Vaccine microarray patch self-administration: An innovative approach to improve pandemic and routine vaccination rates

The high-density microprojection array patch (HD-MAP) is a novel vaccine delivery system with potential for self-administered vaccination. HD-MAPs provide an alternative to needle and syringe (N&S) vaccination. Additional advantages could include reduced cold-chain requirements, reduced vaccine dose, reduced vaccine wastage, an alternative for needle phobic patients and elimination of needlestick injuries. The drivers and potential benefits of vaccination by self-administering HD-MAPs are high patient acceptance and preference, higher vaccination rates, speed of roll-out, cost-savings, and reduced sharps and environmental waste. The HD-MAP presents a unique approach in pandemic preparedness and routine vaccination of adults. It could alleviate strain on the healthcare workforce and allows vaccine administration by minimally-trained workers, guardian or subjects themselves. Self-vaccination using HD-MAPs could occur in vaccination hubs with supervision, at home after purchasing at the pharmacy, or direct distribution to in-home settings. As a result, it has the potential to increase vaccine coverage and expand the reach of vaccines, while also reducing labor costs associated with vaccination. Key challenges remain around shifting the paradigm from medical professionals administrating vaccines using N&S to a future of self-administration using HD-MAPs. Greater awareness of HD-MAP technology and improving our understanding of the implementation processes required for adopting this technology, are critical factors underpinning HD-MAP uptake by the public.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Tubo-ovarian abscess: A proposed new scoring system to guide clinical management

OBJECTIVE

To create a risk scoring system comprised of clinical and radiological characteristics that can predict the likelihood of antibiotic treatment failure of tubo-ovarian abscesses. The score should guide clinicians in identifying patients to whom early intervention should be offered instead of a prolonged trial of antibiotics.

METHODS

A multicenter, retrospective cohort study carried out between January 1, 2013 and September 30, 2019, identified consecutive patients with tubo-ovarian abscess. Using a chronological split, patients were allocated to two groups for the development and subsequent validation of the postulated scoring system. Univariate and bivariate analyses were performed to identify statistically significant variables for the failure of intravenous antibiotic treatment.

RESULTS

In total, 214 consecutive patients with tubo-ovarian abscesses were identified. Data from the first 150 patients were used for the development of the postulated scoring system; data from the subsequent 64 patients were used for validation. Statistically significant clinical features between those having successful and unsuccessful management were: temperature (median = 37.1℃ vs 38.2℃, P = 0.0001), C-reactive protein (151 mg/L vs 243 mg/L, P = 0.0001), and tubo-ovarian abscess diameter (6.0 cm vs 8.0 cm, P = 0.0001). These parameters were used to create a risk prediction score. A score of four or more was predictive of requiring surgical/radiological intervention of tubo-ovarian abscess (P < 0.001). The score had a sensitivity of 69% and a specificity of 88%, with area under the curve (AUC) = 0.859.

CONCLUSION

Currently, there is no guidance for clinicians on when to operate on a tubo-ovarian abscess. Our prediction score is simple, using only three easily obtained clinical characteristics.

P–344 Clarifying tubo-ovarian abscess management: a risk score for predicting antibiotic failure

Study question

Can antibiotic treatment failure of tubo-ovarian abscesses (TOA) be predicted based on clinical features at the time of diagnosis?

Summary answer

We propose a risk score including patient temperature, c-reactive protein and TOA size that could predict which patients are likely to fail parental antibiotic treatment.

What is known already

Current guidance is that the first line management of non-ruptured TOA is with parental antibiotics. However, it is reported that treatment failure rate is 20–30%. Alternative treatment modalities include radiological drainage or laparoscopic/open surgery. In patients who require intervention, outcomes, such as morbidity, length of hospital stay and fertility, are improved when this is performed early rather than later in their hospital admission. However, our current guidance is scant with regards to the decision making for interventional TOA management.

Study design, size, duration

This is a multicentre retrospective cohort study over 81 months (01/01/13- 30/09/19) identifying 214 consecutive patients admitted to hospitals in North-West London with diagnosed TOA. Participants/materials, setting, methods: Demographics, medical history, presenting symptoms, laboratory results, radiological findings, treatments administered, hospital length of stay and follow up data was collected. The patients were chronologically split with the first 150 being used for the development of our risk score. Univariate and bivariate analyses were employed to ascertain statistically significant variables in the failure of parental antibiotic. The remaining 64 patients were used for risk score validation.

