Serial image interpretation tasks improve accuracy and increase confidence in Level 1 echocardiography reporting: a pilot study

BACKGROUND

Focused echocardiography is increasingly used in acute and emergency care, with point-of-care ultrasound integrated into several specialist training curricula (e.g. Emergency Medicine, Cardiology, Critical Care). Multiple accreditation pathways support development of this skill but there is scant empirical evidence to inform selection of teaching methods, accreditation requirements or quality assurance of education in focussed echocardiography. It has also been noted that access to in-person teaching can be a barrier to completing accreditation programmes, and that this may affect learners disproportionately depending on the location or nature of their institution. The purpose of the study was to determine whether serial image interpretation tasks as a distinct learning tool improved novice echocardiographers' ability to accurately identify potentially life-threatening pathology from focused scans. We also aimed to describe the relationship between accuracy of reporting and participants' confidence in those reports, and to assess users' satisfaction with a learning pathway that could potentially be delivered remotely.

METHODS

27 participants from a variety of healthcare roles completed a program of remote lectures and 2 in-person study days. During the program they undertook 4 'packets' of 10 focused echocardiography reporting tasks (total = 40) based on images from a standardised dataset. Participants were randomized to view the scans in varying orders. Reporting accuracy was compared with consensus reports from a panel of expert echocardiographers, and participants self-reported confidence in their image interpretation and their satisfaction with the learning experience.

RESULTS

There was a stepwise improvement in reporting accuracy with each set of images reported, from an average reporting score of 66% for the 1st packet to 78% for the 4th packet. Participants felt more confident in identifying common life-threatening pathologies as they reported more echocardiograms. The correlation between report accuracy and confidence in the report was weak and did not increase during the study (r_s = 0.394 for the 1st packet, r_s = 0.321 for the 4th packet). Attrition during the study related primarily to logistical issues. There were high levels of satisfaction amongst participants, with most reporting that they would use and / or recommend a similar teaching package to colleagues.

CONCLUSIONS

Healthcare professionals undertaking remote training with recorded lectures, followed by multiple reporting tasks were capable of interpreting focused echocardiograms. Reporting accuracy and confidence in identifying life-threatening pathology increased with the number of scans interpreted. The correlation between accuracy and confidence for any given report was weak (and this relationship should be explored further given the potential safety considerations). All components of this package could be delivered via distance learning to enhance the flexibility of echocardiography education.

Building a Covid-19 secure intensive care unit: A human-centred design approach

Background

The Covid-19 pandemic has highlighted weaknesses in the National Health Service critical care provision including both capacity and infrastructure. Traditionally, healthcare workspaces have failed to fully incorporate Human-Centred Design principles resulting in environments that negatively affect the efficacy of task completion, patient safety and staff wellbeing. In the summer of 2020, we received funds for the urgent construction of a Covid-19 secure critical care facility. The aim of this project was to design a pandemic resilient facility centred around both staff and patient requirements and safety, within the available footprint.

Methods

We developed a simulation exercise, underpinned by Human-Centred Design principles, to evaluate intensive care designs through Build Mapping, Tasks Analysis and Qualitative data. Build Mapping involved taping out sections of the design and mocking up with equipment. Task Analysis and qualitative data were collected following task completion.

Results

56 participants completed the build simulation exercise generating 141 design suggestions (69 task related, 56 patient and relative related, 16 staff related). Suggestions translated to 18 multilevel design improvements; five significant structural changes (Macro level) including wall moves and lift size change. Minor improvements were made at a Meso and Micro design level. Critical care design drivers identified included functional drivers (visibility, Covid-19 secure environment, workflow, and task efficiency) and behavioural drivers (learning and development, light, humanising intensive care and design consistency).

Conclusion

Success of clinical tasks, infection control, patient safety and staff/patient wellbeing are highly dependent on clinical environments. Primarily, we have improved clinical design by focusing on user requirements. Secondly, we developed a replicable approach to exploring healthcare build plans revealing significant design changes, that may have only been identified once built.

O-058 Obstetric outcomes of twin gestation after In-Vitro Fertilization and Embryo Transfer (IVT-ET) treatment in patients who underwent hysteroscopic septoplasty for subseptate uterus

Study question

Is there an associated increased risk of preterm birth (PTB) in patients who underwent hysteroscopic septoplasty for subseptate uterus (SSU) with twin gestation through IVF-ET?

Summary answer

This study suggests an increased risk of PTB in patients, who underwent hysteroscopic septoplasty for SSU, and subsequently conceived twins after IVF-ET treatment.

