Whole-Genome sequencing in routine Mycobacterium bovis epidemiology - scoping the potential

Mycobacterium bovis the main agent of bovine tuberculosis (bTB), presents as a series of spatially-localised micro-epidemics across landscapes. Classical molecular typing methods applied to these micro-epidemics, based on genotyping a few variable loci, have significantly improved our understanding of potential epidemiological links between outbreaks. However, they have limited utility owing to low resolution. Conversely, whole-genome sequencing (WGS) provides the highest resolution data available for molecular epidemiology, producing richer outbreak tracing, insights into phylogeography and epidemic evolutionary history. We illustrate these advantages by focusing on a common single lineage of M. bovis (1.140) from Northern Ireland. Specifically, we investigate the spatial sub-structure of 20 years of herd-level multi locus VNTR analysis (MLVA) surveillance data and WGS data from a down sampled subset of isolates of this MLVA type over the same time frame. We mapped 2108 isolate locations of MLVA type 1.140 over the years 2000-2022. We also mapped the locations of 148 contemporary WGS isolates from this lineage, over a similar geographic range, stratifying by single nucleotide polymorphism (SNP) relatedness cut-offs of 15 SNPs. We determined a putative core range for the 1.140 MLVA type and SNP-defined sequence clusters using a 50 % kernel density estimate, using cattle movement data to inform on likely sources of WGS isolates found outside of core ranges. Finally, we applied Bayesian phylogenetic methods to investigate past population history and reproductive number of the 1.140 M. bovis lineage. We demonstrate that WGS SNP-defined clusters exhibit smaller core ranges than the established MLVA type - facilitating superior disease tracing. We also demonstrate the superior functionality of WGS data in determining how this lineage was disseminated across the landscape, likely via cattle movement and to infer how its effective population size and reproductive number has been in flux since its emergence. These initial findings highlight the potential of WGS data for routine monitoring of bTB outbreaks.

Managing magnets: An audit of introduction of the Royal College of Emergency Medicine Best Practice Guideline

AIM

To evaluate management of children and young people presenting to the Emergency Department (ED) with magnet ingestion before and after new guidance.

METHODS

In May 2021, a National Patient Safety Agency and Royal College of Emergency Medicine (RCEM) Best Practice Guideline about management of ingested magnets was published. This was implemented in our department. Children and young people presenting after magnet ingestion were identified from SNOMED (coded routinely collected data) and X-ray requests between January 2016 and March 2022. Management was compared to national guidance.

RESULTS

There were 138 patient episodes of magnet ingestion, with a rising incidence over the 5-year period. Following introduction of the guideline, there was a higher incidence of admission (36% vs. 20%) and operative intervention (15.7% vs. 8%). Use of follow-up X-ray increased from 56% to 90%. There was substantial variation in the management prior to guidance which reduced after introduction of the RCEM guidance.

CONCLUSION

Management of magnet ingestion has become more standardised since introduction of the National RCEM Best Practice Guideline, but there is still room for improvement.

The Sheen Paajanen grOin Recommended Treatment 'SPoRT' score for groin pain

INTRODUCTION

Evaluating groin pain still evades many clinicians at times as they have difficulty determining the cause of pain when no true hernia exists. This study's aim was to evaluate a simple and novel scoring system which is reproducible, to help determine whether conservative measures or surgery is recommended for the management of groin pain attributable to inguinal disruption.

MATERIAL & METHODS

A retrospective analysis of all patients from 2018 to 2020 that underwent surgery or conservative management for inguinal disruption with at least a 1-year follow-up were evaluated. The scoring system is based on MRI and ultrasound imaging as well as clinical findings, with scores given from - 2 to + 2 based on the defined findings listed. A maximum total of four points scored for each assessment was used. Sensitivity and specificity analysis was conducted for each potential score cut off point.

RESULTS

A total of 172 patients were evaluated with 33 patients (19%) undergoing conservative management and 139 patients (81%) undergoing surgery. The median SPoRT score for the surgery group was 2.0 (1.0, 3.0), and - 1.0 (- 3.0, 0.0) in the physiotherapy group which was a significant difference (p < 0.001). An optimal cut off of ≤ 0 for physio and ≥ 1 for surgery was established, yielding a sensitivity of 90.9% (95% CI 75.7%-98.1%), a specificity of 89.2% (95% CI 82.8%-93.8%) and an area under the curve (AUC) of 0.936 (95% CI 0.874-0.997).

