1277 A Closed-Loop Audit of the use of qFIT in Symptomatic “Two Week Wait” referrals in Somerset Foundation Trust

Introduction

Quantitative faecal immunochemical test (qFIT) is recommended as the replacement test for faecal occult blood testing by NICE. We audited qFIT use in two week-wait (2WW) referrals in Somerset Foundation Trust (SFT) following its introduction in 2019.

Method

Following qFIT being made available to general practitioners, all 2WW referrals received before (July 2019) and after (December 2019) the introduction of the new 2WW referral form were reviewed. Electronic patient records were analysed to determine investigations performed and if a diagnosis of cancer was made.

Results

July 2019: 288 2WW referrals with 74 patients eligible for qFIT – only 7 of these underwent qFIT; total of 93 qFIT performed by GPs with 11 positive tests. December 2019: 222 2WW referrals with 18 patients eligible for qFIT – all of whom underwent qFIT; total of 155 qFIT performed by GPs with 18 positive (and 137 negative) tests. 1 patient with a positive qFIT was found to have colorectal malignancy (qFIT = 267 g/dL, investigation showed benign TVA). An increase in qFIT was observed over time, coinciding with a reduction in 2WW referrals, including reduction in patients who were qFIT eligible. The 2WW service identified 11 (3.8%) cases of colorectal cancer in July 2019 compared to 12 (5.4%) cases in December 2019, showing an increased pickup rate.

Conclusions

High proportions of 2WW referrals undergo investigation. The results of this audit highlight the utility of qFIT in screening 2WW referrals and reducing burden on the service, particularly where access to investigations is severely restricted due to coronavirus.

Evaluation of urinary chloride dipsticks for the rapid estimation of hydration status in patients receiving artificial nutrition: Feasibility study

BACKGROUND AND AIMS

The home parenteral nutrition (HPN) population face many challenges, especially with respect to fluid balance management. A low urinary sodium concentration of <20 mmol/L is commonly used as an indicator of dehydration that requires clinical assessment in these patients. The Quantab titrator dipstick measures chloride concentration of a solution and correlates with sodium concentration. We assessed whether it would be feasible to use the Quantab dipstick in the HPN population and explored relationships between Quantab dipstick estimated chloride concentration and quality of life (QOL).

METHODS

Patients on HPN were asked to collect urine samples at 5 specific times points (day 0,7,14, 21 and 28) to send to the laboratory for formal electrolyte analysis. The participant and a member of laboratory staff tested these samples with the Quantab dipstick to estimate urinary chloride concentration. Participants were instructed to complete a QOL questionnaire at each of the 5 time-points in addition to a baseline demographic questionnaire and an end-of-study questionnaire. Six participants completed an interview at the end of the study period. The relationship between participant-derived and laboratory-derived data was assessed using rank correlation coefficients. QOL assessment was correlated with urine dipstick measurements.

RESULTS

10 patients on HPN completed the study. Data on chloride concentration as estimated by the dipstick (assessed by participants and by the laboratory) and sodium concentration from the laboratory were available for 47 urine samples. There was a positive relationship between participant dipstick estimated chloride concentration and laboratory sodium (Kendall's τ = 0.45; P < 0.001; Spearman's r_s = 0.58 P < 0.001; 47 pairs). There was a strong correlation between chloride concentrations estimated by dipstick in the laboratory and by participants (Kendall 0.58 p < 0.001, Spearman's 0.69 p < 0.001; 47 pairs). In exploratory analyses, there was no relationship between QOL and dipstick estimated chloride concentration. Participants had no issues collecting urine samples but some difficulties were reported with determining the dipstick reading.

CONCLUSIONS

Patients on HPN are able to collect urine specimens, complete QOL questionnaires, and are capable of using the Quantab dipstick to estimate urinary chloride concentration. The Quantab dipstick correlates with laboratory measured sodium and chloride concentrations. Further work is required to fully establish whether this point-of-care test could be used to guide fluid balance management in the HPN population.

Exposure to a National Communication Campaign to Prevent Stunting in Indonesia

Background

Reducing childhood stunting continues to be a priority in Indonesia. In 2015, the National Nutrition Communication Campaign (NNCC) implemented mass media and interpersonal communication (IPC) interventions to disseminate stunting-related information. The purpose of this study was to understand the factors associated with exposure to the media and IPC components of NNCC. The mass-media component was designed to influence attitudes, norms, and behaviors, while the IPC component was designed to develop skills to lead to behavior change.

