A multicentre cross-sectional observational study to determine the effect of living with frailty on digital exclusion from video consultations: (Access-VIGIL)

OBJECTIVES

Many older people regularly access digital services, but many others are totally excluded. Age alone may not explain these discrepancies. As health care services offer more video consultations, we aimed to determine if living with frailty is a significant risk factor for digital exclusion in accessing video consultations, and if this changes if a person has a support network to help with access.

DESIGN

We undertook a muticenter cross-sectional survey across South West England.

SETTING AND PARTICIPANTS

Patients in primary care, hospital at home, and secondary care services were enrolled between February 21 and April 12, 2022.

METHODS

The primary outcome was complete digital exclusion defined as no individual access or network support access to video consultations. Secondary analysis looked at the person's digital exclusion when ignoring any network support. The association between frailty and outcomes was analyzed with logistic regression. In addition, older people's digital skills, motivation, and confidence were examined.

RESULTS

255 patients were included in the analysis. The median age was 63 years (interquartile range 43-77) with 148 (57%) women. Complete digital exclusion was rare (5.1%). Only 1 of 155 who were not frail (Clinical Frailty Scale 1-3) experienced complete digital exclusion compared with 12 of 99 (10.7%) who were living with frailty (Clinical Frailty Scale 4-8). There was no association between frailty and complete digital exclusion. Frailty was associated with individual digital exclusion when no network support was available to assist.

CONCLUSIONS AND IMPLICATIONS

When taking into account a person's support network, complete digital exclusion from video consultation was rare. When no support network was available, frailty was associated with individual digital exclusion. Health care services should ask about a person's support network to help people living with frailty access video consultations.

Radiological analysis and outcomes of isolated greater tuberosity fracture-dislocations

BACKGROUND

The purpose of this study was to investigate different radiological characteristics for isolated greater tuberosity (GT) fracture-dislocations and their effects on complication and reoperation rates.

METHODS

A two-centre, retrospective study was performed on patients with a minimum 1-year follow-up (median 4.5 years). Patients were split into two groups, Group A (<65 years old) and Group B (≥65 years old). Outcomes included initial injury characteristics (dislocation and fracture type, AC/BC ratio and distances), the reduction environment and postreduction outcomes including complications.

RESULTS

A total of 55 patients were included in this study, with a reduction in the emergency department (ED) performed in 93% of patients. Complication rates (47% overall) were similar in both groups, with an overall nonunion rate of 27%. No nonunions occurred in fractures reduced in theatre compared with 29% occurring in reductions in ED (p<0.001); 11% of patients experienced surgical neck fractures, the majority of which were in Group B (p=0.003). A larger fracture fragment (i.e. higher AC/BC or AC distances) was correlated with a higher incidence of nonunion in Group B compared with Group A (p=0.003), and a higher risk of stiffness in both groups (p=0.049); 16% of patients demonstrated delayed displacement of their GT.

CONCLUSIONS

This study highlights the high complication rates associated with these injuries. Age and specific radiological parameters should be taken into consideration when risk stratifying, as should reducing these fractures in a theatre setting. Interval radiographs are also advised to monitor GT displacement for at least 2-3 weeks.

A Principle-Based Approach to Visual Identification Systems for Hospitalized People with Dementia

A large proportion of hospital inpatients are affected by cognitive impairment, posing challenges in the provision of their care in busy, fast-paced acute wards. Signs and symbols, known as visual identifiers, are employed in many U.K. hospitals with the intention of helping healthcare professionals identify and respond to the needs of these patients. Although widely considered useful, these tools are used inconsistently, have not been subject to full evaluation, and attract criticism for acting as a shorthand for a routinized response. In order for visual identifiers to be used effectively in acute care settings, thorough consideration must be given to the ethical and legal issues that are engaged in this context, and their potential benefits and harms must be weighed and balanced. This paper proposes a set of legal and ethical principles that can be used to guide the implementation of visual identifiers. Together, these principles provide a framework applicable in the design and implementation phases to systematically identify relevant considerations arising from the use of these tools. We outline some tensions that arise between principles and conclude that selecting a preferred moral framework could help to guide decision-making, as does clarity around the purpose and objectives of the identifier.

Ethical and legal implications of implementing risk algorithms for early detection and screening for oesophageal cancer, now and in the future

BACKGROUND

Oesophageal cancer has significant morbidity and mortality but late diagnosis is common since early signs of disease are frequently misinterpreted. Project DELTA aims to enable earlier detection and treatment through targeted screening using a novel risk prediction algorithm for oesophageal cancer (incorporating risk factors of Barrett's oesophagus including prescriptions for acid-reducing medications (CanPredict)), together with a non-invasive, low-cost sampling device (CytospongeTM). However, there are many barriers to implementation, and this paper identifies key ethical and legal challenges to implementing these personalised prevention strategies for Barrett's oesophagus/oesophageal cancer.

METHODS

To identify ethical and legal issues relevant to the deployment of a risk prediction tool for oesophageal cancer into primary care, we adopted an interdisciplinary approach, incorporating targeted informal literature reviews, interviews with expert collaborators, a multidisciplinary workshop and ethical and legal analysis.

RESULTS

Successful implementation raises many issues including ensuring transparency and effective risk communication; addressing bias and inequity; managing resources appropriately and avoiding exceptionalism. Clinicians will need support and training to use cancer risk prediction algorithms, ensuring that they understand how risk algorithms supplement rather than replace medical decision-making. Workshop participants had concerns about liability for harms arising from risk algorithms, including from potential bias and inequitable implementation. Determining strategies for risk communication enabling transparency but avoiding exceptionalist approaches are a significant challenge. Future challenges include using artificial intelligence to bolster risk assessment, incorporating genomics into risk tools, and deployment by non-health professional users. However, these strategies could improve detection and outcomes.

CONCLUSIONS

Novel pathways incorporating risk prediction algorithms hold considerable promise, especially when combined with low-cost sampling. However immediate priorities should be to develop risk communication strategies that take account of using validated risk algorithms, and to ensure equitable implementation. Resolving questions about liability for harms arising should be a longer-term objective.