Main results and the role of chance

Statistically significant variables were: temperature at admission (median= 37.1 °C vs 38.2 °C, p = 0.0001), C-reactive protein (CRP) at admission (151mg/L vs 243mg/L, p = 0.0001) and size of TOA (6.0cm vs 8.0cm, p = 0.0001). Those requiring intervention, stayed in hospital twice as long as those who did not (4 days vs 8 days, p &lt; 0.001). A scoring system was formulated using the statistically significant variables. A score of ≥ 4 was associated with requiring radiological/surgical intervention (p &lt; 0.001), with sensitivity 69% and specificity 88% (AUC 0.859) when tested on the validation cohort.

Limitations, reasons for caution

Being a retrospective study, which puts the data at risk of information and selection bias. Although there are merits to a multi-centre study, variation in patient management will invariably cause data heterogeneity.

Wider implications of the findings: TOA patients may have their hospital management tailored early according to the postulated tool, alleviating uncertainty in their treatment as well as possibly reducing morbidity and length of hospital stay.

Trial registration number

Not applicable

Repeatable glucocorticoid expression is associated with behavioural syndromes in males but not females in a wild primate

Behavioural syndromes are a well-established phenomenon in human and non-human animal behavioural ecology. However, the mechanisms that lead to correlations among behaviours and individual consistency in their expression at the apparent expense of behavioural plasticity remain unclear. The 'state-dependent' hypothesis posits that inter-individual variation in behaviour arises from inter-individual variation in state and that the relative stability of these states within an individual leads to consistency of behaviour. The endocrine stress response, in part mediated by glucocorticoids (GCs), is a proposed behavioural syndrome-associated state as GC levels are linked to an individual's behavioural responses to stressors. In this study, in wild Barbary macaques (Macaca sylvanus), consistent inter-individual differences were observed in both sexes for GC activity (faecal glucocorticoid, fGC concentrations), but not GC variation (coefficient of variation in fGC concentrations). The expression of the behavioural syndrome 'Excitability' (characterized by the frequencies of brief affiliation or aggressive interactions) was related to GC activity in males but not in females; more 'excitable' males had lower GC activity. There was no relationship in females between any of the behavioural syndromes and GC activity, nor in either sex with GC variation. The negative relationship between GC activity and Excitability in males provides some support for GC expression as a behavioural syndrome-generating state under the state-dependent framework. The absence of this relationship in females highlights that state-behavioural syndrome associations may not be generalizable within a species and that broader sex differences in state need to be considered for understanding the emergence and maintenance of behavioural syndromes.

Protocol for a Randomised controlled trial to Evaluate the effectiveness and cost benefit of prescribing high dose FLuoride toothpaste in preventing and treating dEntal Caries in high-risk older adulTs (reflect trial)

BACKGROUND

Dental caries in the expanding elderly, predominantly-dentate population is an emerging public health concern. Elderly individuals with heavily restored dentitions represent a clinical challenge and significant financial burden for healthcare systems, especially when their physical and cognitive abilities are in decline. Prescription of higher concentration fluoride toothpaste to prevent caries in older populations is expanding in the UK, significantly increasing costs for the National Health Services (NHS) but the effectiveness and cost benefit of this intervention are uncertain. The Reflect trial will evaluate the effectiveness and cost benefit of General Dental Practitioner (GDP) prescribing of 5000 ppm fluoride toothpaste and usual care compared to usual care alone in individuals 50 years and over with high-risk of caries.

METHODS/DESIGN

A pragmatic, open-label, randomised controlled trial involving adults aged 50 years and above attending NHS dental practices identified by their dentist as having high risk of dental caries. Participants will be randomised to prescription of 5000 ppm fluoride toothpaste (frequency, amount and duration decided by GDP) and usual care only. 1200 participants will be recruited from approximately 60 dental practices in England, Scotland and Northern Ireland and followed up for 3 years. The primary outcome will be the proportion of participants receiving any dental treatment due to caries. Secondary outcomes will include coronal and root caries increments measured by independent, blinded examiners, patient reported quality of life measures, and economic outcomes; NHS and patient perspective costs, willingness to pay, net benefit (analysed over the trial follow-up period and modelled lifetime horizon). A parallel qualitative study will investigate GDPs' practises of and beliefs about prescribing the toothpaste and patients' beliefs and experiences of the toothpaste and perceived impacts on their oral health-related behaviours.

DISCUSSION

The Reflect trial will provide valuable information to patients, policy makers and clinicians on the costs and benefits of an expensive, but evidence-deficient caries prevention intervention delivered to older adults in general dental practice.

