Skeletal muscle fitness and physiology as determinants of firefighter performance and safety: a narrative review

Firefighters routinely perform tasks that are reliant on their muscular fitness, which includes muscular strength, power and endurance. Separately, firefighters can present with unique skeletal muscle physiology characteristics due to the strenuous nature of this occupation. This review aims to summarise muscular fitness and physiology as determinants of a firefighter's ability to perform occupation-specific tasks, identify the relevance of both muscular fitness and physiology to a firefighter's risk for sustaining a work-related injury, and address the contributions of muscular fitness and physiology on a firefighter's ability to recover from tasks and their readiness for performing subsequent or future tasks. The presented evidence reveals muscular fitness can determine a firefighter's capacity to perform their job effectively, while also influencing risk for occupational injury. Collectively, this review indicates exercise training emphasising improvements in muscular strength, power, and endurance (i.e. resistance training) should be encouraged in this occupation.

Research note: Expert opinions of feather sucking and licking behavior in meat chicken breeder birds

Feather sucking, or feather licking, has been reported anecdotally by employees in the Australian meat chicken breeder industry, but scarcely in the scientific literature. Consequently, the causes and implications of this behavior in meat chicken breeding chickens is relatively unknown. We surveyed 17 industry experts to generate hypotheses about feather sucking behavior. We aimed to understand the frequency and when it occurs, and attempted to understand what may cause an "outbreak". The recruitment of participants was intentionally biased towards Australian perspectives; only 5 of the 17 participants were international. All participants, except 1, had seen feather sucking/licking behavior (94.1%) and most participants (80%) suggested that the behavior was most frequently observed during rearing. Participants presented varying concerns about this behavior, ranging from the perspective that it was "normal" and had no impact on welfare, to concerns about mating injuries due to damaged feathers, increased risk of feather pecking and cannibalism, and psychological stress indicated by expression of repetitive (seemingly) functionless behavior. "Feather licking," "feather sucking," "feather eating," and "feather pecking" were terms used interchangeably, leading to confusion by participants about the cause and implications of the target behavior. The most common factors reported as the cause were boredom (52.9%), nutritional deficiencies (47.1%), and feed restriction (41.2%) and more than 80% of respondents agreed that stress contributes to feather sucking. The outputs from this study reflect only a small, but expert, number of opinions on feather sucking/licking behaviors in the Australian meat chicken breeder industry. A systematic understanding of this behavior is needed to provide insight into causation and the implications for welfare.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Inconsistent discharge diagnoses for young cardiac arrest episodes: insights from a statewide registry

BACKGROUND

Administrative coding of out-of-hospital cardiac arrest (OHCA) is heterogeneous, with the prevalence of noninformative diagnoses uncertain.

AIM

To characterize the prevalence and type of non-informative diagnoses in a young cardiac arrest population.

METHODS

Hospital discharge diagnoses provided to a statewide OHCA registry were characterised as either 'informative' or 'noninformative.' Informative diagnoses stated an OHCA had occurred or defined OHCA as occurring due to coronary artery disease, cardiomyopathy, channelopathy, definite noncardiac cause, or no known cause. Noninformative diagnoses were blank, stated presenting cardiac rhythm only, provided irrelevant information or presented a complication of the OHCA as the main diagnosis. Characteristics of patients receiving informative versus noninformative diagnoses were compared.

RESULTS

Of 1479 patients with OHCA aged 1 to 50 years, 290 patients were admitted to 15 hospitals. Ninety diagnoses (31.0%) were noninformative (arrest rhythm = 50, blank = 21, complication = 10 and irrelevant = 9). Two hundred diagnoses (69.0%) were informative (cardiac arrest = 84, coronary artery disease = 54, noncardiac diagnosis = 48, cardiomyopathy = 8, arrhythmia disorder = 4 and unascertained = 2). Only 10 diagnoses (3.5%) included both OHCA and an underlying cause. Patients receiving a noninformative diagnosis were more likely to have survived OHCA or been referred for forensic assessment (P = 0.011) and had longer median length of stay (9 vs 5 days, P = 0.0019).

CONCLUSION

Almost one third of diagnoses for young patients discharged after an OHCA included neither OHCA nor any underlying cause. Underestimating the burden of OHCA impacts ongoing patient and at-risk family care, data sampling strategies, international statistics and research funding.

Sudden Cardiac Death in People With Schizophrenia: Higher Risk, Poorer Resuscitation Profiles, and Differing Pathologies

BACKGROUND

People with schizophrenia account for approximately 1.0% of the population and seem to experience increased rates of sudden cardiac death (SCD).

OBJECTIVES

This study sought to determine characteristics of increased SCD in people with schizophrenia.

METHODS

The End Unexplained Cardiac Death (EndUCD) prospective state-wide registry compared people aged 15 to 50 years with and without schizophrenia who experienced SCD within a 2-year time period and were referred for forensic evaluation.

RESULTS

We identified 579 individuals, of whom 65 (11.2%) had schizophrenia. Patients with schizophrenia were more commonly smokers (46.2% vs 23.0%; P < 0.0001), consumed excess alcohol (32.3% vs 21.4%; P = 0.05), and used QTc-prolonging medications (69.2% vs 17.9%; P < 0.0001). They were less likely to arrest while exercising (0.0% vs 6.4%; P = 0.04). Unfavorable arrest-related factors included lower rates of witnessed arrest (6.2% vs 23.5%; P < 0.0001), more likely to be found in asystole (92.3% vs 73.3%; P < 0.0001), and being more likely to be found as part of a welfare check after a prolonged period of time (median 42 hours vs 12 hours; P = 0.003). There was more frequent evidence of decomposition, and they more commonly underwent autopsy (41.2% vs 26.4%; P = 0.04 and 93.8% vs 82.5%; P = 0.05), with a diagnosis of nonischemic cardiomyopathy being more common (29.2% vs 18.1%; P = 0.04).

CONCLUSIONS

People with schizophrenia account for 11% of young SCD patients referred for forensic investigations, exceeding population rates by 11-fold. They have a higher preexisting cardiac risk factor burden, unfavorable resuscitation profiles, and higher rates of nonischemic cardiomyopathy. Strategies targeting biopsychosocial support may deliver not only psychological benefits, but also help to decrease unwitnessed cardiac arrest.

Causes, circumstances, and potential preventability of cardiac arrest in the young: insights from a state-wide clinical and forensic registry

AIMS

The causes, circumstances, and preventability of young sudden cardiac arrest remain uncertain.

