Resistance to bacteriophage incurs a cost to virulence in drug-resistant Acinetobacter baumannii

Introduction . Acinetobacter baumannii is a critical priority pathogen for novel antimicrobials (World Health Organization) because of the rise in nosocomial infections and its ability to evolve resistance to last resort antibiotics. A. baumannii is thus a priority target for phage therapeutics. Two strains of a novel, virulent bacteriophage (LemonAid and Tonic) able to infect carbapenem-resistant A. baumannii (strain NCTC 13420), were isolated from environmental water samples collected through a citizen science programme.Gap statement. Phage-host coevolution can lead to emergence of host resistance, with a concomitant reduction in the virulence of host bacteria; a potential benefit to phage therapy applications.Methodology. In vitro and in vivo assays, genomics and microscopy techniques were used to characterize the phages; determine mechanisms and impact of phage resistance on host virulence, and the efficacy of the phages against A. baumannii.Results. A. baumannii developed resistance to both viruses, LemonAid and Tonic. Resistance came at a cost to virulence, with the resistant variants causing significantly reduced mortality in a Galleria mellonella larval in vivo model. A replicated 8 bp insertion increased in frequency (~40 % higher frequency than in the wild-type) within phage-resistant A. baumannii mutants, putatively resulting in early truncation of a protein of unknown function. Evidence from comparative genomics and an adsorption assay suggests this protein acts as a novel phage receptor site in A. baumannii. We find no evidence linking resistance to changes in capsule structure, a known virulence factor. LemonAid efficiently suppressed growth of A. baumanni in vitro across a wide range of titres. However, in vivo, while survival of A. baumannii infected larvae significantly increased with both remedial and prophylactic treatment with LemonAid (107 p.f.u. ml-1), the effect was weak and not sufficient to save larvae from morbidity and mortality.Conclusion. While LemonAid and Tonic did not prove effective as a treatment in a Galleria larvae model, there is potential to harness their ability to attenuate virulence in drug-resistant A. baumannii.

Evaluation of a virtual interprofessional oral-systemic health simulation experience in nursing, dentistry, medicine, and pharmacy education

PURPOSE

The annual teaching oral-systemic health (TOSH) virtual clinical simulation and case study activity exposes interprofessional teams of nurse practitioner, nurse midwifery, dental, medical, and pharmacy students to a virtual clinical simulation experience that uses oral-systemic health as a clinical exemplar for promoting interprofessional core competencies. The present study examines changes in participating students' self-reported interprofessional competencies following participation in virtual TOSH from 2020 to 2022. These findings are also compared to those from in-person TOSH (2019) to examine the equivalence of student outcomes of both the in-person and virtual programs.

METHODS

A pre- and post-test evaluation design was used to examine the effectiveness of exposure to the TOSH program on self-reported attainment of interprofessional competencies for participating students using the interprofessional collaborative competency attainment scale.

RESULTS

Analysis of pre- and post-surveys demonstrated statistically significant improvement in students' self-rated interprofessional experience competencies following the virtual TOSH program, which aligns with results from the in-person cohorts. Similar findings between the in-person and virtual cohorts indicated no statistically significant difference between the two formats.

CONCLUSION

These findings demonstrate the success of TOSH in promoting attainment of interprofessional competencies among future health professionals. We encourage administrators and faculty who lead health professional programs to take advantage of using virtual simulations as an integral component of interprofessional oral health clinical experiences where students from different health professions learn from and about each other in assessing and treating patients across the lifespan.

Consumers lived experiences and satisfaction with sub-acute mental health residential services

PURPOSE

Sub-acute recovery-oriented facilities offer short-term residential support for people living with mental illness. They are generally highly regarded by consumers, with emerging evidence indicating that these services may support recovery. The aim of the current study was to explore the relationship between personal recovery and consumers' satisfaction with sub-acute residential services, and consumers' views about service features that aid recovery.

METHODS

Consumers at 19 adult Prevention and Recovery Care Services in Victoria, Australia, were invited to complete measures containing sociodemographic information and measures on personal recovery and wellbeing. After going home, participants were invited to complete measures on service satisfaction and experience.

RESULTS

Total and intrapersonal scores on the personal recovery measure increased significantly between Time 1 and Time 2, indicating marked improvement. Personal recovery and satisfaction measures were moderately to strongly correlated. Thematically analysed open-ended responses revealed themes of feeling connected, finding meaning and purpose, and self-empowerment as important aspects of these services, with some recommendations for improvements.

CONCLUSION

Sub-acute residential mental health care may support individuals' personal recovery; consumer satisfaction indicates these services also offer an acceptable and supportive environment for the provision of recovery-oriented care. Further exploring consumers' experiences of sub-acute residential services is essential to understand their effectiveness, opportunities for improvement and intended impacts on personal recovery.