Methods

The media campaign targeted a national audience and the IPC component of the campaign operated at a district level. IMA World Health collected data in three rural districts targeted with both media and IPC intervention components. Using simple random sampling, a sample of 1,734 caregivers was collected. Responses relating to demographic and socioeconomic factors, use of social media and WhatsApp, and electronic device ownership were analyzed using multiple linear regression analyses.

Results

Participants averaged 28.9 years old and most completed primary school. Exposure to the media component was higher than exposure to IPC. Ownership of an internet-accessible device (IAD) and social media use was negatively associated with exposure to IPC. Mothers who used a device to access health information were more likely to have been exposed to the media component. Exposure to the media campaign was positively associated with owning an IAD with WhatsApp.

Conclusions

Access to internet-accessible devices was predictive of positive exposure to mass-media and negative exposure to IPC. This latter finding was unexpected and may suggest people with IADs consume health online and feel less inclined to participate in IPC activities. Caregivers with technology and internet access may benefit from media-based interventions, whereas those with limited access may benefit from traditional interpersonal mediums.

Key messages

Future community health efforts in similar rural regions, should consider the use of both mass media and interpersonal communication interventions to influence health behaviors. Use of internet-accessible technology was positively related to exposure to the mass media campaign while negatively related to IPC exposure.

Fluoroquinolone-resistant Salmonella typhi infection: a report of two cases in South Africa

Typhoid and paratyphoid fever are acute, life-threatening febrile illnesses caused by systemic infection with the bacterium Salmonella enterica. Nineteen cases were reported in South Africa in 2016. We report on two cases of bacteraemic invasive S. typhi with fluoroquinolone resistance.

Profiling microRNAs in individuals at risk of progression to rheumatoid arthritis

Background

Individuals at risk of rheumatoid arthritis (RA) demonstrate systemic autoimmunity in the form of anti-citrullinated peptide antibodies (ACPA). MicroRNAs (miRNAs) are implicated in established RA. This study aimed to (1) compare miRNA expression between healthy individuals and those at risk of and those that develop RA, (2) evaluate the change in expression of miRNA from “at-risk” to early RA and (3) explore whether these miRNAs could inform a signature predictive of progression from “at-risk” to RA.

Methods

We performed global profiling of 754 miRNAs per patient on a matched serum sample cohort of 12 anti-cyclic citrullinated peptide (CCP) + “at-risk” individuals that progressed to RA. Each individual had a serum sample from baseline and at time of detection of synovitis, forming the matched element. Healthy controls were also studied. miRNAs with a fold difference/fold change of four in expression level met our primary criterion for selection as candidate miRNAs. Validation of the miRNAs of interest was conducted using custom miRNA array cards on matched samples (baseline and follow up) in 24 CCP+ individuals; 12 RA progressors and 12 RA non-progressors.

Results

We report on the first study to use matched serum samples and a comprehensive miRNA array approach to identify in particular, three miRNAs (miR-22, miR-486-3p, and miR-382) associated with progression from systemic autoimmunity to RA inflammation. MiR-22 demonstrated significant fold difference between progressors and non-progressors indicating a potential biomarker role for at-risk individuals.

Conclusions

This first study using a cohort with matched serum samples provides important mechanistic insights in the transition from systemic autoimmunity to inflammatory disease for future investigation, and with further evaluation, might also serve as a predictive biomarker.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1492-9) contains supplementary material, which is available to authorized users.

Do Riparian Buffers Protect Stream Invertebrate Communities in South American Atlantic Forest Agricultural Areas?

We investigated the influence and relative importance of insecticides and other agricultural stressors in determining variability in invertebrate communities in small streams in intensive soy-production regions of Brazil and Paraguay. In Paraguay we sampled 17 sites on tributaries of the Pirapó River in the state of Itapúa and in Brazil we sampled 18 sites on tributaries of the San Francisco River in the state of Paraná. The riparian buffer zones generally contained native Atlantic forest remnants and/or introduced tree species at various stages of growth. In Brazil the stream buffer width was negatively correlated with sediment insecticide concentrations and buffer width was found to have moderate importance in mitigating effects on some sensitive taxa such as mayflies. However, in both regions insecticides had low relative importance in explaining variability in invertebrate communities, while various habitat parameters were more important. In Brazil, the percent coverage of soft depositional sediment in streams was the most important agriculture-related explanatory variable, and the overall stream-habitat score was the most important variable in Paraguay streams. Paraguay and Brazil both have laws requiring forested riparian buffers. The ample forested riparian buffer zones typical of streams in these regions are likely to have mitigated the effects of pesticides on stream invertebrate communities. This study provides evidence that riparian buffer regulations in the Atlantic Forest region are protecting stream ecosystems from pesticides and other agricultural stressors. Further studies are needed to determine the minimum buffer widths necessary to achieve optimal protection.