METHODS AND RESULTS

A prospective state-wide multi-source registry identified all out-of-hospital cardiac arrests (OHCAs) in 1-50 year olds in Victoria, Australia, from 2019 to 2021. Cases were adjudicated using hospital and forensic records, clinic assessments and interviews of survivors and family members. For confirmed cardiac causes of OHCA, circumstances and cardiac history were collected. National time-use data was used to contextualize circumstances. 1319 OHCAs were included. 725 (55.0%) cases had a cardiac aetiology of OHCA, with coronary disease (n = 314, 23.8%) the most common pathology. Drug toxicity (n = 226, 17.1%) was the most common non-cardiac cause of OHCA and the second-most common cause overall. OHCAs were most likely to occur in sleep (n = 233, 41.2%). However, when compared to the typical Australian day, OHCAs occurred disproportionately more commonly during exercise (9% of patients vs. 1.3% of typical day, P = 0.018) and less commonly while sedentary (39.6 vs. 54.6%, P = 0.047). 38.2% of patients had known standard modifiable cardiovascular risk factors. 77% of patients with a cardiac cause of OHCA had not reported cardiac symptoms nor been evaluated by a cardiologist prior to their OHCA.

CONCLUSION

Approximately half of OHCAs in the young have a cardiac cause, with coronary disease and drug toxicity dominant aetiologies. OHCAs disproportionately occur during exercise. Of patients with cardiac cause of OHCA, almost two-thirds have no standard modifiable cardiovascular risk factors, and more than three-quarters had no prior warning symptoms or interaction with a cardiologist.

Prevalence of illicit drug use in young sudden cardiac death patients; an Australian prospective cohort study

Background

Illicit drug use may accelerate coronary disease and cardiac hypertrophy or stimulate arrhythmias. Rates of illicit drug use in young sudden cardiac death (SCD) patients are uncertain.

Purpose

To identify rates of illicit drug use in young SCD patients in Australia.

Methods

A prospective multi-centre registry identified out of hospital cardiac arrest (OHCA) patients aged 1–50 years between April 2019 and April 2020. Clinical characteristics were compared between patients with and without illicit drug use (defined by toxicological results or reported regular use). Illicit drugs included stimulants such as amphetamine-type substances and cocaine, or non-stimulants such as heroin, cannabis and novel psychoactive substances (cathinones and synthetic cannabinoids).

Results

770 OHCAs occurred, with 555 patients undergoing forensic assessment. 287 patients had confirmed cardiac cause of OHCA, with 274 undergoing toxicological assessment and 79 (28.8%) having positive toxicology for illicit drugs (n=60) or reported regular drug use (n=19). An additional 121 patients experienced non-cardiac SCD due to illicit drug toxicity, resulting in a total of 200 patients (36.0% of OHCAs) with illicit drug use. Patients with SCD and illicit drug use were more commonly male (86.1% vs 72.3%, p=0.015), regular smokers (36.7% vs 21.5%, p=0.009), had cardiomegaly (76.5% vs 57.5%, p=0.007), and higher rates of coronary disease and cardiomyopathy (coronary disease 44.3% vs 33.3%, cardiomyopathy 30.4% vs 18.5%, p=0.003). Methamphetamines (n=42, 53.1%) were the most common illicit drug identified and polysubstance abuse occurred frequently (n=15, 19.0%).

Conclusion

Approximately one-third of young SCD patients use illicit drugs, with high rates of polysubstance abuse. Illicit drug use in SCD patients is associated with coronary disease and cardiomyopathy.

Funding Acknowledgement

Type of funding sources: None.

Prevalence of coronary artery anomalies in young sudden cardiac death: insights from a prospective state-wide registry

Background

Coronary artery anomalies (CAAs) have been previously implicated as a major cause of young sudden cardiac death (SCD), particularly in exercise-related SCD with a reported prevalence of up to 33%.

Methods

A state-wide prospective out-of-hospital cardiac arrest registry identified all patients aged 1–50 years who experienced an SCD and underwent autopsy from April 2019 to April 2021. Rates of normal anatomy, normal variants and CAAs were identified and circumstances and cause of death for patients with CAAs examined.

Results

Of 1,477 patients who experienced cardiac arrest during the study period, 490 underwent autopsy and were confirmed to have experienced SCD. Of these 490 patients, five (1.0%) had a CAA identified with three having anomalies of coronary origin and two having anomalies of coronary course. In no cases was the CAA deemed responsible for the SCD. In two cases, severe coronary disease and intra-coronary thrombus with histological evidence of acute myocardial infarction were identified, in the third critical coronary disease was found, the fourth had an unrelated thoracic aortic dissection and the fifth had cardiomegaly in the setting of illicit drug use. Of 27 patients who experienced their SCD during exercise, only one had a CAA identified (the patient with thoracic aortic dissection).

Conclusion

In this prospective cohort of consecutive young patients with SCD who underwent autopsy, CAAs occurred in 1.0% of patients and did not cause any deaths. The role of CAAs in causing young SCD appears to be less significant than previously hypothesised.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): NHMRC, NHF

Clinical and pathologic features of out-of-hospital cardiac arrest in pregnancy: insights from a state-wide registry

Background

Cardiovascular disease is the most common cause of indirect maternal mortality worldwide, and cardiac arrest occurs in up to 1 in 12,000 pregnancies.

Objective

To define rates, clinical and pathologic factors of out-of-hospital cardiac arrest (OHCA) in pregnant and post-partum females.

Methods

A prospective state-wide cardiac arrest registry combining ambulance, hospital and forensic data captured all OHCAs from 2019–2021. Clinical and pathological details for pregnant patients were identified.

Results

1,482 OHCAs occurred, including 376 females of child-bearing age of whom eight were pregnant or post-partum. OHCA incidence was lower in pregnant females compared to non-pregnant females of child-bearing age (5.2 OHCAs per 100,000 pregnant females vs 23.1 per 100,000 females of child-bearing age, p&lt;0.0001). Seven patients (87.5%) died, with five (62.5%) having a cardiac cause of OHCA (unascertained = 2, cardiomyopathy = 2 (1 hypertrophic), ischemic heart disease = 1). Two patients had pre-existing cardiac risk factors, but none had a cardiac diagnosis pre-arrest. Compared to in-hospital cardiac arrests (IHCAs) in pregnancy, OHCAs are more likely to have a cardiac cause (odds ratio 3.81) and lower maternal survival (odds ratio 0.09).