TRIAL REGISTRATION

ISRCTN: 2017-002402-13 registered 02/06/2017, first participant recruited 03/05/2018. Ethics Reference No: 17/NE/0329/233335. Funding Body: Health Technology Assessment funding stream of National Institute for Health Research. Funder number: HTA project 16/23/01. Trial Sponsor: Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL. The Trial was prospectively registered.

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.

Uterus didelphys: two pregnancies, two term breech caesarean deliveries

We report the case of a woman with uterus didelphys who spontaneously conceived two singleton pregnancies, one in each uterus, and was delivered in both instances of a healthy breech infant at term by elective caesarean section.

Pharmacokinetics, clot strength and safety of a new fibrinogen concentrate: randomized comparison with active control in congenital fibrinogen deficiency

Essentials Congenital afibrinogenemia causes a potentially life-threatening bleeding and clotting tendency. Two human fibrinogen concentrates (HFCs) were compared in a randomized pharmacokinetic study. Bioequivalence was not shown for AUCnorm , which was significantly larger for the new HFC. Increases in clot strength were comparable, and no thromboses or deaths occurred in the study.

SUMMARY

Background Human fibrinogen concentrate (HFC) corrects fibrinogen deficiency in congenital a-/hypofibrinogenemia. Objectives To assess pharmacokinetics (PK), effects on thromboelastometry maximum clot firmness (MCF), and safety of a new double virus-inactivated/eliminated, highly purified HFC vs. active control. Patients/Methods In this multinational, randomized, phase II, open-label, crossover study in 22 congenital afibrinogenemia patients aged ≥ 12 years, 70 mg kg-1 of new HFC (FIBRYGA, Octapharma AG) or control (Haemocomplettan® P/RiaSTAP™, CSL Behring GmbH) were administered, followed by crossover to the other concentrate. Fibrinogen activity, PK and MCF in plasma were assessed. Results The concentrates were not bioequivalent for the primary endpoint, AUCnorm (mean ratio, 1.196; 90% confidence interval [CI], 1.117, 1.281). Remaining PK parameters (Cmaxnorm , IVR, t1/2 , MRT) reflected bioequivalence between concentrates, except for clearance (mean ratio, 0.836; 90% CI, 0.781, 0.895) and Vss (mean ratio, 0.886; 90% CI, 0.791, 0.994). Mean AUCnorm was significantly larger for the new HFC (1.62 ± 0.45 vs. 1.38 ± 0.47 h kg g L-1  mg-1 , P = 0.0001) and mean clearance was significantly slower (0.665 ± 0.197 vs. 0.804 ± 0.255 mL h-1  kg-1 , P = 0.0002). Mean MCF increased from 0 mm to 9.68 mm (new HFC) and 10.00 mm (control) 1-hour post-infusion (mean difference, -0.32 mm; 95% CI, -1.70, 1.07, n.s.). No deaths, thromboses, viral seroconversions or serious related adverse events occurred. Conclusions Bioequivalence was not demonstrated for AUCnorm , clearance and Vss . Larger AUCnorm and slower clearance were observed for the new HFC. Remaining pharmacokinetic parameters reflected bioequivalence to control. Safety profiles and increases in clot strength were comparable between concentrates.

Interspecific Variation in Coral Settlement and Fertilization Success in Response to Hydrogen Peroxide Exposure

Hydrogen peroxide (H₂O₂) is involved in the regulation of numerous reproductive and morphogenic processes across an array of taxa. Extracellular H₂O₂ can be widespread in oceanic waters, and elevated sea surface temperatures can cause increased levels of intracellular H₂O₂ within cnidarian tissue, but it remains unclear how this compound affects early life-history processes in corals, such as fertilization, metamorphosis, and settlement. To evaluate the effects of H₂O₂ on multiple stages of recruitment, experiments were conducted using Caribbean corals with various reproductive modes, including the brooders Porites astreoides and Favia fragum and the broadcast-spawning species Acropora palmata and Orbicella franksi. H₂O₂ accelerated settlement in all brooding species tested. Concentrations of 1000 µmol l^-1 H₂O₂ caused close to 100% settlement in all larval age classes, regardless of exposure duration. As larvae aged, the required threshold of H₂O₂ capable of inducing settlement decreased. In contrast, H₂O₂ concentrations of 100 µmol l^-1 or greater caused a significant reduction in metamorphosis and settlement in the larvae of spawners. Furthermore, fertilization of their gametes was inhibited in the presence of H₂O₂ concentrations as low as 100 µmol l^-1. In Porites astreoides larvae, internal levels of H₂O₂ reached a maximal value of 75 µmol l^-1 following 48 h of incubation at 31 °C. This concentration was found to significantly alter settlement rates in both brooding coral species and likely induced a cellular cascade in the settlement signaling pathway. The results of this study suggest that temperature stress influences H₂O₂ production, which in turn impacts coral settlement. While it is unlikely that the current levels of externally derived concentrations of oceanic H₂O₂ are affecting coral larvae, internal concentrations (produced under heat stress) have the capacity to impact recruitment under a changing climate.