Poor patient outcome correlates with active engulfment of cytokeratin positive CTCs within cancer-associated monocyte population in lung cancer

High rates of mortality in non-small cell lung cancer lung cancer is due to inherent and acquired resistance to systemic therapies and subsequent metastatic burden. Metastasis is supported by suppression of the immune system at secondary organs and within the circulation. Modulation of the immune system is now being exploited as a therapeutic target with immune checkpoint inhibitors. The tracking of therapeutic efficacy in a real-time can be achieved with liquid biopsy, and evaluation of circulating tumour cells and the associated immune cells. A stable liquid biopsy biomarker for non-small cell lung cancer lung cancer has yet to be approved for clinical use. We performed a cross-sectional single-site study, and collected liquid biopsies from patients diagnosed with early, locally advanced, or metastatic lung cancer, undergoing surgery, or systemic therapy (chemotherapy/checkpoint inhibitors). Evaluation of overall circulating tumour cell counts, or cluster counts did not correlate with patient outcome. Interestingly, the numbers of Pan cytokeratin positive circulating tumour cells engulfed by tumour associated monocytes correlated strongly with patient outcome independent of circulating tumour cell counts and the use of checkpoint inhibitors. We suggest that Pan cytokeratin staining within monocytes is an important indicator of tumour-associated inflammation post-therapy and an effective biomarker with strong prognostic capability for patient outcome.

Gamifying simulated nursing education: a digital technology approach to enhancing pedagogy and student experience

Higher educational institutions have responded to a shortage of clinical placements for students by adopting innovative approaches, such as the use of simulated learning environments. The integration of gamification in simulated placements presents a promising opportunity to enrich and diversify the learning experience. A series of game-based resources to support simulated practice learning was developed by the academic team at the University of Bolton. This study involved evaluating the experiences of students who engaged in these interactive scenarios to assess the potential impact of these digital interventions on learning. The findings indicate that the approach had a significant impact on student learning, improving both their knowledge and their confidence in applying procedures in practice. These findings are of particular significance since it is commonly considered that students in fields such as nursing, which are known for their emphasis on human-centred care, place less value on digital learning technologies.

The Citizen Phage Library: Rapid Isolation of Phages for the Treatment of Antibiotic Resistant Infections in the UK

Antimicrobial resistance poses one of the greatest threats to global health and there is an urgent need for new therapeutic options. Phages are viruses that infect and kill bacteria and phage therapy could provide a valuable tool for the treatment of multidrug-resistant infections. In this study, water samples collected by citizen scientists as part of the Citizen Phage Library (CPL) project, and wastewater samples from the Environment Agency yielded phages with activity against clinical strains Klebsiella pneumoniae BPRG1484 and Enterobacter cloacae BPRG1482. A total of 169 and 163 phages were found for K. pneumoniae and E. cloacae, respectively, within four days of receiving the strains. A third strain (Escherichia coli BPRG1486) demonstrated cross-reactivity with 42 E. coli phages already held in the CPL collection. Seed lots were prepared for four K. pneumoniae phages and a cocktail combining these phages was found to reduce melanisation in a Galleria mellonella infection model. The resources and protocols utilised by the Citizen Phage Library enabled the rapid isolation and characterisation of phages targeted against multiple strains. In the future, within a clearly defined regulatory framework, phage therapy could be made available on a named-patient basis within the UK.

Long-Term Imaging Follow-up from the Management of Myelomeningocele Study

BACKGROUND AND PURPOSE

Short-term results demonstrate that prenatal repair of a myelomeningocele is associated with a reduction in hydrocephalus and an increased likelihood of the reversal of Chiari II malformations compared with postnatal repair. The purpose of this study was to identify the long-term imaging findings at school age among subjects who underwent pre- versus postnatal repair of a myelomeningocele.

MATERIALS AND METHODS

A subset of subjects enrolled in the Management of Myelomeningocele Study who underwent either prenatal (n = 66) or postnatal (n = 63) repair of a lumbosacral myelomeningocele and had follow-up brain MR imaging at school age were included. The prevalence of posterior fossa features of Chiari II malformation and supratentorial abnormalities and the change in these findings from fetal to school-age MR imaging were compared between the 2 groups.

RESULTS

Prenatal repair of a myelomeningocele was associated with higher rates of normal location of fourth ventricle and lower rates of hindbrain herniation, cerebellar herniation, tectal beaking, brainstem distortion, and kinking at school age compared with postnatal repair (all P < .01). Supratentorial abnormalities, including corpus callosal abnormalities, gyral abnormalities, heterotopia, and hemorrhage, were not significantly different between the 2 groups (all P > .05). The rates of resolution of brainstem kinking, tectal beaking, cerebellar and hindbrain herniation, and normalization of fourth ventricle size from fetal to school age MR imaging were higher among the prenatal compared with postnatal surgery group (all, P < .02).

CONCLUSIONS

Prenatal repair of a myelomeningocele is associated with persistent improvement in posterior fossa imaging findings of Chiari II malformation at school age compared with postnatal repair.