What is known already

In general, the incidence of PTB is higher after IVF-ET treatment. In addition, Müllerian uterine anomalies, such as unicornuate uterus, are considered risk factors for PTB, even with singleton pregnancy. Furthermore, historical data suggest that some patients with uterine anomaly may have cervical incompetence. Twin gestation is associated with PTB in approximately 50% of cases. It is assumed that the obstetric outcome of twin gestation after successful septoplasty should be no different from those with normal uterine cavity. The impact of previous septoplasty for SSU on the obstetric outcomes of twin gestation after IVF-ET treatment has not been adequately studied.

Study design, size, duration

This retrospective cohort study included 377 fertility patients who received treatment between 2006-2019. The study group included 162 patients who underwent hysteroscopic septoplasty for SSU and subsequently conceived dichorionic-diamniotic (DI-DI) twins after IVF-ET treatment (Group 1). The control group included 215 patients who had normal endometrial cavity on hysteroscopy (#109) or Transvaginal 3D ultrasound scan with saline sonohysterogram (#106) and subsequently conceived DI-DI twins after IVF-ET treatment (Group 2).

Participants/materials, setting, methods

This study was conducted at an infertility clinic affiliated with an academic hospital. Demographic, clinical, and obstetric outcome data were collected for both groups and compared using appropriate statistical methods. PTB, severe PTB, extreme PTB, and peri-viable birth were defined as < 37 weeks, <32 weeks, <28 weeks and between 20 weeks-25 weeks 6 days gestation respectively.

Main results and the role of chance

There was no significant difference in mean age, BMI and infertility duration or in the incidence of smoking, primary infertility, tubal factors and unexplained infertility between the two groups. There was significantly lower mean baseline FSH levels (p < 0.01), lower incidence of male infertility (p < 0.001) and higher incidence of ovulatory disorders (p < 0.001) and endometriosis (p < 0.05) in Group 1 compared to Group 2. As expected, there was past history of lower parity rate (p < 0.01) and higher miscarriage rate (p < 0.001) in Group 1 compared to Group 2 prior to septum division. There was significantly higher incidence of PTB (72.8% vs 56.3%, p < 0.01), severe PTB (20.3% vs 8.2%, p < 0.01), extreme PTB (8.3% vs 3.9%, p < 0.05), and peri-viable birth (6.3% vs 1.9%, p < 0.05) in Group 1 compared to Group 2. There was no significant difference in cesarean section rate (82.8% vs 87.5%, p = 0.349) between Group1 and Group 2 respectively. There was significantly lower gestational age at birth in weeks (34.0 + 4.0 vs 35.6 + 3.0, p < 0.001), birth weight of the first newborn (2180.5 + 717.9 vs 2436.4 + 606.6, p < 0.001), and the second newborn (2235.2 + 674.2 vs 2398.0 + 537.9, p < 0.05) in grams in Group 1 compared to Group 2.

Limitations, reasons for caution

Our study has limitations being retrospective in nature. Data on cervical length measurements via ultrasound, if performed, was not available. However, recall bias was prevented by retrieving data from that submitted to the Society of Assisted Reproductive Technology. Additionally, procedural variation was reduced as this was a single-center study.

Wider implications of the findings

Our study suggests that twin gestation after IVF-ET in patients who underwent successful hysteroscopic septoplasty for SSU may increase the likelihood of PTB. Such patients may require increased surveillance with ultrasound cervical length and signs for preterm labor. Future research should focus on measures to reduce PTB in such patients.

Trial registration number

Not Applicable

Risk of metformin failure in the treatment of women with gestational diabetes

OBJECTIVES

To estimate the metformin failure rate in women with gestational diabetes.

METHODS

The study was designed as a retrospective cohort of women diagnosed with gestational diabetes by the 75 g 2 h oral glucose tolerance test. Women were placed into two groups: metformin success (107 patients not requiring insulin therapy) or metformin failure (15 patients requiring the addition of, or, transition to insulin). Primary outcome: rate of metformin failure. Secondary outcomes: maternal and neonatal factors.

RESULTS

The failure rate of metformin was 15% (19/122 women) in the study. The failure group was more likely to have 3 abnormal values on a 2-h 75 g oral glucose tolerance test (37% (n=7/19) vs. 15% (n=15/103), p=0.02). Patients who failed had higher average fasting blood glucose levels on the glucose tolerance test as well as on pretreatment fasting finger stick values. Those who failed metformin were diagnosed with gestational diabetes and started on metformin earlier in gestation.

CONCLUSIONS

Overall low rate of metformin failure in treatment of gestational diabetes.

P-746 Obstetric outcomes of singleton birth after hysteroscopic division of septate uterus

Study question

The aim of this study is to determine the obstetric outcomes in patients with a singleton birth after hysteroscopic division of septate uterus.

