Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Inflammatory biomarker signatures in post-surgical drain fluid may detect anastomotic leaks within 48 hours of colorectal resection

BACKGROUND

The optimal treatment of colorectal cancer is surgical resection and primary anastomosis. Anastomotic leak can affect up to 20% of patients and creates significant morbidity and mortality. Current diagnosis of a leak is based on clinical suspicion and subsequent radiology. Peritoneal biomarkers have shown diagnostic utility in other conditions and could be useful in providing earlier diagnosis. This pilot study was designed to assess the practical utility of peritoneal biomarkers after abdominal surgery utilising an automated immunoassay system in routine use for quantifying cytokines.

METHODS

Patients undergoing an anterior resection for a rectal cancer diagnosis were recruited at University Hospital of Wales, Cardiff between June 2019 and June 2021. A peritoneal drain was placed in the proximity of the anastomosis during surgery, and peritoneal fluid was collected at days 1 to 3 post-operatively, and analysed using the Siemens IMMULITE platform for interleukin (IL)-1β, IL-6, IL-10, CXCL8, tumour necrosis factor alpha (TNFα) and C-reactive protein (CRP).

RESULTS

A total of 42 patients were recruited (22M:20F, median age 65). Anastomotic leak was detected in four patients and a further five patients had other intra-abdominal complications. The IMMULITE platform was able to provide robust and reliable results from the analysis of the peritoneal fluid. A metric based on the combination of peritoneal IL-6 and CRP levels was able to accurately diagnose three anastomotic leaks, whilst correctly classifying all negative control patients including those with other complications.

CONCLUSIONS

This pilot study demonstrates that a simple immune signature in surgical drain fluid could accurately diagnose an anastomotic leak at 48 h postoperatively using instrumentation that is already widely available in hospital clinical laboratories.

A novel method for measuring the burden of breast cancer in neighborhoods

Community-based breast cancer prevention efforts often focus on women who live in the same neighborhoods, as they tend to have similar demographic characteristics, health behaviors, and environmental exposures; yet little research describes methods of selecting neighborhoods of focus for community-based cancer prevention interventions. Studies frequently use demographics from census data, or single breast cancer outcomes (e.g., mortality, morbidity) in order to choose neighborhoods of focus for breast cancer interventions, which may not be optimal. This study presents a novel method for measuring the burden of breast cancer among neighborhoods that could be used for selecting neighborhoods of focus. In this study, we 1) calculate a metric composed of multiple breast cancer outcomes to describe the burden of breast cancer in census tracts Philadelphia, PA, USA; 2) map the neighborhoods with the greatest breast cancer burden; and 3) compare census tracts with the highest burden of breast cancer to those with demographics sometimes used for geo-based prioritization, i.e., race and income. The results of our study showed that race or income may not be appropriate proxies for neighborhood breast cancer burden; comparing the breast cancer burden with demographics at the census tract level, we found few overlaps with the highest percentage African American or the lowest median incomes. Agencies implementing community-based breast cancer interventions should consider this method to inform the selection of neighborhoods for breast cancer prevention interventions, including education, screening, and treatment.

Using CT scans to determine the optimal sizes of hard armour plates to protect the torso for UK female Armed Forces personnel

INTRODUCTION

Hard armour plates provide coverage to essential anatomical structures in the torso that, if injured, would likely be responsible for death before damage control surgery can be undertaken. Existing front and rear OSPREY plates in conjunction with Mark 2 plates used at the sides in current UK Armed Forces personal armour systems are provided in a single size, used by both female and male users.

METHODS

CT scans of 45 female UK military personnel were analysed. Distances between anatomical structures representing threshold (absolute minimum) and objective (the maximum level of coverage beyond which there is limited further benefit) coverage of the torso were determined and compared with OSPREY and Mark 2 plate dimensions. Sample characteristics were compared with the 2006/2007 UK Armed Forces Anthropometric Survey.

RESULTS

No statistical difference was found between sample means for stature (p=0.131) and mass (p=0.853) from those of the anthropometric survey in this sample. The height of both the front OSPREY plates exceeded the threshold coverage (suprasternal notch to lower border of the 10th rib) for all women studied. The height of the Mark 2 plate exceeds the objective coverage from the side for all women studied.

CONCLUSIONS

Based on a plate height providing threshold coverage of all women up to the 50th percentile, the height of the front and rear OSPREY plates could be reduced by 36mm and 31mm respectively. Based on a presumption that a side plate should cover up to the 95th percentile, the Mark 2 plate achieves the objective height and width for the female population studied. Strong evidence was found to support the UK Ministry of Defence requirement for procurement of new front and rear plates of multiple heights for both female and male users.