DISCUSSION

SPoRT score of ≤ 0 can recommend a patient should undergo conservative measures or physiotherapy as a mainstay of treatment with a score of ≥ 1 recommending surgery. Further validation of the score is necessary.

The Blunt Liver and Spleen Trauma (BLAST) audit: national survey and prospective audit of children with blunt liver and spleen trauma in major trauma centres

PURPOSE

To compare the reported and observed management of UK children with blunt liver or spleen injury (BLSI) to the American Pediatric Surgical Association (APSA) 2019 BLSI guidance.

METHODS

UK Paediatric Major Trauma Centres (pMTCs) undertook 1 year of prospective data collection on children admitted to or discussed with those centres with BLSI and an online questionnaire was distributed to all consultants who care for children with BLSI in those centres.

RESULTS

All 21/21 (100%) pMTCs participated; 131 patients were included and 100/152 (65%) consultants responded to the survey. ICU care was reported and observed to be primarily determined using haemodynamic status or concomitant injuries rather than injury grade, in accordance with APSA guidance. Bed rest was reported to be determined by grade of injury by 63% of survey respondents and observed in a similar proportion of patients. Contrary to APSA guidance, follow-up radiological assessment of the injured spleen or liver was undertaken in 44% of patients before discharge and 32% after discharge, the majority of whom were asymptomatic.

CONCLUSIONS

UK management of BLSI differs from many aspects of APSA guidance. A shift towards using clinical features to determine ICU admission and readiness for discharge is demonstrated, in line with a strong evidence base. However, routine bed rest and re-imaging after BLSI is common, contrary to APSA guidance. This disparity may exist due to concern that evidence around the incidence, presentation and natural history of complications after conservatively managed BLSI, particularly bleeding from pseudoaneurysms, is weak.

Genomic epidemiology of Mycobacterium bovis infection in sympatric badger and cattle populations in Northern Ireland

Bovine tuberculosis (bTB) is a costly, epidemiologically complex, multi-host, endemic disease. Lack of understanding of transmission dynamics may undermine eradication efforts. Pathogen whole-genome sequencing improves epidemiological inferences, providing a means to determine the relative importance of inter- and intra-species host transmission for disease persistence. We sequenced an exceptional data set of 619 Mycobacterium bovis isolates from badgers and cattle in a 100 km² bTB 'hotspot' in Northern Ireland. Historical molecular subtyping data permitted the targeting of an endemic pathogen lineage, whose long-term persistence provided a unique opportunity to study disease transmission dynamics in unparalleled detail. Additionally, to assess whether badger population genetic structure was associated with the spatial distribution of pathogen genetic diversity, we microsatellite genotyped hair samples from 769 badgers trapped in this area. Birth death models and TransPhylo analyses indicated that cattle were likely driving the local epidemic, with transmission from cattle to badgers being more common than badger to cattle. Furthermore, the presence of significant badger population genetic structure in the landscape was not associated with the spatial distribution of M. bovis genetic diversity, suggesting that badger-to-badger transmission is not playing a major role in transmission dynamics. Our data were consistent with badgers playing a smaller role in transmission of M. bovis infection in this study site, compared to cattle. We hypothesize, however, that this minor role may still be important for persistence. Comparison to other areas suggests that M. bovis transmission dynamics are likely to be context dependent, with the role of wildlife being difficult to generalize.

P52 Feasibility of “The Defect Study”: Neonatal diaphragmatic defect measurement and repair techniques in Congenital Diaphragmatic Hernia

Introduction

Defect size and closure technique in neonates with congenital diaphragmatic hernia (CDH) has long term consequences for morbidity in survivors. Although subjective operative reporting of defect size has been standardised, objective evaluation is lacking. There is no reported optimum closure technique related to size and position of diaphragmatic defect. We aimed to objectively describe diaphragmatic defects and repair methods at the time of neonatal CDH repair.