Summary answer

The data suggest excellent obstetric outcomes for singleton gestation after hysteroscopic division of a septate uterus reaching either the internal or the external cervical os.

What is known already

Septate uterus is a rare Müllerian anomaly with major impact on reproductive outcomes, particularly with a septum over 10mm. Controversy still exists over the need for surgical correction of the septum due to conflicting data on outcomes, particularly in women with histories of good obstetric outcomes and incidental septum findings. Placental location in relation to the septum may account for such conflicting reports. Most data on reproductive outcomes after hysteroscopic surgical correction combine both septate and subseptate uteri. There is limited published data on obstetric outcomes after hysteroscopic surgical correction of septate uteri, especially septate uteri reaching the external os.

Study design, size, duration

This retrospective cohort study included 107 patients with infertility and/or recurrent pregnancy loss (RPL) who received treatment between 2002 -2019. The study group included 24 patients with a singleton birth after hysteroscopic correction of septate uterus (Class Va; ASRM classification) that was diagnosed on trans-vaginal 3D ultrasound. The control group included 83 patients with a singleton birth who had normal endometrial cavity on hysteroscopy during the same period of time, before starting treatment.

Participants/materials, setting, methods

This study was conducted at an infertility clinic affiliated with a teaching hospital. In the study group the septum reached the internal or the external cervical os in 14 and 10 patients respectively. After hysteroscopic correction, all patients were offered various infertility treatments depending on the underlying etiology. The inclusion criterion in this study was to have a singleton birth after hysteroscopy. Demographic and clinical data and obstetric outcomes were compared between the two groups.

Main results and the role of chance

There was no significant difference in mean age, infertility duration, infertility type and incidence of male infertility or ovulatory disorders between the two groups. There was a significantly higher BMI (0.048), and a higher incidence of history of miscarriage (P=0.002) and history of RPL (P=0.017) in the study group. There was significant lower incidence of tubal factors infertility (P=0.005) and endometriosis (P=0.03) in the study group, therefore there was higher incidence of spontaneous conception (70.8% vs 19.3%; P=0.000) and lower incidence of conception with IVF-ET (20.8% vs 66.3%; P=0.000) in the study group compared to the control group respectively. There was significantly higher incidence of prophylactic cervical cerclage (17.4% vs 0%; P=0.000), and delivery by CS (69.6% vs 41.2%; P=0.019) and lower incidence of vaginal delivery (30.4% vs 58.8%; P=0.019), in the study group compared to the control group. There was no significant difference in gestational age in weeks (38.3 + 1.8 vs 38.6 + 2.0), newborn birth weight in grams (3173.9 + 630.0 vs 3202.1 + 555.6), incidence of premature birth (12.5% vs 12.2%), or other obstetric complications (25% vs 17.6%) between the study and the control groups respectively. For premature births, mean gestational age was 34.3 + 0.47 and 34.6 + 1.2 weeks in the study and control groups respectively.

Limitations, reasons for caution

A retrospective study has its own inherent bias. Furthermore, the small sample size is explained by the fact that a septate uterus is a rare anomaly leading to difficulties finding cases and organizing a prospective study to achieve a larger sample size. A multicenter prospective study is needed.

Wider implications of the findings

Regardless of whether the septum reached the internal or external os, there were excellent obstetric outcomes in singleton gestations after hysteroscopic correction of septate uteri. There was no increased risk with septate uteri involving the cervix. Hysteroscopic surgical correction should be the treatment of choice for patients with septate uteri.

Trial registration number

Not Applicable

P–746 Obstetric outcomes of singleton birth after hysteroscopic division of septate uterus

Study question

The aim of this study is to determine the obstetric outcomes in patients with a singleton birth after hysteroscopic division of septate uterus.

Summary answer

The data suggest excellent obstetric outcomes for singleton gestation after hysteroscopic division of a septate uterus reaching either the internal or the external cervical os.

What is known already

Septate uterus is a rare Müllerian anomaly with major impact on reproductive outcomes, particularly with a septum over 10mm. Controversy still exists over the need for surgical correction of the septum due to conflicting data on outcomes, particularly in women with histories of good obstetric outcomes and incidental septum findings. Placental location in relation to the septum may account for such conflicting reports. Most data on reproductive outcomes after hysteroscopic surgical correction combine both septate and subseptate uteri. There is limited published data on obstetric outcomes after hysteroscopic surgical correction of septate uteri, especially septate uteri reaching the external os.

Study design, size, duration

This retrospective cohort study included 107 patients with infertility and/or recurrent pregnancy loss (RPL) who received treatment between 2002 –2019. The study group included 24 patients with a singleton birth after hysteroscopic correction of septate uterus (Class Va; ASRM classification) that was diagnosed on trans-vaginal 3D ultrasound. The control group included 83 patients with a singleton birth who had normal endometrial cavity on hysteroscopy during the same period of time, before starting treatment.