A fit and function analysis of the UK OSPREY body armour system for female users

INTRODUCTION

OSPREY personal armour has been issued to UK forces since 2005. From 2015, the VIRTUS personal armour and load carriage system have been progressively replacing OSPREY. In 2016, the ban on women in ground close combat roles throughout the UK's Armed Forces was lifted. In anticipation of this, work has been ongoing to prepare future ballistic protection programmes for a potential increase in the number of female users.

METHOD

A human factors questionnaire was provided to 150 female users of OSPREY body armour to complete while on combat operations in Afghanistan. The questionnaire asked the users to rate the comfort of their OSPREY body armour along with their ability to carry out basic tasks. Other background data such as size of body armour worn and bra size were also collected for the analysis.

RESULTS

The female participants reported various types of discomfort when wearing their OSPREY body armour, with 135 instances of discomfort experienced in the hip region, for example. Challenges were reported in the ability to carry out basic movements, with the tasks rated on a Likert scale as difficult or very difficult by between 29% and 59% of participants. In addition, a restriction in ability to access personal equipment worn on the person (including pouches, trouser pockets) was commented on by 39% of participants.

CONCLUSIONS

Female users reported challenges relating to the fit and function of OSPREY body armour. The VIRTUS body armour system for UK Armed Forces Personnel has already addressed many of the reported issues with OSPREY. Further optimisation for VIRTUS with regard to female users is planned and includes sizing of ballistic hard plates.

A cross-linguistic, sound symbolic relationship between labial consonants, voiced plosives, and Pokémon friendship

Introduction

This paper presents a cross-linguistic study of sound symbolism, analysing a six-language corpus of all Pokémon names available as of January 2022. It tests the effects of labial consonants and voiced plosives on a Pokémon attribute known as friendship. Friendship is a mechanic in the core series of Pokémon video games that arguably reflects how friendly each Pokémon is.

Method

Poisson regression is used to examine the relationship between the friendship mechanic and the number of times /p/, /b/, /d/, /m/, /g/, and /w/ occur in the names of English, Japanese, Korean, Chinese, German, and French Pokémon.

Results

Bilabial plosives, /p/ and /b/, typically represent high friendship values in Pokémon names while /m/, /d/, and /g/ typically represent low friendship values. No association is found for /w/ in any language.

Discussion

Many of the previously known cases of cross-linguistic sound symbolic patterns can be explained by the relationship between how sounds in words are articulated and the physical qualities of the referents. This study, however, builds upon the underexplored relationship between sound symbolism and abstract qualities.

Long-Term Benzodiazepine Use and Discontinuation Among Patients in the U.S. Veterans Health Administration

OBJECTIVE

Although long-term benzodiazepine use is not recommended, patients are often prescribed benzodiazepines for &gt;30 days (long-term use). Data from the Veterans Health Administration (VHA) may inform efforts to discontinue such use. This study sought to describe benzodiazepine use and discontinuation among VHA patients and compared patients who continued and discontinued use.

METHODS

The study used nationwide electronic health record data for all VHA-enrolled patients (age ≥18) from fiscal year (FY) 2019 (N=6,032,613). The primary outcome, benzodiazepine discontinuation, was defined as no prescription refill for 120 days.

RESULTS

In FY2019, 3.5% of VHA enrollees were prescribed benzodiazepines for &gt;30 days, which was 72.0% of those prescribed benzodiazepines. One-third of veterans prescribed long-term benzodiazepines discontinued use. Continuation was more likely among patients who were older, not Black, taking benzodiazepines longer, and taking higher doses. When demographic factors were controlled, patients who continued long-term use were more likely to have a diagnosis of anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, or psychosis and less likely to have depression or an alcohol or drug use disorder. Continuation was associated with a lower likelihood of sleep and cardiopulmonary disorders and of dementia.

CONCLUSIONS

Higher discontinuation prevalence among patients with substance use disorders, dementia, or cardiopulmonary disorders is encouraging. However, the challenge remains of discontinuing long-term use among patients who are White, older, or diagnosed as having anxiety, PTSD, bipolar disorder, or psychosis. There is a need to identify provider, patient, and contextual factors driving long-term benzodiazepine use in these patient groups to effectively apply evidence-based discontinuation strategies.

PARADISE-MI – event rates and treatment effect of sacubitril/valsartan v ramipril by the presence or absence of transient pulmonary congestion and/or LVEF less or greater than 40

Background/Introduction

Sacubitril/valsartan was compared to ramipril in patients with acute myocardial infarction in the PARADISE-MI trial. In the whole trial population sacubitril/valsartan did not reduce the composite primary outcome of CV death or incident heart failure compared to ramipril. Whether or not event rates and/or treatment effects vary in patients with different baseline characteristics is unknown.