Quasi-planar InGaAsSb p-B-n photodiodes for spectroscopic sensing

An InGaAsSb p-B-n structure has been designed and characterized for zero bias low power detection applications. Devices were grown by molecular beam epitaxy and fabricated into quasi-planar photodiodes with a 2.25 µm cut-off wavelength. Maximum responsivity was measured to be 1.05 A/W at 2.0 µm, achieved at zero bias. D* of 9.4 × 10¹⁰ Jones was determined from room temperature spectra of noise power measurements with calculated D* remaining >1 × 10¹⁰ Jones up to 380 K. With a view to simple miniaturized detection and measurement of low concentration biomarkers, optical powers down to 40 pW were detected, without temperature stabilization or phase-sensitive detection, indicating the photodiode's potential.

OP0068 DISTINCT STROMAL AND IMMUNE CELL INTERACTIONS SHAPE THE PATHOGENESIS OF RHEUMATOID AND PSORIATIC ARTHRITIS

Background

Rheumatoid (RA) and psoriatic arthritis (PsA) are common autoimmune and autoinflammatory diseases of unknown aetiology characterised by complex synovial pathology with a detrimental effect on the patient’s quality of life. Significant differences in pathophysiology may explain distinct clinical manifestations and account for differential responses to specific therapeutics. Recent implementation of single cell transcriptomic analysis of sorted synovial cells has revealed the diverse cellular landscape of the RA synovial stromal and immune cell compartments, however, a complete analysis of immune and stromal cells in tandem, for RA and PsA patient synovial tissue has not been performed.

Objectives

To combine novel scRNA transcriptomic approaches and ex vivo assays in order to: identify differences in the cellular landscape of RA and PsA synovial tissue inflammation and immune – stromal cell interactions that drive pathology in RA and PsA.

Methods

Single cell transcriptomic profiling of 178,000 synovial tissue cells from 5 PsA and 4 RA patients, importantly, without prior sorting of immune and stromal cells. This approach enabled the generation of a unique cell atlas of intact synovial tissue identifying immune and stromal cell interactions. State of the art data integration and annotation techniques identified and characterised 18 stromal and 14 immune cell clusters. Bioinformatic examination of cell-cell communication via construction of receptor-ligand interaction networks with further in vitro validation of stromal and immune cell crosstalk through flow cytometric analysis, multiplex ELISA and mitochondrial and single cell metabolic profiling by multiphoton and florescent lifetime imaging microscopy, seahorse.

Results

Following quality control and data integration the PsA and RA cellular landscape was generated and nine mega clusters indicative of fibroblasts, endothelial cells, pericytes, macrophages, dendritic cells (DC), B cells, plasma cells, T cells and NKT consisting of several sub clusters were identified. Distinct points of transcriptomic deviation and convergence between RA and PsA were identified for each of the major cell types of the joint. Specifically, cell cycle and trajectory analysis revealed that only a fraction of synovial T cells are actively proliferating. Additionally, the differential usage of immunoglobulin light chains by memory and plasma cells indicates that plasma cells are potentially not derived from the local memory B cell pool of the synovial tissue. Importantly, we report distinct fibroblast and endothelial cell transcriptomes indicating differentially abundant subpopulations in RA and PsA characterised by distinct transcription factor usage and signalling pathway enrichment. Specifically transcriptomic imputation analysis revealed abundance of invasive FAPα+THY1+ regulated by transcription factor TEAD1 in RA compared to PsA synovial tissue. In order to identify potential cell-cell communication driving inflammation in RA and PsA, novel receptor–ligand interaction networks were generated and downstream of the receptor, target characterisation was performed. Herein we identify RA-specific synovial T cell-derived TGF-β and macrophage IL-1β synergy in driving the transcriptional profile of FAPα+THY1+ invasive synovial-fibroblasts, expanded in RA compared to PsA synovial tissue biopsies (Figure 1). Ex vivo treatment of RA patient synovial fibroblasts identified TGF-b and IL-1b synergy are a major driver of IL-6 production, fibroblast activation and adhesion molecule expression. Interestingly, the aforementioned proinflammatory changes of RA patient synovial fibroblasts were coupled with significant alterations in mitochondrial eccentricity and size and a marked metabolic adaptation towards a strongly glycolytic profile (Figure 1).

Figure 1.

Conclusion

Disrupting specific immune and stromal cell interactions offers novel opportunities for targeted therapeutic intervention in RA and PsA.

Disclosure of Interests

Achilleas Floudas: None declared, Conor Smith: None declared, Orla Tynan: None declared, Nuno Neto: None declared, Vinod Krishna Employee of: Janssen Pharmaceuticals, Sarah Wade: None declared, Megan Hanlon: None declared, Clare Cunningham: None declared, Viviana Marzaioli: None declared, Mary Canavan: None declared, Jean Fletcher: None declared, Suzanne Cole Employee of: Janssen Pharmaceuticals, Ling-Yang Hao Employee of: Janssen Pharmaceuticals, Sunil Nagpal Employee of: Janssen Pharmaceuticals, GSK, Michael Monaghan: None declared, Douglas Veale Consultant of: Janssen, Eli Lilly, Pfizer, Ursula Fearon Consultant of: Janssen, Eli Lilly, Pfizer.

