National Survey of Current Follow-up Protocols for Patients Treated for Endometrial Cancer in the UK

AIMS

The aim of this study was to establish a baseline of national practice for follow-up after treatment for endometrial cancer in the UK.

MATERIALS AND METHODS

An online cross-sectional survey was developed and distributed through the Royal College of Radiologists via an email link to the audit leads of radiotherapy centres in the UK. The survey was conducted from November 2021 to 5 January 2022. The main themes assessed in the survey were the form, frequency and duration of follow-up practices.

RESULTS

There were a total of 43/61 (70%) complete responses. 93% of centres had a standard follow-up protocol and 7% who did not have a follow-up protocol discharged patients after the post-operative review. Five centres (13%) used molecular profiling to inform follow-up practices. Patient-initiated follow-up was mainly used in the cohort of patients who had surgery alone with no adjuvant treatment (68%, (19/28)). In the cohort who had face-to-face follow-up, the majority had pelvic examinations as part of their review and total follow-up for five years. 93% of respondents are interested in a national follow-up protocol.

CONCLUSION

Our data shows that there is national variation in practise with regard to follow-up of women treated for endometrial cancer. Many of the follow-up practises are based on conventional follow-up regimens and these may fail to address the more holistic needs of cancer survivors. Recent publication of updated guidance from the British Gynaecological Cancer Society may help standardise practise and provide a more relevant approach to follow-up for women treated for endometrial cancer.

Emergency Department Pediatric Readiness: A Trauma Center Quality Improvement Initiative

BACKGROUND

Most pediatric patients present to general emergency departments, yet maintaining pediatric equipment, skilled staff, and resources remains a challenge for many hospitals. Pediatric readiness assessment is now a requirement for trauma center verification.

OBJECTIVE

This study aims to assess the impact of a quality improvement initiative to improve emergency department pediatric readiness.

METHODS

A pre- and poststudy design was used to evaluate a quality improvement initiative to improve the National Pediatric Readiness assessment survey results conducted at a Southwestern United States adult Level I trauma center from September 2022 to April 2023. The multicomponent initiative included implementing a pediatric emergency care coordinator, pediatric-specific policies and procedures, identifying pediatric-specific quality and performance indicators, and educating pediatric-specific staff. Study inclusion criteria were all patients younger than 18 years who presented to the emergency department. The primary outcome measure was the improvement in the weighted Pediatric Readiness Score. Secondary outcomes were throughput, nursing documentation of vital signs, and pain scores.

RESULTS

A total of N = 2,356 patients met inclusion, of which n = 1,158 (49.2%) were in the preintervention group and n = 1,198 (50.8%) postintervention group. The weighted Pediatric Readiness Score improved by 45.4%. Transfers to a pediatric hospital increased from 4.1% to 8.6% (p = .016). Blood pressure documentation improved slightly from 88.3% to 88.6%. Pain score documentation decreased from 83.9% to 63.1% (p = .008). Pain medication and administration improved from 19.8% to 26.7% (p = .046).

CONCLUSION

We found that participation in the quality improvement initiative was associated with emergency department pediatric readiness improvements.

Capnodynamic monitoring of lung volume and pulmonary blood flow during alveolar recruitment: a prospective observational study in postoperative cardiac patients

Alveolar recruitment manoeuvres may mitigate ventilation and perfusion mismatch after cardiac surgery. Monitoring the efficacy of recruitment manoeuvres should provide concurrent information on pulmonary and cardiac changes. This study in postoperative cardiac patients applied capnodynamic monitoring of changes in end-expiratory lung volume and effective pulmonary blood flow. Alveolar recruitment was performed by incremental increases in positive end-expiratory pressure (PEEP) to a maximum of 15 cmH2O from a baseline of 5 cmH2O over 30 min. The change in systemic oxygen delivery index after the recruitment manoeuvre was used to identify responders (> 10% increase) with all other changes (≤ 10%) denoting non-responders. Mixed factor ANOVA using Bonferroni correction for multiple comparisons was used to denote significant changes (p < 0.05) reported as mean differences and 95% CI. Changes in end-expiratory lung volume and effective pulmonary blood flow were correlated using Pearson's regression. Twenty-seven (42%) of 64 patients were responders increasing oxygen delivery index by 172 (95% CI 61-2984) mL min-1 m-2 (p < 0.001). End-expiratory lung volume increased by 549 (95% CI 220-1116) mL (p = 0.042) in responders associated with an increase in effective pulmonary blood flow of 1140 (95% CI 435-2146) mL min-1 (p = 0.012) compared to non-responders. A positive correlation (r = 0.79, 95% CI 0.5-0.90, p < 0.001) between increased end-expiratory lung volume and effective pulmonary blood flow was only observed in responders. Changes in oxygen delivery index after lung recruitment were correlated to changes in end-expiratory lung volume (r = 0.39, 95% CI 0.16-0.59, p = 0.002) and effective pulmonary blood flow (r = 0.60, 95% CI 0.41-0.74, p < 0.001). Capnodynamic monitoring of end-expiratory lung volume and effective pulmonary blood flow early in postoperative cardiac patients identified a characteristic parallel increase in both lung volume and perfusion after the recruitment manoeuvre in patients with a significant increase in oxygen delivery.Trial registration This study was registered on ClinicalTrials.gov (NCT05082168, 18th of October 2021).