Participants/materials, setting, methods

This study was conducted at an infertility clinic affiliated with a teaching hospital. In the study group the septum reached the internal or the external cervical os in 14 and 10 patients respectively. After hysteroscopic correction, all patients were offered various infertility treatments depending on the underlying etiology. The inclusion criterion in this study was to have a singleton birth after hysteroscopy. Demographic and clinical data and obstetric outcomes were compared between the two groups.

Main results and the role of chance

There was no significant difference in mean age, infertility duration, infertility type and incidence of male infertility or ovulatory disorders between the two groups. There was a significantly higher BMI (0.048), and a higher incidence of history of miscarriage (P = 0.002) and history of RPL (P = 0.017) in the study group. There was significant lower incidence of tubal factors infertility (P = 0.005) and endometriosis (P = 0.03) in the study group, therefore there was higher incidence of spontaneous conception (70.8% vs 19.3%; P = 0.000) and lower incidence of conception with IVF-ET (20.8% vs 66.3%; P = 0.000) in the study group compared to the control group respectively. There was significantly higher incidence of prophylactic cervical cerclage (17.4% vs 0%; P = 0.000), and delivery by CS (69.6% vs 41.2%; P = 0.019) and lower incidence of vaginal delivery (30.4% vs 58.8%; P = 0.019), in the study group compared to the control group. There was no significant difference in gestational age in weeks (38.3 + 1.8 vs 38.6 + 2.0), newborn birth weight in grams (3173.9 + 630.0 vs 3202.1 + 555.6), incidence of premature birth (12.5% vs 12.2%), or other obstetric complications (25% vs 17.6%) between the study and the control groups respectively. For premature births, mean gestational age was 34.3 + 0.47 and 34.6 + 1.2 weeks in the study and control groups respectively.

Limitations, reasons for caution

A retrospective study has its own inherent bias. Furthermore, the small sample size is explained by the fact that a septate uterus is a rare anomaly leading to difficulties finding cases and organizing a prospective study to achieve a larger sample size. A multicenter prospective study is needed.

Wider implications of the findings: Regardless of whether the septum reached the internal or external os, there were excellent obstetric outcomes in singleton gestations after hysteroscopic correction of septate uteri. There was no increased risk with septate uteri involving the cervix. Hysteroscopic surgical correction should be the treatment of choice for patients with septate uteri.

Trial registration number

Not applicable

A minimum dataset for a Level 1 echocardiogram: a guideline protocol from the British Society of Echocardiography

The British Society of Echocardiography has previously outlined a minimum dataset for a standard transthoracic echocardiogram, and this remains the basis on which an echocardiographic study should be performed. The importance of ultrasound in excluding critical conditions that may require urgent treatment is well known. Several point-of-care echo protocols have been developed for use by non-echocardiography specialists. However, these protocols are often only used in specific circumstances and are usually limited to 2D echocardiography. Furthermore, although the uptake in training for these protocols has been reasonable, there is little in the way of structured support available from accredited sonographers in the ongoing training and re-accreditation of those undertaking these point-of-care scans. In addition, it is well recognised that the provision of echocardiography on a 24/7 basis is extremely challenging, particularly outside of tertiary cardiac centres. Consequently, following discussions with NHS England, the British Society of Echocardiography has developed the Level 1 echocardiogram in order to support the rapid identification of critical cardiac pathology that may require emergency treatment. It is intended that these scans will be performed by non-specialists in echocardiography and crucially are not designed to replace a full standard transthoracic echocardiogram. Indeed, it is expected that a significant number of patients, in whom a Level 1 echocardiogram is required, will need to have a full echocardiogram performed as soon as is practically possible. This document outlines the minimum dataset for a Level 1 echocardiogram. The accreditation process for Level 1 echo is described separately.

Effects of opioids on the parental brain in health and disease

The epidemic of opioid use disorder (OUD) directly affects millions of women of child-bearing age. Unfortunately, parenting behaviors - among the most important processes for human survival - are vulnerable to the effects of OUD. The standard of care for pregnant women with OUD is opioid maintenance therapy (OMT), of which the primary objective is to mitigate addiction-related stress. The aim of this review is to synthesize current information specific to pregnancy and parenting that may be affected by OUD. We first summarize a model of the parental brain supported by animal research and human neuroimaging. We then review animal models of exogenous opioid effects on parental brain and behavior. We also present preliminary data for a unifying hypothesis that may link different effects of exogenous opioids on parenting across species and in the context of OMT. Finally, we discuss future directions that may inform research and clinical decision making for peripartum women with OUD.