Methods

A national, three centre cohort feasibility study was undertaken over a 4-month period. Data collection was registered as service evaluation at participating centres. All surviving neonates with CDH undergoing defect closure were eligible. Anonymised data were collected using a RedCAP database. Data collection variables (n = 47) included both antenatal and postnatal measures. Data were checked for normality and reported as mean±SD or median (IQR).

Results

12 neonates were eligible for inclusion, 10 (83%) were included. Observed/Expected Lung Head Ratio (%) was reported in 5 cases (45±8), neonates were term, male (60%), birth weight (3.3±0.5kg). 80% of patients had a laparotomy, 80% had a left-sided defect, 60% a patch repair with PTFE and 60% graded defect size C. Poorly reported variables included pre-operative oxygenation and defect size was measured in 30%.

Discussion

Data collection through RedCAP was feasible and most variables were documented. Simplifying the intraoperative data collection form and providing clear instructions for taking measurements may improve reporting. A further pilot study with these modifications and improving engagement through advertisement, emails and online presence is intended to optimize the study before roll-out.

Tele-rehabilitation for people with dementia in the COVID-19 pandemic: A case-study

Introduction

The Promoting Activity, Independence and Stability in Early Dementia (PrAISED) is delivering an exercise programme for people with dementia. The Lincolnshire partnership NHS foundation Trust successfully delivered PrAISED through a video-calling platform during the COVID-19 pandemic.

Objectives

This qualitative case-study identified participants that video delivery worked for, and highlighted its benefits and challenges.

Methods

Interviews were conducted with participants with dementia, caregivers and therapists, and analysed through thematic analysis.

Results

Video delivery worked best when participants had a supporting carer, when therapists showed enthusiasm and had an established rapport with the client. Benefits included time-efficiency of sessions, enhancing participants’ motivation, caregivers’ dementia awareness and therapists’ creativity. Limitations included users’ poor IT skills and resources.

Conclusions

The COVID-19 pandemic required innovative ways of delivering rehabilitation. This study supports that people with dementia can use tele rehab, but success is reliant on having a caregiver and an enthusiastic and known therapist.

73 Using the Gold Standards Framework to Identify Opportunities for Advance Care Planning

Introduction

Departmental discharge data (January 2017–January 2018) suggested a high number of “Day 1 Deaths” i.e. an individual who was readmitted 24 hours after discharge, and subsequently died during their readmission. We wondered if this was due to a lack of Advance Care Planning (ACP).

Methods

We undertook a retrospective case note audit of 50 cases from the “readmissions who died” (total 176/7421) subgroup, to understand whether or not they were predictably within the last days, weeks or months of life and whether there was ACP in place. We reviewed all Day 1 Deaths (16/50), and a random selection of cases across the Day 2–30 (34/50) data set.

We used the Gold Standards Framework (GSF) as a prognostic tool, by use of the intuitive “surprise question” (“would you be surprised if this person died within the next days, weeks, months?”) and the disease-specific Prognostic Indictors (PI).

Results

Using the GSF we (retrospectively) predicted death in 94% of the Day 1 deaths and 63% of the Day 2–30 deaths.

There was evidence of ACP in 32/50 patients (64%), predominantly in the form of a DNAR CPR (61%). There was very little evidence of other forms of ACP.

Readmissions were justified on the basis of a medical condition in 100% of cases; this was infective in 60% (30/50).

There were few interactions with secondary care in the 12 months prior to death (mode was 2 admissions in the month prior to death, 4 in the 12 months prior to death).

Conclusions

We must consider our discharge processes and medical decision making at the front door.

A Prognostic indicator Tool would be useful to focus medical decision making.

We must recognise infections as end stage disease in advanced ill health, including advanced frailty.

We need to consider how we facilitate meaningful involvement of older people in their medical care towards the end of life.