Ethical and legal considerations influencing human involvement in the implementation of artificial intelligence in a clinical pathway: A multi-stakeholder perspective

Introduction

Ethical and legal factors will have an important bearing on when and whether automation is appropriate in healthcare. There is a developing literature on the ethics of artificial intelligence (AI) in health, including specific legal or regulatory questions such as whether there is a right to an explanation of AI decision-making. However, there has been limited consideration of the specific ethical and legal factors that influence when, and in what form, human involvement may be required in the implementation of AI in a clinical pathway, and the views of the wide range of stakeholders involved. To address this question, we chose the exemplar of the pathway for the early detection of Barrett's Oesophagus (BE) and oesophageal adenocarcinoma, where Gehrung and colleagues have developed a “semi-automated”, deep-learning system to analyse samples from the CytospongeTM TFF3 test (a minimally invasive alternative to endoscopy), where AI promises to mitigate increasing demands for pathologists' time and input.

Methods

We gathered a multidisciplinary group of stakeholders, including developers, patients, healthcare professionals and regulators, to obtain their perspectives on the ethical and legal issues that may arise using this exemplar.

Results

The findings are grouped under six general themes: risk and potential harms; impacts on human experts; equity and bias; transparency and oversight; patient information and choice; accountability, moral responsibility and liability for error. Within these themes, a range of subtle and context-specific elements emerged, highlighting the importance of pre-implementation, interdisciplinary discussions and appreciation of pathway specific considerations.

Discussion

To evaluate these findings, we draw on the well-established principles of biomedical ethics identified by Beauchamp and Childress as a lens through which to view these results and their implications for personalised medicine. Our findings are not only relevant to this context but have implications for AI in digital pathology and healthcare more broadly.

Quality of life (QoL) in patients with heart failure with preserved ejection fraction (HFpEF): a systematic review

Introduction

Heart failure with preserved ejection fraction (HFpEF) is associated with significant clinical unmet need as mortality and morbidity rates are high despite current treatments. Patient-reported quality of life (QoL) is an important and clinically relevant endpoint in patients with HF so understanding the impact of HFpEF on QoL is essential.

Purpose

The aim of this systematic review was to identify and summarize data on QoL in HFpEF.

Methods

Systematic searches of Medline, Medline Epub Ahead of Print (In-Process & Other Non-Indexed Citations), Embase, and EBM Reviews were conducted in October 2021. Congress proceedings from the past 3 years and reference lists of included publications were also searched. Publications were screened against eligibility criteria by title/abstract and then by full text. Eligibility criteria included clinical studies of any design reporting baseline QoL in adults with HFpEF published from 2016 onwards.

Results

The electronic database search identified 6,403 articles on HFpEF. After screening, 35 full publications reporting HFpEF and QoL were included. Study designs included observational cohort (n=17), cross-sectional (n=3), and post-hoc analyses of interventional studies (n=15). Tools used to measure QoL included KCCQ (n=17), MLHFQ (n=12), EQ-5D-VAS (n=8), SF-12 (n=2), SF-36 (n=2), and EHFSQ-1 (n=1). Health-state utility values (HSUVs) were captured using EQ-5D in four studies. HSUVs in HFpEF ranged from 0.67–0.74, indicating a substantial QoL burden. Eleven studies using various instruments compared QoL in patients with HFpEF vs non-HFpEF (Table 1). Of these, five reported statistically significantly poorer QOL in HFpEF vs non-HFpEF, one reported statistically significantly poorer QOL in non-HFpEF vs HFpEF and five found no statistically significant difference between HF subtypes. Four studies compared QoL in men vs women with three reporting statistically significantly worse QoL in women. Three studies examined the impact of comorbidities, and all reported statistically significantly poorer QoL in patients with comorbid atrial fibrillation, diabetes, or metabolic syndrome. Two studies examined the effect of age; one reported that, vs elderly patients (age ≥85 years), younger patients (age ≤55 years) with HFpEF had statistically significantly worse QoL despite having fewer comorbidities; in contrast, the second study reported that younger patients (age ≤55 years) had statistically significantly better QoL than elderly patients (age ≥75 years). Two studies reported on hospitalizations, with one reporting no difference in QoL between patients who had previously been hospitalized and those who had not and the other reporting that readmission for HF correlated with QoL.

Conclusions

QoL burden among HFpEF patients is substantial. QoL may be affected by age, comorbidities, gender, and prior hospitalization, and may be associated with poorer outcomes. QoL in HFpEF is generally poorer than in non-HFpEF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca

The burden of end-stage osteoarthritis in Australia: a population-based study on the incidence of total knee replacement attributable to overweight/obesity

OBJECTIVES

To determine the risk of total knee replacement (TKR) for primary osteoarthritis (OA) associated with overweight/obesity in the Australian population.

METHODS

This population-based study analyzed 191,723 cases of TKR collected by the Australian Orthopaedic Association National Joint Registry and population data from the Australian Bureau of Statistics. The time-trend change in incidence of TKR relating to BMI was assessed between 2015 and 2018. The influence of obesity on the incidence of TKR in different age and gender groups was determined. The population attributable fraction (PAF) was then calculated to estimate the effect of obesity reduction on TKR incidence.

RESULTS

The greatest increase in incidence of TKR was seen in patients from obese class III. The incidence rate ratio for having a TKR for obesity class III was 28.683 at those aged 18-54 years but was 2.029 at those aged >75 years. Females in obesity class III were 1.7 times more likely to undergo TKR compared to similarly classified males. The PAFs of TKR associated with overweight or obesity was 35%, estimating 14,287 cases of TKR attributable to obesity in 2018. The proportion of TKRs could be reduced by 20% if overweight and obese population move down one category.