The subgingival microbiomes in periodontitis and health of individuals with rheumatoid arthritis and at risk of developing rheumatoid arthritis

Serum anti-citrullinated protein antibodies (ACPAs), present in 70% of people with rheumatoid arthritis (RA), can be detected ≤10years before the onset of clinical disease. RA and periodontitis are epidemiologically associated and we have reported a high incidence of periodontitis in people who are ACPA+ and at risk of RA. Periodontal bacteria may contribute by multiple routes to the generation of RA-autoantibodies. This study aims to characterise the subgingival microbiomes from periodontitis and health in individuals with/without RA and at risk of RA.

Forty-five ACPA+ no RA (RA-at-risk; RAR), 31 healthy controls (HC) and 30 ACPA+ RA patients (RA) underwent a periodontal examination. DNA from subgingival plaque from healthy and deep pocket sites were paired-end sequenced using the Illumina HiSeq3000 and data analysed using MG-RAST + DESeq.

Metagenomes in RA samples had high proportions of Actinobacteria; RAR microbiomes contained higher proportions of Bacteroidetes than HC. The relative abundance of P. gingivalis was high in periodontitis and RAR; Aggregatibacter actinomycetemcomitans was detected with similar frequency in each group. Other bacteria implicated in periodontitis and/or autoantibody generation (Filifactor alocis, Prevotella spp, Leptotrichia spp.) were detected. Analyses are on-going to elucidate the diversity and functional potential of the subgingival microbiome associated with RA.

Species at Risk (SPEAR) index indicates effects of insecticides on stream invertebrate communities in soy production regions of the Argentine Pampas

We investigated relationships among insecticides and aquatic invertebrate communities in 22 streams of two soy production regions of the Argentine Pampas over three growing seasons. Chlorpyrifos, endosulfan, cypermethrin, and lambda-cyhalothrin were the insecticides most frequently detected in stream sediments. The Species at Risk (SPEAR) pesticide bioassessment index (SPEARpesticides) was adapted and applied to evaluate relationships between sediment insecticide toxic units (TUs) and invertebrate communities associated with both benthic habitats and emergent vegetation habitats. SPEARpesticides was the only response metric that was significantly correlated with total insecticide TU values for all three averaged data sets, consistently showing a trend of decreasing values with increasing TU values (r2=0.35 to 0.42, p-value=0.001 to 0.03). Although pyrethroids were the insecticides that contributed the highest TU values, toxicity calculated based on all insecticides was better at predicting changes in invertebrate communities than toxicity of pyrethroids alone. Crustaceans, particularly the amphipod Hyalella spp., which are relatively sensitive to pesticides, played a large role in the performance of SPEARpesticides, and the relative abundance of all crustaceans also showed a significant decreasing trend with increasing insecticide TUs for two of three data sets (r2=0.30 to 0.57, p-value=0.003 to 0.04) examined. For all data sets, total insecticide TU was the most important variable in explaining variance in the SPEARpesticides index. The present study was the first application of the SPEAR index in South America, and the first one to use it to evaluate effects of pesticides on invertebrate communities associated with aquatic vegetation. Although the SPEAR index was developed in Europe, it performed well in the Argentine Pampas with only minor modifications, and would likely improve in performance as more data are obtained on traits of South American taxa, such as pesticide sensitivity and generation time.

T cell subsets: an immunological biomarker to predict progression to clinical arthritis in ACPA-positive individuals

Objectives

Anticitrullinated protein antibody (ACPA)+ individuals with non-specific musculoskeletal symptoms are at risk of inflammatory arthritis (IA). This study aims to demonstrate the predictive value of T cell subset quantification for progression towards IA and compare it with previously identified clinical predictors of progression.

Methods

103 ACPA+ individuals without clinical synovitis were observed 3-monthly for 12 months and then as clinically indicated. The end point was the development of IA. Naïve, regulatory T cells (Treg) and inflammation related cells (IRCs) were quantified by flow cytometry. Areas under the ROC curve (AUC) were calculated. Adjusted logistic regressions and Cox proportional hazards models for time to progression to IA were constructed.

