives

This study aimed to examine the prevalence of SRC in hockey players within the Southern Gauteng Hockey Association (SGHA) premier league. Concussion knowledge and attitudes of hockey players, coaches, umpires, and officials were also investigated.

Methods

A partially mixed sequential dominant status design (QUANT-qual) was used, divided into two phases. In Phase One hockey players, coaches, umpires, and technical officials (n=119) completed a modified RoCKAS-ST questionnaire. In Phase Two, a focus group discussion with umpires (n=3) and interviews with coaches (n=3) were conducted.

Results

Injuries to the shoulder, neck, head, and face were reported from stick use (n=98); ball use (n=102) and collisions (n=187). Only 19% of hockey players were diagnosed with SRC, indicating that many of these injuries were undetected or not reported. Responses from the focus group discussion and interviews indicated that coaches, umpires, and officials felt they had insufficient knowledge of SRC.

Conclusion

The recognition and management of on-field injuries require improvement to enhance the injury detection system.

FEEDING PRACTICES AND NUTRITIONAL STATUS OF UNDER-FIVE CHILDREN IN A PERI-URBAN SETTING IN IBADAN, SOUTHWEST NIGERIA: A COMPARATIVE CROSS-SECTIONAL STUDY

Background

Existing literature suggests inequalities in nutritional and feeding practices for children in rural communities compared to their urban counterparts. However, with increasing urbanization and changing social norms, re-assessment of rural-urban differences in feeding practices for under-five children is essential. This study therefore aimed to assess the feeding practices and nutritional status of children in a peri-urban setting in Ibadan.

Methods

We conducted a community-based cross-sectional comparative study in peri-urban LGA (Lagelu) in Ibadan. Participants were 617 caregivers of underfive children identified, from wards typical of rural and urban settings, through a multistage sampling technique. Caregivers' sociodemographic details, 24-hour dietary recall of the child's feeding, and anthropometric measurements were obtained.

Results

Nearly half of the children were 2 years or older (rural: n=142, 47.2%; urban: n=147, 46.2%). There was significant difference between settings in terms of maternal age and education, father's education, caregiver's occupation and socioeconomic status. In total, 611 children (99.0%) were breastfed. Of those breastfed, 45% and 39% in rural and urban settings respectively were initiated within an hour of delivery. Children in rural setting had longer duration of breast feeding. However, they are less likely to be exclusively breast fed for 6 - months compared with children whose caregivers are urban dwellers. Dietary diversity was similar in both settings but higher among males. (20.3% male, 11.7% female in rural; 17.3% male and 15.5% female in urban). Overall, 108 (22.3%), 107 (21.9%), 152 (30.6%) and 34 (7.0%) of children aged 6-59 months were cachetic, underweight, stunted, and overweight respectively but commoner among children in rural settings.

Conclusion

Feeding and nutrition programmes need to apply a gender lens if sustained behavioural interventions on child nutrition are to reach equitable outcomes.

FEEDING PRACTICES AND NUTRITIONAL STATUS OF UNDER-FIVE CHILDREN IN A PERI-URBAN SETTING IN IBADAN, SOUTHWEST NIGERIA: A COMPARATIVE CROSS-SECTIONAL STUDY

Background

Existing literature suggests inequalities in nutritional and feeding practices for children in rural communities compared to their urban counterparts. However, with increasing urbanization and changing social norms, re-assessment of rural-urban differences in feeding practices for under-five children is essential. This study therefore aimed to assess the feeding practices and nutritional status of children in a peri-urban setting in Ibadan.

Methods

We conducted a community-based cross-sectional comparative study in peri-urban LGA (Lagelu) in Ibadan. Participants were 617 caregivers of underfive children identified, from wards typical of rural and urban settings, through a multistage sampling technique. Caregivers' sociodemographic details, 24-hour dietary recall of the child's feeding, and anthropometric measurements were obtained.

Results

Nearly half of the children were 2 years or older (rural: n=142, 47.2%; urban: n=147, 46.2%). There was significant difference between settings in terms of maternal age and education, father's education, caregiver's occupation and socioeconomic status. In total, 611 children (99.0%) were breastfed. Of those breastfed, 45% and 39% in rural and urban settings respectively were initiated within an hour of delivery. Children in rural setting had longer duration of breast feeding. However, they are less likely to be exclusively breast fed for 6 - months compared with children whose caregivers are urban dwellers. Dietary diversity was similar in both settings but higher among males. (20.3% male, 11.7% female in rural; 17.3% male and 15.5% female in urban). Overall, 108 (22.3%), 107 (21.9%), 152 (30.6%) and 34 (7.0%) of children aged 6-59 months were cachetic, underweight, stunted, and overweight respectively but commoner among children in rural settings.

Conclusion

Feeding and nutrition programmes need to apply a gender lens if sustained behavioural interventions on child nutrition are to reach equitable outcomes.