Conclusion

Maternal OHCA affects approximately 1 in 20,000 pregnancies with high maternal mortality rates. OHCA occurs at one-quarter the rate in non-pregnant females of child-bearing age. Approximately two-thirds of maternal OHCAs had an underlying cardiac cause, but low rates of cardiac diagnosis pre-arrest. OHCAs differ markedly from IHCAs in pregnant females, requiring ongoing evaluation as to specific causes and preventability.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): NHMRC, NHF

Obesity in young sudden cardiac death: rates, clinical features, and insights into people with body mass index &gt;50kg/m2

Background

Obesity is common in young sudden cardiac death (SCD) victims but it is unclear whether it is more common than in the general population. This study aimed to contextualize young SCD obesity rates, identifying clinical and pathologic features in WHO class II and III obesity.

Methods

A prospective state-wide out-of-hospital cardiac arrest registry included all SCDs in Victoria, Australia from 2019–2021. Body mass indices (BMIs) of patients 18–50 years were compared to age-referenced general population. Characteristics of SCD patients with WHO Class II obesity (BMI ≥30kg/m2) and non-obesity (BMI &lt;30kg/m2) were compared. Clinical characteristics of people with BMI &gt;50kg/m2 were assessed.

Results

504 patients were included. Obesity was strongly over-represented in young SCD compared to the age-matched general population (55.0% vs 28.7%, p&lt;0.0001). Obese SCD patients more frequently had hypertension, diabetes and obstructive sleep apnoea (p&lt;0.0001, p=0.009 and p=0.001 respectively), ventricular fibrillation as their arrest rhythm (p=0.008) and left ventricular hypertrophy (LVH) (p&lt;0.0001). Obese patients were less likely to have toxicology positive for illicit substances (22.0% vs 32.6%, p=0.008) or significant alcohol history (18.8% vs 26.9%, p=0.030). Patients with BMI &gt;50 kg/m2 represented 8.5% of young SCD. LVH (n=26, 60.5%) was their predominant cause of death and only 10 (9.3%) patients died from coronary disease.

Conclusion

Over half of young Australian SCD patients are obese, with all obesity classes over-represented compared to the general population. Obese patients had more cardiac risk factors. Almost two thirds of patients with BMI&gt;50 kg/m2 died with LVH, with fewer than 10% dying from coronary disease.

Funding Acknowledgement

Type of funding sources: None.

Obesity in young sudden cardiac death: Rates, clinical features, and insights into people with body mass index >50kg/m2

•

55.0% of young sudden cardiac death (SCD) patients in Victoria, Australia are obese.

•

This obesity prevalence exceeds that in the age-matched general Australian population, with all classes of obesity over-represented in our SCD cohort.

•

Patients with BMI>50 kg/m² represented 8.5% of young SCD. Almost two thirds of patients with BMI>50 kg/m² died from left ventricular hypertrophy, with fewer than 10% dying from coronary disease.

Objective

To contextualize obesity rates in young sudden cardiac death (SCD) against the age-matched national population, and identify clinical and pathologic features in WHO class II and III obesity.

Methods

A prospective state-wide out-of-hospital cardiac arrest registry included all SCDs in Victoria, Australia from 2019–2021. Body mass indices (BMIs) of patients 18-50 years were compared to age-referenced general population. Characteristics of SCD patients with WHO Class II obesity (BMI ≥30kg/m²) and non-obesity (BMI<30kg/m²) were compared. Clinical characteristics of people with BMI>50kg/m² were assessed.

Results

504 patients were included. Obesity was strongly over-represented in young SCD compared to the age-matched general population (55.0% vs 28.7%, p<0.0001). Obese SCD patients more frequently had hypertension, diabetes and obstructive sleep apnoea (p<0.0001, p=0.009 and p=0.001 respectively), ventricular fibrillation as their arrest rhythm (p=0.008) and left ventricular hypertrophy (LVH) (p<0.0001). Obese patients were less likely to have toxicology positive for illicit substances (22.0% vs 32.6%, p=0.008) or history of alcohol abuse (18.8% vs 26.9%, p=0.030). Patients with BMI>50 kg/m² represented 8.5% of young SCD. LVH (n=26, 60.5%) was their predominant cause of death and only 10 (9.3%) patients died from coronary disease.

Conclusion

Over half of young Australian SCD patients are obese, with all obesity classes over-represented compared to the general population. Obese patients had more cardiac risk factors. Almost two thirds of patients with BMI>50 kg/m² died from LVH, with fewer than 10% dying from coronary disease.

Prevalence of Coronary Artery Anomalies in Young and Middle-Aged Sudden Cardiac Death Victims (from a Prospective State-Wide Registry)

Coronary artery anomalies (CAAs) have been previously implicated as a major cause of young sudden cardiac death (SCD), particularly in exercise-related SCD, with a prevalence of up to 33%. A state-wide prospective out-of-hospital cardiac arrest registry identified all patients aged 1 to 50 years who experienced an SCD and underwent autopsy from April 2019 to April 2021. Rates of normal anatomy, normal variants, and CAAs were identified, and circumstances and causes of death for patients with CAAs examined. Of 1,477 patients who experienced cardiac arrest during the study period, 490 underwent autopsy and were confirmed to have experienced SCD. Of these 490 patients, 5 (1%) had a CAA identified, with 3 having anomalies of coronary origin and 2 having anomalies of coronary course. In no cases were the CAA deemed responsible for the SCD. In 2 cases, severe coronary disease and intra-coronary thrombus with histological evidence of acute myocardial infarction were identified. In the third, critical coronary disease was found, the fourth had an unrelated thoracic aortic dissection, and the fifth had cardiomegaly in the setting of illicit drug use. Of 27 patients who experienced their SCD during exercise, only 1 had a CAA identified (the patient with thoracic aortic dissection). In conclusion, in this prospective cohort of consecutive young patients with SCD who underwent autopsy, CAAs occurred in 1% of patients and did not cause any deaths. The role of CAAs in causing young and middle-aged SCD appears to be less significant than previously hypothesized.