CONCLUSIONS

Obesity has resulted in a significant increase in the incidence of TKR in the youngest population in Australia. The impact of obesity is greatest in the young and the female population. Effective strategies to reduce the national obese population could potentially reduce 35% of the TKR, with over 10,000 cases being avoided.

What is the impact of dexamethasone on postoperative pain in adults undergoing general anaesthesia for elective abdominal surgery: a systematic review and meta-analysis

Background

Previous meta-analysis of heterogeneous surgical cohorts demonstrated reduction in postoperative pain with perioperative intravenous dexamethasone, but none have addressed adults undergoing elective abdominal surgery. The aim of this study was to determine the impact of intravenous perioperative dexamethasone on postoperative pain in adults undergoing elective abdominal surgery under general anaesthesia.

Methods

This review was prospectively registered on the international prospective register of systematic reviews (CRD42020176202). Electronic databases Medical Analysis and Retrieval System Online (MEDLINE), Exerpta Medica Database (EMBASE), (CINAHL) Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and trial registries were searched to January 28 2021 for randomised controlled trials, comparing dexamethasone to placebo or alternative antiemetic, that reported pain. The primary outcome was pain score, and secondary outcomes were time to first analgesia, opioid requirements and time to post-anaesthesia care unit (PACU) discharge.

Results

Fifty-two studies (5768 participants) were included in the meta-analysis. Pain scores ≤ 4 hour (h) were reduced in patients who received dexamethasone at rest (mean difference (MD), − 0.54, 95% confidence interval (CI) − 0.72 to − 0.35, I² = 81%) and on movement (MD − 0.42, 95% CI − 0.62 to − 0.22, I² = 35). In the dexamethasone group, 4–24 h pain scores were less at rest (MD − 0.31, 95% CI − 0.47 to − 0.14, I² = 96) and on movement (MD − 0.26, 95% CI − 0.39 to − 0.13, I² = 29) and pain scores ≥ 24 h were reduced at rest (MD − 0.38, 95% CI − 0.52 to − 0.24, I² = 88) and on movement (MD − 0.38, 95% CI − 0.65 to − 0.11, I² = 71). Time to first analgesia (minutes) was increased (MD 22.92, 95% CI 11.09 to 34.75, I² = 98), opioid requirements (mg oral morphine) decreased (MD − 6.66, 95% CI − 9.38 to − 3.93, I² = 88) and no difference in time to PACU discharge (MD − 3.82, 95% CI − 10.87 to 3.23, I² = 59%).

Conclusions

Patients receiving dexamethasone had reduced pain scores, postoperative opioid requirements and longer time to first analgesia. Dexamethasone is an effective analgesic adjunct for patients undergoing abdominal surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-022-00243-6.

341 Consenting Practices in Plastic Surgery

Introduction

Informed consent is a vital aspect of safe patient care within any surgical specialty, and if not completed thoroughly, may result in misinformation and patient dissatisfaction.

Traditional paper consent forms are notoriously poorly completed by medical professionals, with common issues ranging from ineligible handwriting, to missing key components of the form.

The aim of this audit was to assess our departments’ compliance with standard trust consent forms and compare adherence to local and national consenting policies.

Method

All elective and emergency plastic surgical procedures carried out over a one-week period from 17/05/2021 to 23/05/2021 were identified using eTrauma and Cerner operative records. In total, 40 procedures were identified. Consent forms were then reviewed and assessed for completion in key areas. 4 procedures were excluded due to the consent form not being available for review, and 1 procedure was excluded due to a cancellation.

Results

The risks and benefits of procedures were generally documented to a high standard. Providing written information to patients, confirmation of consent if the procedure was being performed on a different day, and possible additional procedures were poorly completed throughout. 90% of consent forms screened, failed to include confirmation of the surgical site within the specific section of the form.

Conclusions

Overall, the department demonstrated good compliance with completing trust consent forms. Electronic consent forms would likely address the shortcomings identified in this audit and should be adopted. Continued responsibility from the whole team should be highlighted and maintained to ensure a high standard of consenting.

Perceptions of the use of artificial intelligence in the diagnosis of skin cancer: an outpatient survey

BACKGROUND

Convolutional neural networks (artificial intelligence, AI) are rapidly appearing within the field of dermatology, with diagnostic accuracy matching that of dermatologists. As technologies become available for use by both the health professionals and the general public, their uptake in healthcare will become more acceptable. National Health Service England recognizes the potential of AI for healthcare but emphasizes that patient-centred care should be at the forefront of these technological advancements.

AIM

To obtain opinions of patients on the use of AI in a dermatology setting, when aiding the diagnosis of skin cancers.

METHODS

A cross-sectional 14-point questionnaire was handed out to patients attending dermatology outpatient skin cancer clinics in two UK hospitals, between March and August 2018.

RESULTS

In total, 603 patient questionnaires were completed. Nearly half (47%; n = 282) of respondents were not concerned if AI technology was used by a skin specialist to aid skin cancer diagnosis. However, the majority (81%; n = 491) of respondents, considered it important for a dermatologist to examine and confirm a diagnosis and to be present for discussion of a cancer diagnosis.

CONCLUSION

Although the majority of respondents were not reluctant about the use of AI for skin cancer diagnosis, respondents still considered it important that dermatologists are involved in the diagnosis and/or confirmation of skin cancer. Furthermore, the study results demonstrate that personal interaction with a clinician is important. This is in keeping with proposals that AI be used as an adjunctive technology to increase accuracy of skin cancer diagnoses, but not as a substitute for a dermatologist.

AB0034 PD-1 AGONISM INHIBITS ACTIVATION OF PLASMACYTOID DENDRITIC CELLS

Background:

T cell function is regulated by complex signaling networks of interconnected activators and inhibitors. Blockade of inhibitory receptors such as programmed death-1 (PD-1) has emerged as a novel treatment for multiple forms of cancer. One of the most common adverse events associated with blockade of the endogenous PD-1/PD-L1 pathway is the induction of autoimmune pathology in multiple tissues, demonstrating that PD-1 activation is necessary for normal immune homeostasis in humans (Kostine, et al., 2018). Given this body of clinical data, we sought to develop a PD-1 agonist antibody as a therapeutic approach to restore immune homeostasis in patients living with autoimmune diseases. PD-1 expression and function has been primarily described on T cells (Ishida, et al., 1992), with additional data available from several other immune cell populations (Ohaegbulam, et al., 2015).