Results

Compared with healthy controls (age adjusted where appropriate), ACPA+ individuals demonstrated reduced naïve (22.1% of subjects) and Treg (35.8%) frequencies and elevated IRC (29.5%). Of the 103 subjects, 48(46.6%) progressed. Individually, T cell subsets were weakly predictive (AUC between 0.63 and 0.66), although the presence of 2 T cell abnormalities had high specificity. Three models were compared: model-1 used T cell subsets only, model-2 used previously published clinical parameters, model-3 combined clinical data and T cell data. Model-3 performed the best (AUC 0.79 (95% CI 0.70 to 0.89)) compared with model-1 (0.75 (0.65 to 0.86)) and particularly with model-2 (0.62 (0.54 to 0.76)) demonstrating the added value of T cell subsets. Time to progression differed significantly between high-risk, moderate-risk and low-risk groups from model-3 (p=0.001, median 15.4 months, 25.8 months and 63.4 months, respectively).

Conclusions

T cell subset dysregulation in ACPA+ individuals predates the onset of IA, predicts the risk and faster progression to IA, with added value over previously published clinical predictors of progression.

Reliability of intra-abdominal pressure measurements using the modified Kron technique

OBJECTIVES

Assessment of intra-abdominal pressure (IAP) and the likelihood of abdominal compartment syndrome using valid and reliable measures is an important tool in the assessment of critically ill patients. The current method of relying on a single IAP per measurement period to determine patient clinical status raises the question: is a single intermittent IAP measurement an accurate indicator of clinical status or should more than one measurement be taken per measurement period?

METHODS

This study sought to assess the reliability of IAP measurements. Measurements were taken using the modified Kron technique. A total of two transvesical intra-abdominal pressure measurements were undertaken per patient using a standardized protocol. Recordings were taken at intervals of 5 minutes.

RESULTS

The majority of participants (58%) were surgical patients. Thirty-two were males and the mean age was 58 years (SD: 16·7 years). The concordance correlation coefficient between the two measurements was 0·95. Both the scatter and Bland-Altman plots demonstrate that the comparisons of two measurements are highly reproducible.

CONCLUSION

The findings of this study suggest that conducting two IAP measurements on single patient produce comparable results; therefore, there appears to be no advantage in doing two IAP measurements on a single patient. The measurement of an IAP requires the implementation of a standardized protocol and competent and credentialed assessors trained in the procedure.

Predicting the development of clinical arthritis in anti-CCP positive individuals with non-specific musculoskeletal symptoms: a prospective observational cohort study

OBJECTIVES

To monitor progression to inflammatory arthritis (IA) in individuals with non-specific musculoskeletal (MSK) symptoms and positive anticyclic citrullinated peptide (anti-CCP) antibodies. To develop a pragmatic model to predict development of IA in this patient group.

METHODS

In this prospective observational cohort, patients with new non-specific MSK symptoms and positive anti-CCP were recruited from regional primary care and secondary care referrals. Clinical, imaging and serological parameters were assessed at baseline. Cox regression analysis was performed to identify predictors of progression to IA and develop a risk score to stratify patients at presentation.

FINDINGS

100 consecutive patients (73 women, mean age 51 years) were followed up for median 19.8 months (range 0.1-69.0); 50 developed IA after a median 7.9 months (range 0.1-52.4), 34 within 12 months. The majority (43/50) fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism criteria for rheumatoid arthritis. A model for progression to IA was devised using four variables: tenderness of hand or foot joints, early morning stiffness ≥30 min, high-positive autoantibodies, and positive ultrasonographic power Doppler signal. None of the five individuals at low risk (score 0) progressed to IA, compared with 31% of 29 at moderate risk (1-2) and 62% of 66 at high risk (≥3). Adding shared epitope increased the number at low risk (score 0-1; 0/11 progressed).

CONCLUSIONS

In patients presenting with non-specific MSK symptoms and anti-CCP, the risk of progression to IA could be quantified using data available in clinical practice. The proposed risk score may be used to stratify patients for early therapeutic intervention.

TRIAL REGISTRATION NUMBER

NCT02012764 at ClinicalTrials.gov.

Memory and attention problems in children with chronic fatigue syndrome or myalgic encephalopathy

OBJECTIVE

To understand more about the problems children with chronic fatigue syndrome (CFS) or myalgic encephalopathy (ME) experience with memory and attention, and to test the feasibility of quantitative measurement of both memory and attention.

DESIGN

Four-item semistructured questionnaire and neuropsychological test battery with 10 psychometric subtests.