Mediator Kinase Inhibition Impedes Transcriptional Plasticity and Prevents Resistance to ERK/MAPK-Targeted Therapy in KRAS-Mutant Cancers

Acquired resistance remains a major challenge for therapies targeting oncogene activated pathways. KRAS is the most frequently mutated oncogene in human cancers, yet strategies targeting its downstream signaling kinases have failed to produce durable treatment responses. Here, we developed multiple models of acquired resistance to dual-mechanism ERK/MAPK inhibitors across KRAS-mutant pancreatic, colorectal, and lung cancers, and then probed the long-term events enabling survival against this class of drugs. These studies revealed that resistance emerges secondary to large-scale transcriptional adaptations that are diverse and cell line-specific. Transcriptional reprogramming extends beyond the well-established early response, and instead represents a dynamic, evolved process that is refined to attain a stably resistant phenotype. Mechanistic and translational studies reveal that resistance to dual-mechanism ERK/MAPK inhibition is broadly susceptible to manipulation of the epigenetic machinery, and that Mediator kinase, in particular, can be co-targeted at a bottleneck point to prevent diverse, cell line-specific resistance programs.

Promising Practices Observed in High-Throughput COVID-19 Vaccination Sites in the United States, February-May 2021

Objectives. To identify promising practices for implementing COVID-19 vaccination sites. Methods. The Centers for Disease Control and Prevention (CDC) and Federal Emergency Management Agency (FEMA) assessed high-throughput COVID-19 vaccination sites across the United States, including Puerto Rico, after COVID-19 vaccinations began. Site assessors conducted site observations and interviews with site staff. Qualitative data were compiled and thematically analyzed. Results. CDC and FEMA conducted 134 assessments of high-throughput vaccination sites in 25 states and Puerto Rico from February 12 to May 28, 2021. Promising practices were identified across facility, clinical, and cross-cutting operational areas and related to 6 main themes: addressing health equity, leveraging partnerships, optimizing site design and flow, communicating through visual cues, using quick response codes, and prioritizing risk management and quality control. Conclusions. These practices might help planning and implementation of future vaccination operations for COVID-19, influenza, and other vaccine-preventable diseases. Public Health Implications. These practices can be considered by vaccination planners and providers to strengthen their vaccination site plans and implementation of future high-throughput vaccination sites. (Am J Public Health. 2023;113(8):909-918. https://doi.org/10.2105/AJPH.2023.307331).

When public health crises collide: 5 years of pediatric firearm injury prevention opportunities

Objectives

Prior publications on pediatric firearm-related injuries have emphasized significant social disparities. The pandemic has heightened a variety of these societal stresses. We sought to evaluate how we must now adapt our injury prevention strategies.

Patients and methods

Firearm-related injuries in children 15 years old and under at five urban level 1 trauma centers between January 2016 and December 2020 were retrospectively reviewed. Age, gender, race/ethnicity, Injury Severity Score, situation, timing of injury around school/curfew, and mortality were evaluated. Medical examiner data identified additional deaths.

Results

There were 615 injuries identified including 67 from the medical examiner. Overall, 80.2% were male with median age of 14 years (range 0-15; IQR 12-15). Black children comprised 77.2% of injured children while only representing 36% of local schools. Community violence (intentional interpersonal or bystander) injuries were 67.2% of the cohort; 7.8% were negligent discharges; and 2.6% suicide. Median age for intentional interpersonal injuries was 14 years (IQR 14-15) compared with 12 years (IQR 6-14, p<0.001) for negligent discharges. Far more injuries were seen in the summer after the stay-at-home order (p<0.001). Community violence and negligent discharges increased in 2020 (p=0.004 and p=0.04, respectively). Annual suicides also increased linearly (p=0.006). 5.5% of injuries were during school; 56.7% after school or during non-school days; and 34.3% were after legal curfew. Mortality rate was 21.3%.

Conclusions

Pediatric firearm-related injuries have increased during the past 5 years. Prevention strategies have not been effective during this time interval. Prevention opportunities were identified specifically in the preteenage years to address interpersonal de-escalation training, safe handling/storage, and suicide mitigation. Efforts directed at those most vulnerable need to be reconsidered and examined for their utility and effectiveness.