Comparing a single dose of xylanase to a double dose or cocktail of non-starch polysaccharide-degrading enzymes in broiler chicken diets

This study compared supplementation with a single dose of xylanase to a double dose of xylanase or a non-starch polysaccharide (NSP) degrading enzyme cocktail (NSP-ase cocktail) on productive performance, nutrient utilisation and the gastrointestinal environment in broilers fed commercial diets. Cobb 500 broilers (n=1,080) were fed 12 dietary treatments; four Australian commercial diets (based on wheat-barley, wheat-maize, wheat-sorghum or wheat only) with three different enzyme treatments (single dose of xylanase (16,000 BXU/kg), double dose of xylanase (32,000 BXU/kg) or NSP-ase cocktail (xylanase, β-glucanase, cellulase, pectinase, mannanase, galactanase, arabinofuranosidase). There were 108 pens, nine replicates per dietary treatment, with 10 birds per pen. Performance (total pen body weight, feed intake and feed conversion ratio corrected for mortality) was determined at d 0-35. On d 35, one male and one female were weighed individually and used to determine breast meat, thigh and drumstick weight, dry matter (DM) contents from the gizzard, jejunum and ileum, ileal protein, energy, starch and dry matter digestibility, ileal viscosity and xylo-oligosaccharide (XOS) concentration, caecal microbiota and short chain fatty acid (SCFA) composition. The double dose of xylanase and NSP-ase cocktail had no effect on bird performance, meat yield, ileal viscosity, ileal starch, energy or DM digestibility or digesta DM content. The double xylanase dose and NSP-ase cocktail increased protein digestibility in birds fed the wheat-sorghum based diet (P=0.041) and increased caecal concentration of butyric acid in birds fed the wheat-maize based diet (P=0.040), and propionic, valeric and lactic acid and Bifidobacteria and Enterobacteria spp. in birds fed the wheat-based diet (P<0.05). The double xylanase dose increased XOS production, particularly in birds fed the wheat-barley based diets (P<0.05). The lack of performance effects observed when feeding the double xylanase dose or NSP-ase cocktail suggested that the current recommended xylanase dose (16,000 BXU/kg) is sufficient.

Higher rates but similar causes of young out-of-hospital cardiac arrest in rural Australian patients

OBJECTIVE

To determine whether young rural Australians have higher rates or different underlying causes of out-of-hospital cardiac arrest (OHCA).

DESIGN

A case-control design identified patients experiencing an OHCA, then compared annual OHCA rates and underlying causes in rural versus metropolitan Victoria. OHCA causes were defined as either cardiac or non-cardiac, with specific aetiologies including coronary disease, cardiomyopathy, unascertained cause of arrest, drug toxicity, respiratory event, neurological event and other cardiac and non-cardiac. For OHCAs with confirmed cardiac aetiology, cardiovascular risk profiles were compared.

SETTING

A state-wide prospective OHCA registry (combining ambulance, hospital and forensic data) in the state of Victoria, Australia (population 6.5 million).

PARTICIPANTS

Victorians aged 1-50 years old experienced an OHCA between April 2019 and April 2020.

MAIN OUTCOME MEASURES

Rates and underlying causes of OHCA in young rural and metropolitan Victorians.

RESULTS

Rates of young OHCA were higher in rural areas (OHCA 22.5 per 100 000 rural residents vs. 13.4 per 100 000 metropolitan residents, standardised incidence ratio 168 (95% CI 101-235); confirmed cardiac cause of arrest 12.1 per 100 000 rural residents versus 7.5 per 100 000 metropolitan residents, standardised incidence ratio 161 (95% CI 71-251). The underlying causation of the OHCA and cardiovascular risk factor burden did not differ between rural and metropolitan areas.

CONCLUSION

Higher rates of OHCA occur in young rural patients, with standardised incidence ratio of 168 compared to young metropolitan residents. Rural status did not influence causes of cardiac arrest or known cardiovascular risk factor burden in young patients experiencing OHCA.

Intracoronary IgG4-related disease as an unusual cause of sudden cardiac arrest: a case series

Background

IgG4-related disease (IgG4-RD) is a fibro-inflammatory condition classically causing retroperitoneal fibrosis, aortitis, thyroiditis, or pancreatitis. Diagnosis includes the presence of lymphoplasmacytic infiltrate (with >40% ratio IgG4+:IgG plasma cells) and fibrosis. Cardiac involvement may include aortic, pericardial, or coronary disease. Coronary manifestations encompass obstructive intra-luminal lesions, external encasing pseudo-tumour on imaging, or lymphoplasmacytic arteritis.

Case summary

Case 1: A fit and healthy 50-year-old man was found deceased. His only known medical condition was treated Hashimoto’s thyroiditis. Post-mortem examination demonstrated an isolated severe stenosis of the left anterior descending (LAD) coronary artery without histopathological evidence of acute myocardial infarction. Coronary plaque histopathology showed florid IgG4-positive plasma cell infiltrate throughout all layers of the artery with dense fibrous tissue connective tissue stroma, all features consistent with coronary artery IgG4-RD. Case 2: A 48-year-old man collapsed at work. Computed tomography scan 1 week prior reported an ill-defined para-aortic retroperitoneal soft tissue density. No cardiac symptoms were reported in life. Post-mortem examination showed coronary arteritis and peri-arteritis with sclerosing peri-aortitis in the LAD. There was myocardial fibrosis of the anterior left ventricle and focal myocarditis of the right ventricle.

Discussion

IgG4-related disease presenting as sudden cardiac death without any preceding symptoms is very rare (six prior cases identified on literature review). Reported targeted successful interventions for intracoronary IgG4-RD diagnosed in life have included steroid therapy and B cell depleting therapy (i.e. rituximab). If cardiac symptoms are present in a patient with known IgG4-RD, cardiac investigations should be promptly arranged.

Nurse perspectives on the psychosocial care of patients with urinary incontinence in home hospice: A qualitative study

BACKGROUND

Urinary incontinence is prevalent among patients receiving home hospice and presents multiple care management challenges for nurses and family caregivers.

AIM

This study sought to understand how urinary incontinence influences the psychosocial care of patients receiving home hospice and the strategies that nurses employ to maximize patient and family comfort.

DESIGN

Qualitative descriptive study using semi-structured interviews.

SETTING/PARTICIPANTS

Nurses employed at a large not-for-profit hospice agency in New York City.

RESULTS

Analyses of 32 interviews revealed three primary themes. First, nurses considered urinary incontinence to be associated with multiple psychosocial issues including embarrassment for patients and caregiver burden. Second, nurses described urinary incontinence as a threat to patient dignity and took steps to preserve their continence function. Third, nurses assisted patients and their families to cope with urinary incontinence through normalization, reframing incontinence as part of the disease process, mobilizing caregiving assistance, and encouraging use of continence supplies such as diapers and liners.

CONCLUSION

Urinary incontinence influences the psychosocial care of patients receiving home hospice and nurses employ strategies to maximize patient and family comfort. Additional research is needed to examine the psychosocial benefits of facilitated discussions with patients and family members about incontinence, provision of caregiving support, and distribution of comprehensive incontinence supplies to patients with fewer resources.