Objectives:

To study the effect of PD-1 agonism on plasmacytoid dendritic cell (pDC) function.

Methods:

Human PBMCs stimulated with or without toll-like receptor (TLR)-9 agonist, CpG were analyzed by flow cytometry for PD-1 expression on immune cell subsets. To assess the impact of PD-1 agonist on pDC function human PBMCs were activated by CpG in the presence or absence of PD-1 agonist. Type-I interferon (IFN) levels were quantified using ELISA from culture supernatants. The expression of interferon stimulated genes was analyzed by qPCR as a measure of type-I IFN activation.

Results:

We have discovered that TLR9 activation can induce PD-1 expression on plasmacytoid dendritic cells, which has not been previously reported. Further, we have demonstrated that PD-1 agonism inhibits TLR9-mediated activation and the effector functions of plasmacytoid dendritic cells.

Conclusion:

These data suggest the potential of PD-1 as a target for regulating diseases with pathology generated by type-I IFN.

References:

[1]Ishida, Y., Agata, Y., Shihibahara, K., & Honjo, T. (1992). Induced expression of PD-1, a novel member of the immunoglobulin gene superfamily, upon programmed cell death. EMBO J., 11(11):3887-95.

[2]Kostine, M., Rouxel, L., Barnetche, T., Veillon, R., Martin, F., Dutriaux, C., . . . Schaeverbeke, T. (2018). Rheumatic disorders associated with immune checkpoint inhibitors in patients with cancer-clinical aspects and relationship with tumour response: a single-centre prospective cohort study. Annual Rheumatic Disease, 77(3):393-398.

[3]Ohaegbulam, K. C., Assal, A., Lazar-Molnar, E., Yao, Y., & Zang, X. (2015). Human cancer immunotherapy with antibodies to the PD-1 and PD-L1 pathway. Trends in Molecular Medicine, 21(1); 24-33.

Disclosure of Interests:

Ishita Banerjee Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Lindsay Edwards Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Patrick Halvey Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Salvatore Alioto Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, David Cluckley Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Caitlin Mitchell Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Christopher Cox Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Emily Lurier Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Michael Cianci Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Soumya Bengeri Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Susmita Borthakur Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Katalin Kis-Toth Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Nathan Higginson-Scott Shareholder of: Pandion Therapeutics, Consultant of: Biotech Companies, Employee of: Pandion Therapeutics, Jo Viney Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Kevin L. Otipoby Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics

Oxidative stress in response to heat stress in wild caught Namaqua rock mice, Micaelamys namaquensis

Modelling of anthropogenic induced climate suggests more frequent and severe heatwaves in the future, which are likely to result in the mass die-off of several species of organisms. Oxidative stress induced by severe heat stress has previously been associated with a reduction in animal cognitive performance, depressed reproduction and lower life expectancy. Little is known about the non-lethal consequences of species should they survive extreme heat exposure. We investigated the oxidative stress experienced by the Namaqua rock mouse, a nocturnal rodent, using two experimental heat stress protocols, a 6 hour acute heat stress protocol without access to water and a 3-day heatwave simulation with ad libitum water. Oxidative stress was determined in the liver, kidney and brain using malondialdehyde (MDA) and protein carbonyl (PC) as markers of oxidative damage, and superoxide dismutase (SOD) and total antioxidant capacity (TAC) as markers of antioxidant defence. Incubator heat stress (heat and dehydration stress) was brought about by increasing the body temperatures of animals to 39-40.8 °C for 6 hours. Following incubator heat stress, significantly higher levels of MDA were observed in the liver. Dehydration did not explain the variation in oxidative markers and is likely a combined effect of thermal and dehydration stress. Individual body mass was significantly negatively correlated to kidney SOD and lipid peroxidation. A heatwave was simulated using a temperature cycle that would naturally occur during a heatwave in the species' local habitat, with a maximal ambient temperature of 38 °C. Following the simulated heatwave, SOD activity of the kidney demonstrated significantly lowered activity suggesting oxidative stress. Current heat waves in this species have the potential of causing oxidative stress. Heat and dehydration stress following exacerbated temperatures are likely to incur significant oxidative stress in multiple tissues demonstrating the importance of water availability to allow for rehydration to prevent oxidative stress.

Prevalence of Salmonella spp. in translocated wild reptiles and effect of duration of quarantine on their body condition

AIMS

To assess the prevalence of carriage of Salmonella spp. in wild reptiles translocated from multiple locations to a single island, and determine changes in their body condition (BC) during quarantine.

METHODS

Between 2007 and 2009, six endemic reptile species (Oligosoma aeneum, O. moco, O. ornatum, O. smithi, Dactylocnemis pacificus, and Woodworthia maculata) were caught from several locations in the northern North Island of New Zealand. Reptiles were held in quarantine for 14-41 days while being tested for carriage of Salmonella spp. Morphometric data were collected, and scaled body mass index for each species was calculated to determine changes in BC during the quarantine.

RESULTS

Of 221 individuals tested 12 (5%) were positive for Salmonella spp. All 12 were shore skinks (O. smithi; n = 30), with a test prevalence of 0.4 (95% CI = 0.25-0.58). Eleven were carrying Salmonella enterica Warragul and one S. enterica Mississipi. There was no difference in BC at the start of quarantine of shore skinks between those that tested negative and those that tested positive for Salmonella spp. (p = 0.184). Reptiles that were quarantined for 15-20 days (three species) lost 3-5% of BC (mean proportional change 0.03-0.05), while those quarantined for >30 days increased BC by 3-13% (mean proportional change 0.03-0.13). All animals except the one individual positive for S. Mississippi were translocated to the recipient island, while the latter was returned to the source site.