In vitro efficacy of antibiotic loaded calcium sulfate beads (Stimulan Rapid Cure) against polymicrobial communities and individual bacterial strains derived from diabetic foot infections

Introduction. Diabetic foot infection (DFI) is the main reason for diabetes-related hospitalisation and is a major cause of diabetes-related amputation. DFIs are often complicated by ischaemia in the affected limb, the presence of polymicrobial biofilms and increasingly the occurrence of antibiotic resistant bacteria.Hypothesis/Gap statement. Antibiotic loaded beads could inhibit the growth of polymicrobial DFI communities with differing compositions in vitro.Aim. This study investigates the in vitro efficacy of antibiotic loaded calcium sulfate beads (Stimulan Rapid Cure, Biocomposites Ltd., UK) against polymicrobial DFI communities and individual bacterial strains derived from DFIs.Methodology. Debrided tissue obtained from the base of infected diabetic foot ulcers was homogenised and spread over the surface of Columbia blood agar (CBA) and fastidious anaerobe agar (FAA) plates. Calcium sulfate beads containing a combination of vancomycin and gentamicin were then placed on the surface of the agar and following incubation, zones of inhibition (ZOI) were measured. For individual bacterial strains isolated from the infected tissue, calcium sulfate beads containing vancomycin, gentamicin, flucloxacillin or rifampicin and beads containing a combination of vancomycin and gentamicin or flucloxacillin and rifampicin were tested for their ability to inhibit growth.Results. Calcium sulfate beads loaded with a combination of vancomycin and gentamicin were able to inhibit bacterial growth from all polymicrobial tissue homogenates tested, with ZOI diameters ranging from 15 to 40 mm. In the case of individual bacterial strains, beads containing combinations of vancomycin and gentamicin or flucloxacillin and rifampicin were able to produce ZOI with Gram-positive facultatitive anaerobic strains such as Staphylococcus aureus and Enterococcus faecalis, Gram-negative facultative anaerobic strains such as Pseudomonas aeruginosa and obligate anaerobic strains such as Finegoldia magna even where acquired resistance to one of the antibiotics in the combination was evidenced.Conclusion. The local use of calcium sulfate beads containing a combination of two antibiotics demonstrated high efficacy against polymicrobial DFI communities and individual DFI bacterial strains in in vitro zone of inhibition tests. These results show promise for clinical application, but further research and clinical studies are required.

855 Patient Specific Digital Modelling And 3D Printing of Abdominal Anatomy- The Next Frontier in Surgical Simulation?

Introduction

Innovations in digital technologies afford new opportunities in surgical education.

We describe a novel method of combining medical imaging data with virtual 3D modelling and printing techniques that could facilitate patient specific pre-operative planning and rehearsal.

Method

A series of silicone castings was produced to simulate upper abdominal viscera using a novel polyvinyl alcohol (PVA) injection moulding method. Digital models were generated by segmenting CT dual phase imaging in ITK-SNAP. A 3D polygon mesh was exported and optimised in the computer graphics software: Blender. Two 3D printers were used to manufacture a dissolvable mould of the digital models. Moulds were injected with coloured silicones and dissolved in water to reveal the multicolour/multi-material models.

Results

The silicone models retained the anatomical detail of the digitally segmented CT data sets. The multi-colour models were achieved with a single print and at very low cost (approx. £248/ model) and possessed varying shore hardness between viscera recreating lifelike fidelity.

Conclusions

The hybrid 3D printing/injection moulding method offers an avenue to realistic surgical and anatomical simulation. A combination of both virtual models and 3D physical models may provide an enhanced surgical experience for preoperative and intraoperative planning allowing patient specific rehearsal.

43 Digital Human Project: 3D Photogrammetry for Human Cadaveric Pelvic Specimens: An Innovation in Colorectal Anatomical Education

Introduction

Cadaveric dissection remains an essential aspect of anatomical education but is not readily available to the majority of surgical trainees. 3D photogrammetry is the process of creating a 3D model from a series of 2D images and has tremendous potential in anatomical education. We describe a novel low-cost single-camera 3D photogrammetry technique to reconstruct cadaveric specimens as digital models.

Method

A formalin preserved hemipelvis was mounted on a turntable. Photos were taken sequentially at 5 o increments through 360° at three different fixed viewing angles (n = 216 photos) using a mirrorless camera with a 12-60mm f3.5-5.6 kit lens. Four surroundings LED standing lights were used to ensure diffuse ambient lighting of the specimen. Photos were imported into Agisoft Metashape software in order to generate a point cloud and produce the final virtual model composed of a polygon mesh.

Results

The specimen was successfully reconstructed and can be visualised at; https://sketchfab.com/3d-models/pelvic-sidewall-b76450b787824c968f864791d47318f2. The total processing time was 20 hrs.