Multi-carbohydrase enzymes improve feed energy in broiler diets containing standard or low crude protein

This study evaluated the effect of multi-carbohydrase (MC) on energy and nitrogen (N) balance and gene expression in broilers fed diets with different crude protein (CP) contents. The study employed a 2 × 2 factorial arrangement of treatments. The factors were presence or absence of MC, and standard (SCP) or low (LCP) dietary CP concentration. A 3-phase feeding program was used, including starter (0 to 7 d), grower (8 to 17 d) and finisher (18 to 28 d) phases. The study was undertaken in closed calorimetry chambers. Each of the 4 dietary treatments was replicated 8 times in total across 2 runs, with 2 birds per replicate (n = 64). Data for energy partitioning and N balance were collected from d 25 to 28. On d 28, birds were euthanized to collect muscle and intestinal tissue samples for gene expression. The results showed that the MC increased apparent metabolizable energy (AME, P < 0.01) and net energy (NE, P < 0.05), and reduced the feed conversion ratio (FCR, P < 0.01) in all diets. The proportion of energy retained as fat per total energy retention (REf/RE) was positively correlated with feed AME and NE (r = 0.541, P < 0.01 and r = 0.665, P < 0.001, respectively), suggesting that feed energy augmented with increased fat gain. Muscle ATP synthase subunit alpha (ATP5A1W) gene expression had a positive correlation with REf/RE and feed NE (r = 0.587, P < 0.001 and r = 0.430, P < 0.05, respectively). Similarly, muscle peroxisome proliferator-activated receptor gamma coactivator 1 alpha (PGC-1A) expression was negatively correlated with weight gain and positively correlated with FCR (r = −0.451, P < 0.05 and r = 0.359, P < 0.05, respectively). These correlations show that over-expressions of muscle genes related to energy production reduce bird performance. This study demonstrated that MC increase dietary energy utilization, regardless of dietary CP concentration. However, the energy released by the enzymes increases feed energy-to-CP ratio, meaning there is excess energy that is then deposited as body fat. This suggests that supplemental MC in broiler feeds is beneficial if diets are formulated to contain marginal energy levels.

Dietary soluble non-starch polysaccharide level and composition influences grower and finisher phase performance, excreta moisture content and total tract nutrient digestibility in broilers

1. The aim of this study was to examine the impact of dietary soluble non-starch polysaccharide (sNSP) level and composition on grower and finisher phase performance, total tract nutrient digestibility and excreta moisture content in broiler chickens.2. Cobb 500 broilers (n = 1080) were fed 12 dietary treatments; four diets with differing primary grain sources (barley, corn, sorghum and wheat) and three different sNSP levels (low, medium and high). Diets were formulated to have similar protein and energy levels but differing sNSP levels, induced by manipulating the quantity of the ingredients in the diet. The diets were fed in three phases, starter (d 0-12), grower (d 12-23) and finisher (d 23-31).3. For birds aged d 23 and 31, total pen body weight and feed intake were determined, and fresh excreta and litter samples were collected per pen. Dry matter (DM) content was measured in the excreta and litter samples. Total tract DM digestibility, apparent metabolisable energy corrected to nitrogen (AMEn), and soluble and insoluble NSP and free oligosaccharide degradability were evaluated.4. In birds fed the sorghum- and corn-based diets, feeding high sNSP resulted in a lower cFCR at d 0-23 compared to low sNSP (P = 0.004 and P = 0.044, respectively). In birds fed the corn-based diet, feeding low sNSP resulted in the lowest litter DM but highest DM digestibility at d 23 (P = 0.045 and P < 0.001) and d 31 (P = 0.022 and P = 0.008). For all diets, degradability of sNSP was higher and insoluble NSP was lower when feeding low compared to high sNSP (P < 0.001). In birds fed the barley- and sorghum-based diets, AMEn was lower when feeding the low compared to high sNSP level (P < 0.001 and P = 0.016, respectively).6. Results from this study showed that level of dietary sNSP impacts broiler productive performance and nutrient utilisation.

The economic impact of sudden cardiac arrest

BACKGROUND

There are 20,000 sudden cardiac arrests (SCAs) in Australia annually, with 90% case-fatality.

OBJECTIVE

The present study calculated both the health and economic impact of SCAs in Victoria, Australia.

METHODS

Data on all SCAs attended by Ambulance Victoria from July 2017 to June 2018 were collected regarding age, gender, and survival to hospital, discharge and 12 months. Pre-SCA employment status of all patients was modelled using age and gender-matched Australian economic data. A Markov state-transition model with a five-year horizon calculated health and economic impact in years of life lived (YLL), productivity-adjusted life years (PALYs) and gross domestic product (GDP) lost. A counterfactual Markov state-transition model assessed outcomes of an identical cohort of patients who did not experience SCA. All values were discounted by 5%.

RESULTS

In 12 months, 4637 people suffered SCAs in Victoria, of whom 1516 (32.7%) were working at the time. 695 patients (15.0%) survived to hospital, 325 (7.0%) to discharge, and 303 (6.5%) to 12 months. In five years following their SCA, the cohort lost 15,922 years of life and 2327 PALYs. Reduced productivity led to GDP losses of AUD$448 million (92.8% relative reduction). Extrapolated to the 20,000 SCAs occurring across all of Australia, total GDP losses approached AUD$2 billion.

CONCLUSION

The health and economic burden of SCAs is high, predominantly underpinned by very high mortality. Annual national losses approach AUD$2 billion (USD$1.42 billion) and are comparable to productivity losses from all cancers combined. Prioritising research and state-of-the-art care for SCA patients appears economically sound.