Cytomegalovirus infection is a risk factor for venous thromboembolism in ANCA-associated vasculitis

BACKGROUND

Venous thromboembolism (VTE) is a common complication in patients with anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitides (AAV) and confers significant morbidity and mortality. Both acute and past cytomegalovirus (CMV) infection have been identified as risk factors for VTE in immunocompetent and immunosuppressed individuals. Here, we examine whether past exposure to CMV is a risk factor for VTE amongst patients with AAV.

METHODS

We retrospectively analysed outcomes of patients with a new diagnosis of AAV from a UK cohort. All confirmed cases of VTE where CMV IgG serology was available were recorded. Retrospective collection of the same data for patients at a North American centre was used as a validation cohort.

RESULTS

VTE was common with 12% of patients from the study cohort (total 259 patients) developing an event during the median follow-up period of 8.5 years of which 60% occurred within the first 12 months following diagnosis. Sixteen percent of CMV seropositive patients developed a VTE compared with 5% of patients who were seronegative (p = 0.007) and CMV seropositivity remained an independent predictor of VTE in multivariable analysis (HR 2.96 [1.094-8.011] p = 0.033). CMV seropositivity at diagnosis was confirmed as a significant risk factor for VTE in the American validation cohort (p = 0.032).

CONCLUSIONS

VTE is common in patients with AAV, especially within the first year of diagnosis. Past infection with CMV is an independent risk factor associated with VTE in AAV.

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.

816 COORDINATE MY CARE: INCREASING STAFF ACCESS AND NUMBER OF PATIENT RECORDS CREATED IN A BUSY ACUTE HOSPITAL - A QI PROJECT

Introduction

The Royal College of Physicians have emphasised the need to provide good end of life care for patients in the acute care setting, with the publication of the Acute Care Resource (1) in February 2021. This follows on from their key recommendations in 2018, which proposed that ‘all healthcare professionals reviewing patients with chronic conditions,…more than one serious medical problem, or terminal illness, should initiate shared decision making including advance care planning in line with patient preferences’ (2). Coordinate My Care (CMC) is an electronic urgent care plan accessible to all relevant health and social care professionals caring for patients residing in London Boroughs, enabling communication of wishes and preferences, including those of resuscitation status and advance care plans.

Method

Multiple PDSA Cycles, including requesting logins for CMC for emergency medicine, acute and general medical senior and junior doctors, and hosting CMC training sessions. Teaching sessions given to the above cohorts with regard to advance care planning and the use of CMC. Creation of live link to CMC via Trust’s electronic patient record.

Results

An increase in average monthly CMC record views from 45 to 108 by clinicians at North Middlesex Hospital. An increase from an average of 18 CMC records created per month, compared to 27 records created per month after the QI project, with an estimated additional cost saving of almost £19,000 per month (3).

Conclusion

Successful QI project, with demonstrated increase in staff access to CMC and number of patient CMC records created in a busy acute hospital. Ongoing success will be reflected in sustainability of the current numbers of acute hospital staff accessing CMC and creation of records.

Mutant clones in normal epithelium outcompete and eliminate emerging tumours

Human epithelial tissues accumulate cancer-driver mutations with age1-9, yet tumour formation remains rare. The positive selection of these mutations suggests that they alter the behaviour and fitness of proliferating cells10-12. Thus, normal adult tissues become a patchwork of mutant clones competing for space and survival, with the fittest clones expanding by eliminating their less competitive neighbours11-14. However, little is known about how such dynamic competition in normal epithelia influences early tumorigenesis. Here we show that the majority of newly formed oesophageal tumours are eliminated through competition with mutant clones in the adjacent normal epithelium. We followed the fate of nascent, microscopic, pre-malignant tumours in a mouse model of oesophageal carcinogenesis and found that most were rapidly lost with no indication of tumour cell death, decreased proliferation or an anti-tumour immune response. However, deep sequencing of ten-day-old and one-year-old tumours showed evidence of selection on the surviving neoplasms. Induction of highly competitive clones in transgenic mice increased early tumour removal, whereas pharmacological inhibition of clonal competition reduced tumour loss. These results support a model in which survival of early neoplasms depends on their competitive fitness relative to that of mutant clones in the surrounding normal tissue. Mutant clones in normal epithelium have an unexpected anti-tumorigenic role in purging early tumours through cell competition, thereby preserving tissue integrity.

Differences in Inflammatory Marker Kinetics between the First and Second Wave of COVID-19 Patients Admitted to the ICU: A Retrospective, Single-Center Study

BACKGROUND

We sought to determine if there was a difference in the longitudinal inflammatory response measured by white blood cell count (WBC), C-reactive protein (CRP), procalcitonin (PCT), and ferritin levels between the first and the second COVID-19 wave of ICU patients.

METHODS

In a single-center retrospective observational study, ICU patients were enrolled during the first and second waves of the COVID-19 pandemic. Data were collected on patient demographics, comorbidities, laboratory results, management strategies, and complications during the ICU stay. The inflammatory response was evaluated using WBC count, CRP, PCT, and Ferritin levels on the day of admission until Day 28, respectively. Organ dysfunction was measured by the SOFA score.