Conclusions

Through this technique, we can produce accurate, interactive, and accessible 3D prosection models for surgical education. The method could be employed to establish a digital library of human anatomy for surgical training worldwide.

Dissociating the effects of distraction and proactive interference on object memory through tests of novelty preference

Encoding information into memory is sensitive to distraction while retrieving that memory may be compromised by proactive interference from pre-existing memories. These two debilitating effects are common in neuropsychiatric conditions, but modelling them preclinically to date is slow as it requires prolonged operant training. A step change would be the validation of functionally equivalent but fast, simple, high-throughput tasks based on spontaneous behaviour. Here, we show that spontaneous object preference testing meets these requirements in the subchronic phencyclidine rat model for cognitive impairments associated with schizophrenia. Subchronic phencyclidine rats show clear memory sensitivity to distraction in the standard novel object recognition task. However, due to this, standard novel object recognition task cannot assess proactive interference. Therefore, we compared subchronic phencyclidine performance in standard novel object recognition task to that using the continuous novel object recognition task, which offers minimal distraction, allowing disease-relevant memory deficits to be assessed directly. We first determined that subchronic phencyclidine treatment did not affect whisker movements during object exploration. Subchronic phencyclidine rats exhibited the expected distraction standard novel object recognition task effect but had intact performance on the first continuous novel object recognition task trial, effectively dissociating distraction using two novel object recognition task variants. In remaining continuous novel object recognition task trials, the cumulative discrimination index for subchronic phencyclidine rats was above chance throughout, but, importantly, their detection of object novelty was increasingly impaired relative to controls. We attribute this effect to the accumulation of proactive interference. This is the first demonstration that increased sensitivity to distraction and proactive interference, both key cognitive impairments in schizophrenia, can be dissociated in the subchronic phencyclidine rat using two variants of the same fast, simple, spontaneous object memory paradigm.

Changes in pain catastrophization and neuropathic pain following operative stabilisation for patellofemoral instability: a prospective study with twelve month follow-up

PURPOSE

To determine the prevalence and change in neuropathic pain or pain catastrophizing before and 12 months following patellar stabilisation surgery for patellofemoral instability.

METHODS

We conducted a prospective clinical audit within a UK NHS orthopaedic surgical centre. Data from 84 patients with patellofemoral instability requiring stabilisation were analysed. Fifty percent (42/84) underwent MPFL reconstruction alone, and 16% (13/84) had both trochleoplasty and MPFL reconstruction. Neuropathic pain was assessed using painDETECT score. Pain catastrophizing was assessed using the Pain Catastrophizing Score. The Norwich Patellar Instability (NPI) Score and Kujala Patellofemoral Disorder Score were also routinely collected pre-operatively and one year post-operatively.

RESULTS

At 12 months post-operatively there was a statistically significant reduction in mean Pain Catastrophizing Scores (18.9-15.7; p < 0.02), but no change in mean painDETECT scores (7.3-7.8; p = 0.72). There was a statistically significant improvement in NPI scores (90.2-61.9; p < 0.01) and Kujala Patellofemoral Disorder Scores (48.7-58.1; p = 0.01). The prevalence of pain catastrophizing decreased from 31% pre-operatively to 24% post-operatively, whereas the prevalence of neuropathic pain remained consisted (10-11%).

CONCLUSIONS

Neuropathic pain and catastrophizing symptoms are not commonly reported and did not significantly change following patellofemoral stabilisation surgery. Whilst low, for those affected, there remains a need to intervene to improve outcomes following PFI surgery.

Standardising clinical outcomes measures for adult clinical trials in Fabry disease: A global Delphi consensus

BACKGROUND

Recent years have witnessed a considerable increase in clinical trials of new investigational agents for Fabry disease (FD). Several trials investigating different agents are currently in progress; however, lack of standardisation results in challenges to interpretation and comparison. To facilitate the standardisation of investigational programs, we have developed a common framework for future clinical trials in FD.

METHODS AND FINDINGS

A broad consensus regarding clinical outcomes and ways to measure them was obtained via the Delphi methodology. 35 FD clinical experts from 4 continents, representing 3389 FD patients, participated in 3 rounds of Delphi procedure. The aim was to reach a consensus regarding clinical trial design, best treatment comparator, clinical outcomes, measurement of those clinical outcomes and inclusion and exclusion criteria. Consensus results of this initiative included: the selection of the adaptative clinical trial as the ideal study design and agalsidase beta as ideal comparator treatment due to its longstanding use in FD. Renal and cardiac outcomes, such as glomerular filtration rate, proteinuria and left ventricular mass index, were prioritised, whereas neurological outcomes including cerebrovascular and white matter lesions were dismissed as a primary or secondary outcome measure. Besides, there was a consensus regarding the importance of patient-related outcomes such as general quality of life, pain, and gastrointestinal symptoms. Also, unity about lysoGb3 and Gb3 tissue deposits as useful surrogate markers of the disease was obtained. The group recognised that cardiac T1 mapping still has potential but requires further development before its widespread introduction in clinical trials. Finally, patients with end-stage renal disease or renal transplant should be excluded unless a particular group for them is created inside the clinical trial.