Efficacy of supplemental multi-carbohydrases in broiler diets depends on soluble arabinoxylan-to-total arabinoxylan content

1. The objective of this study was to investigate the effect of multi-carbohydrase enzymes (MC) on net energy (NE), performance and gene expression in Cobb 500 broilers fed diets containing different levels of soluble and total arabinoxylan (sAX/tAX) ratios.2. The study employed a 2 × 3 factorial arrangement of treatments, with factors including with or without MC and three ratios of sAX/tAX: high (HS, 27.3%), intermediate (IS, 21.3%) and low (LS, 15.7%).3. Six dietary treatments were formulated, with each diet replicated five times in the calorimetric study (Experiment 1) and eight times for a floor pen feeding trial (Experiment 2).4. Experiment 1 showed significant (P < 0.01) MC × sAX/tAX interactions for apparent metabolisable energy (AME) and NE. These interactions indicated that the supplemental MC increased AME only in the HS diet, and NE in the HS and LS diets.5. Experiment 2 results showed MC × sAX/tAX interactions for feed conversion ratio (FCR, P < 0.01) and ileal digesta viscosity (P < 0.05), demonstrating that MC lowered FCR only in the LS-fed birds, and reduced digesta viscosity only in the HS-fed birds. Apparent ileal digestible crude protein (AID CP) was negatively correlated with ileal digesta viscosity (r = -0.735, P < 0.001), which suggested that increasing ileal digesta viscosity reduced AID CP.6. A significant (P < 0.05) MC × sAX/tAX interaction was observed for duodenal COX III mRNA gene expression, which indicated that this gene was upregulated in the IS-fed birds relative to the HS-fed birds, but only when MC was added. This gene was downregulated (P < 0.05) in the muscle in the presence of MC application in all diets.7. The results from this study showed that supplemental MC can improve NE and FCR in birds fed diets containing the low sAX/tAX ratios.

Bacillus amyloliquefaciens CECT 5940 improves performance and gut function in broilers fed different levels of protein and/or under necrotic enteritis challenge

Two studies were conducted to investigate the effect of Bacillus amyloliquefaciens CECT 5940 (BA) as a probiotic on growth performance, amino acid digestibility and bacteria population in broiler chickens under a subclinical necrotic enteritis (NE) challenge and/or fed diets with different levels of crude protein (CP). Both studies consisted of a 2 × 2 factorial arrangement of treatments with 480 Ross 308 mix-sexed broiler chickens. In study 1, treatments included 1) NE challenge (+/-), and 2) BA (1.0 × 10⁶ CFU/g of feed) supplementation (+/-). In study 2, all birds were under NE challenge, and treatments were 1) CP level (Standard/Reduced [2% less than standard]) and 2) BA (1.0 × 10⁶ CFU/g of feed) supplementation (+/-). After inducing NE infection, blood samples were taken on d 16 for uric acid evaluation, and cecal samples were collected for bacterial enumeration. In both studies, ileal digesta was collected on d 35 for nutrient digestibility evaluation. In study 1, the NE challenge reduced body weight gain (BWG), supressed feed conversion ratio (FCR) and serum uric acid levels (P < 0.001). Supplementation of BA increased BWG (P < 0.001) and reduced FCR (P = 0.043) across dietary treatments, regardless of challenge. Bacillus (P = 0.030) and Ruminococcus (P = 0.029) genomic DNA copy numbers and concentration of butyrate (P = 0.017) were higher in birds fed the diets supplemented with BA. In study 2, reduced protein (RCP) diets decreased BWG (P = 0.010) and uric acid levels in serum (P < 0.001). Supplementation of BA improved BWG (P = 0.001) and FCR (P = 0.005) and increased Ruminococcus numbers (P = 0.018) and butyrate concentration (P = 0.033) in the ceca, regardless of dietary CP level. Further, addition of BA reduced Clostridium perfringens numbers only in birds fed with RCP diets (P = 0.039). At d 35, BA supplemented diets showed higher apparent ileal digestibility of cystine (P = 0.013), valine (P = 0.020), and lysine (P = 0.014). In conclusion, this study suggests positive effects of BA supplementation in broiler diets via modulating gut microflora and improving nutrient uptake.

Healthcare staff perceptions and misconceptions regarding antibody testing in the United Kingdom: implications for the next steps for antibody screening

BACKGROUND

Healthcare workers have been at increased risk of exposure, infection and serious complications from COVID-19. Antibody testing has been used to identify staff members who have been previously infected by SARS-CoV-2, and has been rolled out rapidly in the United Kingdom. A number of comment and editorial articles have been published that raise concerns about antibody testing in this context. We present perceptions of National Health Service (NHS) healthcare workers in relation to SARS-CoV-2 antibody testing.

METHODS

An electronic survey regarding perceptions towards SARS-CoV-2 antibody testing was distributed to all healthcare workers at a major NHS tertiary hospital following implementation of antibody testing.

RESULTS

In total, 560 healthcare workers completed the survey (80% female; 25% of Black and Minority Ethnic background; 58% from frontline clinical staff). Exploring whether they previously had COVID-19 was the primary reported reason for choosing to undergo antibody testing (85.2%). In case of a positive antibody test, 72% reported that they would feel relieved, whilst 48% felt that they would be happier to work in a patient-facing area. Moreover, 12% responded that a positive test would mean "social distancing is less important", with 34% of the responders indicating that in this case they would be both less likely to catch COVID-19 and happier to visit friends/relatives.

CONCLUSIONS

NHS staff members primarily seek out SARS-CoV-2 antibody testing for an appropriate reason. Based on our findings and given the lack of definite data regarding the extent of immunity protection from a positive SARS-CoV-2 antibody test, significant concerns may be raised regarding the reported interpretation by healthcare workers of positive antibody test results. This needs to be further explored and addressed to protect NHS staff and patients.

Can post-mortem coronary artery calcium scores aid diagnosis in young sudden death?

This study sought to explore the feasibility and utility of post-mortem coronary artery calcium (CAC) scoring in identifying patients with ischemic heart disease as cause of sudden death. 100 deceased patients aged 18-50 years underwent post-mortem examination in the setting of sudden death. At post-mortem, fifty cases were determined to have ischemic heart disease, and fifty had death attributed to trauma or unascertained causes. The CAC score was calculated in a blinded manner from post-mortem CTs performed on all cases. CAC scores were assessable in 97 non-decomposed cases (feasibility 97%). The median CAC score was 88 Agatston units [IQR 0-286] in patients deceased from ischemic heart disease vs 0 [IQR 0-0] in patients deceased from other causes (p < 0.0001). Presence of any coronary calcification differed significantly between ischemic heart disease and non-ischemic groups (adjusted odds ratio 10.7, 95% CI 3.2-35.5). All cases with a CAC score > 100 (n = 22) had ischemic heart disease as the cause of death. Fifteen cases had a CAC score of zero but severe coronary disease at post-mortem examination. Post-mortem CAC scoring is highly feasible. An elevated CAC score in cases 18-50 years old with sudden death predicts ischemic heart disease at post-mortem examination. However, a CAC score of zero does not exclude significant coronary artery disease. Post-mortem CAC score may be considered as a further assessment tool to help predict likely cause of death when there is an objection to or unavailability of post-mortem examination.