RESULTS

65 patients were admitted during the first and 113 patients during the second wave. WBC and ferritin levels were higher in the second wave. CRP and PCT showed markedly different longitudinal kinetics up until day 28 of ICU stay between the first and second wave, with significantly lower levels in the second wave. Steroid and immunomodulatory therapy use was significantly greater in the second wave. Mortality was similar in both waves.

CONCLUSIONS

We found that there was a significantly reduced inflammatory response in the second wave, which is likely to be attributable to the more widespread use of immunomodulatory therapies.

Towards transforming community eye care: an observational study and time-series analysis of optometrists' prescribing for eye disorders

OBJECTIVES

This study aimed to provide evidence on the therapeutic prescribing activity by community optometrists in Scotland and to determine its impact on workload in general practice and ophthalmology clinics.

STUDY DESIGN

Scottish administrative healthcare data for a 53-month period (November 2013-April 2018) were used to analyse non-medical prescribing practice by optometrists.

METHODS

Using interrupted time-series regression (Autoregressive Integrated Moving Average), we assessed the impact of optometrist prescribing on ophthalmology outpatient attendances and general practice prescribing for eye disorders.

RESULTS

A total of 54,246 items were prescribed by 205 optometrists over the study period. Since the commencement of data recording, optometrist prescribing activity increased steadily from a baseline of zero to 1.2% of all ophthalmic items prescribed. Neither the monthly number of items prescribed nor the size of optometric workforce were associated with a reduction in ophthalmology outpatient appointments over time.

CONCLUSIONS

Optometrists increasingly contribute to community ophthalmic prescribing in Scotland, releasing capacity and lessening general practice, but not secondary care workload. There appears to be an underutilisation of optometrists related to the management of dry eye, which represents an opportunity to release further capacity.

Reducing Immunogenicity of Pegloticase With Concomitant Use of Mycophenolate Mofetil in Patients With Refractory Gout: A Phase II, Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVE

Pegloticase is used for the treatment of severe gout, but its use is limited by immunogenicity. This study was undertaken to evaluate whether mycophenolate mofetil (MMF) prolongs the efficacy of pegloticase.

METHODS

Participants were randomized 3:1 to receive 1,000 mg MMF twice daily or placebo for 14 weeks, starting 2 weeks before receiving pegloticase and continuing while receiving intravenous pegloticase 8 mg biweekly for 12 weeks. Participants then received pegloticase alone from week 12 to week 24. The primary end points were the proportion of patients who sustained a serum urate level of ≤6 mg/dl at 12 weeks and the rate of adverse events (AEs). Secondary end points included 24-week durability of serum urate level ≤6 mg/dl. Fisher's exact test and Wilcoxon's 2-sample test were used for analyses, along with Kaplan-Meier estimates and log rank tests.

RESULTS

A total of 32 participants received ≥1 dose of pegloticase. Participants were predominantly men (88%), with a mean age of 55.2 years, mean gout duration of 13.4 years, and mean baseline serum urate level of 9.2 mg/dl. At 12 weeks, a serum urate level of ≤6 mg/dl was achieved in 19 (86%) of 22 participants in the MMF arm compared to 4 (40%) of 10 in the placebo arm (P = 0.01). At week 24, the serum urate level was ≤6 mg/dl in 68% of MMF-treated patients versus 30% of placebo-treated patients (P = 0.06), and rates of AEs were similar between groups, with more infusion reactions occurring in the placebo arm (30% versus 0%).

CONCLUSION

Our findings indicate that MMF therapy with pegloticase is well tolerated and shows a clinically meaningful improvement in targeted serum urate level of ≤6 mg/dl at 12 and 24 weeks. This study suggests an innovative approach to pegloticase therapy in gout.

AAPS Perspective on the EURL Recommendation on the use of Non-Animal-Derived Antibodies

In May 2020, the EU Reference Laboratory for alternatives to animal testing (EURL ECVAM) published a recommendation report entitled "Recommendation on nonanimal-derived antibodies". In this report, the EURL ECVAM specifically states: "Therefore, taking into consideration the ESAC Opinion on the scientific validity of replacements for animal-derived antibodies, EURL ECVAM recommends that animals should no longer be used for the development and production of antibodies for research, regulatory, diagnostic and therapeutic applications. The provisions of Directive 2010/63/EU should be respected, and EU countries should no longer authorise the development and production of antibodies through animal immunisation, where robust, legitimate scientific justification is lacking." (1). Here, we are providing the American Association of Pharmaceutical Scientists (AAPS) opinion on the EURL ECVAM recommendation report. In brief, there has been a clear and strong progress in reduction of animal use in the drug discovery and development process, including significant reduction of animal use in production of antibody reagents. Yet, it is proposed that more data need to be generated, shared and discussed within the scientific community before a decision to implement the change to non-animal derived antibodies is made.

'Physio's not going to repair a torn tendon': patient decision-making related to surgery for rotator cuff related shoulder pain

BACKGROUND

Rotator cuff related shoulder pain (RCRSP) is a common and disabling shoulder condition and surgical management is becoming more common. The rates and costs of surgical interventions have been on the rise. Understanding decision-making related to surgery and providing adequate information to people with RCRSP may improve patient-centred care and potentially reduce rates of surgery.