CONCLUSIONS AND CLINICAL RELEVANCE

The prevalence of Salmonella spp. carriage in the translocated reptiles was low overall and consistent with other records of Salmonella spp. in wild New Zealand reptiles. However, the prevalence of 0.4 in shore skinks is the highest recorded in this species. In addition to time required for health-screening, we recommend that duration of quarantine should include time to allow animals to recover from captive stress and to provide an opportunity to increase their BC before release.

Association between intrahospital transfer and hospital-acquired infection in the elderly: a retrospective case-control study in a UK hospital network

Background

Intrahospital transfers have become more common as hospital staff balance patient needs with bed availability. However, this may leave patients more vulnerable to potential pathogen transmission routes via increased exposure to contaminated surfaces and contacts with individuals.

Objective

This study aimed to quantify the association between the number of intrahospital transfers undergone during a hospital spell and the development of a hospital-acquired infection (HAI).

Methods

A retrospective case–control study was conducted using data extracted from electronic health records and microbiology cultures of non-elective, medical admissions to a large urban hospital network which consists of three hospital sites between 2015 and 2018 (n=24 240). As elderly patients comprise a large proportion of hospital users and are a high-risk population for HAIs, the analysis focused on those aged 65 years or over. Logistic regression was conducted to obtain the OR for developing an HAI as a function of intrahospital transfers until onset of HAI for cases, or hospital discharge for controls, while controlling for age, gender, time at risk, Elixhauser comorbidities, hospital site of admission, specialty of the dominant healthcare professional providing care, intensive care admission, total number of procedures and discharge destination.

Results

Of the 24 240 spells, 2877 cases were included in the analysis. 72.2% of spells contained at least one intrahospital transfer. On multivariable analysis, each additional intrahospital transfer increased the odds of acquiring an HAI by 9% (OR=1.09; 95% CI 1.05 to 1.13).

Conclusion

Intrahospital transfers are associated with increased odds of developing an HAI. Strategies for minimising intrahospital transfers should be considered, and further research is needed to identify unnecessary transfers. Their reduction may diminish spread of contagious pathogens in the hospital environment.

Heat and dehydration induced oxidative damage and antioxidant defenses following incubator heat stress and a simulated heat wave in wild caught four-striped field mice Rhabdomys dilectus

Heat waves are known for their disastrous mass die-off effects due to dehydration and cell damage, but little is known about the non-lethal consequences of surviving severe heat exposure. Severe heat exposure can cause oxidative stress which can have negative consequences on animal cognition, reproduction and life expectancy. We investigated the current oxidative stress experienced by a mesic mouse species, the four striped field mouse, Rhabdomys dilectus through a heat wave simulation with ad lib water and a more severe temperature exposure with minimal water. Wild four striped field mice were caught between 2017 and 2019. We predicted that wild four striped field mice in the heat wave simulation would show less susceptibility to oxidative stress as compared to a more severe heat stress which is likely to occur in the future. Oxidative stress was determined in the liver, kidney and brain using malondialdehyde (MDA) and protein carbonyl (PC) as markers for oxidative damage, and superoxide dismutase (SOD) and total antioxidant capacity (TAC) as markers of antioxidant defense. Incubator heat stress was brought about by increasing the body temperatures of animals to 39-40.8°C for 6 hours. A heat wave (one hot day, followed by a 3-day heatwave) was simulated by using temperature cycle that wild four striped field mice would experience in their local habitat (determined through weather station data using temperature and humidity), with maximal ambient temperature of 39°C. The liver and kidney demonstrated no changes in the simulated heat wave, but the liver had significantly higher SOD activity and the kidney had significantly higher lipid peroxidation in the incubator experiment. Dehydration significantly contributed to the increase of these markers, as is evident from the decrease in body mass after the experiment. The brain only showed significantly higher lipid peroxidation following the simulated heat wave with no significant changes following the incubator experiment. The significant increase in lipid peroxidation was not correlated to body mass after the experiment. The magnitude and duration of heat stress, in conjunction with dehydration, played a critical role in the oxidative stress experienced by each tissue, with the results demonstrating the importance of measuring multiple tissues to determine the physiological state of an animal. Current heat waves in this species have the potential of causing oxidative stress in the brain with future heat waves to possibly stress the kidney and liver depending on the hydration state of animals.

Value and learning from carer involvement in a cluster randomised controlled trial and process evaluation - Organising Support for Carers of Stroke Survivors (OSCARSS)

BACKGROUND

Patient, Carer and Public Involvement (PCPI) should be embedded in health care research. Delivering PCPI can be challenging, but even when PCPI is carried out it is rarely reported resulting in lost opportunities for learning. This paper aims to describe PCPI in the OSCARSS study, a pragmatic-cluster randomised controlled trial with an embedded economic and process evaluation.

METHODS

A carer research user group (RUG) co-developed OSCARSS to evaluate how to best deliver support to caregivers of stroke survivors. The PCPI activity involved regular meetings and preparatory work, from the initial conceptualisation of the study through to dissemination. Written reports, structured group discussions and individual interviews were carried out with the RUG and researchers to capture the added value and learning. This paper was co-authored by two of the RUG members with contributions from the wider RUG and researchers.

RESULTS

The core six members of the caregiver RUG attended the majority of the meetings alongside three researchers, one of whom was the co-chief investigator. PCPI was instrumental in changing many aspects of the research protocol, design and delivery and contributed to dissemination and sharing of good practice. There were challenges due to the emotional toll when PCPI members shared their stories and the extensive time commitment. Positive experiences of learning and fulfilment were reported by the individual researchers and PCPI members. Wider organisational administrative and financial support facilitated the PCPI. The researchers' existing positive regard for PCPI and the clear focus of the group were key to the successful co-design of this research.

CONCLUSIONS

The value and learning from the PCPI collaborative work with the researchers was of benefit to the study and the individuals involved. Specific PCPI influences were a challenge to pinpoint as successful co-design meant the researchers' and carers' contributions were intertwined and decision-making shared.