Multi-carbohydrase effects on energy utilization depend on soluble non-starch polysaccharides-to-total non-starch polysaccharides in broiler diets

Non-starch polysaccharides (NSP), especially in water-soluble form, are a common anti-nutritional factor in cereal-based poultry diets. Consequently, carbohydrases are applied to diets to combat the negative effects of NSP on bird performance and health, particularly when feeding viscous grains. This study investigated the effect of supplementing multi-carbohydrases (MC) to broiler diets containing either low (LS) or high (HS) soluble NSP (sNSP) to total NSP (tNSP) ratios on energy partitioning, nitrogen (N) balance, and performance. A 2 × 2 factorial arrangement of treatments (MC, no or yes; sNSP/tNSP, LS vs. HS) was applied, resulting in 4 dietary treatments, each replicated 8 times. These treatments were fed to Ross 308 broilers in closed-circuit indirect calorimetry chambers, with 2 birds (a male and a female) per replicate chamber (n = 64). The results showed that MC addition increased AME, net energy (NE), and AME/gross energy, regardless of sNSP/tNSP content (P < 0.01 for all). There was an MC × sNSP/tNSP interaction for feed intake (FI, P < 0.05), denoting that in the absence of MC, the HS-fed birds had lower FI than LS-fed birds, but this difference was eliminated when MC was present. There were MC × sNSP/tNSP interactions observed for AME intake (AMEi) per metabolic BW (BW^0.70, P < 0.05), AMEi/N retention (Nr, P < 0.01), NE intake (NEi)/Nr (P < 0.05), retained energy (RE) as fat per total RE (REf/RE, P < 0.01), and N efficiency (Nr/N intake, P < 0.05). These interactions showed that MC application increased AMEi/BW^0.70, AMEi/Nr, NEi/Nr, and REf/RE only in the HS-fed birds, and N efficiency only in the LS-fed broilers. This study demonstrated that MC application markedly increased feed energy utilization in all diets, and increased N efficiency in birds fed an LS diet.

Economic impact of sudden cardiac arrest

Background

Each year, there are approximately 5,000 out-of-hospital cardiac arrests (OHCAs) in the state of Victoria, Australia (population 6.4 million, state healthcare budget AUD$2.9 billion / €1.8billion). Mortality from OHCA approaches ninety percent. High mortality rates and survivors not returning to work is likely to have an adverse effect on the Victorian economy but this has not been previously investigated.

Purpose

To model the economic impact of OHCA mortality and survivors not returning to work.

Methods

Data on all OHCAs transported by Ambulance Victoria from July 2017- June 2018 in Victoria, Australia was collected, including age, gender, survival to hospital, survival to discharge, and survival to 12 months. Cases were excluded if arrest was precipitated by trauma, exsanguination, overdose, terminal illness, hanging, SIDS, electrocution, sepsis, respiratory causes, drowning, or neurological causes. Pre-arrest employment status of patients was modelled using the Australian Bureau of Statistics Economic Security dataset, which provides contemporary employment rates for gender-matched five-year cohorts for Australians aged 15–79 years. For survivors to 12 months, pre-arrest and post-arrest work status were confirmed. Economic impact was then calculated to a five year horizon utilizing a Markov model with probabilistic sensitivity analysis.

Results

4,934 arrests meeting the inclusion criteria were transported by Ambulance Victoria in twelve months, of whom 4,639 were determined to be cardiac arrests without any exclusion criteria as a precipitant. 695 patients survived to hospital (15.0%), and 325 to discharge (7.0%). At 12 months, 303 patients were alive (6.5% of overall cases, 93.2% of those discharged from hospital). Economic modelling of age and gender-matched data indicated that 1516 patients (35%) would have been employed pre-cardiac arrest, but only 216 survivors (4.7%) would be employed at five years post-arrest. Using Markov modelling incorporating estimated earnings and the pre-determined value of a statistical life, the annual economic burden of cardiac arrest approximated AUD$4 billion (€2.5 billion) at a five-year horizon.

Conclusion

The annual economic impact of cardiac arrest in Victoria, Australia is approximately AUD$4 billion (€2.5 billion) in a five-year horizon. As the annual Victorian state budget for all healthcare is AUD$2.93 billion (€1.8 billion), our data suggests that the economic impact of cardiac arrest is under-appreciated. Therefore, research in this area and providing state-of-the-art care for all cardiac arrest patients should be a healthcare priority.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): NHMRC/NHF Postgraduate Scholarship, RACP JJ Billings Scholarship

Connectedness With Nature and Individual Responses to a Pandemic: An Exploratory Study

Most recent epidemics have originated in complex human-nature interactions and yet, our knowledge is very limited regarding the psychological aspects of human-nature relationships that underlie individual human responses in times of pandemic crises. We propose that the concept of connectedness with nature and associated individual difference measures offer a relevant and useful lens to inform us about how humans think, feel and behave in such critical times. Our two-wave study, conducted with 486 United States residents at the end of March 2020 (wave 1) and 533 United States residents at the beginning of May 2020 (wave 2), focuses on the 2020 coronavirus situation. It maps individual responses to the current pandemic in terms of mental representations, behavioral tendencies and perceived impact, and explores the relationships of these constructs to individual levels of connectedness with nature. As this research employs an exploratory methodology, our results provide an account of potential relationships rather than their validation and thus represent an encouraging steppingstone for research on human behavior in the time of a global pandemic. We identify a series of research propositions and questions for systematic future inquiry.

Precision Measurement of the Beam-Normal Single-Spin Asymmetry in Forward-Angle Elastic Electron-Proton Scattering

A beam-normal single-spin asymmetry generated in the scattering of transversely polarized electrons from unpolarized nucleons is an observable related to the imaginary part of the two-photon exchange process. We report a 2% precision measurement of the beam-normal single-spin asymmetry in elastic electron-proton scattering with a mean scattering angle of θ_{lab}=7.9° and a mean energy of 1.149 GeV. The asymmetry result is B_{n}=-5.194±0.067(stat)±0.082 (syst) ppm. This is the most precise measurement of this quantity available to date and therefore provides a stringent test of two-photon exchange models at far-forward scattering angles (θ_{lab}→0) where they should be most reliable.