OBJECTIVES

To explore the decision-making processors of people who have undertaken surgery for RCRSP.

DESIGN

An in-depth thematic analysis.

METHOD

Interviews were conducted with patients from Melbourne who had had surgical management for RCRSP. Data were analysed using an inductive thematic approach.

RESULTS

Fifteen participants were recruited. Six key themes emerged: (1) Needing to get it done: "It was necessary to remedy the dire situation"; (2) Non-surgical treatment experience:" I knew that I'd done all I could"; (3) Mechanical problem:" Physio's not going to repair a torn tendon"; (4) Trust in medical professionals "If they told me that I needed to swallow a thousand spiders, I would have done it."; (5) Varied information sources "Dr Google played a big part in it"; (6) Organisational barriers "It was absolutely useless, my insurance."

CONCLUSION

Surgery appears to be commonly precipitated by unremitted severe symptoms and failed non-surgical treatment. While there was strong trust in highly trained surgeons, decision to undergo surgery also drew on questionable pathoanatomical beliefs and instances of inadequate patient information about treatment choices and risks that may be addressed by adopting a more patient-centred care approach.IMPLICATIONS FOR REHABILITATIONUnderstanding decision-making related to surgery and providing adequate information to people with rotator cuff related shoulder pain may improve patient-centred care.Surgery appears to be commonly precipitated by unremitted severe symptoms and failed non-surgical treatment.Decision to undergo surgery sometimes drew on questionable pathoanatomical beliefs.There was strong trust in highly trained surgeons but there were instances of inadequate patient information about treatment choices and risks.

Risk factors of SARS-CoV-2 infection in healthcare workers: a retrospective study of a nosocomial outbreak

Background

Healthcare workers (HCWs) are at the forefront of fighting against the COVID-19 pandemic. However, they are at high risk of acquiring the pathogen from infected patients and transmitting to other HCWs. We aimed to investigate risk factors for nosocomial COVID-19 infection among HCWs in a non-COVID-19 hospital yard.

Methods

Retrospective data collection on demographics, lifestyles, contact status with infected subjects for 118 HCWs (including 12 COVID-19 HCWs) at Union Hospital of Wuhan, China. Sleep quality and working pressure were evaluated by the Pittsburgh Sleep Quality Index (PSQI) and The Nurse Stress Index (NSI), respectively. The follow-up duration was from Dec 25, 2019, to Feb 15, 2020.

Results

A high proportion of COVID-19 HCWs had engaged in night shift-work (75.0% vs. 40.6%) and felt working under pressure (66.7% vs. 32.1%) than uninfected HCWs. SARS-CoV-2 infected HCWs had significantly higher scores of PSQI and NSI than uninfected HCWs (P < 0.001). Specifically, scores of 5 factors (sleep quality, sleep time, sleep efficiency, sleep disorder, and daytime dysfunction) in PSQI were higher among infected HCWs. For NSI, its 5 subscales (nursing profession and work, workload and time allocation, working environment and resources, patient care, management and interpersonal relations) were all higher in infected than uninfected nurse. Furthermore, total scores of PSQI (HR = 2.97, 95%CI = 1.86−4.76; P <0.001) and NSI (HR = 4.67, 95%CI = 1.42−15.45; P = 0.011) were both positively associated with the risk of SARS-CoV-2 infection.

Conclusion

Our analysis shows that poor sleep quality and higher working pressure may increase the risk of nosocomial SARS-CoV-2 infection among HCWs.

•

Risk factors of the susceptibility of HCWs to COVID-19 remained largely unknown.

•

Infected HCWs had poorer sleep quality and higher working pressure than uninfected.

•

Poor sleep quality and high working pressure were associated with COVID-19 risk.

•

Improving the night duty system, decreasing psychological pressure is necessary for HCWs.

Nepenthes maximoides (Nepenthaceae) a new, critically endangered (possibly extinct) species in Sect. Alatae from Luzon, Philippines showing striking pitcher convergence with N. maxima (Sect. Regiae) of Indonesia

Nepenthes maximoides sp. nov. (Sect. Alatae) is described and assessed as Critically Endangered (Possibly Extinct) from Luzon, Philippines and appears unrecorded in 110 years. The spectacular, large, narrowly funnel-shaped upper pitchers, lids with recurved basal and filiform apical appendages, unlike any other species in the Philippines, closely resemble those of N. maxima (Sect. Regiae) of Sulawesi-New Guinea, likely due to convergent evolution. Following recent phylogenomic analysis, sect. Alatae is divided into two, Sect. Alatae sensu stricto of Luzon to Sibuyan (including N. maximoides), and Sect. Micramphorae, expanded and recircumscribed to encompass those species of the southern Visayas, and Mindanao. A key is provided to the six species now recognised in the newly narrowly recircumscribed Sect. Alatae. The number of Nepenthes species recorded from Luzon has increased from two in 2001, to eight in 2020, all but one of which are endemic to that island, and four of which appear to be point endemics.

