799 Do Not Attempt Cardiopulmonary Resuscitation Decisions in Neck of Femur Fractures – Is Documentation Adequate?

Introduction

‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) documentation is essential to communicate decisions regarding ceilings of care for patients to the clinical team. Patients admitted to hospital with a fractured neck of femur (#NOF) are often elderly with multiple comorbidities, and so robust and clear anticipatory care plans are especially indicated.

Method

All patients admitted to a large district general hospital in Scotland with a #NOF over a three-week period between 23/10/2020 and 12/11/2020 were identified prospectively and included in this audit. Patients’ demographic information, DNACPR status and the quality of their DNACPR documentation was recorded.

Results

20 patients (85% Female, 15% Male) were identified and included. Median ASA grade was 3, with 77.8% of patients ASA grade 3 or 4. 63.2% of patients had DNACPR documentation in place, all of which were ASA grade 3 or above. Most DNACPR documentation had patient information clearly identifiable (91.7%), was completed preoperatively (90.9%), and involved either the patient or appropriate relative or power of attorney (91.6%). However, only 75% of patients’ documentation had the rationale for the DNACPR decision documented and only 25% of DNACPR decisions were reviewed by a senior clinician within 72 hours. No DNACPR decisions were documented as having been communicated to the wider healthcare team.

Conclusions

DNACPR documentation is a crucial for anticipatory care planning in #NOF patients. This audit shows improvement is needed in documenting whether decisions have been reviewed by senior clinicians, and if they have been communicated to the wider healthcare team.

Anxiety disorders in people with learning disabilities: a review of literature

People with learning disabilities experience anxiety disorders, as do the general population. Many studies have highlighted the incidence of anxiety disorders in this population, but they have fallen short of addressing prevalence and issues associated with anxiety disorders and its impact. This paper brings together major published studies of anxiety disorder on people with learning disabilities. Its purpose is to raise awareness among health professionals in the field of learning disabilities, and to highlight the need for continued research to address this issue effectively.

Pethia sanjaymoluri, a new species of barb (Teleostei: Cyprinidae) from the northern Western Ghats, India

Pethia sanjaymoluri, a new cyprinid, is described from the Pavana and Nira tributaries of Bhima River, Krishna drainage, Maharashtra, India. It can be distinguished from congeners by a combination of characteristics that includes an incomplete lateral line, absence of barbels, upper lip thick and fleshy, 23-25 lateral series scales, 7-12 lateral-line pored scales, 10 predorsal scales, 11-14 prepelvic scales, 17-20 pre-anal scales, 4½ scales between dorsal-fin origin and lateral line, four scales between lateral line and pelvic-fin origin, 8-15 pairs of serrae on distal half of dorsal-fin spine, 12-14 branched pectoral-fin rays, 4 + 26 total vertebrae, 4 + 5 predorsal vertebrae, 4 + 13 abdominal vertebrae, 13 caudal vertebrae and a unique colour pattern comprising a humeral spot positioned below the lateral line and encompassing the third and fourth lateral-line scales and one scale below, one caudal spot on 17th-21st lateral-line scales with a yellow hue on its anterior side and apical half of dorsal fin studded with melanophores making the fin tip appear black. Genetic analysis based on the mitochondrial cytochrome b gene sequence suggests that the species is distinct from other known species of Pethia for which data are available.

Abstract P6-08-12: Gains in women’s education has not led to commensurate gains in seeking health-care early in breast cancer patients in urban India

Introduction:

Breast cancer is the leading cancer diagnosed in urban Indian women. Historically the proportion of women presenting with advanced disease has been in excess of 50% at most regional cancer centres. The past 20 years has witnessed rapid economic growth and urbanization with significant gains in women's education and access to health. However, it is not clear if this has translated to earlier seeking of care in the educated.

The aim of this study was to examine if higher education (College) was a determinant in the time of seeking first medical consultation, and whether there were significant differences between women under the age of 40 versus women over 60 years old at the time of diagnosis.

Methods:

The data for analysis were obtained from a prospective longitudinal observational study conducted between 2008-2013 at a medical teaching hospital and a tertiary specialized cancer care centre. A total of 460 patients have been enrolled so far. All patients provided informed consent and the study has been reviewed and approved by the institutional ethics committees at these institutions. We have collected from the patients and their medical records information about their age at diagnosis, educational level, stage of disease, histopathology reports and clinical details.