CONCLUSION

This consensus will help to shape the future of clinical trials in FD. We note that the FDA has, coincidentally, recently published draft guidelines on clinical trials in FD and welcome this contribution.

Dynamics of structural relaxation in bioactive 45S5 glass

Kinetics of physical aging in archetypic 45S5 bioactive silicate glass composition with different types of phase separation are studied in situ below the glass transition temperature (T _g). The qualitative nature of aging is found to be almost independent of the structural differences on the micrometer scale. A well-expressed step-like behavior in the enthalpy recovery kinetics is observed for aging temperatures T _a ∼ 0.90T _g and T _a ∼ 0.85T _g, which, however, disappears when the aging occurs at T _a ∼ 0.95T _g. The overall kinetics are described by a stretched-exponential function with stretching exponent close to 3/7 at T _a ∼ 0.95T _g, and 1/3 when the aging temperature drops to ∼0.90T _g and below. The values correlate well with the predictions of Phillips' diffusion-to-traps and percolating fractals models. Appearance of step-like behavior at larger departure from T _g is attributed to the hierarchical scheme of approaching equilibrium based on an alignment-shrinkage mechanism of physical aging proposed earlier for chalcogenide glasses.

A guide to the NMC emergency standards for nurse education during the current deployment of student nurses

The Nursing and Midwifery Council (NMC) recognises the important contribution that nursing students are making to the national response to the COVID-19 pandemic. This article reports on the Greater Manchester Supervision and Delegation Framework, providing practical guidance for students and practice staff (practice supervisor/practice assessor and registered nurse) on how to support student nurses who have opted into a paid (deployed) healthcare role. The framework operationalises NMC emergency standards for Nursing and Midwifery education, enabling students to complete their pre-registration undergraduate or postgraduate nursing programme while also supporting the healthcare workforce (NMC, 2020).

Synthesis of a Vocal Sound from the 3,000 year old Mummy, Nesyamun 'True of Voice'

The sound of a 3,000 year old mummified individual has been accurately reproduced as a vowel-like sound based on measurements of the precise dimensions of his extant vocal tract following Computed Tomography (CT) scanning, enabling the creation of a 3-D printed vocal tract. By using the Vocal Tract Organ, which provides a user-controllable artificial larynx sound source, a vowel sound is synthesised which compares favourably with vowels of modern individuals.

Training Student Pharmacists in Medication Dispensing and Checking Within a High-Fidelity Clinical Environment

Objective. To describe the implementation of and student pharmacist experience with high-fidelity training in medication dispensing and clinical checking processes and procedures. Methods. An actual dispensary in a large teaching hospital was used as the setting in which to provide undergraduate student pharmacists the opportunity to develop skills and knowledge regarding the process and procedures of medication dispensing and clinical checking. The sessions were facilitated by a member of the hospital pharmacy team and overseen by a faculty member. Students were required to conduct legal and clinical checks and process anonymized hospital prescriptions. Students recorded their experiences in their professional portfolio as blog entries, which were then discussed with academic staff members on a biweekly basis. Content analysis of the blogs was conducted to investigate the student experience. Results. Forty-eight students attended 30 hours of dispensing sessions over a 20-week period from September to April. Content analysis of 102 blog entries demonstrated students reporting observations and experiences which mapped to the three components of communities of practice: the domain of pharmacy practice, the working dynamics of a community of professionals within the workplace, and the commonality of practice and shared repertoire of resources. Conclusion. The high-fidelity teaching of students about the dispensing and checking process in an actual dispensary environment supports student pharmacists' knowledge and skills development. The work-based nature of this approach also provides experiential learning opportunities for students to observe and participate in the professional community of practice.

Recurrent vertebral fractures in a young adult: a closer look at bone health in type 1 diabetes mellitus

The association between type 1 diabetes mellitus (T1DM) and bone health has garnered interest over the years. Fracture risk is known to be increased in individuals with T1DM, although bone health assessment is not often performed in the clinical setting. We describe the case of a 21-year-old male with longstanding T1DM with multilevel vertebral fractures on imaging, after presenting with acute back pain without apparent trauma. Dual-energy X-ray absorptiometry (DXA) revealed significantly reduced bone mineral density at the lumbar spine and femoral neck. Extensive investigations for other secondary or genetic causes of osteoporosis were unremarkable, apart from moderate vitamin D deficiency. High-resolution peripheral quantitative computed tomography and bone biospy revealed significant alterations of trabecular bone microarchitecture. It later transpired that the patient had sustained vertebral fractures secondary to unrecognised nocturnal hypoglycaemic seizures. Intravenous zoledronic acid was administered for secondary fracture prevention. Despite anti-resorptive therapy, the patient sustained a new vertebral fracture after experiencing another hypoglycaemic seizure in his sleep. Bone health in T1DM is complex and not well understood. There are significant challenges in the assessment and management of osteoporosis in T1DM, particularly in young adults, where fracture prediction tools have not been validated. Clinicians should be aware of hypoglycaemia as a significant risk factor for fracture in patients with T1DM.