Purpose

To investigate a) event rates b) the treatment effect of sacubitril/valsartan compared to ramipril and c) safety by the presence or absence of transient pulmonary congestion and/or left ventricular ejection fraction (LVEF) ≤40%.

Methods

PARADISE-MI was a double-blind, randomised clinical trial that compared sacubitril/valsartan to ramipril in 5661 patients with an acute myocardial infarction with either LVEF ≤40% and/or transient pulmonary congestion. 3 groups were investigated: 1) LVEF ≤40% with pulmonary congestion (n=2012) and 2) LVEF ≤40% without pulmonary congestion (n=2596) and 3) LVEF not ≤40% with pulmonary congestion (n=1044).

Results

Patients with pulmonary congestion (with and without LVEF ≤40%) were more likely to have had a prior MI, prior CABG or PCI, had more atrial fibrillation and were more often treated with mineralocorticoid receptor antagonists and diuretics than patients with no pulmonary congestion and LVEF ≤40%. Patients with LVEF ≤40% and pulmonary congestion had more than twice the rate of the primary composite outcome compared to those with LVEF ≤40% without pulmonary congestion: 10.2 (95% CI 9.2–11.3) vs. 4.8 (4.3–5.5) events per 100 patient-years, respectively). Patients with pulmonary congestion and LVEF not ≤40% had an intermediate event rate (6.6, 5.5–7.9, events per 100 patient-years). A similar pattern of event rates was seen for the components of the primary outcome and for all secondary outcomes whether Clinical Events Committee or investigator-reported events were analysed. The treatment effect of sacubitril/ valsartan versus ramipril did not vary between the 3 congestion/ LVEF subgroups. The safety of sacubitril/valsartan compared to ramipril did not vary between congestion/LVEF subgroups.

Conclusion

Patients with pulmonary congestion with or without LVEF ≤40% had higher rates of primary and all secondary outcomes than those without pulmonary congestion and LVEF ≤40%. The treatment effect, and safety, of sacubitril/valsartan compared to ramipril was consistent in patients with or without pulmonary congestion and with or without LVEF ≤40%.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis

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.

Enteric viruses replicate in salivary glands and infect through saliva

Enteric viruses like norovirus, rotavirus and astrovirus have long been accepted as spreading in the population through fecal-oral transmission: viruses are shed into feces from one host and enter the oral cavity of another, bypassing salivary glands (SGs) and reaching the intestines to replicate, be shed in feces and repeat the transmission cycle1. Yet there are viruses (for example, rabies) that infect the SGs2,3, making the oral cavity one site of replication and saliva one conduit of transmission. Here we report that enteric viruses productively and persistently infect SGs, reaching titres comparable to those in the intestines. We demonstrate that enteric viruses get released into the saliva, identifying a second route of viral transmission. This is particularly significant for infected infants, whose saliva directly transmits enteric viruses to their mothers' mammary glands through backflow during suckling. This sidesteps the conventional gut-mammary axis route4 and leads to a rapid surge in maternal milk secretory IgA antibodies5,6. Lastly, we show that SG-derived spheroids7 and cell lines8 can replicate and propagate enteric viruses, generating a scalable and manageable system of production. Collectively, our research uncovers a new transmission route for enteric viruses with implications for therapeutics, diagnostics and importantly sanitation measures to prevent spread through saliva.

Whole genome and transcriptome analysis enhances precision cancer treatment options

BACKGROUND

Recent advances are enabling delivery of precision genomic medicine to cancer clinics. While the majority of approaches profile panels of selected genes or hotspot regions, comprehensive data provided by whole genome and transcriptome sequencing and analysis (WGTA) presents an opportunity to align a much larger proportion of patients to therapies.

PATIENTS AND METHODS

Samples from 570 patients with advanced or metastatic cancer of diverse types enrolled in the Personalized OncoGenomics (POG) program underwent WGTA. DNA-based data, including mutations, copy number, and mutation signatures, were combined with RNA-based data, including gene expression and fusions, to generate comprehensive WGTA profiles. A multidisciplinary molecular tumour board used WGTA profiles to identify and prioritize clinically actionable alterations and inform therapy. Patient responses to WGTA-informed therapies were collected.

RESULTS

Clinically actionable targets were identified for 83% of patients, 37% of whom received WGTA-informed treatments. RNA expression data were particularly informative, contributing to 67% of WGTA-informed treatments; 25% of treatments were informed by RNA expression alone. Of a total 248 WGTA-informed treatments, 46% resulted in clinical benefit. RNA expression data were comparable to DNA-based mutation and copy number data in aligning to clinically beneficial treatments. Genome signatures also guided therapeutics including platinum, PARP inhibitors, and immunotherapies. Patients accessed WGTA-informed treatments through clinical trials (19%), off-label use (35%), and as standard therapies (46%) including those which would not otherwise have been the next choice of therapy, demonstrating the utility of genomic information to direct use of chemotherapies as well as targeted therapies.