Pregnancy outcomes and postpartum relapse rates in women with RRMS treated with alemtuzumab in the phase 2 and 3 clinical development program over 16 years

BACKGROUND

Relapsing-remitting multiple sclerosis (RRMS) is frequently diagnosed in women of reproductive age. Because the use of disease-modifying therapies (DMTs) early in the disease course is increasing, it is important to evaluate the safety of DMTs in pregnant women and their developing fetuses. Alemtuzumab, approved for the treatment of relapsing forms of MS, is administered as 2 courses of 12 mg/day on 5 consecutive days at baseline and on 3 consecutive days 12 months later. Alemtuzumab is eliminated from the body within approximately 30 days after administration; it is recommended that women of childbearing potential use effective contraception during and for 4 months after treatment. Here, we report pregnancy outcomes in alemtuzumab-treated women from the phase 2 and 3 clinical development program over 16 years.

METHODS

We followed 972 women who had alemtuzumab in phase 2 (CAMMS223 [NCT00050778]) and phase 3 (CARE-MS I [NCT00530348], CARE-MS II [NCT00548405]) studies, and/or in 2 consecutive extension studies (NCT00930553; NCT02255656 [TOPAZ]). In the extension studies, patients could receive additional alemtuzumab (12 mg/day on 3 days; ≥12 months apart) as needed for disease activity. All women who received alemtuzumab in the clinical development program were included. Pregnant or lactating patients were followed up for safety.

RESULTS

As of November 26, 2018, 264 pregnancies occurred in 160 alemtuzumab-treated women, with a mean age at conception of 32.6 years, and mean time from last alemtuzumab dose to conception of 35.9 months. Of the 264 pregnancies, 233 (88%) were completed, 11 (4%) were ongoing, and 20 (8%) had unknown outcomes; 16 (6%) conceptions occurred within 4 months, and 5 conceptions within 1 month of the last alemtuzumab dose. Of the 233 completed pregnancies with known outcomes, there were 155 (67%) live births with no congenital abnormalities or birth defects, 52 (22%) spontaneous abortions, 25 (11%) elective abortions, and 1 (0.4%) stillbirth. Maternal age was associated with an increased risk of spontaneous abortion in alemtuzumab-treated patients (<35 years: 15%; ≥35 years: 37%; relative risk [RR], 2.46 [95% CI: 1.53-3.95], p=0.0002). Risk of spontaneous abortion was not increased in patients becoming pregnant ≤4 months versus >4 months since alemtuzumab exposure (19% vs 23%; RR, 1.08 [95% CI: 0.41-2.85], p=0.88). Autoimmune thyroid adverse events did not increase risk for spontaneous abortion (patients with vs without thyroid adverse events, 23.7% vs 21.3%; RR, 1.11 [95% CI: 0.69-1.80], p=0.75). Annualized relapse rate was 0.10 and 0.12 in the 2 years prior to pregnancy (post alemtuzumab), and was 0.22, 0.12, and 0.12 in each of the first 3 years postpartum, respectively.

CONCLUSION

Normal live births were the most common outcome in women exposed to alemtuzumab 12 mg or 24 mg in clinical studies. Spontaneous abortion rate in alemtuzumab-treated patients was comparable with rates in the general population and treatment-naive MS patients, and was not increased in women with pregnancy onset within 4 months of alemtuzumab exposure. There was a minimal increase in postpartum relapses.

Effect of Multiple Sclerosis on Daily Activities, Emotional Well-being, and Relationships: The Global vsMS Survey

Background

The vsMS survey was conducted to better understand the negative effects of fatigue, cognitive impairment, emotional burden, and decreased physical functioning on the personal, professional, and social lives of individuals with multiple sclerosis (MS).

Methods

The vsMS survey was an online survey conducted in Australia, Canada, France, Italy, Spain, the United Kingdom, and the United States that assessed the impact of MS on individuals' daily activities, emotional well-being, relationships, and employment.

Results

The survey included 1075 participants with relapsing-remitting MS. Almost 42% of participants reported that their ability to perform and manage daily activities had worsened during the previous 2 years. More than 50% reported limitations in daily activities due to fatigue, physical weakness, problems with balance/coordination, heat/cold sensitivity, memory problems, numbness/tingling, trouble concentrating, impaired movement/muscle stiffness, and impaired sleeping. Participants also reported a negative effect on emotional and social factors, including self-esteem, general outlook, well-being, maintaining/starting relationships, ability to progress in their career/keep their job, and ability to cope with life roles.

Conclusions

These data highlight the importance of addressing the impact of MS and the social and emotional disease burdens on daily activities when planning the care of patients with MS.

A novel discharge pathway for patients with advanced cancer requiring home parenteral nutrition

BACKGROUND

The use of home parenteral nutrition (HPN) for palliative indications is increasing internationally and is the leading indication in some countries. Discharge on HPN can be complex in metabolically unstable patients and requires intestinal failure expertise.

METHODS

Between 2012 and 2018, we performed a retrospective analysis aiming to assess the impact of a novel remote discharge pathway for palliative HPN patients. This was evaluated using a quality improvement approach.

RESULTS

One hundred and twenty-five patients with active malignancy [mean (range) age 58 (25-80) years] were referred to the intestinal failure unit (IFU) for remote discharge. Of 82 patients were discharged from the oncology Centre on HPN using the pathway. The remaining 43 patients either declined HPN or the Oncology team felt that the patient became too unwell for HPN or died prior to discharge. There was an increase in patients referred for remote discharge from 13 in 2012 to 43 in 2017. The mean number of days between receipt of referral by the IFU to discharge on HPN from the oncology centre reduced from 29.4 days to 10.1 days. Following remote discharge, the mean number of days on HPN was 215.9 days. Catheter-related blood stream infection rates in this cohort were very low at 0.169 per 1000 catheter days.