Learning points

Type 1 diabetes mellitus (T1DM) is a secondary cause of osteoporosis, characterised by reduced bone mass and disturbed bone microarchitecture.Hypoglycaemic seizures generate sufficient compression forces along the thoracic column and can cause fractures in individuals with compromised bone quality.Unrecognised hypoglycaemic seizures should be considered in patients with T1DM presenting with fractures without a history of trauma.Patients with T1DM have increased fracture risk and risk factors should be addressed. Evaluation of bone microarchitecture may provide further insights into mechanisms of fracture in T1DM.Further research is needed to guide the optimal screening and management of bone health in patients with T1DM.

Neonatal Acute Kidney Injury: A Survey of Neonatologists' and Nephrologists' Perceptions and Practice Management

BACKGROUND

Neonatal acute kidney injury (AKI) occurs in 40 to 70% of critically ill neonatal intensive care admissions. This study explored the differences in perceptions and practice variations among neonatologists and pediatric nephrologists in diagnostic criteria, management, and follow-up of neonatal AKI.

METHODS

A survey weblink was emailed to nephrologists and neonatologists in Australia, Canada, New Zealand, India, and the United States. Questions consisted of demographic and unit practices, three clinical scenarios assessing awareness of definitions of neonatal AKI, knowledge, management, and follow-up practices.

RESULTS

Many knowledge gaps among neonatologists, and to a lesser extent, pediatric nephrologists were identified. Neonatologists were less likely to use categorical definitions of neonatal AKI (p < 0.00001) or diagnose stage 1 AKI (p < 0.00001) than pediatric nephrologists. Guidelines for creatinine monitoring for nephrotoxic medications were reported by 34% (aminoglycosides) and 62% (indomethacin) of respondents. Nephrologists were more likely to consider follow-up after AKI than neonatologists (p < 0.00001). Also, 92 and 86% of neonatologists and nephrologists, respectively, reported no standardization or infrastructure for long-term renal follow-up.

CONCLUSION

Neonatal AKI is underappreciated, particularly among neonatologists. A lack of evidence on neonatal AKI contributes to this variation in response. Therefore, dissemination of current knowledge and areas for research should be the priority.

Formalising multidisciplinary peer review: developing a haematological malignancy-specific electronic proforma and standard operating procedure to facilitate procedural efficiency and evidence-based clinical practice

BACKGROUND

Multidisciplinary team (MDT) meetings aimed at facilitating peer review have become standard practice in oncology. However, there is scant literature on the optimal structure and conduct of such meetings.

AIMS

To develop a process for formal peer review of patients with haematological malignancies and to audit any resulting changes made to the management recommendations of the treating physician.

METHODS

A standard operating procedure (SOP) for MDT meetings was developed essentially to integrate clinical peer review with weekly pathology and radiology meetings. The centrepiece is the electronic submission of a patient-specific proforma (Microsoft InfoPath) prior to the meeting. It serves as the template for presentation, discussion and recording of recommendations and conclusions. The final verified document is stored in the electronic patient record, and a copy is sent to the general practitioner. The proposed management plans were compared to the consensus recommendations of the meeting for the first 4 years since inception.

RESULTS

Both SOP and proforma underwent continual improvements. These provided the framework for the conduct of a robust weekly MDT meeting for peer review of the management of patients with haematological malignancies. On 20% of occasions, patient management plans were altered to optimise patient care as a direct consequence on peer review at the MDT.

CONCLUSION

Our streamlined process, in its ultimate format, has provided a mature and efficient forum for formal peer review in a genuine multidisciplinary environment. Both initial data and informal feedback support its ongoing activity as an integral component of delivering quality patient care.

Development of simple sequence repeat (SSR) markers for discrimination among isolates of Fusarium proliferatum

The plant pathogen Fusarium proliferatum has a wide host range and occurs worldwide. Many isolates of the fungus produce mycotoxins in plant tissues, which, if ingested, can cause harm to animals and humans. In 2008, an outbreak of salmon blotch of onions, caused by F. proliferatum, was detected in southern Israel. The source and distribution of the fungus in Israel were unknown. Inter-simple sequence repeats (ISSR) were used to identify repetitive motifs present in seven isolates of F. proliferatum from Israel, Germany and Austria. ISSR repeat motifs were, used to develop 17 simple sequence repeat (SSR) loci. Six of these SSR markers were polymorphic in and consistently amplified from ten isolates collected in Israel, Germany, Austria and North America, from cucumber, onion, garlic, maize, and asparagus. These six polymorphic SSR alleles included 5 to 12 copies of di-, tri, and pentanucleotide motifs and yielded six to 9 alleles each. Sixteen of the SSR loci were amplified at least one of the seven Fusarium species, F. verticillioides, F. thapsinum, F. subglutinans, F. andiyazi, F. globosum, F. fujikoroi and F. oxysporum. The data demonstrate that these SSRs can be used for characterization of F. proliferatum isolates from diverse hosts and geographic locations and that they are transferable to other species of Fusarium.