Prevalence of phenotypes of acute respiratory distress syndrome in critically ill patients with COVID-19: a prospective observational study

Background

In acute respiratory distress syndrome (ARDS) unrelated to COVID-19, two phenotypes, based on the severity of systemic inflammation (hyperinflammatory and hypoinflammatory), have been described. The hyperinflammatory phenotype is known to be associated with increased multiorgan failure and mortality. In this study, we aimed to identify these phenotypes in COVID-19-related ARDS.

Methods

In this prospective observational study done at two UK intensive care units, we recruited patients with ARDS due to COVID-19. Demographic, clinical, and laboratory data were collected at baseline. Plasma samples were analysed for interleukin-6 (IL-6) and soluble tumour necrosis factor receptor superfamily member 1A (TNFR1) using a novel point-of-care assay. A parsimonious regression classifier model was used to calculate the probability for the hyperinflammatory phenotype in COVID-19 using IL-6, soluble TNFR1, and bicarbonate levels. Data from this cohort was compared with patients with ARDS due to causes other than COVID-19 recruited to a previous UK multicentre, randomised controlled trial of simvastatin (HARP-2).

Findings

Between March 17 and April 25, 2020, 39 patients were recruited to the study. Median ratio of partial pressure of arterial oxygen to fractional concentration of oxygen in inspired air (PaO₂/FiO₂) was 18 kpa (IQR 15–21) and acute physiology and chronic health evaluation II score was 12 (10–16). 17 (44%) of 39 patients had died by day 28 of the study. Compared with survivors, patients who died were older and had lower PaO₂/FiO₂. The median probability for the hyperinflammatory phenotype was 0·03 (IQR 0·01–0·2). Depending on the probability cutoff used to assign class, the prevalence of the hyperinflammatory phenotype was between four (10%) and eight (21%) of 39, which is lower than the proportion of patients with the hyperinflammatory phenotype in HARP-2 (186 [35%] of 539). Using the Youden index cutoff (0·274) to classify phenotype, five (63%) of eight patients with the hyperinflammatory phenotype and 12 (39%) of 31 with the hypoinflammatory phenotype died. Compared with matched patients recruited to HARP-2, levels of IL-6 were similar in our cohort, whereas soluble TNFR1 was significantly lower in patients with COVID-19-associated ARDS.

Interpretation

In this exploratory analysis of 39 patients, ARDS due to COVID-19 was not associated with higher systemic inflammation and was associated with a lower prevalence of the hyperinflammatory phenotype than that observed in historical ARDS data. This finding suggests that the excess mortality observed in COVID-19-related ARDS is unlikely to be due to the upregulation of inflammatory pathways described by the parsimonious model.

Funding

US National Institutes of Health, Innovate UK, and Randox.

2020 American College of Rheumatology Guideline for the Management of Gout

OBJECTIVE

To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.

METHODS

Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional.

RESULTS

Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.

CONCLUSION

Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.

Optimising the management of concurrent symphyseal/parasymphyseal and bilateral extracapsular condylar fractures using three-dimensional printing

PURPOSE

Three-dimensional (3D) printing plays an important role in the diagnosis and treatment planning of many elective procedures in oral and maxillofacial surgery (OMFS). 3D printers and the associated print materials are now within the price range of most maxillofacial units, requiring less work to be sent out to commercial printers. Whilst their use in the planning of elective procedures is commonplace, acute trauma is an area where 3D printing remains underutilised. The successful management of complex fracture patterns such as concomitant symphyseal/parasymphyseal and bilateral condylar fractures often warrants this approach.

METHODS

Freeware digital processing and manipulation software packages were used to view and segment structures from computed tomography (CT) data. Thereafter, fractures were digitally reduced. 3D printed models were produced from the digitally reduced models, allowing preoperative custom adaptation of osteosynthesis plates, facilitating accurate fracture fixation intraoperatively.

RESULTS

For less than one hundred pounds sterling (STG), a 3D printer (with print material) capable of producing a model of sufficient quality can be purchased. The use of freeware digital processing software allows digital manipulation of CT data. Production of 3D models and plate adaptation can be carried out within hours after CT examination.

CONCLUSIONS

The construction of digitally reduced 3D models and custom adapted plates enables the surgeon to achieve accurate fixation of complex fracture patterns in theatre which is clearly of benefit to patients. The potential for reduced theatre time also renders this approach more desirable, making this a worthwhile investment despite the additional non-clinical time associated with training and initial expenditure.

Prevalence of pfdhfr and pfdhps mutations in Plasmodium falciparum associated with drug resistance among pregnant women receiving IPTp-SP at Msambweni County Referral Hospital, Kwale County, Kenya

BACKGROUND

Prevention and treatment of malaria during pregnancy is crucial in dealing with maternal mortality and adverse fetal outcomes. The World Health Organization recommendation to treat all pregnant women with sulfadoxine-pyrimethamine (SP) through antenatal care structures was implemented in Kenya in the year 1998, but concerns about its effectiveness in preventing malaria in pregnancy has arisen due to the spread of SP resistant parasites. This study aimed to determine the prevalence of SP resistance markers in Plasmodium falciparum parasites isolated from pregnant women seeking antenatal care at Msambweni County Referral Hospital, located in coastal Kenya, between the year 2013 and 2015.