Detection and Quantification of Clostridium perfringens and Eimeria spp. in Poultry Dust Using Real-Time PCR Under Experimental and Field Conditions

Infection of poultry with Eimeria spp., the causative agent of coccidiosis, can predispose birds to necrotic enteritis (NE) caused by netB gene-positive strains of Clostridium perfringens. The detection of Eimeria spp., C. perfringens, and netB were examined in settled dust from broiler flocks under experimental and field conditions. Dust samples were collected from settle plates twice weekly from two experimental flocks inoculated with three species of pathogenic Eimeria in 9-day-old chicks, followed by netB gene-positive C. perfringens 5 days later to produce subclinical and clinical NE. A noninoculated flock was sampled weekly from day 0 and served as a control flock. An additional 227 dust samples from commercial broiler flocks were collected at the end-of-batch (6-7 wk of age; one scraped dust sample per flock). In the NE-subclinical and NE-clinical flocks, high levels of Eimeria spp. and C. perfringens were detected after inoculation followed by a gradual decline over time. In the control flock, C. perfringens and netB were detected at low levels. No significant effect of sampling location was evident on Eimeria spp., C. perfringens, and netB load within poultry houses. These results provide evidence that Eimeria spp., C. perfringens, and netB gene copies can be readily measured in poultry dust samples collected in settle plates and may provide an alternative sampling method for monitoring flock coccidiosis and NE status. Further studies are required to assess the utility for such a test in commercial flocks.

Influence of meat and bone meal, phytase, and antibiotics on broiler chickens challenged with subclinical necrotic enteritis: 2. intestinal permeability, organ weights, hematology, intestinal morphology, and jejunal gene expression

Undigested proteins entering the hindgut may favor the proliferation of Clostridium perfringens. Using phytase to eliminate the need for meat and bone meal (MBM) as a P source may reduce potential infection with C. perfringens. A study was conducted to determine the impact of MBM, phytase, and antibiotics (AB) on intestinal permeability and morphology, organ weights, and jejunal gene expression in Ross 308 chickens challenged with subclinical necrotic enteritis (NE). Male Ross 308-day-old chicks (672 each) were randomly allocated to 8 treatments with 6 replicate pens each housing 14 birds. A 2 × 2 × 2 factorial arrangement of treatments was used: MBM (no or yes); AB (no or yes-Zn bacitracin 100 in S and 50 ppm in G/F and salinomycin Na 60 ppm in all phases); phytase (500 or 1,500 FTU/kg, both using 500 FTU matrix values) using wheat-SBM-canola meal diets. Birds were challenged with Eimeria spp on day 9, and C. perfringens strain EHE-NE18 on day 14 and 15. An AB × MBM interaction (P < 0.05) was detected for relative gizzard weight (with contents) being lower in birds fed MBM and AB compared to those fed MBM and no AB. A MBM × AB interaction (P > 0.01) was detected for lymphocyte counts being lower with MBM and AB compared to MBM without AB. A phytase × AB interaction (P < 0.05) was observed for villi length being increased with high phytase and no AB compared to with AB. Inclusion of MBM increased (P < 0.05) blood FICT-d concentration, whereas AB decreased it (P < 0.05). Antibiotics increased RBC (P < 0.05), Hgb (P < 0.05), and PCV (P < 0.05) and expression of Ca-binding protein, CALB1 (P > 0.05). Inclusion of MBM decreased expression of MUC2 (P < 0.05). Results indicate that dietary MBM has a detrimental effect on gut health of broilers but this may be counteracted using AB.

Two different Clostridium perfringens strains produce different levels of necrotic enteritis in broiler chickens

Subclinical necrotic enteritis (NE) is primarily caused by the gram-positive bacterium, Clostridium perfringens (Cp). The trend towards removal of in-feed antimicrobials and subsequent increased emergence of infection in poultry has resulted in a wide interest in better understanding of the mechanism behind this disease. The virulence of NE, to a large extent, depends on the virulence of Cp strains. Thus, this study was to assess how 2 different strains of Cp affect performance and gut characteristics of broiler chickens. Ross 308 male broilers (n = 468) were assigned to a 2 × 3 factorial arrangement of treatments with antibiotics (Salinomycin at 72 ppm and zinc bacitracin at 50 ppm -, or +) and challenge (non-challenge, Cp EHE-NE18, or Cp WER-NE36). Oral administration of Eimeria oocysts (day 9) followed by inoculation with 1 mL 108 CFU Cp strains (day 14 and 15) were used to induce NE. Broiler performance was analyzed at day 10, 24, and 35. On day 16, intestinal lesion score and intestinal pH were evaluated and samples of cecal content were analyzed for bacterial counts and short-chain fatty acid concentrations (SCFA). Birds in both challenged groups showed higher feed conversion ratio (FCR), lower weight gain (P < 0.001), increased lesion scores in the jejunum (P < 0.01), and reduced pH in the ileum and cecum (P < 0.01), compared to the non-challenged birds. They also showed decreased numbers of Bacillus spp. (P < 0.001), and Ruminococcus spp. (P < 0.01) in the cecal content. On day 35, the NE36 challenged birds had a lower weight gain (P < 0.001) and higher FCR (P < 0.001) compared to the NE18 challenged birds. Interestingly, cecal Lactobacillus and lactate were increased by the NE challenge (P < 0.001), and to a greater extent in birds challenged with NE36 compared to the NE18 strain (P < 0.001). This study suggests that Cp strains varying in virulence produce different levels of disease in broiler chickens through modulating the gut environment, intestinal microbiota, and SCFA profile to different extents.

Cardiac arrest and sudden cardiac death registries: a systematic review of global coverage

Background

Sudden cardiac death (SCD) is a major global health problem, accounting for up to 20% of deaths in Western societies. Clinical quality registries have been shown in a range of disease conditions to improve clinical management, reduce variation in care and improve outcomes.

Aim

To identify existing cardiac arrest (CA) and SCD registries, characterising global coverage and methods of data capture and validation.

Methods

Biomedical and public search engines were searched with the terms ‘registry cardio*’; ‘sudden cardiac death registry’ and ‘cardiac arrest registry’. Registries were categorised as either CA, SCD registries or ‘other’ according to prespecified criteria. SCD registry coordinators were contacted for contemporaneous data regarding registry details.

Results

Our search strategy identified 49 CA registries, 15 SCD registries and 9 other registries (ie, epistries). Population coverage of contemporary CA and SCD registries is highly variable with registries densely concentrated in North America and Western Europe. Existing SCD registries (n=15) cover a variety of age ranges and subpopulations, with some enrolling surviving patients (n=8) and family members (n=5). Genetic data are collected by nine registries, with the majority of these (n=7) offering indefinite storage in a biorepository.

Conclusions

Many CA registries exist globally, although with inequitable population coverage. Comprehensive multisource surveillance SCD registries are fewer in number and more challenging to design and maintain. Challenges identified include maximising case identification and case verification.

Trial registration number

CRD42019118910.