An analysis of emergency leaves of absence from a United Kingdom high secure psychiatric hospital with a view to identifying ways to reduce their number

Introduction

Emergency leaves of absence (ELOAs) from high secure psychiatric care are both costly and increase the risk posed to staff, patients and the general public. ELOAs were analysed to identify whether greater on-site physical health provision could reduce their number, and quantify the potential financial saving to the trust to do so.

Method

All ELOAs from Broadmoor hospital between 15.5.15–14.11.15 were assessed by a team of psychiatrists and a GP to identify whether they were “avoidable”, “unavoidable” or “potentially avoidable” if measures were taken. For the “potentially avoidable” group, we then calculated the staffing cost of these LoAs to help ascertain whether these measures would be cost effective.

Results

There were 30 ELOAs during the period assessed, costing £79,240 (Table 1). The table also shows which additional on-site services or training may have prevented these ELOAs, and the cost saving to the trust if they had.

Conclusions

The number of ELOAs from the hospital could be reduced by increased on-site physical health provision and training. This would improve the quality of care patients receive, as well as reducing both the cost to the trust and the risk posed to staff, patients and the general public. We must also consider the large potential cost and risks associated with a patient absconding from an ELOA.

Combined Carotid Endarterectomy and Vertebral Transposition or Bypass for Cerebral and Vertebrobasilar Insufficiency

The purpose of this report is to determine the indication for a combined carotid endarterectomy and vertebral transposition or bypass in patients who have transient ischemic attack (TIA) or stroke and intractable vertebral ischemic symptoms of dizziness and syncope. A retrospective review was made on 49 patients with the combined symptoms of generalized global ischemia, TIA, amaurosis fugax or stroke, and vertebral basilar insufficiency manifested as syncope, intractable dizziness, and unsteady gait. Diagnostic studies employed were carotid duplex scan, computed tomography (CT) or magnetic resonance imaging (MRI) brain scan, xenon blood flow study, transcranial Doppler analysis, electronystagmography, electroencephalography, and cardiac arrhythmia evaluation. Twenty-one of 49 patients (43%) with internal carotid occlusion underwent carotid endarterectomy plus vein patch or internal carotid to external carotid onlay patch angioplasty and proximal vertebral to common carotid artery transposition (n: 19), or bypass (n:2). Twenty-seven of 49 patients (57%) received carotid endarterec tomy and vertebral transposition (n:27) or bypass (n:2) for carotid and vertebral stenosis. There was no operative mortality, stroke, or neurologic deficit following the carotid and vertebral operations in the 49 patients. Six patients had transient palpebral ptosis. Postoperative cerebral angiogram or magnetic resonance angiogram showed patent vertebral arteries. All 49 patients have resolution of TIA, dizziness, syncope, and unsteady gait. Combined carotid endarterectomy and vertebral transposition or bypass should be considered in patients with solitary, dominant, or bilateral vertebral artery critical stenosis whose symptoms are unrelated to vestibular, cardiac, or seizure disorders and lateralized TIA or stroke.

Measuring and evaluating interferon b-induced antibodies in patients with multiple sclerosis

Author for correspondence: Klaus Bendtzen, Institute for Inflammation Research IIR 7521, Rigshospitalet University Hospital, 9 Blegdamsvej, DK-2100 Copenhagen, Denmark. E-mail: address: kben@mail.dk Administration of interferons (IFNs) may induce antibodies that interfere with therapeutic efficacy. We have optimized and validated methods for large-scale economic screening. Sera from patients with relapsing-remitting multiple sclerosis (MS) were investigated for binding antibody (BAb) by protein-G affinity-chromatography radioimmunoassay and a commercially available enzyme immunoassay (EIA). Neutralizing antibody (NAb) was investigated by cytopathic effect assays (CEA) using both fixed amount and serially diluted sera. BAb correlated with log10-transformed titres obtained by EIA (r=0.70, p<0.0001); the latter, however, failed to demonstrate low-level BAb. Comparison of clinical significance of NAb-positivity measured by biological assays with different sensitivities demonstrated an optimal odds ratio for relapse rate using 10 laboratory units (LU)/mL. Purification of IgG prior to CEA removed toxicity from toxic sera. The neutralizing capacity data correlated linearly with log10-transformed titres obtained by a Kawade 10-to-1 LU/mL CEA (r=0.77, p<0.0001). In conclusion, neutralizing capacity CEA utilizing a fixed amount of serum predicts differences in relapse rates in IFNβ-treated MS patients and correlates with NAb titres of the 10-to- 1 LU/mL CEA. Neutralizing capacity CEA is less laborious and more economical than titre-based NAb assays and suitable for large-scale screenings of MS patients.