SETTING

Family home of the child taking part.

PATIENTS

20 children with a diagnosis of CFS/ME experiencing memory and/or concentration problems were recruited between April and October 2007 from a regional CFS/ME clinical service (female 13; average age 13.5 years; range 8-16).

METHODS

Each child, parent and teacher was asked to describe the child's memory and attention problems. Responses were subject to thematic analysis by two independent researchers. In addition, each child completed a battery of 10 tests to measure: processing speed; attention; immediate and delayed memory; working memory; executive function. Raw scores were converted into age-scaled scores and the children's psychometric scores on the 10 tests taken were compared with normative data using t tests.

RESULTS

Children with CFS/ME, their parents and teachers described problems with focussed attention, sustained attention, recall and stress. Scores for sustained attention (mean 8.1, 95% CI 6.3 to 9.9), switching attention (7.5, 5.5 to 9.4), divided attention (6.9, 5.5 to 8.2), auditory learning (8.2, 6.8 to 9.6) and immediate recall (8.7, 7.3 to 10.0) appeared lower than the normative mean of 10.

CONCLUSIONS

Children with CFS/ME appear to experience problems with attention, which may have adverse implications for verbal memory. These cognitive problems may explain some of the educational difficulties associated with CFS.

Laparoscopic management of an obstructed obturator hernia: should laparoscopic assessment be the default option?

An obturator hernia is a rare diagnosis that is frequently missed. Patients present with few clinical signs to identify the cause, apart from symptoms of intestinal obstruction. Therefore, obturator hernias are often diagnosed at exploratory laparotomy. The use of computed tomography (CT) has increased the chance of definitive preoperative diagnosis. However, despite these advances, patients who present acutely will frequently undergo an open procedure rather than laparoscopy. We present a case of an acute obstructed obturator hernia diagnosed in a 62-year-old female that was successfully managed laparoscopically.

Captive breeding of the white rhinoceros, Ceratotherium simum, and the Cape buffalo, Syncerus caffer : research communication

Breeding records of 40 white rhinoceros and 155 Cape buffalo were analysed. Three rhinoceros cows bred in captivity, themselves conceived for the first time at 84, 87 and 95 months of age, respectively. Rhinoceros cows breed throughout the year. There is no evidence of a relationship between calving interval and month of birth. Calving intervals were normally distributed about the mean of 34 months and there were no significant differences between bulls, cows or sex of calf. There was no difference in the sex ratio of calves born to young cows nor older cows. The male:female ratio of the calves was Younger cows did not have shorter birth intervals. Although captive Cape buffaloes breed throughout the year, there is a preponderance of births in midsummer. There was some evidence that larger cows produce heavier calves and that season of birth may influence birth weight. Male calves weighed 41.20 + 0.68 kg vs 39.00 + 0.73 kg (range 24-60 kg) for female calves but this difference was not significant. Calving intervals were normally distributed about the mean of 395 days and the male:female ratio of the calves was 1:1.2.

Captive breeding of the white rhinoceros, Ceratotherium simum, and the Cape buffalo, Syncerus caffer

Breeding records of 40 white rhinoceros and 155 Cape buffalo were analysed. Three rhinoceros cows bred in captivity, themselves conceived for the first time at 84, 87 and 95 months of age, respectively. Rhinoceros cows breed throughout the year. There is no evidence of a relationship between calving interval and month of birth. Calving intervals were normally distributed about the mean of 34 months and there were no significant differences between bulls, cows or sex of calf. There was no difference in the sex ratio of calves born to young cows nor older cows. The male:female ratio of the calves was 1:1. Younger cows did not have shorter birth intervals. Although captive Cape buffaloes breed throughout the year, there is a preponderance of births in midsummer. There was some evidence that larger cows produce heavier calves and that season of birth may influence birth weight. Male calves weighed 41.20 +/- 0.68 kg vs 39.00 +/- 0.73 kg (range 24-60 kg) for female calves but this difference was not significant. Calving intervals were normally distributed about the mean of 395 days and the male:female ratio of the calves was 1:1.2.

Touch detection of neonatal hypothermia in Nepal

The use of touch by health workers to detect hypothermia was examined in 250 newborns in Nepal. Palpation of the feet shows fair interobserver agreement (kappa = 0.4-0.7) and high sensitivity (>80%) but low specificity (36%-74%) compared with axillary thermometry. Traditional birth attendants should feel an infant's feet to detect hypothermia.