Level of evidence

Level III; epidemiological study type.

Evaluation of a complex intervention for prisoners with common mental health problems, near to and after release: the Engager randomised controlled trial

BACKGROUND

Many male prisoners have significant mental health problems, including anxiety and depression. High proportions struggle with homelessness and substance misuse.

AIMS

This study aims to evaluate whether the Engager intervention improves mental health outcomes following release.

METHOD

The design is a parallel randomised superiority trial that was conducted in the North West and South West of England (ISRCTN11707331). Men serving a prison sentence of 2 years or less were individually allocated 1:1 to either the intervention (Engager plus usual care) or usual care alone. Engager included psychological and practical support in prison, on release and for 3-5 months in the community. The primary outcome was the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), 6 months after release. Primary analysis compared groups based on intention-to-treat (ITT).

RESULTS

In total, 280 men were randomised out of the 396 who were potentially eligible and agreed to participate; 105 did not meet the mental health inclusion criteria. There was no mean difference in the ITT complete case analysis between groups (92 in each arm) for change in the CORE-OM score (1.1, 95% CI -1.1 to 3.2, P = 0.325) or secondary analyses. There were no consistent clinically significant between-group differences for secondary outcomes. Full delivery was not achieved, with 77% (108/140) receiving community-based contact.

CONCLUSIONS

Engager is the first trial of a collaborative care intervention adapted for prison leavers. The intervention was not shown to be effective using standard outcome measures. Further testing of different support strategies for prison with mental health problems is needed.

Determining a threshold measurement of endometrial thickness for asymptomatic postmenopausal women: A tertiary centre case series

BACKGROUND

An incidental finding of a thickened endometrium on ultrasound in the postmenopausal patient without bleeding is a common presentation to gynaecological services; however there is limited evidence to guide clinical practice as to when hysteroscopic evaluation and endometrial sampling is required.

AIMS

To determine the endometrial thickness at which endometrial sampling is indicated in asymptomatic postmenopausal women referred with thickened endometrium on ultrasound.

MATERIALS AND METHODS

A single-centre retrospective case series of postmenopausal women without bleeding undergoing hysteroscopy was conducted. Logistic regression was used to examine the association between a range of variables and pre-malignant or malignant pathology and endometrial thickness. The optimal endometrial thickness threshold was identified to maximise model sensitivity.

RESULTS

A total of 404 postmenopausal women were included in this study, having undergone a hysteroscopy at the study site between 1 July 2008 and 30 June 2018. The mean (SD) age of patients at presentation was 65 (9.09) years and the mean body mass index was 29.86 kg/m² (6.52). Of these women, nine (2.2%) were diagnosed with endometrial carcinoma and seven (1.7%) had endometrial hyperplasia with atypia. The most common histopathological finding was of a benign endometrial polyp (153: 37.9%). When including hyperplasia with or without atypia in histopathology of interest, a cut-off of ≥9 mm provides the greatest sensitivity (83.3%) and specificity (63.8%) for a diagnosis of pre-malignant or malignant pathology (classification accuracy of 64.8%; area under the receiver operating characteristic: 0.7358, 95% CI: 0.6439, 0.8278) in this cohort.

CONCLUSIONS

Using an endometrial thickness of ≥9 mm can be used as a cut-off for endometrial sampling in postmenopausal women without bleeding.

The tight rope act: A multicenter regional experience of tourniquets in acute trauma resuscitation

BACKGROUND

As tourniquets have become more prevalent, device use has been questioned. This study sought to characterize the incidence, indication, and efficacy of tourniquet placement in acute trauma resuscitation.

METHODS

Nine regional level 1 trauma centers prospectively enrolled for 12 months adult patients (18 years or older) who had a tourniquet placed. Age, sex, mechanism, tourniquet type, indication, applying personnel, location placed, level of occlusion, and degree of hemostasis were collected. Major vascular injury, imaging and operations performed, and outcomes were assessed. Analyses were performed with significance at p < 0.05.

RESULTS

A total of 216 tourniquet applications were reported on 209 patients. There were significantly more male patients (183 [88%]) and penetrating injuries (186 [89%]) with gunshots being most common (127 [61%]). Commercial tourniquets were most often used (205 [95%]). Ninety-two percent were placed in the prehospital setting (by fire/paramedics, 56%; police, 33%; bystanders, 2%). The most common indications were pooling (47%) and pulsatile (32%) hemorrhage. Only 2% were for amputation. The most frequent location was high proximal extremity (70%). Four percent were placed over the wound, and 0.5% were distal to the wound. Only 61% of applications were arterial occlusive. Median application time was 30 minutes (interquartile range, 20-40 minutes). Imaging was performed in 54% of patients. Overall, 36% had a named arterial injury. Tourniquet application failed to achieve hemostasis in 22% of patients with a named vascular injury. There was no difference in hemostasis between those with and without vascular injury (p = 0.12) or between who placed the tourniquet (p = 0.07). Seventy patients (34%) required vascular operations. Thirty-four percent of patients were discharged home without admission.