Effectiveness of Paliperidone Depot in Seriously Violent Men With Comorbid Schizophrenia and Dissocial Personality Disorder in a Uk High-Security Hospital

Introduction

High-security hospital patients are often complex in presentation characterised by treatment resistance, medication non-concordance and history of violence. Paliperidone is licensed as both an oral and depot antipsychotic for the treatment of schizophrenia. Whilst there is data for the effectiveness of paliperidone palmitate (PP), there are no studies involving patients in forensic settings or those with comorbid personality disorder.

Objective

To determine the effects of PP on violence, aggression and personality pathology.

Aim

To evaluate the clinical effectiveness of PP.

Methods

This was a retrospective service evaluation involving 11 patients. Medical records and interviews with the treating psychiatrist were used to formulate clinical global impression (CGI) and to identify incidents of violence. The effect on personality symptom domains; cognitive-perceptual, impulsive-behavioural dyscontrol and affective dysregulation was ascertained, as well as engagement with occupational and psychological therapies.

Results

Six patients were being prescribed PP. All 6 showed improvement in the CGI score with benefits in the symptom domains. Two patients demonstrated a reduction in violence risk and 2 remained incident-free. There was improvement in engagement with therapies. Benefits were also seen in aspects of personality for those who had discontinued PP.

Conclusions

This pragmatic study of a small but complex patient group demonstrated that PP was effective in reducing symptoms of schizophrenia. Additionally and for the first time, it was shown that PP was also effective in reducing violence as well as improving personality pathology dimensions in a comorbid patient. This could have significant implications for management of high-security patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Management of cardiac arrest survivors in UK intensive care units: a survey of practice

BACKGROUND

Cardiac arrest is a common presentation to intensive care units. There is evidence that management protocols between hospitals differ and that this variation is mirrored in patient outcomes between institutions, with standardised treatment protocols improving outcomes within individual units. It has been postulated that regionalisation of services may improve outcomes as has been shown in trauma, burns and stroke patients, however a national protocol has not been a focus for research. The objective of our study was to ascertain current management strategies for comatose post cardiac arrest survivors in intensive care in the United Kingdom.

METHOD

A telephone survey was carried out to establish the management of comatose post cardiac arrest survivors in UK intensive care units. All 235 UK intensive care units were contacted and 208 responses (89%) were received.

RESULTS

A treatment protocol is used in 172 units (82.7%). Emergency cardiology services were available 24 hours a day, 7 days a week in 54 (26%) hospitals; most units (123, 55.8%) transfer patients out for urgent coronary angiography. A ventilator care bundle is used in 197 units (94.7%) and 189 units (90.9%) have a policy for temperature management. Target temperature, duration and method of temperature control and rate of rewarming differ between units. Access to neurophysiology investigations was poor with 91 units (43.8%) reporting no availability.

CONCLUSIONS

Our results show that treatments available vary considerably between different UK institutions with only 28 units (13.5%) able to offer all aspects of care. This suggests the need for 'cardiac arrest care bundles' and regional centres to ensure cardiac arrests survivors have access to appropriate care.

Human trafficking and health: a cross-sectional survey of NHS professionals' contact with victims of human trafficking

OBJECTIVES

(1) To estimate the proportion of National Health Service (NHS) professionals who have come into contact with trafficked people and (2) to measure NHS professionals' knowledge and confidence to respond to human trafficking.

DESIGN

A cross-sectional survey.

SETTING

Face-to-face mandatory child protection and/or vulnerable adults training sessions at 10 secondary healthcare provider organisations in England, and meetings of the UK College of Emergency Medicine.

PARTICIPANTS

782/892 (84.4%) NHS professionals participated, including from emergency medicine, maternity, mental health, paediatrics and other clinical disciplines.

MEASURES

Self-completed questionnaire developed by an expert panel. Questionnaire asks about prior training and contact with potential victims of trafficking, perceived and actual human trafficking knowledge, confidence in responding to human trafficking, and interest in future human trafficking training.