Influence of Size and Shape on the Anatomical Distribution of Endotoxin-Free Gold Nanoparticles

The transport and the delivery of drugs through nanocarriers is a great challenge of pharmacology. Since the production of liposomes to reduce the toxicity of doxorubicin in patients, a plethora of nanomaterials have been produced and characterized. Although it is widely known that elementary properties of nanomaterials influence their in vivo kinetics, such interaction is often poorly investigated in many preclinical studies. The present study aims to evaluate the actual effect of size and shape on the biodistribution of a set of gold nanoparticles (GNPs) after intravenous administration in mice. To this goal, quantitative data achieved by inductively coupled plasma mass spectrometry and observational results emerging from histochemistry (autometallography and enhanced dark-field hyperspectral microscopy) were combined. Since the immune system plays a role in bionano-interaction we used healthy immune-competent mice. To keep the immune surveillance on the physiological levels we synthesized endotoxin-free GNPs to be tested in specific pathogen-free animals. Our study mainly reveals that (a) the size and the shape greatly influence the kinetics of accumulation and excretion of GNPs in filter organs; (b) spherical and star-like GNPs showed the same percentage of accumulation, but a different localization in liver; (c) only star-like GNPs are able to accumulate in lung; (d) changes in the geometry did not improve the passage of the blood brain barrier. Overall, this study can be considered as a reliable starting point to drive the synthesis and the functionalization of potential candidates for theranostic purposes in many fields of research.

Identification of Receptor Binding to the Biomolecular Corona of Nanoparticles

Biomolecules adsorbed on nanoparticles are known to confer a biological identity to nanoparticles, mediating the interactions with cells and biological barriers. However, how these molecules are presented on the particle surface in biological milieu remains unclear. The central aim of this study is to identify key protein recognition motifs and link them to specific cell-receptor interactions. Here, we employed an immuno-mapping technique to quantify epitope presentations of two major proteins in the serum corona, low-density lipoprotein and immunoglobulin G. Combining with a purpose-built receptor expression system, we show that both proteins present functional motifs to allow simultaneous recognition by low-density lipoprotein receptor and Fc-gamma receptor I of the corona. Our results suggest that the "labeling" of nanoparticles by biomolecular adsorption processes allows for multiple pathways in biological processes in which they may be "mistaken" for endogenous objects, such as lipoproteins, and exogenous ones, such as viral infections.

Clostridium perfringens sepsis complicated by right ventricular cardiogenic shock

Clostridium perfringens sepsis has been ascribed a dismal prognosis when associated with massive intravascular haemolysis. We present a 71-year-old woman's fatal case which was compounded by isolated right ventricular cardiogenic shock. In this context, combined use of transthoracic echocardiography and pulmonary artery catheter monitoring is able to yield an individualized hemodynamic resuscitation. We discuss key aspects related to right and left heart mechanical efficiency, hypothesize as to the pulmonary hypertension mechanism of our case and set to emphasize a physiologically based framework for right ventricular failure hemodynamic management.

The Intracellular Destiny of the Protein Corona: A Study on its Cellular Internalization and Evolution

It has been well established that the early stages of nanoparticle-cell interactions are governed, at least in part, by the layer of proteins and other biomolecules adsorbed and slowly exchanged with the surrounding biological media (biomolecular corona). Subsequent to membrane interactions, nanoparticles are typically internalized into the cell and trafficked along defined pathways such as, in many cases, the endolysosomal pathway. Indeed, if the original corona is partially retained on the nanoparticle surface, the biomolecules in this layer may play an important role in determining subsequent cellular processing. In this work, using a combination of organelle separation and fluorescence labeling of the initial extracellular corona, we clarify its intracellular evolution as nanoparticles travel within the cell. We show that specific proteins present in the original protein corona are retained on the nanoparticles until they accumulate in lysosomes, and, once there, they are degraded. We also report on how different bare surfaces (amino and carboxyl modified) affect the details of this evolution. One overarching discovery is that the same serum proteins can exhibit different intracellular processing when carried inside cells by nanoparticles, as components of their corona, compared to what is observed when they are transported freely from the extracellular medium.