CONCLUSION

Discerning which injuries require tourniquets over pressure dressings remains elusive. Trained responders had high rates of superfluous and inadequate deployments. As tourniquets continue to be disseminated, emphasis should be placed on improving education, device development, and quality control.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, Level III.

CLAVATA modulates auxin homeostasis and transport to regulate stem cell identity and plant shape in a moss

The CLAVATA pathway is a key regulator of stem cell function in the multicellular shoot tips of Arabidopsis, where it acts via the WUSCHEL transcription factor to modulate hormone homeostasis. Broad-scale evolutionary comparisons have shown that CLAVATA is a conserved regulator of land plant stem cell function, but CLAVATA acts independently of WUSCHEL-like (WOX) proteins in bryophytes. The relationship between CLAVATA, hormone homeostasis and the evolution of land plant stem cell functions is unknown. Here we show that in the moss, Physcomitrella (Physcomitrium patens), CLAVATA affects stem cell activity by modulating hormone homeostasis. CLAVATA pathway genes are expressed in the tip cells of filamentous tissues, regulating cell identity, filament branching, plant spread and auxin synthesis. The receptor-like kinase PpRPK2 plays the major role, and Pprpk2 mutants have abnormal responses to cytokinin, auxin and auxin transport inhibition, and show reduced expression of PIN auxin transporters. We propose a model whereby PpRPK2 modulates auxin gradients in filaments to determine stem cell identity and overall plant form. Our data indicate that CLAVATA-mediated auxin homeostasis is a fundamental property of plant stem cell function, probably exhibited by the last shared common ancestor of land plants.

Feasibility of implementing systematic social needs assessment for children with medical complexity

Background

Children with medical complexity (CMC) have inter-related health and social needs; however, interventions to identify and respond to social needs have not been adapted for CMC. The objective of this study was to evaluate the feasibility of implementing social needs screening and assessment within pediatric complex care programs.

Methods

We implemented systematic social needs assessment for CMC (SSNAC) at two tertiary care centers in three phases: (1) pre-implementation, (2) implementation, and (3) implementation monitoring. We utilized a multifaceted implementation package consisting of discrete implementation strategies within each phase. In phase 1, we adapted questions from evidence-informed screening tools into a 21-item SSNAC questionnaire, and we used published frameworks to inform implementation readiness and process. In phases 2–3, clinical staff deployed the SSNAC questionnaire to parents of CMC in-person or by phone as part of usual care and adapted to local clinical workflows. Staff used shared decision-making with parents and addressed identified needs by providing information about available resources, offering direct assistance, and making referrals to community agencies. Implementation outcomes included fidelity, feasibility, acceptability, and appropriateness.

Results

Observations from clinical staff characterized fidelity to use of the SSNAC questionnaire, assessment template, and shared decision-making for follow-up on unmet social needs. Levels of agreement (5-point Likert scale; 1 = completely disagree; 5 = completely agree) rated by staff for key implementation outcomes were moderate to high for acceptability (mean = 4.7; range = 3–5), feasibility (mean = 4.2; range = 3–5), and appropriateness (mean = 4.6; range = 4-5). 49 SSNAC questionnaires were completed with a 91% response rate. Among participating parents, 37 (76%) reported ≥ 1 social need, including food/nutrition benefits (41%), housing (18%), and caregiver needs (29%). Staff responses included information provision (41%), direct assistance (30%), and agency referral (30%).

Conclusions

It was feasible for tertiary care center-based pediatric complex care programs to implement a standardized social needs assessment for CMC to identify and address parent-reported unmet social needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00237-3.

Smoky heart: cardiovascular manifestations of carbon monoxide poisoning

Background

Carbon monoxide (CO) poisoning is one of the most critical health concerns worldwide due to severe clinical effects with high morbidity and mortality. Tissue hypoxia and cellular damage from CO poisoning results in oxidative stress. Organs and tissues with high O2 demand including central nervous system (CNS) and cardiovascular (CV) system are the most susceptible to this oxidative stress. We investigate and describe the cardiovascular manifestations in 350 patients who were admitted for moderate to severe CO poisoning and treated with hyperbaric oxygen (HBO2) therapy.

Purpose

This study was conducted to identify the common cardiovascular manifestations of carbon monoxide poisoning.