METHODS

This hospital-based study included 106 malaria positive whole blood samples for analysis of SP resistance markers within the Pfdhfr gene (codons 51, 59 and 108) and Pfdhps gene (codons 437 and 540). The venous blood collected from all pregnant women was tested for malaria via light microscopy, then the malaria positive samples were separated into plasma and red cells and stored in a - 86° freezer for further studies. Archived red blood cells were processed for molecular characterization of SP resistance markers within the Pfdhfr and Pfdhps genes using real time PCR platform and Sanger sequencing.

RESULTS

All samples had at least one mutation in the genes associated with drug resistance; polymorphism prevalence of Pfdhfr51I, 59R and 108N was at 88.7%, 78.3% and 93.4%, respectively, while Pfdhps polymorphism accounted for 94.3% and 91.5% at 437G and 540E, respectively. Quintuple mutations (at all the five codons) conferring total SP resistance had the highest prevalence of 85.8%. Quadruple mutations were observed at a frequency of 10.4%, and 24.5% had a mixed outcome of both wildtype and mutant genotypes in the genes of interest.

CONCLUSION

The data suggest a high prevalence of P. falciparum genetic variations conferring resistance to SP among pregnant women, which may explain reduced efficacy of IPTp treatment in Kenya. There is need for extensive SP resistance profiling in Kenya to inform IPTp drug choices for successful malaria prevention during pregnancy.

2020 American College of Rheumatology Guideline for the Management of Gout

OBJECTIVE

To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.

METHODS

Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional.

RESULTS

Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.

CONCLUSION

Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.

Mass deworming for improving health and cognition of children in endemic helminth areas: A systematic review and individual participant data network meta-analysis

Background

Soil transmitted (or intestinal) helminths and schistosomes affect millions of children worldwide.

Objectives

To use individual participant data network meta-analysis (NMA) to explore the effects of different types and frequency of deworming drugs on anaemia, cognition and growth across potential effect modifiers.

Search Methods

We developed a search strategy with an information scientist to search MEDLINE, CINAHL, LILACS, Embase, the Cochrane Library, Econlit, Internet Documents in Economics Access Service (IDEAS), Public Affairs Information Service (PAIS), Social Services Abstracts, Global Health CABI and CAB Abstracts up to March 27, 2018. We also searched grey literature, websites, contacted authors and screened references of relevant systematic reviews.

Selection Criteria

We included randomised and quasirandomised deworming trials in children for deworming compared to placebo or other interventions with data on baseline infection.

Data Collection and Analysis

We conducted NMA with individual participant data (IPD), using a frequentist approach for random-effects NMA. The covariates were: age, sex, weight, height, haemoglobin and infection intensity. The effect estimate chosen was the mean difference for the continuous outcome of interest.

Results

We received data from 19 randomized controlled trials with 31,945 participants. Overall risk of bias was low. There were no statistically significant subgroup effects across any of the potential effect modifiers. However, analyses showed that there may be greater effects on weight for moderate to heavily infected children (very low certainty evidence).

Authors' Conclusions

This analysis reinforces the case against mass deworming at a population-level, finding little effect on nutritional status or cognition. However, children with heavier intensity infections may benefit more. We urge the global community to adopt calls to make data available in open repositories to facilitate IPD analyses such as this, which aim to assess effects for the most vulnerable individuals.

Understanding the relationship between pet owners and their companion animals as a key context for antimicrobial resistance-related behaviours: an interpretative phenomenological analysis

Objectives: Drivers of antimicrobial resistance (AMR) are diffuse and complex including a range of interspecies behaviours between pet owners and their animals. We employed interpretative phenomenological analysis (IPA) to explore the relationship between pet owners and their companion animals in relation to AMR. Design: Cross sectional, qualitative study. Methods: Semi-structured interviews were conducted with twenty-three British pet owners, transcribed verbatim and subjected to Interpretative Phenomenological Analysis (IPA). Results: Three, inter-related Superordinate themes are presented 1) 'They're my fur babies': unconditional love and anthropomorphism; 2) 'They share everything with you': affection and transmission behaviours; and 3) 'We would err on the side of caution': decision making and antibiotic use'. Conclusions: Affectionate behaviours between companion animals and their owners pose a risk for AMR transmission but they are so deeply treasured that they are unlikely to be amenable to change. In contrast, the promotion of appropriate antibiotic stewardship for pet owners and vets may offer a viable pathway for intervention development, benefitting from synergies with other interventions that target prescribers.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Routine splenic flexure mobilization may increase compliance with pathological quality metrics in patients undergoing low anterior resection

AIM

Mandatory splenic flexure mobilization (SFM) has been debated for rectal cancers. Proponents argue that additional mobilization facilitates a tension-free anastomosis; however, this must be weighed against heightened morbidity. Little is known about the impact of specific techniques on pathology quality metrics. We aim to determine the impact of SFM on pathology quality metrics for patients undergoing rectal resections for colorectal adenocarcinoma.