CONCLUSIONS

Integrating RNA expression and genome data illuminated treatment options that resulted in 46% of treated patients experiencing positive clinical benefit, supporting the use of comprehensive WGTA profiling in clinical cancer care.

CLINICAL TRIAL NUMBER

NCT02155621.

Estimating Eligibility for Lung Cancer Screening by Neighborhood in Philadelphia Using Previous and Current USPSTF Guidelines

The National Lung Screening Trial established the benefits of low-dose computed tomography for lung cancer screening (LCS) to identify lung cancer at earlier stages. In February 2021, the US Preventive Services Task Force (USPSTF) revised the eligibility recommendations to increase the number of high-risk individuals eligible for LCS and, in effect, expand screening eligibility for vulnerable populations. One strategy for facilitating LCS is to implement targeted screening in geographic areas with the greatest need. In Philadelphia, although neighborhood smoking rates have been defined, it is not known which neighborhoods have the greatest number of people eligible for LCS. In this study, the authors estimate eligibility for LCS within Philadelphia neighborhoods using both previous and current USPSTF guidelines. They used the Public Health Management Corporation's Household Health Survey from 2010, 2012, and 2015 to identify the number of people within ever-smoker groups (current every day, current occasional, and former smokers) by neighborhood in Philadelphia. Using the 2015 National Health Interview Survey (NHIS) Cancer Supplement, they identified the percentages within ever-smoker groups that were LCS eligible using the previous and current USPSTF guidelines. Finally, they applied the percentages eligible for the ever-smoker groups from the NHIS to the numbers in these groups within Philadelphia neighborhoods. They found that the number of Philadelphians eligible for LCS increased from 41,946 to 89,231 after the revised USPSTF guidelines. The current USPSTF guidelines increased eligibility for LCS within all Philadelphia neighborhoods, with the greatest increases in the River Wards planning district. Local providers should use these results to prioritize LCS services within neighborhoods with greatest eligibility.

127 Optimum Treatment for Sigmoid Volvulus Remains Elusive but Surgery May Provide Considerable Benefit: Results of a 5-Year Audit

Background

Sigmoid volvulus is a surgical emergency and patients are often elderly with significant comorbidities. Whilst endoscopic decompression is easy and effective in the short-term, recurrence and repeated admissions are common with surgery generally being reserved for non-resolution or complications. Consensus an optimum management is lacking.

Method

A retrospective audit of all patients admitted with sigmoid volvulus to a DGH General Surgery service between 01/01/2015-20/10/2020 was undertaken. Patient demographics, comorbidities, clinical findings, investigations, and treatment were recorded.

Results

Sixty-three patients were identified (median age 71.5 years; 58.7% male]. Some 50.8% had more than one previous presentation (range 1–6), 19% presented after 3 days of symptoms and 3.2% presented with perforation. Plain radiography and CT scanning was undertaken in 90.5% and 54%, respectively.

Endoscopic detorsion was performed in 77.77% and repeated in the same admission for 33.3% of cases. Flatus tubes and rigid sigmoidoscopy was used in 47.6% with a 59.6% success rate. Seventeen patients (27%) underwent sigmoid resection, 14 having open surgery and 3 laparoscopic. Primary anastomosis was undertaken in 64.7% (11 patients), with only one anastomotic leak; the remaining 6 patients had a colostomy. The re-admission rate was 30.1% (19% non-operated patients, 11.1% operated patients).

Conclusions

Most patients with sigmoid volvulus are managed non-operatively with endoscopic detorsion which may be associated with a considerable healthcare burden and high readmission rates. Selective resection can be associated with low morbidity and good outcomes. Clinicians could reasonably adopt a lower threshold for surgical intervention, particularly for recurrent volvulus.

A platform for oncogenomic reporting and interpretation

Manual interpretation of variants remains rate limiting in precision oncology. The increasing scale and complexity of molecular data generated from comprehensive sequencing of cancer samples requires advanced interpretative platforms as precision oncology expands beyond individual patients to entire populations. To address this unmet need, we introduce a Platform for Oncogenomic Reporting and Interpretation (PORI), comprising an analytic framework that facilitates the interpretation and reporting of somatic variants in cancer. PORI integrates reporting and graph knowledge base tools combined with support for manual curation at the reporting stage. PORI represents an open-source platform alternative to commercial reporting solutions suitable for comprehensive genomic data sets in precision oncology. We demonstrate the utility of PORI by matching 9,961 pan-cancer genome atlas tumours to the graph knowledge base, calculating therapeutically informative alterations, and making available reports describing select individual samples.