Methods

We retrospectively collected data on 350 consecutive adult patients treated for CO poisoning between January 2011 to April 2018. Cardiac biomarkers, EKG and carboxyhemoglobin (COHb) levels were obtained from pre-hospital sources including EMS (emergency medical services) and from outside hospital records at the time of transfer. Glasgow Coma Scale (GCS) measurements were obtained at initial pre-hospital evaluation and upon arrival to the emergency room. Patient demographics, CV, CNS history and cardiac risk factors including hypertension, hyperlipidemia, diabetes, smoking history were obtained from electronic medical record. Myocardial injury was defined by cardiac troponin I level of ≥0.05 ng/mL.

Results

There were 350 patients admitted for CO poisoning from 2011 to 2018. 72% of the patients received HBO treatment due to severity of their symptoms. The mean age was 47.3 years with 60% men, 89% of the admissions were accidental exposure. Cardiac biomarkers were elevated in 40% of the patients and with 21% having sinus tachycardia. 6% had ischemic EKG changes with 23% having regional wall motion abnormalities on echocardiogram. In terms of intervention, 83% of the patients with elevated cardiac biomarkers received HBO treatment, 9% underwent coronary angiogram out of which 50% were candidate for either percutaneous intervention (PCI) or coronary artery bypass graft (CABG). In hospital mortality amongst this population was 2%.

Conclusion

Myocardial injury is common and widely seen with CO poisoning as seen by elevated cardiac biomarkers in 40% of the tested population. Initial work up for patients with CO poisoning should include evaluation with an EKG and serial biomarkers. If an abnormality is detected, patient should undergo an echocardiogram. Further evaluation with coronary angiography may be warranted in patients with new left ventricular dysfunction or wall motion abnormalities, especially in patients with risk factors.

Funding Acknowledgement

Type of funding sources: None.

Pharmacy stakeholder reports on ethical and logistical considerations in anti-opioid vaccine development

BACKGROUND

As opioid use disorder (OUD) incidence and its associated deaths continue to persist at elevated rates, the development of novel treatment modalities is warranted. Recent strides in this therapeutic area include novel anti-opioid vaccine approaches. This work compares logistical and ethical considerations surrounding currently available interventions for opioid use disorder with an anti-opioid vaccine approach.

METHODS

The opinions of student pharmacists and practicing pharmacists assessing knowledge, perceptions, and attitudes toward current and future OUD management strategies were characterized using a staged, multi-modal research approach incorporating a focus group, pilot survey development and refinement, and final survey deployment. Survey responses were assessed using one- and two-way parametric and non-parametric analyses where appropriate, and multi-dimensional matrix profiles were compared using z-tests following an exhaustive combinatorial sum of differences calculation between items within each compared matrix.

RESULTS

Focus group content analysis revealed a high level of agreeableness among participants regarding anti-opioid vaccine technology and a sense of shared ownership regarding solutions to the opioid epidemic at large. Pilot survey results demonstrated subject ability to consider both pragmatic and ethical considerations related to current therapeutics and novel interventions in a single instrument, with high endurance amongst engaged subjects. Access inequality was the most concerning ethical consideration identified for anti-opioid vaccines. Support for anti-opioid vaccine implementation across various clinical scenarios was strongest for voluntary use amongst individuals in recovery, and lowest for mandatory use in at-risk individuals.

CONCLUSIONS

Ethical and logistical concerns surrounding anti-opioid vaccines were largely similar to those for current OUD therapeutics overall. Anti-opioid vaccines were endorsed as helpful potential additions to current OUD therapeutic approaches, particularly for voluntary use in the later stages of clinical progression.

Geographic Disparities in Clinical Characteristics of Duodenitis-Proximal Jejunitis in Horses in the United States

Duodenitis-proximal jejunitis (DPJ) is an idiopathic and potentially fatal disease of horses characterized by abdominal pain, proximal intestinal inflammation, and subsequent gastric and small intestinal fluid accumulation. Although this disease is known to be costly and life threatening in the equine industry, the severity of clinical signs can vary widely, and an exact etiology has yet to be elucidated. This study looked to identify differences in clinical parameters of horses with DPJ between geographic regions in an effort to corroborate anecdotal reports and support theories of differing etiologies. Case records were compared from veterinary academic referral hospitals in three different geographic locations in the United States to determine if significant differences in clinical, clinicopathologic, and prognostic characteristics exist among horses with DPJ. Clinical measurements on presentation that were significantly different between regions included heart rate, peritoneal total protein, albumin, anion gap, aspartate aminotransferase, gamma-glutamyl transferase, sodium, chloride, potassium, and creatinine. Duration of hospitalization and maximum body temperature while hospitalized were also different between regions. There were no significant differences in peritoneal cell count, total white blood cell count, neutrophil count, band neutrophils, calcium, total plasma protein, temperature on presentation, duration of reflux, total reflux volume, or age between hospitals. The mortality rates between hospitals were not significantly different. Increased severity of clinical signs and biochemical abnormalities were identified in the Southeastern United States hospital compared with the Northeastern and Western hospitals. A prospective, multicenter case-control study could identify risk factors contributing toward regional differences in this disease in the future.