RESULTS

13% participants reported previous contact with a patient they knew or suspected of having been trafficked; among maternity services professionals this was 20.4%. However, 86.8% (n=679) reported lacking knowledge of what questions to ask to identify potential victims and 78.3% (n=613) reported that they had insufficient training to assist trafficked people. 71% (n=556), 67.5% (n=528) and 53.4% (n=418) lacked confidence in making appropriate referrals for men, women and children, respectively, who had been trafficked. 95.3% (n=746) of respondents were unaware of the scale of human trafficking in the UK, and 76.5% (n=598) were unaware that calling the police could put patients in more danger. Psychometric analysis showed that subscales measuring perceived knowledge, actual knowledge and confidence to respond to human trafficking demonstrated good internal consistency (Cronbach's αs 0.93, 0.63 and 0.64, respectively) and internal correlations.

CONCLUSIONS

NHS professionals working in secondary care are in contact with potential victims of human trafficking, but lack knowledge and confidence in how to respond appropriately. Training is needed, particularly for maternity staff, on how to identify and respond to victims' needs, including through making safe referrals.

Assessing adaptability and reactive scope: Introducing a new measure and illustrating its use through a case study of environmental stress in forest-living baboons

In order to maintain regulatory processes, animals are expected to be adapted to the range of environmental stressors usually encountered in their environmental niche. The available capacity of their stress responses is termed their reactive scope, which is utilised to a greater or lesser extent to deal with different stressors. Typically, non-invasive hormone assessment is used to measure the physiological stress responses of wild animals, but, for methodological reasons, such measurements are not directly comparable across studies, limiting interpretation. To overcome this constraint, we propose a new measure of the relative strength of stress responses, 'demonstrated reactive scope', and illustrate its use in a study of ecological correlates (climate, food availability) of faecal glucocorticoid (fGC) levels in two forest-living troops of baboons. Results suggest the wild-feeding troop experiences both thermoregulatory and nutritional stress, while the crop-raiding troop experiences only thermoregulatory stress. This difference, together with the crop-raiding troop's lower overall physiological stress levels and lower demonstrated fGC reactive scope, may reflect nutritional stress-buffering in this troop. The relatively high demonstrated fGC reactive scope levels of both troops compared with other baboons and primate species, may reflect their extreme habitat, on the edge of the geographic range for baboons. Demonstrated reactive scope provides a means of gauging the relative strengths of stress responses of individuals, populations, or species under different conditions, enhancing the interpretive capacity of non-invasive studies of stress hormone levels in wild populations, e.g. in terms of animals' adaptive flexibility, the magnitude of their response to anthropogenic change, or the severity of impact of environmental conditions.

Heme oxygenase-1 and heme oxygenase-2 expression in bruises

The first step in catabolism of hemoglobin in a bruise is performed by the enzyme heme oxygenase, which produces biliverdin that is then reduced to bilirubin. The development of yellow coloration in bruises can be attributed to local accumulation of degradation products of hemoglobin, including bilirubin, but it is not clear why there is a delay before this color change is apparent. One explanation may be that time is required for the establishment of heme oxygenase activity at the bruise site. This study used immunohistochemistry to examine the time course of expression of heme oxygenase-1 and heme oxygenase-2 in a rat bruise model. Heme oxygenase-1 levels rose above background from 6 h to peak from days 1 to 3. There was strong expression by macrophages, but only occasional neutrophils expression of heme oxygenase-1. Heme oxygenase-2 did not change significantly from background levels. The results suggest that the delay in the development of yellow coloration of bruises may in part be attributed to the requirement for macrophages to be recruited to the site of injury.

Geographic variation in polyandry of the Eastern Honey Bee, Apis cerana, in Thailand

The repeated evolution of extreme polyandry in advanced social insects is exceptional and its explanation has attracted significant attention. However, most reported estimates of the number of matings are derived from limited sampling. Temporal and geographic variation in mating behavior of social insects has not been sufficiently studied. Worker offspring of 18 Eastern Honey Bee (Apis cerana Fabr.) queens from three populations across Thailand were genotyped at five microsatellite markers to test for population differences of mating behavior across three different ecosystems. The number of matings decreased from a northern, more seasonal environment to a southern tropical population and was lowest in a tropical island population. Our study confirms earlier findings that social insect mating behavior shows biogeographic variation and highlights that data from several populations are needed for reliable species-specific estimates of the number of matings. Detailed studies of populations that show significant differentiation in the number of matings may be able to discriminate effectively among the different hypotheses that have been proposed to explain the evolution of polyandry in honey bees and other advanced social insects.