Longitudinal dynamics of herd-level Mycobacterium bovis MLVA type surveillance in cattle in Northern Ireland 2003-2016

Investigating genetically-structured diversity in pathogen populations over time is important to better understand disease maintenance and spread. Herd-level surveillance of Mycobacterium bovis genotypes (multi-locus VNTR analysis types, MLVA types) from all culture-confirmed bovine tuberculosis (TB) herd cases was undertaken in Northern Ireland (NI), generating an unparalleled, longitudinal, population-level 14-year survey for this pathogen. Across this population, 295 genetically-distinct M. bovis MLVA types were identified in the 19,717 M. bovis isolates surveyed. Of these, the most frequent was MLVA type 002 (23.0%); 151 MLVA types were represented more than once, in groups ranging from 2 to 4438 isolates. Only 23 MLVA types were isolated in all 14 years. Investigating inter-annual frequency of M. bovis MLVA types, examples of statistically-significant expansions (MLVA types 002, 004, 006, 009 and 027), contractions (MLVA types 001, 007 and 011) and maintenance (MLVA types 003 and 005) were disclosed, during a period of fluctuating bovine TB herd-level incidence at the NI scale. The fixed period frequency distribution of MLVA types remained highly right-skewed. Novel VNTR copy number variant MLVA types (N = 242; an average of 17 per annum) were identified throughout the survey. The MLVA type distribution in the landscape was not random; MLVA types showed statistically-significant geographical localization and strong spatial associations with Divisional Veterinary Office (DVO) regions. There was also evidence of differential risk of particular MLVA types across breeds (Holstein/Friesian vs. other), age-class, and sex and some evidence of an association between the number of animals testing positive for bovine TB during the disclosing test and particular MLVA types, although there was substantial variation.

Assessment of concurrent infection with bovine viral diarrhoea virus (BVDV) and Mycobacterium bovis: A herd-level risk factor analysis from Northern Ireland

Bovine viral diarrhoea virus (BVDV) is a significant pathogen of cattle, leading to severe economic and animal-welfare impacts. Furthermore, the pathogen has been associated with impacting the progression or spread of other pathogens (e.g. Mycobacterium bovis, the causative agent of bovine tuberculosis (bTB)). During this study we investigated (i) risk factors for BVDV at a herd-level and (ii) whether there was any association between BVDV and herd-level bTB risk. The data for this study were gathered from a voluntary BVDV control programme in Northern Ireland (2013-2015) based on the identification of virus positive animals through tissue tag testing of calves. We assigned a herd-level BVDV status to 2827 participating herds, where a herd was assumed "infected" if one or more animals tested positive for BVDV. Two model suites were developed. Firstly, we assessed risk factors for BVDV herd status using multivariable logit random-effects modelling, aggregating to the calendar year level (2013-2015; n=4828; model 1). Secondly, we aggregated data across the three years of the study to give an overall status for the whole study period (n=2827; logistic model 2). Risk factors included year, herd-type, herd size, number of births, inward trade moves, calf mortality, and region. Furthermore, the herd-level bovine tuberculosis status (based on the single intradermal comparative cervical tuberculin (SICCT) test outcomes, or confirmation at post-mortem), or the size of bTB breakdowns (number of SICCT test positive animals), of herds was also investigated to assess whether there was an association (co-infection) with herd BVDV status. The final models suggested that BVDV herd status was positively associated with increased levels of calf mortality, herd size, number of births, the number of BVDV tests undertaken and the number of animals introduced to the herd. There was a significant univariable positive association between BVDV status, and SICCT breakdown risk, breakdown size and confirmed bTB status in model 2. However, there was no evidence of significant associations between bTB status (using SICTT status, confirmed status or herd breakdown size) and BVDV status in final multivariable models when controlling for other significant confounders. These results provide information for action for the future control and eradication of BVDV in Northern Ireland, though these data provide little support for the hypothesised association between BVDV and bTB status at herd-level. Further animal-level analyses are necessary to investigate whether there is support for a BVD-bTB co-infection association, including the impact of co-infection on the severity of infection.

Measurement of health-related quality of life for people with dementia: development of a new instrument (DEMQOL) and an evaluation of current methodology

OBJECTIVES

To develop and validate a psychometrically rigorous measure of health-related quality of life (HRQoL) for people with dementia: DEMQOL.

DATA SOURCES

Literature review. Expert opinion. Interviews and questionnaires.