Results:

Data from 194 patients have been used for the analysis. Patients were divided into one group of < = 40Y of age (Group I, N = 58) and the second of > = 60 years of age (Group II, N = 136). Mean age at presentation for the groups was 35 and 68 years respectively. As expected almost 1.5 times as many women under the age of 40 (36%) were college educated compared to the women over 60 (22%) (p = 0.05). The proportion of LABC in the two groups was not different with group I having 27% and group II 25%. The proportion of older women with LABC and a college degree was 20%. However, rather than the expected decrease in proportion of women with high education and LABC, 31% of young women with LABC had a college degree. LABC in the college educated was not different in the group I when compared to group II. (p = 0.39).

Conclusion:

The determinants of seeking health care are complex and influenced by a variety of factors including socio-economic status, access to health care, education, cultural beliefs, and personal preferences. While urban India's steady economic growth has been highlighted by the scholarly as well as the lay press, the data presented here suggest that there is not an automatic and linear transfer between education, economics and healthcare seeking behaviours. We suggest that while a lot of attention has been paid to awareness and screening, we may need to focus on local cultural factors, and perhaps provide support from female counsellors and care providers as critical components of attempting to bring our women to the hospital at the earliest.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-08-12.

Family carers' perspectives on post-school transition of young people with intellectual disabilities with special reference to ethnicity

BACKGROUND

School leavers with intellectual disabilities (ID) often face difficulties in making a smooth transition from school to college, employment or more broadly to adult life. The transition phase is traumatic for the young person with ID and their families as it often results in the loss of friendships, relationships and social networks.

METHOD

The aim of this study was to explore the family carers' views and experiences on transition from school to college or to adult life with special reference to ethnicity. Forty-three families (consisting of 16 White British, 24 Pakistani, 2 Bangladeshi and one Black African) were interviewed twice using a semi-structured interview schedule. The carers were interviewed twice, Time 1 (T1) and Time 2 (T2), T2 being a year later to observe any changes during transition.

RESULTS

The findings indicate that although transition planning occurred it was relatively later in the young person's school life. Parents were often confused about the process and had limited information about future options for their son or daughter. All family carers regardless of ethnicity, reported lack of information about services and expressed a sense of being excluded. South Asian families experienced more problems related to language, information about services, culture and religion.

CONCLUSIONS

The majority of families lacked knowledge and awareness of formal services and the transition process. Socio-economic status, high levels of unemployment and caring for a child with a disability accounted for similar family experiences, regardless of ethnic background. The three key areas relevant for ethnicity are interdependence, religion and assumptions by service providers.

Evaluation and comparison of the internal fit and marginal accuracy of base metal (nickelchromium) and zirconia copings before and after ceramic veneering: a sem study

This study compares the internal fit and marginal adaptation of copy milled Zirconia copings with Nickel-Chromium (Ni-Cr) copings fabricated using a lost wax technique before and after ceramic veneering. A standardized metal master die simulating a prepared crown was fabricated and twenty impressions of the metal die were made and poured with die stone. Wax patterns were made on ten dies and cast while light cure resin patterns were made on the other ten dies for copy milling the Zirconia copings. Five specimens from each group were subjected to ceramic veneering. All the test specimens were luted on to the fresh dies, embedded in dental plaster, sectioned and image analysis done using scanning electron microscopy. Thereafter statistical analysis is done using student t-test. The linear measurements for internal fit and marginal discrepancy were increased for Zirconia compared with Ni-Cr copings. The difference in the values of all the specimens of all the groups were not statistically significant (P > 0.05) except the values comparing the internal fit of Zirconia and Ni-Cr copings before ceramic veneering (P < 0.001) which was statistically significant. The internal fit and marginal adaptability of Ni-Cr copings were found to be better than the Copy milled Zirconia copings but internal fit and marginal adaptability deteriorated after ceramic veneering.

Rhinosporidiosis on HIV - a case report

Rhinosporidiosis is a chronic disease that classically presents with the involvement of nose and nasopharynx. However, it can be present in various other sites including conjunctiva, vulva, vagina, larynx and scalp. We report a case with a Rhinosporidial mass in the nose extending to oropharynx and multiple cutaneous lesions of Rhinosporidiosis in a patient with HIV, This case is the first of its kind where HIV has been associated with Rhinosporidiosis.