[Detection of intrinsic ligament and TFCC lesions of the wrist. Direct versus indirect MRI arthrography]

BACKGROUND

The purpose of this study was to validate the diagnostic value of direct magnetic resonance imaging (dMRI) arthrography and indirect MRI (iMRI) arthrography concerning intrinsic ligament injuries and tears of the triangular fibrocartilage complex (TFCC).

PATIENTS AND METHODS

A randomized prospective trial was conducted with patients who presented with wrist pain potentially due to carpal lesions and 10 patients aged 19-60 years (3 female and 7 male) were included. Between the clinical examination and the diagnostic and therapeutic arthroscopy, dMRI and iMRI arthrography were performed for the diagnostics of injuries of the intrinsic ligaments or the TFCC. The results of dMRI and iMRI arthrography were evaluated by two radiologists blinded to the injuries of the patients and a consensus was reached. The results were compared with the findings obtained by arthroscopy.

RESULTS

In the arthroscopy five lesions of the scapholunate ligament (SL), one of the lunotriquetral ligament (LT) and seven of the TFCC were identified. The sensitivity of iMRI and dMRI for carpal ligament lesions (SL and LT) was low (50 %) whereas the specificity was high (93 %). For injuries of the TFCC the sensitivity (up to 100 %) and the specificity (100 %) were both excellent. The area under the curve (AUC) in the receiver operating characteristics (ROC) analysis was high for TFCC lesions in both dMRI and iMRI arthrography.

CONCLUSION

Indirect MRI arthrography is a suitable method for detection of injuries of the TFCC and intrinsic ligaments of the wrist with good sensitivity and specificity. Despite the low number of patients the results of this study showed that there were no essential differences between dMRI and iMRI arthrography with respect to the diagnostic value for carpal injuries of the wrist.

Measurement of the cosmic microwave background polarization lensing power spectrum with the POLARBEAR experiment

Gravitational lensing due to the large-scale distribution of matter in the cosmos distorts the primordial cosmic microwave background (CMB) and thereby induces new, small-scale B-mode polarization. This signal carries detailed information about the distribution of all the gravitating matter between the observer and CMB last scattering surface. We report the first direct evidence for polarization lensing based on purely CMB information, from using the four-point correlations of even- and odd-parity E- and B-mode polarization mapped over ∼30 square degrees of the sky measured by the POLARBEAR experiment. These data were analyzed using a blind analysis framework and checked for spurious systematic contamination using null tests and simulations. Evidence for the signal of polarization lensing and lensing B modes is found at 4.2σ (stat+sys) significance. The amplitude of matter fluctuations is measured with a precision of 27%, and is found to be consistent with the Lambda cold dark matter cosmological model. This measurement demonstrates a new technique, capable of mapping all gravitating matter in the Universe, sensitive to the sum of neutrino masses, and essential for cleaning the lensing B-mode signal in searches for primordial gravitational waves.

Evidence for gravitational lensing of the cosmic microwave background polarization from cross-correlation with the cosmic infrared background

We reconstruct the gravitational lensing convergence signal from cosmic microwave background (CMB) polarization data taken by the Polarbear experiment and cross-correlate it with cosmic infrared background maps from the Herschel satellite. From the cross spectra, we obtain evidence for gravitational lensing of the CMB polarization at a statistical significance of 4.0σ and indication of the presence of a lensing B-mode signal at a significance of 2.3σ. We demonstrate that our results are not biased by instrumental and astrophysical systematic errors by performing null tests, checks with simulated and real data, and analytical calculations. This measurement of polarization lensing, made via the robust cross-correlation channel, not only reinforces POLARBEAR auto-correlation measurements, but also represents one of the early steps towards establishing CMB polarization lensing as a powerful new probe of cosmology and astrophysics.

Reduce, reuse and recycle: a green solution to Canada's medical isotope shortage

Due to the unforeseen maintenance issues at the National Research Universal (NRU) reactor at Chalk River and coincidental shutdowns of other international reactors, a global shortage of medical isotopes (in particular technetium-99m, Tc-99m) occurred in 2009. The operation of these research reactors is expensive, their age creates concerns about their continued maintenance and the process results in a large amount of long-lived nuclear waste, whose storage cost has been subsidized by governments. While the NRU has since revived its operations, it is scheduled to cease isotope production in 2016. The Canadian government created the Non-reactor based medical Isotope Supply Program (NISP) to promote research into alternative methods for producing medical isotopes. The NRC was a member of a collaboration looking into the use of electron linear accelerators (LINAC) to produce molybdenum-99 (Mo-99), the parent isotope of Tc-99m. This paper outlines NRC's involvement in every step of this process, from the production, chemical processing, recycling and preliminary animal studies to demonstrate the equivalence of LINAC Tc-99m with the existing supply. This process stems from reusing an old idea, reduces the nuclear waste to virtually zero and recycles material to create a green solution to Canada's medical isotope shortage.