The interpretation of somatic variants in cancer is challenging due to the scale and complexity of sequencing data. Here, the authors present PORI, an open-source framework for interpreting somatic variants in cancer using graph knowledge base tools, automated reporting, and manual curation.

A Mixed Methods Case Study of Food Shopping in a Community with High Infant Mortality

In the U.S., preterm birth disproportionately impacts certain racial/ethnic groups, with Black women experiencing preterm birth at a rate 50% higher than other groups. Among the numerous factors that likely contribute to these increased rates are neighborhood characteristics, such as food environment. In this mixed-methods case study, we evaluated how pregnant women living in a predominately minority, lower income community with high preterm birth rates navigate and perceive their food environment. Qualitative interviews were performed to assess perceptions of food environment (n = 7) along with geographic and observational assessments of their food environment. Participants traveled an average of 2.10 miles (SD = 1.16) and shopped at an average of 3 stores. They emphasized the importance of pricing and convenience when considering where to shop and asserted that they sought out healthier foods they thought would enhance their pregnancy health. Observational assessments of stores' nutrition environment showed that stores with lower nutritional scores were in neighborhoods with greater poverty and a higher percent Black population. Future policies and programmatic efforts should focus on improving nutrition during pregnancy for women living in communities with high rates of poor birth outcomes. Availability, affordability, and accessibility are key aspects of the food environment to consider when attempting to achieve birth equity.

Corticotropin-Releasing Hormone from the Pontine Micturition Center Plays an Inhibitory Role in Micturition

Lower urinary tract or voiding disorders are prevalent across all ages and affect >40% of adults over 40 years old, leading to decreased quality of life and high health care costs. The pontine micturition center (PMC; i.e., Barrington's nucleus) contains a large population of neurons that localize the stress-related neuropeptide, corticotropin-releasing hormone (CRH) and project to neurons in the spinal cord to regulate micturition. How the PMC and CRH-expressing neurons in the PMC control volitional micturition is of critical importance for human voiding disorders. To investigate the specific role of CRH in the PMC, neurons in the PMC-expressing CRH were optogenetically activated during in vivo cystometry in unanesthetized mice of either sex. Optogenetic activation of CRH-PMC neurons led to increased intermicturition interval and voided volume, similar to the altered voiding phenotype produced by social stress. Female mice showed a significantly more pronounced phenotype change compared with male mice. These effects were eliminated by CRH-receptor 1 antagonist pretreatment. Optogenetic inhibition of CRH-PMC neurons led to an altered voiding phenotype characterized by more frequent voids and smaller voided volumes. Last, in a cyclophosphamide cystitis model of bladder overactivity, optogenetic activation of CRH-PMC neurons returned the voiding pattern to normal. Collectively, our findings demonstrate that CRH from PMC spinal-projecting neurons has an inhibitory function on micturition and is a potential therapeutic target for human disease states, such as voiding postponement, urinary retention, and underactive or overactive bladder.SIGNIFICANCE STATEMENT The pontine micturition center (PMC), which is a major regulator of volitional micturition, is neurochemically heterogeneous, and excitatory neurotransmission derived from PMC neurons is thought to mediate the micturition reflex. In the present study, using optogenetic manipulation of CRH-containing neurons in double-transgenic mice, we demonstrate that CRH, which is prominent in PMC-spinal projections, has an inhibitory function on volitional micturition. Moreover, engaging this inhibitory function of CRH can ameliorate bladder hyperexcitability induced by cyclophosphamide in a model of cystitis. The data underscore CRH as a novel target for the treatment of voiding dysfunctions, which are highly prevalent disease processes in children and adults.

Spontaneous neoplasia in captive syngnathid species: A retrospective case series (2003-2014) and literature review

Syngnathidae (seahorses, pipefish and seadragons) are charismatic species commonly kept in commercial aquaria, but published literature on syngnathid diseases is limited and immunohistochemical techniques not routinely employed. A retrospective review of 2,541 syngnathid submissions received between March 2003 and October 2016 identified 18 neoplasms including germ cell tumours, exocrine pancreatic and intestinal carcinomas, chromatophoromas, and single cases of lymphoma, thyroid and renal carcinoma, swim bladder and pituitary adenoma. Big-bellied seahorses accounted for 19% of submissions, but 50% of neoplasms were diagnosed in this species. This study includes the first reported cases of germ cell tumours, chromatophoroma, thyroid carcinoma and pituitary adenoma in Syngnathidae and the first reports of neoplasia in pipefish species. Out of nine commercial antibodies trialled for immunohistochemical characterization of neoplastic tissue, only pan-cytokeratin proved cross-reactive. Electron microscopy was performed in four cases. Tumours should be considered as differential diagnosis in cases with buoyancy issues, debilitated or emaciated animals, and may predispose to secondary infections. This study highlights the value of histopathological disease surveillance for commercial aquarium settings.