METHOD

Patients were selected by querying the University of Kansas electronic medical records and the American College of Surgeons National Surgical Quality Improvement Program database based on Current Procedural Terminology codes. Patients were categorized as SFM or non-SFM. Primary outcomes were node yield less than 12 and margin length.

RESULTS

There were 146 patients who met the inclusion criteria for chart review and 7369 included from the national database. Splenic flexure mobilization was associated with wider margins (3.52 vs 2.51 cm in low anterior resection, P < 0.01) and a decreased rate of inadequate nodal staging in patients undergoing low anterior resection (3.7% vs 19.3% P < 0.01).

CONCLUSIONS

SFM may affect surgical quality metrics in patients undergoing resection for distal colon and rectal adenocarcinoma. Further study is warranted to determine whether these differences in quality and pathology translate into differences in oncological outcomes.

Seroepidemiological Studies of Arboviruses in Africa

The literature on sero-epidemiological studies of flaviviral infections in the African continent is quite scarce. Much of the viral epidemiology studies have been focussing on diseases such as HIV/AIDS because of their sheer magnitude and impact on the lives of people in the various affected countries. Increasingly disease outbreaks caused by arboviruses such as the recent cases of chikungunya virus, dengue virus and yellow fever virus have prompted renewed interest in studying these viruses. International agencies from the US, several EU nations and China are starting to build collaborations to build capacity in many African countries together with established institutions to conduct these studies. The Tofo Advanced Study Week (TASW) was established to bring the best scientists from the world to the tiny seaside town of Praia do Tofo to rub shoulders with African virologists and discuss cutting-edge science and listen to the work of researchers in the field. In 2015 the 1st TASW focussed on Ebola virus. The collections of abstracts from participants at the 2nd TASW which focused on Dengue and Zika virus as well as presentations on other arboviruses are collated in this chapter.

Exploring the behavioural drivers of veterinary surgeon antibiotic prescribing: a qualitative study of companion animal veterinary surgeons in the UK

Background

Multi-drug resistant bacteria are an increasing concern in both human and veterinary medicine. Inappropriate prescribing and use of antibiotics within veterinary medicine may be a contributory factor to antimicrobial resistance (AMR). The ‘One Health’ Initiative aims to work across species and environments to reduce AMR, however; little is currently known about the factors which influence antibiotic prescribing among veterinary surgeons in companion animal practice.

This paper reports on qualitative data analysis of interviews with veterinary surgeons whose practice partially or wholly focuses on companion animals (N = 16). The objective of the research was to explore the drivers of companion animal veterinary surgeons’ antibiotic prescribing behaviours. The veterinary surgeons interviewed were all practising within the UK (England (n = 4), Scotland (n = 11), Northern Ireland (n = 1)). A behavioural thematic analysis of the data was undertaken, which identified barriers and facilitators to specific prescribing-related behaviours.

Results

Five components of prescribing behaviours were identified: 1) confirming clinical need for antibiotics; 2) responding to clients; 3) confirming diagnosis; 4) determining dose, duration and type of antibiotic; and 5) preventing infection around surgery (with attendant appropriate and inappropriate antibiotic prescribing behaviours). Barriers to appropriate prescribing identified include: business, diagnostic, fear, habitual practice and pharmaceutical factors. Facilitators include: AMR awareness, infection prevention, professional learning and regulation and government factors.

Conclusion

This paper uses a behavioural lens to examine drivers which are an influence on veterinary surgeons’ prescribing behaviours. The paper contributes new understandings about factors which influence antibiotic prescribing behaviours among companion animal veterinary surgeons. This analysis provides evidence to inform future interventions, which are focused on changing prescribing behaviours, in order to address the pressing public health concern of AMR.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Barriers and enablers to meticillin-resistant Staphylococcus aureus admission screening in hospitals: a mixed-methods study

BACKGROUND

To reduce the risk of transmission of meticillin-resistant Staphylococcus aureus (MRSA), international guidelines recommend admission screening to identify hospital patients at risk of colonization. However, routine monitoring indicates that optimum screening compliance levels are not always achieved. In order to enhance compliance, we must better understand those factors which influence staff screening behaviours.

AIM

To identify factors which influence staff compliance with hospital MRSA screening policies.

METHODS

A sequential two-stage mixed-methods design applied constructs from normalization process theory and the theoretical domains framework to guide data collection and analysis. Initial qualitative findings informed subsequent development of a national cross-sectional survey of nursing staff (N = 450). Multiple regression modelling identified which barriers and enablers best predict staff compliance.

FINDINGS

Three factors were significant in predicting optimum (>90%) compliance with MRSA screening: having MRSA screening routinized within the admission process; category of clinical area; feedback of MRSA screening compliance within the clinical area. Integration of data-sets indicated that organizational systems which 'make doing the right thing easy' influence compliance, as does local ward culture. Embedded values and beliefs regarding the relative (de)prioritization of MRSA screening are important.