REVIEW METHODS

Gold standard psychometric techniques were used to develop DEMQOL and DEMQOL-Proxy. A conceptual framework was generated from a review of the literature, qualitative interviews with people with dementia and their carers, expert opinion and team discussion. Items for each component of the conceptual framework were drafted and piloted to produce questionnaires for the person with dementia (DEMQOL) and carer (DEMQOL-Proxy). An extensive two-stage field-testing was then undertaken of both measures in large samples of people with dementia (n = 130) and their carers (n = 126) representing a range of severity and care arrangements. In the first field test, items with poor psychometric performance were eliminated separately for DEMQOL and DEMQOL-Proxy to produce two shorter, more scientifically robust instruments. In the second field test, the item-reduced questionnaires were evaluated along with other validating measures (n = 101 people with dementia, n = 99 carers) to assess acceptability, reliability and validity.

RESULTS

Rigorous evaluation in two-stage field testing with 241 people with dementia and 225 carers demonstrated that in psychometric terms: (1) DEMQOL is comparable to the best available dementia-specific HRQoL measures in mild to moderate dementia, but is not appropriate for use in severe dementia [Mini Mental State Examination (MMSE) <10]; and (2) DEMQOL-Proxy is comparable to the best available proxy measure in mild to moderate dementia, and shows promise in severe dementia. In addition, the DEMQOL system has been validated in the UK in a large sample of people with dementia and their carers, and it provides separate measures for self-report and proxy report, which allows outcomes assessment across a wide range of severity in dementia.

CONCLUSIONS

The 28-item DEMQOL and 31-item DEMQOL-Proxy provide a method for evaluating HRQoL in dementia. The new measures show comparable psychometric properties to the best available dementia-specific measures, provide both self- and proxy-report versions for people with dementia and their carers, are appropriate for use in mild/moderate dementia (MMSE >/= 10) and are suitable for use in the UK. DEMQOL-Proxy also shows promise in severe dementia. As DEMQOL and DEMQOL-Proxy give different but complementary perspectives on quality of life in dementia, the use of both measures together is recommended. In severe dementia, only DEMQOL-Proxy should be used. Further research with DEMQOL is needed to confirm these findings in an independent sample, evaluate responsiveness, investigate the feasibility of use in specific subgroups and in economic evaluation, and develop population norms. Additional research is needed to address the psychometric challenges of self-report in dementia and validating new dementia-specific HRQoL measures.

A method for the numerical assessment of sediment interceptors

The problems associated with the presence of sediments in sewers and stormwater drainage systems represent a major engineering challenge. Their accumulation can result in operational difficulties, including low restriction and premature overflows. Sediments themselves are known to contribute significantly to the polluting load of storm overflows. The use of sediment interceptors within sewer systems or downstream of stormwater intakes represents one way of alleviating these problems. A study of stormwater sediment interceptors using Computational Fluid Dynamics (CFD) has identified that the ability of a chamber to retain, as well as remove, sediments is an important performance characteristic. A methodology for the assessment of such characteristics using CFD is presented in the context of a study of different chamber types. This concludes that primitive chambers, for example, gully pots, are likely to be far more prone to flushing out during high flow inputs than advanced systems such as vortex separators.

Survival in a cohort of social services placements in nursing and residential homes: factors associated with life expectancy and mortality

The aim of this study was to examine the life expectancy of elderly people in nursing and residential care over a 20-month period and its relationship to specific risk factors. Using a retrospective cohort design, data obtained on 1888 residents placed between 1 July 1997 and 30 April 1999 in residential, nursing and dual registered homes within Nottingham Health Authority boundaries were examined. Additional data on physical and mental disability at placement were available for 514 residents. Main outcome measures comprised survival rate overall, and in relation to gender, age, home type (nursing, residential or dual), source of placement (hospital or community) and various disability factors.One-year survival rates were: overall, 66%; nursing homes, 59%; dual homes, 58%; and residential homes 76%. Median survival in nursing homes was 541 days, but was not reached in residential homes. Male gender, admission to nursing or dual registered homes, placement from hospital, decreased mobility and increased age were associated with decreased life expectancy. Although no association was found between length of survival and level of cognitive function, lack of cognitive impairment was associated with lower survival. In conclusion, mortality is high in nursing, dual and residential homes where life expectancy has been shown to be associated with gender, home type, origin of placement and mobility. Rates of survival are related to higher comorbidity and disability. Important data for planning and assessing care needs can be yielded through the analysis of mortality data.