Determining the optimum anatomical coverage of side plates for the VIRTUS body armour and load carriage system

INTRODUCTION

Side plates are worn by UK Armed Forces as part of the VIRTUS body armour and load carriage systems to protect the thorax and abdomen from high-velocity threats. The VIRTUS project has provided the impetus to objectively demonstrate the anatomical coverage provided by side plates.

METHOD

CT scans of 120 male UK Armed Forces personnel were analysed to ascertain the vertical distance between the anterior axillary fold and iliac crest, and horizontal distance between anterior and posterior borders of the liver, delineating the boundaries of essential medical coverage from the side aspects. The percentage of shot-lines intersected by the existing Enhanced Combat Body Armour (ECBA) plates as well as an optimised plate based on the maximum potential dimensions of essential coverage was determined in the Coverage of Armour Tool.

RESULTS

ECBA plates were 101 mm shorter and 4 mm narrower than a plate with dimensions providing essential medical coverage for the 50th percentile subject (157×315 mm). Coverage increased by 35% when using two ECBA plates as side coverage in addition to using the front and rear OSPREY plates in the VIRTUS vest. Two side plates with dimensions providing essential medical coverage for the 50th percentile increased anatomical coverage by a further 16%.

CONCLUSIONS

This analysis has provided strong evidence that ECBA plates are already optimised for side protection, despite not being originally designed for this purpose. They are correctly positioned within the VIRTUS soft body armour vest and the width of the ECBA plate is only 3% less than what would be optimum size for the 50th percentile. Although the height of the plate could be increased to further enhance the anatomical coverage, it is unlikely that this would be acceptable in terms of the human factors, equipment integration or additional mass.

Next-generation sequencing as a screening tool for foodborne pathogens in fresh produce

Next generation sequencing (NGS) approaches are increasingly applied to tracing microbial contaminants entering the food chain due to NGS' untargeted nature and ability to investigate non-culturable (and/or difficult to culture) organisms while yielding genomic information about the microbiota. So far, a plethora of microbes has been shown to be associated with fresh produce, but few studies have utilised NGS to identify contamination with human pathogens. This study aims to establish the limit of detection (LoD) for Salmonella and phage MS2 (a Norovirus surrogate) contamination of fresh produce employing NGS approaches on the Illumina MiSeq: 16S amplicon-sequencing, and RNA-seq, using ScriptSeq (Illumina) and NEBNext (New England BioLabs) kits. ScriptSeq proved the most sensitive approach; delivering an LoD of 10⁴ CFU reaction^-1 (Colony Forming Units) for Salmonella and 10⁵ PFU reaction^-1 (Plaque Forming Units) for phage MS2. Use of the NEBNext kit resulted in detection of Salmonella at 10⁶ CFU reaction^-1 and phage MS2 at 10⁷ PFU reaction^-1. 16S amplicon-sequencing yielded a similar LoD of 10⁵ CFU reaction^-1 for Salmonella but could not detect MS2. The tested NGS methodologies, in combination with bioinformatics approaches applied, proved less sensitive than conventional microbial detection approaches.

Pasture allowance, duration, and stage of lactation-Effects on early and total lactation animal performance

Pasture availability in early spring can be limited due to climatic effects on grass production, increasing the likelihood of feed deficits in early lactation of spring-calving pasture-based systems. We hypothesized that restricting pasture allowance (PA) when animals are at peak milk production will have more negative implications on milk production compared with restricting animals before this period. A total of 105 cows were assigned to 1 of 7 grazing treatments from March 14 to October 31, 2016 (33 wk). The control treatment was offered a PA to achieve a postgrazing sward height > 3.5 cm and mean pasture allowance of 15.5 kg of dry matter per cow. The remaining treatments were offered a PA representing 60% of that offered to the control for a duration of 2 or 6 wk from March 14 (mid-March; MMx2 and MMx6), March 28 (end of March; EMx2 and EMx6), or April 11 (mid-April; MAx2 and MAx6). Within grazing treatment, animals were also assigned to 1 of 2 calving dates (early and late) based on days in milk (DIM) on March 14. Early calved (EC) cows were ≥36 DIM, while late calved (LC) were ≤35 DIM. Restricting PA for 2 and 6 wk reduced daily milk yield (-1.6 and -2.2 kg/cow, respectively), cumulative milk protein yield (-4.0 and -6.3 kg/cow, respectively), and cumulative milk solids yield (-5.8 and -9.5 kg/cow, respectively) in the first 10 wk of the experiment. Daily milk yield was similar across the treatments at the end of the 33-wk period (16.8 kg/cow, average of all treatments), as was daily milk solids yield (1.40 kg/cow). Cows in the EC group produced less milk over the first 10 wk of the experiment (20.0 kg/cow per day) compared with the LC animals (22.1 kg/cow per day). However, body weight was greater (+15 kg/cow) in the EC animals compared with the LC, while body condition score was similar (2.85). This outcome indicates that animals that are restricted later in early lactation (circa onset of peak milk production) partition a greater proportion of available energy to maintenance, resulting in greater losses in milk production. These data indicate that despite the immediate reduction in milk production, restricting intake of grazing cows to 80% of that required to achieve spring grazing targets for postgrazing sward height for up to 6 wk may be used as a method of managing short-term pasture deficits on farm with minimal effects on total lactation performance.