Different responses of Caco-2 and MCF-7 cells to silver nanoparticles are based on highly similar mechanisms of action

The mode of action of silver nanoparticles (AgNPs) is suggested to be exerted through both Ag⁺ and AgNP dependent mechanisms. Ingestion is one of the major NP exposure routes, and potential effects are often studied using Caco-2 cells, a well-established model for the gut epithelium. MCF-7 cells are epithelial breast cancer cells with extensive well-characterized toxicogenomics profiles. In the present study, we aimed to gain a deeper understanding of the cellular molecular responses in Caco-2 and MCF-7 cells after AgNP exposure in order to evaluate whether epithelial cells derived from different tissues demonstrated similar responses. These insights could possibly reduce the size of cell panels for NP hazard identification screening purposes. AgNPs of 20, 30, 60, and 110 nm, and AgNO₃ were exposed for 6 h and 24 h. AgNPs were shown to be taken up and dissolve intracellularly. Compared with MCF-7 cells, Caco-2 cells showed a higher sensitivity to AgNPs, slower gene expression kinetics and absence of NP size-dependent responses. However, on a molecular level, no significant differences were observed between the two cell types. Transcriptomic analysis showed that Ag(NP) exposure caused (oxidative) stress responses, possibly leading to cell death in both cell lines. There was no indication for effects specifically induced by AgNPs. Responses to AgNPs appeared to be induced by silver ions released from the AgNPs. In conclusion, differences in mRNA responses to AgNPs between Caco-2 and MCF-7 cells were mainly related to timing and magnitude, but not to a different underlying mechanism.

Vertical transmission of Zika virus (ZIKV) in early pregnancy: two cases, two different courses

Background:

Vertical Zika virus (ZIKV) transmission is actively being studied. Prior cases of ZIKV in pregnancy have suggested an association with infection and adverse fetal outcomes. We describe two cases of maternal illness and their respective pregnancy courses.

Case 1: A 30-year-old Hispanic female presented with rash, fatigue, and chills after noticing mosquito bites in Honduras. Fetal anatomy appeared normal on ultrasound at 16 and 17 weeks. ZIKV RNA reverse-transcriptase-polymerase-chain-reaction (RT-PCR) was identified in her serum and amniotic fluid. She opted for pregnancy termination. Fetal serum and tissue analysis confirmed ZIKV infection.

Case 2: A 28-year-old Hispanic female presented with rash, fever, and fatigue after sexual intercourse. Her ZIKV serum RNA RT-PCR was positive and amniotic fluid was negative. Fetal anatomy appeared normal at 20 and 22 weeks and her pregnancy remains ongoing.

Conclusion:

The effects of maternal ZIKV infection in early pregnancy can vary.

Revisiting the paradigm of silica pathogenicity with synthetic quartz crystals: the role of crystallinity and surface disorder

BACKGROUND

Exposure to some - but not all - quartz particles is associated to silicosis, lung cancer and autoimmune diseases. What imparts pathogenicity to any single quartz source is however still unclear. Crystallinity and various surface features are implied in toxicity. Quartz dusts used so far in particle toxicology have been obtained by grinding rocks containing natural quartz, a process which affects crystallinity and yields dusts with variable surface states. To clarify the role of crystallinity in quartz pathogenicity we have grown intact quartz crystals in respirable size.

METHODS

Quartz crystals were grown and compared with a fractured specimen obtained by grinding the largest synthetic crystals and a mineral quartz (positive control). The key physico-chemical features relevant to particle toxicity - particle size distribution, micromorphology, crystallinity, surface charge, cell-free oxidative potential - were evaluated. Membranolysis was assessed on biological and artificial membranes. Endpoints of cellular stress were evaluated on RAW 264.7 murine macrophages by High Content Analysis after ascertaining cellular uptake by bio-TEM imaging of quartz-exposed cells.

RESULTS

Quartz crystals were grown in the submicron (n-Qz-syn) or micron (μ-Qz-syn) range by modulating the synthetic procedure. Independently from size as-grown quartz crystals with regular intact faces did not elicit cellular toxicity and lysosomal stress on RAW 264.7 macrophages, and were non-membranolytic on liposome and red blood cells. When fractured, synthetic quartz (μ-Qz-syn-f) attained particle morphology and size close to the mineral quartz dust (Qz-f, positive control) and similarly induced cellular toxicity and membranolysis. Fracturing imparted a higher heterogeneity of silanol acidic sites and radical species at the quartz surface.

CONCLUSIONS

Our data support the hypothesis that the biological activity of quartz dust is not due to crystallinity but to crystal fragmentation, when conchoidal fractures are formed. Besides radical generation, fracturing upsets the expected long-range order of non-radical surface moieties - silanols, silanolates, siloxanes - which disrupt membranes and induce cellular toxicity, both outcomes associated to the inflammatory response to quartz.