CONCLUSIONS

This is the first study to demonstrate the remote safe, effective and rapid discharge of patients requiring palliative HPN between two hospital sites. This allows patients with a short prognosis more time in their desired location.

High-brightness beam tests of the very high frequency gun at the Advanced Photo-injector EXperiment test facility at the Lawrence Berkeley National Laboratory

The very-high-frequency gun (VHF-Gun) is a new concept photo-injector developed and built at the Lawrence Berkeley National Laboratory (LBNL) for generating high-brightness electron beams capable of driving X-ray free electron lasers (FELs) at MHz-class repetition rates. The gun that purposely uses established and mature radiofrequency and mechanical technologies has demonstrated over the last many years the capability of reliably operating in continuous wave mode at the design accelerating fields and required vacuum and mechanical performance. The results of VHF-Gun technology demonstration were reported elsewhere [Sannibale et al., Phys. Rev. Spec. Top.-Accel. Beams 15, 103501 (2012)]; here in this paper, we provide and analyze examples of the experimental results of the first high-brightness beam tests performed at the Advanced Photo-injector EXperiment test facility at LBNL that demonstrated the gun capability of delivering the beam quality required for driving high repetition rate X-ray FELs.

The impact of a pharmacist on post-take ward round prescribing and medication appropriateness

Background Medication communication and prescribing on the post-take ward round following patient admission to hospital can be suboptimal leading to worse patient outcomes. Objective To evaluate the impact of clinical pharmacist participation on the post-take ward round on the appropriateness of medication prescribing, medication communication, and overall patient health care outcomes. Setting Tertiary referral teaching hospital, Brisbane, Australia. Method A pre-post intervention study was undertaken that compared the addition of a senior clinical pharmacist attending the post-take ward was compared to usual wardbase pharmacist service, with no pharmacist present of the post-take ward round. We assessed the proportion of patients with an improvement in medication appropriateness from admission to discharge, using the START/STOPP checklists. Medication communication was assessed by the mean number of brief and in-depth discussions, with health care outcomes measured by comparing length of stay and 28-day readmission rates. Main outcome measures: Medication appropriateness according to the START/STOPP list, number and type of discussions with team members and length of stay and readmission rate. Results Two hundred and sixty patients were recruited (130 pre- and 130-post-intervention), across 23 and 20 post-take ward rounds, respectively. Post-intervention, there was increase in the proportion of patients who had an improvement medication appropriateness (pre-intervention 25.4%, post-intervention 36.9%; p = 0.004), the number of in-depth discussions about patients’ medication (1.9 ± 1.7 per patient pre-intervention, 2.7 ± 1.7 per patient post-, p < 0.001), and the number relating to high-risk medications (0.71 ± 1.1 per patient pre-intervention, to 1.2 ± 1.2 per patient post-, p < 0.05). Length of stay and 28-day mortality were unchanged. Conclusion Clinical pharmacist participation on the post-take ward round leads to improved medication-related communication and improved medication appropriateness but did not significantly improve health care outcomes.

Legal challenges for the implementation of advanced clinical digital decision support systems in Europe

Systems based on artificial intelligence and machine learning that facilitate decision making in health care are promising new tools in the era of 'personalized' or 'precision' medicine. As the volume of patient data and scientific evidence grows, these computerised decision support systems (DSS) have great potential to help healthcare professionals improve diagnosis and care for individual patients. However, the implementation of these tools in clinical care raises some foreseeable legal challenges for healthcare providers and DSS-suppliers in Europe: How does the use of complex and novel DSS relate to professional standards to provide a reasonable standard of care? What should be done in terms of testing before DSS can be used in regular practice? What are the potential liabilities of health care providers and DSS companies if a DSS fails to function well? How do legal requirements for the protection of patient data and general privacy rights apply to likely DSS scenarios? In this article, we provide an overview of the current law and its general implications for the use of DSS, from a European perspective. We conclude that healthcare providers and DSS-suppliers will have the best chance of meeting legal challenges if: they are first tested in translational research with the patients' explicit, informed consent; DSS-suppliers and healthcare providers are able to clarify and agree on their individual legal responsibilities, and; patients are properly informed about privacy risks and able to decide themselves whether their data can be used for other purposes, or are stored and processed outside the EU. DSS developers and healthcare providers will need to work together closely to ensure compliance with national and European regulations and standards required for reasonable and safe patient care.

RELEVANCE FOR PATIENTS

Advanced digital decision support systems have the potential to improve patient diagnosis and care. In this article we discuss key legal issues to support translational research using DSS and ensure that they meet the high standards for protection of patient safety and privacy in Europe.

Feltman: evaluating the utilisation of an Aboriginal diabetes education tool by health professionals

Diabetes contributes considerably to the health disparities in the Aboriginal population. To address the lack of Aboriginal-specific diabetes education tools, Feltman was designed for health professionals to deliver diabetes prevention and management information. This qualitative study aims to explore how this resource was used and its perceived effect on diabetes prevention and management in Victorian Aboriginal communities. Convenience sampling was used to recruit 18 participants (n=6 were Aboriginal) who had attended Feltman training between 2010 and 2016. Semi-structured interviews conducted via telephone or face-to-face were audio-recorded, transcribed and analysed via content analysis. Content analysis identified three main categories regarding Feltman: (1) utilisation in Aboriginal and mainstream health services; (2) as a comprehensive, engaging tool that supports understanding of diabetes; and (3) the barriers and challenges to Feltman's use. Overall, Feltman was regarded as a culturally appropriate diabetes education tool that is visual, tactile, engaging, supportive of health literacy and perceived to enhance Community members' understanding of diabetes prevention and management. This is the first study to provide insight into Feltman's implementation; adding to the evidence-base for Aboriginal-specific diabetes education tools.