UK military helmet design and test methods

The aim of this paper was to provide the military medical community with an expert summary of military helmets used by HM Armed Forces. The design of military helmets and test methods used to determine the fragmentation and non-ballistic impact protection are discussed. The helmets considered are Parachutist, Combat Vehicle Crewman, Mk6, Mk6A, Mk7 and VIRTUS. The helmets considered provide different levels of fragmentation and non-ballistic impact protection dictated by the materials available at the time of the helmet design and the end-user requirement. The UK Ministry of Defence defines the area of coverage of military helmets by considering external anatomical features to provide protection to the brain and the majority of the brainstem. Established test methods exist to assess the performance of the helmet with respect to the threats; however, these test methods do not typically consider anatomical vulnerability.

High-sensitivity salinity sensor based on optical microfiber coil resonator

A simple, compact, and high-sensitivity optical sensor for salinity measurement is reported based on an optical microfiber coil resonator (MCR). The MCR is manufactured by initially wrapping microfiber on a polymethylmethacrylate (PMMA) rod, which is dissolved to leave a hollow cylindrical fluidic channel within the coil for measurement. Based on the light propagation through the MCR, the device's spectrum moves to long wavelengths with increased salinity in the fluid. The MCR device's sensitivity can reach up to 15.587 nm/% with a resolution of 1.28 × 10^-3%. It is also confirmed that the temperature dependence is 79.87 pm/°C, which results from the strong thermal-expansion coefficient of the low refractive index epoxy. The experimental results indicate that the device can be widely used as a high sensitivity salinity sensor in water and other liquids due to its stability, compactness, electromagnetic immunity, and high sensitivity.

The ratio of erythrocyte sedimentation rate to C-reactive protein is useful in distinguishing infection from flare in systemic lupus erythematosus patients presenting with fever

Background Both C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) can be elevated in systemic lupus erythematosus (SLE) flare and infection, and are therefore of limited utility for distinguishing between the two conditions in febrile SLE patients. Methods A medical records review of hospitalizations (1997-2006) of SLE patients in the Michigan Lupus Cohort was performed. Eligible hospitalizations were those in which patients presented with a temperature of >100.3°F or with subjective fevers as a presenting complaint at admission. Detailed demographic, clinical, and laboratory data were collected. Multivariable logistic regression was used to examine the associations between ESR and CRP and the outcome of flare vs infection, adjusted for confounders. Results Among 557 SLE patients screened, there were 53 eligible hospitalizations (28 flares and 25 infections). Each unit increase in the ratio of ESR:CRP was associated with a 17% increase in the odds of fever being attributable to SLE flare compared to infection (OR 1.17, 95% CI 1.04, 1.31; p = 0.009), when adjusted for white blood cell count, SLE duration, sex, race, and age. ESR and CRP were not individually associated with flare vs infection when modeled with their ratio. Conclusions The ratio of ESR:CRP may provide diagnostic value beyond individual ESR and CRP levels in distinguishing flare vs infection in SLE patients presenting with fever.

Quality Assessments of HMO Diagnosis Databases Used to Monitor Childhood Vaccine Safety

Objective: To assess the quality of automated diagnoses extracted from medical care databases by the Vaccine Safety Datalink (VSD) study.

Methods: Two methods are used to assess quality of VSD diagnosis data. The first method compares common automated and abstracted diagnostic categories (“outcomes”) in 1-2% simple random samples of study populations. The second method estimates positive predictive values of automated diagnosis codes used to identify potential cases of rare conditions (e.g., acute ataxia) for inclusion in nested case-control medical record abstraction studies.

Results: There was good agreement (64-68%) between automated and abstracted outcomes in the 1-2% simple random samples at 3 of the 4 VSD sites and poor agreement (44%) at 1 site. Overall at 3 sites, 56% of children with automated cerebella ataxia codes (ICD-9 = 334) and 22% with “lack of coordination” codes (ICD-9 = 781.3) met objective clinical criteria for acute ataxia.

Conclusions: The misclassification error rates for automated screening outcomes substantially reduce the power of screening analyses and limit usefulness of screening analyses to moderate to strong vaccine-outcome associations. Medical record verification of outcomes is needed for definitive assessments.