Internalization of nanopolymeric tracers does not alter characteristics of placental cells

In the cell therapy scenario, efficient tracing of transplanted cells is essential for investigating cell migration and interactions with host tissues. This is fundamental to provide mechanistic insights which altogether allow for the understanding of the translational potential of placental cell therapy in the clinical setting. Mesenchymal stem/stromal cells (MSC) from human placenta are increasingly being investigated for their potential in treating patients with a variety of diseases. In this study, we investigated the feasibility of using poly (methyl methacrylate) nanoparticles (PMMA‐NPs) to trace placental MSC, namely those from the amniotic membrane (hAMSC) and early chorionic villi (hCV‐MSC). We report that PMMP‐NPs are efficiently internalized and retained in both populations, and do not alter cell morphofunctional parameters. We observed that PMMP‐NP incorporation does not alter in vitro immune modulatory capability of placental MSC, a characteristic central to their reparative/therapeutic effects in vitro. We also show that in vitro, PMMP‐NP uptake is not affected by hypoxia. Interestingly, after in vivo brain ischaemia and reperfusion injury achieved by transient middle cerebral artery occlusion (tMCAo) in mice, iv hAMSC treatment resulted in significant improvement in cognitive function compared to PBS‐treated tMCAo mice. Our study provides evidence that tracing placental MSC with PMMP‐NPs does not alter their in vitro and in vivo functions. These observations are grounds for the use of PMMP‐NPs as tools to investigate the therapeutic mechanisms of hAMSC and hCV‐MSC in preclinical models of inflammatory‐driven diseases.

Tissue Doppler indices of diastolic function in critically ill patients and association with mortality - a systematic review

PURPOSE

Systolic impairment is well reported in critically ill patients but diastolic function has been relatively understudied. The objective of this review was to assess tissue Doppler indices of diastolic function in critically ill patients along with any association with mortality.

METHODS

A systematic review of articles in English using Medline, EMBASE, CINAHL and the Cochrane database of systematic reviews. Search terms included diastolic function, diastolic dysfunction, diastolic abnormal*, diastolic heart failure, diastolic filling, ventricular relaxation, pulmonary artery occlusion pressure, left ventricular filling pressure, cardiac dysfunction, intensive care, critical care, critically ill, critical illness, sepsis and septic shock. Only studies of critically ill adult patients (excluding post-cardiac surgical patients) whose diastolic function was assessed using tissue Doppler imaging were included. Study quality was assessed using a modified version of the Newcastle-Ottawa Scale (NOS).

RESULTS

Nineteen studies were included, with a total of 1365 patients. All trials were observational. There was a large heterogeneity in patient populations and the methodology of tissue Doppler assessment of diastology resulting in a descriptive analysis. Patient groups included severe sepsis or septic shock (5 studies), septic shock (5 studies), systemic inflammatory response syndrome and shock (1 study), septic shock and acute lung injury (1 study), cancer and septic shock (2 studies), general ICU patients (1 study), combined medical and surgical ICU (2 studies) and sub-arachnoid haemorrhage patients (2 studies). Seventeen studies scored 5/6 on the NOS with the remaining two scoring 4/6. Fourteen studies reported on numbers of patients diagnosed with diastolic dysfunction (500/999, mean 50%, range 20-92%). Three studies found that diastolic dysfunction was an independent predictor of mortality.

CONCLUSIONS

Current data shows a large range in the incidence of diastolic dysfunction in this patient population and a variable link with mortality. Future research should focus on the definition of normal values for diastolic function in critically ill patients along with the effects of ICU therapies and consensus criteria for its assessment in this patient population.

Bismuth-based nanoparticles as the environmentally friendly replacement for lead-based piezoelectrics

BNT-BT is suitable non-toxic candidate to replace lead-based PZT, as they avoid leaching, imposing less risk during occupational and environmental exposure.

Deprivation of Liberty in Intensive Care

Most patients in intensive care units lack mental capacity to inform decision-making, whether because of drugs or disease. The introduction of the Mental Capacity Act in England and Wales in 2005 has changed the way that doctors and institutions deal with patients who lack capacity. This is especially true when physical, mechanical or pharmacological restraints are used to allow the patient's treatment. Recently, the Supreme Court has ruled that if a person is under continuous supervision and control, and is not free to leave the place they are being treated, then they are deprived of their liberty. This article explains the ramification of this ruling for patients in intensive care whose care must now meet Deprivation of Liberties Standards. The procedures both for staff caring for these patients and for the Trusts where they are receiving care are described.