First evidence of pep solar neutrinos by direct detection in Borexino

We observed, for the first time, solar neutrinos in the 1.0-1.5 MeV energy range. We determined the rate of pep solar neutrino interactions in Borexino to be 3.1±0.6{stat}±0.3{syst}  counts/(day·100  ton). Assuming the pep neutrino flux predicted by the standard solar model, we obtained a constraint on the CNO solar neutrino interaction rate of <7.9  counts/(day·100  ton) (95% C.L.). The absence of the solar neutrino signal is disfavored at 99.97% C.L., while the absence of the pep signal is disfavored at 98% C.L. The necessary sensitivity was achieved by adopting data analysis techniques for the rejection of cosmogenic {11}C, the dominant background in the 1-2 MeV region. Assuming the Mikheyev-Smirnov-Wolfenstein large mixing angle solution to solar neutrino oscillations, these values correspond to solar neutrino fluxes of (1.6±0.3)×10{8}  cm{-2} s^{-1} and <7.7×10{8}  cm{-2} s{-1} (95% C.L.), respectively, in agreement with both the high and low metallicity standard solar models. These results represent the first direct evidence of the pep neutrino signal and the strongest constraint of the CNO solar neutrino flux to date.

Precision measurement of the (7)Be solar neutrino interaction rate in Borexino

The rate of neutrino-electron elastic scattering interactions from 862 keV (7)Be solar neutrinos in Borexino is determined to be 46.0±1.5(stat)(-1.6)(+1.5)(syst) counts/(day·100  ton). This corresponds to a ν(e)-equivalent (7)Be solar neutrino flux of (3.10±0.15)×10(9)  cm(-2) s(-1) and, under the assumption of ν(e) transition to other active neutrino flavours, yields an electron neutrino survival probability of 0.51±0.07 at 862 keV. The no flavor change hypothesis is ruled out at 5.0 σ. A global solar neutrino analysis with free fluxes determines Φ(pp)=6.06(-0.06)(+0.02)×10(10)  cm(-2) s(-1) and Φ(CNO)<1.3×10(9)  cm(-2) s(-1) (95% C.L.). These results significantly improve the precision with which the Mikheyev-Smirnov-Wolfenstein large mixing angle neutrino oscillation model is experimentally tested at low energy.

External quality assessment of smear microscopy by the National Reference Laboratory in nine states of India

The quality of sputum smear microscopy in nine Intermediate Reference Laboratories (IRLs) was assessed based on onsite evaluation conducted by the National Reference Laboratory (NRL) in India, which supervises the IRLs for external quality assessment. The IRLs were evaluated, problems were identified, causes were explored and remedial actions were suggested. The NRL reports and feedback from the states were evaluated. Of the corrective actions recommended during the initial NRL evaluation visits, 65% were implemented within a month. Subsequent visits to seven IRLs showed 80% improvement. The NRL suggestions resulted in immediate corrective actions and had a sustained impact.

Gestational trophoblastic neoplasia: are we compliant with the standards?

This study was conducted to assess the management of gestational trophoblastic diseases (GTN) in a district general hospital in accordance with the RCOG guidelines. A retrospective case notes review over a 5-year period found a total of 23 patients treated in this hospital. The annual incidence of hydatidiform mole was 1.3/1,000 deliveries (3,500 deliveries per annum). Ultrasound scanning diagnosed or suspected GTN in only nine of the 23 cases (39%); six women (26%) were diagnosed as missed miscarriage and another six (26%) were diagnosed as incomplete miscarriage. Eleven patients (48%) were not suspected before histological diagnosis. A total of 16 of the 23 cases (70%) were complete moles and the rest were partial moles; 19 of the 23 (83%) were referred to a specialist centre of which 60% were referred within 1 month. The rest were not documented. Contraceptive advice was documented only in 11 case notes (48%). Women with molar pregnancy should be referred to a specialist centre as early as possible and within 2-4 weeks of histological diagnosis, after appropriate counselling and contraceptive advice.

Hypersharp resonant capture of neutrinos as a laboratory probe of the Planck length

The 18.6 keV antineutrino (nue) line from the two-body decay of 3H in crystals can be emitted with a natural width because of motional averaging by lattice vibrations despite the very long lifetime of 3H and contrary to commonly held views of linewidths in such a case. It can be resonantly captured in 3He with geometrical cross section sigma approximately 10(-17) cm2. Using its hypersharp sensitivity DeltaE/E approximately 10(-29) and the method of "time-filtered" resonance, the basic energy width approximately 10(-24) eV expected of the 3H state can be measured to test if ultimate nuclear widths are limited by the Planck length rather than time-energy uncertainty.