Learning from other people's fear: amygdala-based social reference learning in social anxiety disorder

BACKGROUND

Social anxiety disorder involves fear of social objects or situations. Social referencing may play an important role in the acquisition of this fear and could be a key determinant in future biomarkers and treatment pathways. However, the neural underpinnings mediating such learning in social anxiety are unknown. Using event-related functional magnetic resonance imaging, we examined social reference learning in social anxiety disorder. Specifically, would patients with the disorder show increased amygdala activity during social reference learning, and further, following social reference learning, show particularly increased response to objects associated with other people's negative reactions?

METHOD

A total of 32 unmedicated patients with social anxiety disorder and 22 age-, intelligence quotient- and gender-matched healthy individuals responded to objects that had become associated with others' fearful, angry, happy or neutral reactions.

RESULTS

During the social reference learning phase, a significant group × social context interaction revealed that, relative to the comparison group, the social anxiety group showed a significantly greater response in the amygdala, as well as rostral, dorsomedial and lateral frontal and parietal cortices during the social, relative to non-social, referencing trials. In addition, during the object test phase, relative to the comparison group, the social anxiety group showed increased bilateral amygdala activation to objects associated with others' fearful reactions, and a trend towards decreased amygdala activation to objects associated with others' happy and neutral reactions.

CONCLUSIONS

These results suggest perturbed observational learning in social anxiety disorder. In addition, they further implicate the amygdala and dorsomedial prefrontal cortex in the disorder, and underscore their importance in future biomarker developments.

A review of recent advances in optical fibre sensors for in vivo dosimetry during radiotherapy

This article presents an overview of the recent developments and requirements in radiotherapy dosimetry, with particular emphasis on the development of optical fibre dosemeters for radiotherapy applications, focusing particularly on in vivo applications. Optical fibres offer considerable advantages over conventional techniques for radiotherapy dosimetry, owing to their small size, immunity to electromagnetic interferences, and suitability for remote monitoring and multiplexing. The small dimensions of optical fibre-based dosemeters, together with being lightweight and flexible, mean that they are minimally invasive and thus particularly suited to in vivo dosimetry. This means that the sensor can be placed directly inside a patient, for example, for brachytherapy treatments, the optical fibres could be placed in the tumour itself or into nearby critical tissues requiring monitoring, via the same applicators or needles used for the treatment delivery thereby providing real-time dosimetric information. The article outlines the principal sensor design systems along with some of the main strengths and weaknesses associated with the development of these techniques. The successful demonstration of these sensors in a range of different clinical environments is also presented.

Hot topic: Innovative lactation-stage-dependent prediction of methane emissions from milk mid-infrared spectra

The main goal of this study was to develop, apply, and validate a new method to predict an indicator for CH4 eructed by dairy cows using milk mid-infrared (MIR) spectra. A novel feature of this model was the consideration of lactation stage to reflect changes in the metabolic status of the cow. A total of 446 daily CH4 measurements were obtained using the SF6 method on 142 Jersey, Holstein, and Holstein-Jersey cows. The corresponding milk samples were collected during these CH4 measurements and were analyzed using MIR spectroscopy. A first derivative was applied to the milk MIR spectra. To validate the novel calibration equation incorporating days in milk (DIM), 2 calibration processes were developed: the first was based only on CH4 measurements and milk MIR spectra (independent of lactation stage; ILS); the second included milk MIR spectra and DIM information (dependent on lactation stage; DLS) by using linear and quadratic modified Legendre polynomials. The coefficients of determination of ILS and DLS equations were 0.77 and 0.75, respectively, with standard error of calibration of 63g/d of CH4 for both calibration equations. These equations were applied to 1,674,763 milk MIR spectra from Holstein cows in the first 3 parities and between 5 and 365 DIM. The average CH4 indicators were 428, 444, and 448g/d by ILS and 444, 467, and 471g/d by DLS for cows in first, second, and third lactation, respectively. Behavior of the DLS indicator throughout the lactations was in agreement with the literature with values increasing between 0 and 100 DIM and decreasing thereafter. Conversely, the ILS indicator of CH4 emission decreased at the beginning of the lactation and increased until the end of the lactation, which differs from the literature. Therefore, the DLS indicator seems to better reflect biological processes that drive CH4 emissions than the ILS indicator. The ILS and DLS equations were applied to an independent data set, which included 59 respiration chamber measurements of CH4 obtained from animals of a different breed across a different production system. Results indicated that the DLS equation was much more robust than the ILS equation allowing development of indicators of CH4 emissions by dairy cows. Integration of DIM information into the prediction equation was found to be a good strategy to obtain biologically meaningful CH4 values from lactating cows by accounting for biological changes that occur throughout the lactation.