Fighting antibiotic resistance: a narrative review of public knowledge, attitudes, and perceptions of antibiotics use

AIMS

The aims of this study were to ascertain the comprehensive knowledge, perceptions, and attitudes of people from varying socioeconomic regions towards antibiotic use; identify the misperceptions and malpractices; and inform health policy and practice.

METHOD

EBSCO host databases, PubMed, and Google Scholar were searched to obtain relevant primary research papers within the years 2010-2018. Search phrases included the following: 'antibiotics use', 'community perceptions', 'public opinion, knowledge, behaviour, practices, perceptions'. Initially, selected papers were screened using the Preview, Question, Read, Summarize (PQRS) model.

RESULTS

Review of the 20 articles selected was based on six identified themes. It was found that insufficient knowledge and awareness of antibiotics use; self-medication and the use of leftover antibiotics; treating viral diseases with antibiotics or used as painkillers; expecting antibiotic prescription as a culmination of consultation; and the credibility of information obtained are issues that cut across different countries.

CONCLUSION

Evidence from this review suggests that misconceptions of antibiotic use are similar in different countries. Therefore, the need for the development and implementation of transferable policies as well as educating the public is necessary for the fight against ABR.

Strain-Dependent Inhibition of Clostridioides difficile by Commensal Clostridia Carrying the Bile Acid-Inducible (bai) Operon

Clostridioides difficile is one of the leading causes of antibiotic-associated diarrhea. Gut microbiota-derived secondary bile acids and commensal Clostridia that carry the bile acid-inducible (bai) operon are associated with protection from C. difficile infection (CDI), although the mechanism is not known. In this study, we hypothesized that commensal Clostridia are important for providing colonization resistance against C. difficile due to their ability to produce secondary bile acids, as well as potentially competing against C. difficile for similar nutrients. To test this hypothesis, we examined the abilities of four commensal Clostridia carrying the bai operon (Clostridium scindens VPI 12708, C. scindens ATCC 35704, Clostridium hiranonis, and Clostridium hylemonae) to convert cholate (CA) to deoxycholate (DCA) in vitro, and we determined whether the amount of DCA produced was sufficient to inhibit the growth of a clinically relevant C. difficile strain. We also investigated the competitive relationships between these commensals and C. difficile using an in vitro coculture system. We found that inhibition of C. difficile growth by commensal Clostridia supplemented with CA was strain dependent, correlated with the production of ∼2 mM DCA, and increased the expression of bai operon genes. We also found that C. difficile was able to outcompete all four commensal Clostridia in an in vitro coculture system. These studies are instrumental in understanding the relationship between commensal Clostridia and C. difficile in the gut, which is vital for designing targeted bacterial therapeutics. Future studies dissecting the regulation of the bai operon in vitro and in vivo and how this affects CDI will be important.IMPORTANCE Commensal Clostridia carrying the bai operon, such as C. scindens, have been associated with protection against CDI; however, the mechanism for this protection is unknown. Herein, we show four commensal Clostridia that carry the bai operon and affect C. difficile growth in a strain-dependent manner, with and without the addition of cholate. Inhibition of C. difficile by commensals correlated with the efficient conversion of cholate to deoxycholate, a secondary bile acid that inhibits C. difficile germination, growth, and toxin production. Competition studies also revealed that C. difficile was able to outcompete the commensals in an in vitro coculture system. These studies are instrumental in understanding the relationship between commensal Clostridia and C. difficile in the gut, which is vital for designing targeted bacterial therapeutics.

Steady state pharmacokinetics of cycloserine in patients on terizidone for multidrug-resistant tuberculosis

SETTING

Terizidone/cycloserine (TRD/CS) is included in standard treatment regimens for multidrug-resistant tuberculosis (MDR-TB) in many countries. The steady state pharmacokinetics (PKs) of CS after TRD administration are not known.

OBJECTIVES AND DESIGN

We recruited in-patients treated with 250-750 mg oral TRD daily as part of standard treatment regimens for pulmonary MDR-TB in Cape Town, South Africa. Plasma CS assays were performed in samples taken pre-dose and at 2, 4, 6, 8 and 10 h post-dose. CS concentrations were measured using a validated liquid chromatography-tandem mass spectrometry method. Non-compartmental PK analyses were performed.