Nanomaterials: impact on cells and cell organelles

Colloidal nanoparticles designed for the interactions with cells are very small, nanoscale objects usually consisting of inorganic cores and organic shells that are dispersed in a buffer or biological medium. By tuning the material properties of the nanoparticles a number of different biological applications of nanomaterials are enabled i.e. targeting, labelling, drug delivery, use as diagnostic tools or therapy. For all biological applications of nanoparticles, it is important to understand their interactions with the surrounding biological environment in order to predict their biological impact, in particular when designing the nanoparticles for diagnostic and therapeutic purpose. Due to the high surface-to-volume ratio, the surface of nanomaterials is very reactive. When exposed to biological fluids, the proteins and biomolecules present therein tend to associate with the nanoparticles' surface. This phenomenon is defined as biomolecular corona formation. The biomolecular corona plays a key role in the interaction between nanoparticles and biological systems, impacting on how these particles interact with biological systems on a cellular and molecular level. This book chapter describes the nature of the interactions at the bio-nano interface, shows the design strategy of nanoparticles for nanomedicine, and defines the concepts of biomolecular corona and biological identity of nanoparticles. Moreover, it describes the interaction of functionalised nanomaterials with cell organelles and intracellular fate of nanoparticles and it shows therapeutic application of gold nanoparticles as dose enhancers in radiotherapy.

Racial and ethnic identity in nursing research

Nurse researchers need to be able to identify the race and ethnicity of participants in their studies for several reasons including addressing health disparities, ensuring adequate representation from under-represented minorities, and making sure other nurses can understand how findings may or may not pertain to their own patient population. However, obtaining accurate information about race and ethnicity requires careful attention to norms of study participants. Race and ethnicity are not always viewed as 2 separate constructs and the definition of both changes over time. In fact, a random sample of 100 patients in 1 hospital found an 11% discrepancy between patients' self-identification of race using 2 different methodologies of self-identification. To optimize accuracy of self-identification of race and ethnicity, this paper discusses techniques learned in practice and in the literature for improving self-identification of these 2 constructs.

Nutrition profiles of African [corrected] American women in the third trimester

PURPOSE

To develop a profile of common nutritional patterns among pregnant African American women that will assist healthcare providers in identifying areas for improvement and change.

STUDY DESIGN

This study was part of a larger NIH-funded (R03NR008548-01) study that examined risk factors associated with preterm labor and birth in high- and low-risk African American women. Data were collected on high-risk mothers (women experiencing preterm labor) before 34 weeks gestation and every 4 weeks until birth. Data were also collected on the low-risk mothers beginning at 28 weeks and then every 4 weeks until birth. For this study, high- and low-risk groups were collapsed to examine food choices over time in all participants (n = 58).

METHODS

Nutrition intake was examined by conducting one 24-hour diet recall at each time point. Food models and portion size pictures were used to improve accuracy.

RESULTS

Overall, dietary intake was suboptimal, and micro- and macronutrient intake during the third trimester did not vary. Energy (caloric) intake was inadequate with the time-averaged probability of having inadequate caloric intake 64.4%. Protein intake was the most likely nutritional factor to be inadequate with a time-averaged estimated probability of inadequate intake 25.1%. Micronutrient intake from food was also inadequate.

CLINICAL IMPLICATIONS

The persistence of suboptimal nutritional intake during the third trimester supports the importance of continually assessing nutritional status throughout pregnancy, with a focus on caloric requirements and protein intake.

Rapid and novel prenatal molecular assay for detecting aneuploidies and microdeletion syndromes

OBJECTIVES

To develop a targeted aneuploidy and microdeletion detection platform for use in the prenatal setting, to assess the integrity of the platform with a robust validation system, and to prospectively determine the performance of the platform under routine clinical conditions.

METHODS

To generate proxies for the various disorders assessed by the assay for analytical validation purposes, cells from ten microdeletion syndromes as well as from common aneuploidies were spiked into cleared amniotic fluid. Genomic DNA was isolated, labeled, and hybridized to microbeads that have been coupled to DNA derived from Bacterial Artificial Chromosome (BAC) from the relevant regions targeted by the array. Beads were read using a flow cytometric multiplex bead array detection system. In the prospective part of the study, 104 amniotic fluid samples were collected and analyzed.

RESULTS

All microdeletion syndromes and aneuploidies were validated in a blinded fashion. In the prospective study, the total number of readable samples was 101 of 104 (97%). All sample results were confirmed independently.

CONCLUSION

The bead array approach is a rapid and reliable test for detecting aneuploidies and microdeletions. This assay has the potential to provide the benefit of expanded molecular cytogenetic testing to pregnant women undergoing invasive prenatal diagnosis. This approach may be especially useful in parts of the world where cytogenetic personnel and facilities may be limited.

Posterior uterine rupture in a woman with a previous Cesarean delivery

A 33-year-old primipara with a previous low transverse Cesarean delivery underwent labor induction at 41 weeks' gestation with a 10-mg dinoprostone vaginal insert. Eleven hours later, with the cervix fully dilated, an emergency Cesarean delivery was performed because of repetitive variable decelerations followed by fetal bradycardia. A posterior uterine wall rupture extending from the fundus to the vagina was repaired in layers. The neonate had an Apgar score of 2 and 4 and expired on the 7th day of life.