Response of 33 UK patients with infantile-onset Pompe disease to enzyme replacement therapy

BACKGROUND

Enzyme replacement therapy (ERT) for infantile-onset Pompe disease has been commercially available for almost 10 years. We report the experience of its use in a cohort treated at three specialist lysosomal treatment centres in the UK.

METHODS

A retrospective case-note review was performed, with additional data being gathered from two national audits on all such patients treated with ERT. The impact on the outcome of various characteristics, measured just prior to the initiation of ERT (baseline), was evaluated using logistic regression.

RESULTS

Thirty-three patients were identified; 13/29 (45%) were cross-reactive immunological material (CRIM) negative, and nine were immunomodulated. At baseline assessment, 79% were in heart failure, 66% had failure to thrive and 70% had radiological signs of focal pulmonary collapse. The overall survival rate was 60%, ventilation-free survival was 40% and 30% of patients were ambulatory. Median follow-up of survivors was 4 years, 1.5 months (range 6 months to 13.5 years). As with previous studies, the CRIM status impacted on all outcome measures. However, in this cohort, baseline failure to thrive was related to death and lack of ambulation, and left ventricular dilatation was a risk factor for non-ventilator-free survival.

CONCLUSION

The outcome of treated patients remains heterogeneous despite attempts at immunomodulation. Failure to thrive at baseline and left ventricular dilation appear to be associated with poorer outcomes.

Epithelial and stromal cell urokinase plasminogen activator receptor expression differentially correlates with survival in rectal cancer stages B and C patients

Urokinase plasminogen activator receptor (uPAR) has been proposed as a potential prognostic factor for colorectal cancer (CRC) patient survival. However, CRC uPAR expression remains controversial, especially regarding cell types where uPAR is overexpressed (e.g., epithelium (uPAR^E) or stroma-associated cells (uPAR^S)) and associated prognostic relevance. In this study, two epitope-specific anti-uPAR monoclonal antibodies (MAbs) could discriminate expression of uPAR^E from uPAR^S and were used to examine this association with survival of stages B and C rectal cancer (RC) patients. Using immunohistochemistry, MAbs #3937 and R4 were used to discriminate uPAR^E from uPAR^S respectively in the central and invasive frontal regions of 170 stage B and 179 stage C RC specimens. Kaplan-Meier and Cox regression analyses were used to determine association with survival. uPAR expression occurred in both epithelial and stromal compartments with differential expression observed in many cases, indicating uPAR^E and uPAR^S have different cellular roles. In the central and invasive frontal regions, uPAR^E was adversely associated with overall stage B survival (HR = 1.9; p = 0.014 and HR = 1.5; p = 0.031, respectively) reproducing results from previous studies. uPAR^S at the invasive front was associated with longer stage C survival (HR = 0.6; p = 0.007), reflecting studies demonstrating that macrophage peritumoural accumulation is associated with longer survival. This study demonstrates that different uPAR epitopes should be considered as being expressed on different cell types during tumour progression and at different stages in RC. Understanding how uPAR^E and uPAR^S expression affects survival is anticipated to be a useful clinical prognostic marker of stages B and C RC.

Medical management of patients with peripheral arterial disease

Peripheral arterial disease (PAD) is one of the most frequent manifestations of atherosclerosis and is associated with atherosclerosis in the coronary and carotid arteries, leading to a highly increased incidence of cardiovascular events. Major risk factors of PAD are similar to those that lead to atherosclerosis in other vascular beds. However, there are differences in the power of individual risk factors in the different vascular territories. Cigarette smoking and diabetes mellitus represent the greatest risks of PAD. For prevention of the progression of PAD and accompanying cardiovascular events similar preventative measures are used as in coronary artery disease (CAD). However, recent data indicate that there are some differences in the efficacy of drugs used in the prevention of atherothrombotic events in PAD. Antiplatelet treatment is indicated in virtually all patients with PAD. In spite of the absence of hard evidence- based data on the long term efficacy of aspirin, it is still considered as a first line treatment and clopidogrel as an effective alternative. The new antiplatelet drugs ticagrelol and prasugrel also represent promising options for treatment of PAD. Statin therapy is indicated to achieve the target low density lipoprotein cholesterol level of ≤2.5 mmol/L (100 mg/dL) and there is emerging evidence that lower levels are more effective. Statins may also improve walking capacity. Antihypertensive treatment is indicated to achieve the goal blood pressure (<140/90 mmHg). All classes of antihypertensive drugs including beta-blockers are acceptable for treatment of hypertension in patients with PAD. Diabetic patients with PAD should reduce their glycosylated haemoglobin to ≤7%. As PAD patients represent the group with the highest risk of atherothrombotic events, these patients need the most intensive treatment and elimination of risk factors of atherosclerosis. These measures should be as comprehensive as those in patients with established coronary and cerebrovascular disease.