RESULTS

Of 35 participants enrolled, 22 were males, and 20 (57%) were infected with the human immunodeficiency virus; the median age was 37 years. The median duration on TRD at the time of sampling was 33 days (interquartile range [IQR] 28-39). The area under the concentration-time curve at 0-10 h (AUC0-10) was 319 μg.h/ml (IQR 267.5-378.7), and peak concentration was 38.1 μg/ml (IQR 32.6-47.2). On multiple regression, dose (mg/kg) was the only factor independently associated with AUC0-10.

CONCLUSION

Steady state concentrations of CS in patients treated with TRD for MDR-TB were higher than those reported with CS formulations. Our findings support once-daily dosing.

Use of Medical Countermeasures in Small-Scale Emergency Responses

It is well documented that long-standing focus on public health emergency preparedness medical countermeasures (MCMs) distribution and mass dispensing capabilities for mitigation of bioterrorism incidents and a lack of real-world opportunities to test national preparedness for large-scale emergencies has hindered development of a body of evidence-based practices in the United States. To encourage jurisdictions seeking innovative opportunities for continuous improvement, we describe instances when the MCM capabilities were used to address smaller-scale, more-frequent public health emergencies such as disease outbreaks, natural disasters, or routine influenza vaccination. We argue that small-scale events represent a critical opportunity that state, local, tribal, and territorial entities can utilize for greater gains in MCM operational readiness than through exercises or planned reviews. By using and evaluating MCM capabilities during a real response, jurisdictions can advance preparedness science and support the translation of research into practice, thereby increasing their capacity to scale up for larger, rarer, higher-consequence emergencies.

Anti-fracture efficacy of zoledronate in subgroups of osteopenic postmenopausal women: secondary analysis of a randomized controlled trial

BACKGROUND

We recently reported that the administration of zoledronate every 18 months to osteopenic older women reduces the incidence of fractures.

OBJECTIVE

Here, we present a more detailed analysis of that trial to determine whether baseline clinical characteristics impact on the anti-fracture efficacy of this intervention.

METHODS

This is a prospective, randomized, placebo-controlled, double-blind trial in osteopenic postmenopausal women aged ≥ 65 years, to determine the anti-fracture efficacy of zoledronate. 2000 women were recruited using electoral rolls and randomized to receive 4 infusions of either zoledronate 5 mg or normal saline, at 18-month intervals. Each participant was followed for 6 years. Calcium supplements were not supplied.

RESULTS

Fragility fractures (either vertebral or nonvertebral) occurred in 190 women in the placebo group (227 fractures) and in 122 women in the zoledronate group (131 fractures), odds ratio (OR) 0.59 (95%CI 0.46, 0.76; P < 0.0001). There were no significant interactions between baseline variables (age, anthropometry, BMI, dietary calcium intake, baseline fracture status, recent falls history, bone mineral density, calculated fracture risk) and the treatment effect. In particular, the reduction in fractures appeared to be independent of baseline fracture risk, and numbers needed to treat (NNT) to prevent one woman fracturing were not significantly different across baseline fracture risk tertiles.

CONCLUSIONS

The present analyses indicate that the decrease in fracture numbers is broadly consistent across this cohort. The lack of relationship between NNTs and baseline fracture risk calls into question the need for BMD measurement and precise fracture risk assessment before initiating treatment in older postmenopausal women.

Adapting the Structured Operational Research Training Initiative (SORT IT) for high-income countries

SORT IT (Structured Operational Research Training InitiaTive) is a successful capacity building programme started 10 years ago to develop operational research skills in low- and middle-income countries. Public Health England (PHE) aims to embed a culture of research in front-line staff, and SORT IT has been adapted to train frontline health protection professionals at PHE North West (PHE NW) to collate, analyse and interpret routinely collected data for evidence-informed decision-making. Six participants from the PHE NW Health Protection team were selected to attend a two-module course in Liverpool, UK, in May and in November 2018. Five participants finished the course with completed papers on characteristics and burden of influenza-like illness in elderly care homes (two papers), use of dried blood spots for blood-borne virus screening in prisons, uptake of meningococcal ACWY (groups A, C, W-135 and Y) vaccine in schoolchildren and fires in waste management sites. The SORT IT course led to 1) new evidence being produced to inform health protection practice, and 2) agreement within PHE NW to continue SORT IT with two courses per year, and 3) showed how a research capacity building initiative for low- and middle-income countries that combines 'learning with doing' can be adapted and used in a high-income country.