Mechanical properties of tricalcium phosphate single crystals grown by molten salt synthesis

Mechanical properties of flux-grown tricalcium phosphate (TCP) single crystals ranging in size from 50 to 75microm have been characterized by performing micro- and nanoindentation on their facets. Notwithstanding the inherent brittleness and anisotropy, these single crystals exhibit nanoscale plasticity in the form of pile-up around the edges of indents. A similar plastic response was observed in hydroxyapatite (HA) single crystals during nanoindentation in an earlier study. The hardness and elastic modulus obtained during nanoindentation are discussed in comparison with the polycrystalline forms of both TCP and HA found in the literature. The indentation fracture toughness values of TCP single crystals were found to be higher than those of HA single crystals. The higher values are attributed not only to the difference in crystal structure and corresponding differences in surface energy, but also to extensive crack bridging by ligament formation across crack faces during crack propagation.

Direct measurement of the 7Be solar neutrino flux with 192 days of borexino data

We report the direct measurement of the 7Be solar neutrino signal rate performed with the Borexino detector at the Laboratori Nazionali del Gran Sasso. The interaction rate of the 0.862 MeV 7Be neutrinos is 49+/-3stat+/-4syst counts/(day.100 ton). The hypothesis of no oscillation for 7Be solar neutrinos is inconsistent with our measurement at the 4sigma C.L. Our result is the first direct measurement of the survival probability for solar nu(e) in the transition region between matter-enhanced and vacuum-driven oscillations. The measurement improves the experimental determination of the flux of 7Be, pp, and CNO solar nu(e), and the limit on the effective neutrino magnetic moment using solar neutrinos.

Neuropathogenesis of chimeric simian/human immunodeficiency virus infection in pig-tailed and rhesus macaques

We recently reported that a chimeric simian/human immunodeficiency virus (SHIVKU-1) developed in our laboratory caused progressive depletion of CD4+ T lymphocytes and AIDS within 6 months of inoculation into pig-tailed macaques (M. nemestrina). None of the pig-tailed macaques showed productive SHIV infection in the central nervous system (CNS). In this report, we show that by further passage of the pathogenic virus in rhesus macaques [M. mulatta], we have derived a new strain of SHIV (SHIVKU-2) that has caused AIDS and productive CNS infection in 3 of 5 rhesus macaques infected with the virus. Productive replication of SHIV in the CNS was clearly shown by high infectivity titers and p27 protein levels in brain homogenates, and in 2 of the 3 rhesus macaques this was associated with disseminated, nodular, demyelinating lesions, including focal multinucleated giant cell reaction, largely confined to the white matter. These findings were reminiscent of HIV-1 associated neurological disease, and our immunohistochemical and in situ hybridization data indicated that the neuropathological lesions were associated with the presence of SHIV-specific viral antigens and nucleic acid respectively. However, the concomitant reactivation of opportunistic infections in these macaques suggested that such pathogens may have influenced the replication of SHIV in the CNS, or modified the neuropathological sequelae of SHIV infection in the rhesus species, but not in pig-tailed macaques. Our findings in the two species of macaques highlight the complexities of lentiviral neuropathogenesis, the precise mechanisms of which are still elusive.

Probing the temperature profile of energy production in the sun

The particle kinetic energies of thermonuclear pp fusion in the Sun (Gamow energy) produce small changes in the energies of pp solar neutrinos relative to those due only to exothermal energetics. This effect may be observable via the unique tools of the LENS solar neutrino detector. The temperature profile of energy production in the Sun may thus be directly probed for the first time.

Manifestations of SIV-induced ocular pathology in macaque monkeys

Simian immunodeficiency virus has been shown to cause acquired immunodeficiency syndrome in macaque monkeys. Data gathered from clinical examination and fundus photography have shown that the lentivirus is capable of the induction of choroidal lesions and retinal hemorrhages in the macaque. These findings demonstrate the potential value of the macaque monkey eye as a model of the retinal pathology routinely seen in human AIDS patients.

Hemopneumothorax in a COPD patient treated with noninvasive positive pressure ventilation: the risk of attendant anticoagulation

Noninvasive positive pressure ventilation (NIPPV) modalities have been proven to be effective in the setting of exacerbations of chronic obstructive pulmonary disease (COPD). Reported complications include pneumothorax, increased work of breathing, gastric distension and air embolism. This case demonstrates that patients with severe COPD on anticoagulant therapy are potentially at risk for the serious complication of combined lung barotrauma and hemorrhage while on acute NIPPV therapy. This is the first reported case of hemopneumothorax complicating NIPPV therapy.