Influence of diet and stress on reproductive hormones in Nigerian olive baboons

A female mammal's reproductive function and output are limited by the energy she is able to extract from her environment. Previous studies of the interrelationships between energetic circumstances and reproductive function in a variety of mammal species have produced varied results, which do not all support the common assumption that higher female reproductive hormone levels, specifically progesterone, indicate better ovarian function and greater reproductive potential, and are associated with lower energetic stress. In the present study faecal progesterone and glucocorticoid levels were assessed in two troops of olive baboons (Papio anubis) in the same population. They face similar ecological challenges, except that one troop crop-raids, potentially affecting its energetic intake and stress levels. The energy intake of individual females was assessed by combining detailed feeding observations with nutritional analysis of food samples. The crop-raiding troop experienced 50% higher energy intake rates and 50% lower glucocorticoid levels compared to the non-crop-raiding troop alongside substantially lower progesterone levels. This suggests that energetic stress is associated with elevated progesterone levels and may be the cause of the non-crop-raiding troop's lower reproductive output. By comparing groups which differ little, except in terms of food access, and also by directly assessing energy intake, our study addresses some of the design limitations of previous research investigating variation in progesterone levels and energetic stress. It therefore has the potential to contribute to greater understanding of the factors affecting differences in reproductive and stress hormone levels and reproductive function in mammals experiencing different energetic circumstances.

Does the intensity of the inflammatory reaction in a bruise depend on its proximity to the site of trauma?

Whole blood was withdrawn by tail vessel puncture from anesthetized adult male Sprague-Dawley rats and 0.1 ml was re-injected subcutaneously at each of two sites on their abdominal wall. In addition, two adjacent sites were injected with 0.1 ml of sterile saline, and two more sites were only punctured using an injecting needle. In the second part of the study anesthetized adult male Sprague-Dawley rats had two sites on the abdominal wall pinched using a small pair of forceps, two adjacent sites received an injection of 0.1 ml of whole blood obtained by tail vessel puncture, and two more sites were both pinched and injected with 0.1 ml of whole blood. At intervals of 3, 6, 12 h, 1, 2, 3, 5, and 7 days the animals were euthanized and the skin of the abdomen was processed for histological assessment. Hemosiderin staining in tissues from the first part of the study was assessed qualitatively by scoring sections as 0, 1, 2, or 3 (representing no staining, mild staining, moderate staining, and intense staining) and semi quantitatively using a Nanozoomer Digital Pathology Scanner (NDP Scan U10074-01, Hamamatsu Photonics K.K., Japan). No inflammatory reaction was observed at the sites subjected to needle puncture only. At the sites of saline injection a mild reaction occurred. At the sites where the blood had been injected an intense inflammatory cell response occurred centrally, but not toward the periphery where blood had tracked. In the second experiment the most intense inflammation was also observed in the sites where there had been a pinch and injection of blood. Again, this was maximal centrally with reduced inflammation peripherally. Perls' staining of hemosiderin was comparable in both models, with iron first observed at day 1 at the region of the injection site. At the sites of injection only, and the sites of injection plus pinch, blood had spread laterally. Hemosiderin staining appeared first and more intensely at the site of injection/trauma. The intensity of the inflammatory response in this animal model of bruising was, therefore, directly related to the proximity to the site of trauma; the appearance and intensity of hemosiderin staining was also influenced by the location within the bruises. This study has shown that histological changes that may be utilized to date bruises may be significantly influenced by the site of the biopsy.

[Prevalence and symptoms of vitamin D deficiency in general practices]

In 776 primary care patients serum vitamin D level was measured in month of september showing deficiency (<50 nmol/l) in 45,1%, severe deficiency (<30 nmol/l) in 9,8% and serum levels below the recommended target level of 75 nmol/l in 88,9% of cases. Three possible symptoms of vitamin D deficiency were assessed by a visual analogue scale (0-10): fatigue, muscle weakness, and muscle and joint pain. A significant correlation between muscle weakness and degree of vitamin D deficiency was shown (p=0,04), whereas there was no correlation in the two other symptoms. However, patients with vitamin D deficiency more frequently reported fatigue (p=0,02) and muscle weakness (p=0,009) than patients without deficiency did, and no difference was seen concerning muscle and joint pain.