Prebiotic oligosaccharides in early life alter gut microbiome development in male mice while supporting influenza vaccination responses

Beneficial modulation of the gut microbiota is an attractive therapeutic approach to improve the efficacy of vaccine-induced immunity. In this study, mice were supplemented with the prebiotic milk oligosaccharide 2'-fucosyllactose (2'FL) as well as a complex mixture of immune modulatory prebiotic short-chain galacto-oligosaccharides and long-chain fructo-oligosaccharides (scGOS/lcFOS) from different stages in early life. Adult mice were vaccinated with trivalent influenza vaccine (TIV) and both development of the gut microbiota and antibody-mediated vaccine responses were followed over time. Within the control group, female mice demonstrated a larger antibody response to TIV vaccination than male mice, which was accompanied by enhanced cytokine production by splenocytes and a higher percentage of plasma cells in skin draining lymph nodes. In addition, the prebiotic diet improved vaccine-specific antibody responses in male mice. Introduction of prebiotics into the diet modulated the gut microbiota composition and at the genus level several bacterial groups showed a significant interaction effect which potentially contributed to the immunological effects observed. This study provides insight in the effect of scGOS/lcFOS/2'FL in influenza vaccination antibody production.

Ab initio structure determination of nanocrystals of organic pharmaceutical compounds by electron diffraction at room temperature using a Timepix quantum area direct electron detector. Corrigendum

Corrections are made to Table 1 in the article by van Genderen et al. [Acta Cryst. (2016), A72, 236-242].

The cost of infection: Argulus foliaceus and its impact on the swimming performance of the three-spined stickleback (Gasterosteus aculeatus)

For fish, there can be multiple consequences of parasitic infections, including the physical impacts on swimming and the pathological costs of infection. This study used the three-spined stickleback (Gasterosteus aculeatus) and the ectoparasitic fish louse, Argulus foliaceus, to assess both physical (including form drag and mass) and pathological effects of infection. Both sustained (prolonged swimming within an open channel flume) and burst (C-start) swimming performance were measured on individual fish before (trials 1-2) and after infection (trials 3-5). Experimental infection occurred shortly before the third trial, when the physical impacts of infection could be separated from any subsequent pathology as transmission of adult parasites causes instantaneous drag effects prior to observable pathology. Despite the relatively large size of the parasite and corresponding increase in hydrodynamic drag for the host, there were no observable physical effects of infection on either sustained or burst host swimming. By contrast, parasite-induced pathology is the most probable explanation for reduced swimming performance across both tests. All sticklebacks displayed a preference for flow refugia, swimming in low-velocity regions of the flume, and this preference increased with both flow rate and infection time. This study suggests that even with large, physically demanding parasites their induced pathology is of greater concern than direct physical impact.

The feasibility of following up prisoners, with mental health problems, after release: a pilot trial employing an innovative system, for engagement and retention in research, with a harder-to-engage population

Background

Following up released prisoners is demanding, particularly for those prisoners with mental health problems, for whom stigma and chaotic lifestyles are problematic. Measurement of mental health outcomes after release is challenging. To evaluate mental healthcare for offender populations, using high-quality randomised controlled trials, evidenced-based methods must be developed to engage them while in custody, to locate and re-interview them after release, and to collect potentially stigmatising mental health outcomes data.

Methods

We developed an initial theoretical model and operational procedures for collecting baseline and follow-up data informed by a literature search, focus groups, and case studies. Male prisoners from five prisons in two sites were invited to participate. The inclusion criteria included individuals who were above threshold on nine-item Patient Health Questionnaire, seven-item Generalized Anxiety Disorder, or post-traumatic stress disorder scales, or who had reported mental health problems in the past 2 years or had been assessed with a likely personality disorder. Potential participants were interviewed to generate baseline data and were re-contacted before their release. We then contacted them for a follow-up interview, which included repeating the earlier data collection measures 2–8 weeks after release. A qualitative formative process evaluation produced and refined a model procedure for the recruitment and retention of male prison leavers in trials, identified the mechanisms which promoted engagement and retention, and mapped these against a theoretical behaviour change model.

Results

We developed a flexible procedure which was successful in recruiting male prison leavers to a pilot trial: 185/243 (76%, 95% confidence interval (CI) 70–81%) of those approached agreed to participate. We also retained 63% (95% CI 54–71%) of those eligible to participate in a follow-up interview 2–8 weeks after release. Mental health outcomes data was collected at both these time points.

Conclusions

It is possible to design acceptable procedures to achieve sustained engagement critical for delivering and evaluating interventions in prison and in the community and to collect mental health outcomes data. These procedures may reduce attrition bias in future randomised controlled trials of mental health interventions for prison leavers. This procedure has been replicated and successfully delivered in a subsequent pilot trial and a definitive randomised controlled trial.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2911-1) contains supplementary material, which is available to authorized users.