Cross-cultural validation of the London Handicap Scale in Hong Kong Chinese

STUDY OBJECTIVE

To investigate the cross-cultural validity of London Handicap Scale in Hong Kong Chinese.

DESIGN

Ratings of the utility of 10 hypothetical health scenarios were given by groups of HK Chinese subjects. Measured scores were compared with calculated scores from published scale weights of London Handicap Scale, which were based on utility ratings made by UK subjects.

SETTING

A rehabilitation hospital in Hong Kong.

SUBJECTS

A total of 164 HK Chinese, comprising doctors, medical students, nonmedical hospital staff, geriatric day hospital stroke and nonstroke patients, community day-care centre elderly, old age hostel elderly, young disabled inpatients and young community-dwelling disabled citizens.

MAIN RESULTS

There was a close correlation between the mean scores of HK subjects and the calculated scores derived from the published UK scale weights, apart from one scenario (Pearson's correlation coefficient r = 0.87 p = 0.001). The correlations were high for all subgroups, between which there was good consensus. Measured utilities were significantly different between subgroups for only one scenario. For this scenario of moderate to severe handicap in mobility, physical dependence, occupation and social integration, but with excellent orientation and economic self sufficiency: (1) older age groups gave better scores than younger age groups (p < 0.0005); (2) subjects with poor subjective health status gave better scores than those with good subjective health status (p = 0.002); (3) subjects related to the medical or hospital field, i.e. doctors, medical students and nonmedical hospital staff, gave worse scores than other subject groups (p < 0.0005).

CONCLUSION

The concept of handicap applies across cultures. Perception of severity of selected real life handicap scenarios by HK Chinese were well estimated using scale weights from UK populations developed for the London Handicap Scale. Significant differences in perception of certain handicap scenarios by different population subgroups deserve further study.

Internal reflection sensors with high angular resolution

We discuss the use of total internal reflection for the production of sensors with high angular resolution. These sensors are intended for measurement of the angle between a sensor's axis and the direction to a source of radiation or reflecting object. Sensors of this type are used in controlling the position of machine parts in robotics and industry, orienting space vehicles and astronomic devices in relation to the Sun, and as autocollimators for checking angles of deviation. This kind of sensor was used in the Apollo space vehicle some 20 years ago. Using photodetectors with linear and area CCD arrays has opened up new application possibilities for appropriately designed sensors. A generalized methodology is presented applicable to a wide range of tasks. Some modifications that can improve the performance of the basic design are described.

A comparison of thiopentone and propofol with respect to the incidence of postoperative shivering

One hundred patients (69 female) undergoing surgical excision of three or more wisdom teeth were randomly allocated to receive either thiopentone or propofol for induction of anaesthesia. Other than the induction agent, the anaesthetic regimen was standardised for all cases. All patients were observed for 15 min after entry into the recovery area to assess the presence and intensity of shivering. Twenty-five patients in the thiopentone group (n = 50) and 11 patients in the propofol group shivered postoperatively (p < 0.005). There was no statistically significant difference in axillary temperature between shivering and non-shivering patients. The use of propofol as an induction agent is associated with a lower incidence of postoperative shivering than thiopentone.

The effect of desferrioxamine on fibroblasts and collagen formation in cell cultures

Iron is essential for the activity of proline hydroxylase and is an important co-factor in collagen synthesis. Fibroblast cultures exposed to desferrioxamine show impairment of DNA synthesis and reduced collagen formation, as measured by hydroxyproline synthesis and the deposition of hydroxyproline in the cell mat. In patients with transfusional iron overload long-term treatment with desferrioxamine is said to result in the inhibition of hepatic fibrosis. It is suggested that this may be a direct effect on collagen synthesis rather than an effect of reduced iron stores.