CONCLUSION

To our knowledge, this is the first study to provide original evidence of barriers and enablers to MRSA screening, applying both sociological and psychological theory. As antimicrobial resistance is a global health concern, these findings have international relevance for screening programmes. Future policy recommendations or behaviour change interventions, based on the insights presented here, could have significant impact upon improving screening compliance.

Ultracompliant Heterogeneous Copper-Tin Nanowire Arrays Making a Supersolder

Due to the substantial increase in power density, thermal interface resistance that can constitute more than 50% of the total thermal resistance has generally become a bottleneck for thermal management in electronics. However, conventional thermal interface materials (TIMs) such as solder, epoxy, gel, and grease cannot fulfill the requirements of electronics for high-power and long-term operation. Here, we demonstrate a high-performance TIM consisting of a heterogeneous copper-tin nanowire array, which we term "supersolder" to emulate the role of conventional solders in bonding various surfaces. The supersolder is ultracompliant with a shear modulus 2-3 orders of magnitude lower than traditional solders and can reduce the thermal resistance by two times as compared with the state-of-the-art TIMs. This supersolder also exhibits excellent long-term reliability with >1200 thermal cycles over a wide temperature range. By resolving this critical thermal bottleneck, the supersolder enables electronic systems, ranging from microelectronics and portable electronics to massive data centers, to operate at lower temperatures with higher power density and reliability.

Chemically linked metal-matrix nanocomposites of boron nitride nanosheets and silver as thermal interface materials

Herein, novel hybrid nanocomposite thermal interface materials (TIMs) relying on the chemical linkage of silver, boron nitride nanosheets (BNNSs), and organic ligands are reported. These TIMs were prepared using a co-electrodeposition/chemisorption approach where the electrolytic reduction of silver ions into silver nano-/micro-crystals was coupled with the conjugation of ligand-coated nanosheets onto silver crystals. Furthermore, the influence of the bond strength of silver/nanosheet links on the thermal, mechanical, and structural properties is investigated using a combination of techniques including laser flash analysis, phase-sensitive transient thermoreflectance, nanoindentation, and electron microscopy. The internal nanostructure was found to be strongly dependent on the linker chemistry. While the chemical grafting of 4-cyano-benzoyl chloride (CBC) and 2-mercapto-5-benzimidazole carboxylic acid (MBCA) on BNNSs led to the uniform distribution of functionalized-nanosheets in the silver crystal matrix, the physical binding of 4-bromo-benzoyl chloride linkers on nanosheets caused the aggregation and phase separation. The thermal conductivity was 236-258 W m^-1 K and 306-321 W m^-1 K for physically and chemically conjugated TIMs, respectively, while their hardness varied from 400-495 MPa and from 240 to 360 MPa, respectively. The corresponding ratio of thermal conductivity to hardness, which is a critical parameter controlling the performance of TIMs, was ultrahigh for the chemically conjugated TIMs: 1.3 × 10^-6 m² K^-1 s for MBCA-BNNS and 8.5 × 10^-7 m² K^-1 s for CBC-BNNS. We anticipate that these materials can satisfy some of the emerging thermal management needs arising from the improved performance and efficiency, miniaturization, and/or high throughput of electronic devices, energy storage devices, energy conversion systems, light-emitting diodes, and telecommunication components.

A British Ophthalmological Surveillance Unit Study on metastatic endogenous endophthalmitis

PurposeEndogenous endophthalmitis (EE) is a rare but serious ocular infection caused by the seeding of bacteria into the eye from a source elsewhere in the body. Studies suggest that EE accounts for 2 to 8% of all endophthalmitis.MethodsA prospective observational study was conducted using the British Ophthalmological Surveillance Unit reporting system. Questionnaires were sent to reporting Ophthalmologists in the UK to assess incidence, underlying aetiology, eye findings, management, and final outcomes in endogenous endophthalmitis over a 12-month period within the British Isles.ResultsSixty two cases reported with 48 initial questionnaires returned and 25 6-month follow-up questionnaires returned. The median age of patients affected was 57 years with youngest aged 2 years and oldest aged 85 years. Twenty three were male and 24 were female. The median visual acuity in the affected eye was 3 logMAR (range -0.1 to 5). Blood cultures were taken in 36 patients, 58% of which were positive. Vitreous biopsy was taken in 35 patients, 23% of which were culture positive. The visual function as assessed by visual acuity had significantly improved at 6 months with a median acuity of 0.18 logMAR (P=0.003).ConclusionsThe survey demonstrates the severe nature of endogenous endophthalmitis in patients with active infection or with risk factors for infection. Our study has demonstrated that at least half of the patients who were treated had significant vision improvement.

Outcomes in hospital hostels

Activity and outcome data for two ‘ward-in-a-house’ projects for new long-stay in-patients are described. The results confirm that up to a third may be successfully resettled providing that good quality sheltered housing is available. However, a similar proportion appear to find such environments too demanding and may be transferred after an acute exacerbation of symptoms or a violent incident. The remainder need high quality, ongoing care.