Does A Catheter over Needle System Reduce Infusate Leak in Continuous Peripheral Nerve Blockade: A Randomised Controlled Trial

Continuous peripheral nerve blockade is a common technique in the analgesic management for many procedures. Leakage of local anaesthetic from around the nerve catheter insertion site can increase the chance of catheter dislodgement, risks infective complications, and could divert anaesthetic away from the nerve causing the block to fail. We conducted a randomised controlled trial to assess whether the type of nerve catheter influenced local anaesthetic leak rate. One hundred and ten patients scheduled for elective unilateral total knee arthroplasty were randomised to receive a perineural catheter with either a catheter over needle (CON) system (Pajunk® E-Cath) (PAJUNK® GmbH, Medizintechnologie, Geisingen, Germany), or catheter through needle (CTN) system (Pajunk® SonoLong) (PAJUNK® GmbH, Medizintechnologie, Geisingen, Germany). There was no statistically significant difference in the rate of leaking catheters between groups (CON 1.8% versus CTN 3.7%; P=0.618), however, the overall leak rate was much lower than anticipated from pilot data. The CON system was on average faster to insert (CON 357 seconds versus CTN 482 seconds; P=0.004), but associated with poorer needle visibility under ultrasound (Likert scale 1–5, mean [SD], CON 3.31 [0.96] versus CTN 3.89 [0.84]; P=0.001). All seven instances of inadvertent catheter dislodgement occurred in the CTN group (P=0.006). There was no statistically significant difference between groups in the proportion of patients who had adequate analgesia on day one (CON 80% versus CTN 86.5%; P=0.294) and day two postoperatively (CON 85.5% versus CTN 91.8%; P=0.369). Our findings show the overall leak rate to be very low with both catheter systems; however, the CON system may have advantages in terms of speed of use and rate of inadvertent catheter dislodgement.

Sonar guided focused parathyroidectomy under cervical block

BACKGROUND

Presentation of hyperparathyroidism varies and is highly non-specific. The automated calcium analyzer has made the diagnosis easy. Similarly, the advent of Sestamibi scan has paved the way to minimally invasive parathyroidectomy indicated for parathyroid adenoma. There is no uniformity in the extent of minimally invasive parathyroidectomy that is done through limited incision under radio or sonar guidance and endoscopically. In this study, we are presenting the focused parathyroidectomy performed under sonar guidance and superficial cervical block (SCB). The prerequisite is concordant preoperative Sestamibi and ultrasound imaging.

METHOD

A two-year review of parathyroidectomies performed between January 2013 and December 2014.

OBJECTIVE

To reflect on the result of sonar-guided focused parathyroidectomy under SCB.

RESULTS

There was good correlation between the pre-operative imaging, the intra-operative findings and the postoperative histology result of the 15 cases analysed.

CONCLUSION

The focused parathyroidectomy under SCB yielded a good result with concordant preoperative Sestamibi and ultrasound findings.

Engaging stakeholders in research to address water-energy-food (WEF) nexus challenges

The water-energy-food (WEF) nexus has become a popular, and potentially powerful, frame through which to analyse interactions and interdependencies between these three systems. Though the case for transdisciplinary research in this space has been made, the extent of stakeholder engagement in research remains limited with stakeholders most commonly incorporated in research as end-users. Yet, stakeholders interact with nexus issues in a variety of ways, consequently there is much that collaboration might offer to develop nexus research and enhance its application. This paper outlines four aspects of nexus research and considers the value and potential challenges for transdisciplinary research in each. We focus on assessing and visualising nexus systems; understanding governance and capacity building; the importance of scale; and the implications of future change. The paper then proceeds to describe a novel mixed-method study that deeply integrates stakeholder knowledge with insights from multiple disciplines. We argue that mixed-method research designs-in this case orientated around a number of cases studies-are best suited to understanding and addressing real-world nexus challenges, with their inevitable complex, non-linear system characteristics. Moreover, integrating multiple forms of knowledge in the manner described in this paper enables research to assess the potential for, and processes of, scaling-up innovations in the nexus space, to contribute insights to policy and decision making.

Use of antiretrovirals in HIV-infected children in a tuberculosis prevention trial: IMPAACT P1041

SETTING

International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) P1041, a tuberculosis (TB) prevention trial conducted among children enrolled from 2004 to 2008 during South Africa's roll-out of combination antiretroviral therapy (ART).

OBJECTIVE

To estimate TB incidence and mortality and the effect of ART.

DESIGN

Children were pre-screened to exclude TB disease and exposure, actively screened 3-monthly for TB exposure and symptoms, and provided post-exposure isoniazid prophylaxis therapy (IPT). TB diagnoses were definite, probable, or possible, and mortality all-cause. Testing was at the 5% significance level.

RESULTS

In 539 children (aged 3-4 months) followed up for a median of 74 weeks (interquartile range [IQR] 48-116), incidence/100 person-years (py) was 10.67 (95%CI 8.47-13.26) for any TB and 2.89 (95%CI 1.85-4.31) for definite/probable TB. Any TB incidence was respectively 9.39, 13.59, and 9.83/100 py before, <180 days after, and 180 days after ART initiation. Adjusted analysis showed a non-significant increase in any TB (HR 1.32, 95%CI 0.71-2.52, P = 0.38) and a significant reduction in mortality (HR 0.39, 95%CI 0.17-0.82, P = 0.017) following ART initiation.

CONCLUSIONS

ART reduced mortality but not TB incidence in human immunodeficiency virus (HIV) infected children in IMPAACT P1041, possibly attributable to active screening for TB exposure and symptoms with post-exposure IPT. Research into this as a strategy for TB prevention in high HIV-TB burden settings may be warranted.

Prospective evaluation of quality of life in children treated in UKALL 2003 for acute lymphoblastic leukaemia: A cohort study

BACKGROUND

Health-related quality of life (HRQoL) from diagnosis until end of treatment for children with acute lymphoblastic leukaemia was investigated, examining effects of age, gender, risk-stratified treatment regimen, and therapy intensity (one vs. two 'delayed intensifications' [DIs]).

METHOD

In a multi-centre prospective study, parents reported their child's generic and disease-specific HRQoL and their own care-giving burden at five time points. From 1,428 eligible patients, 874 parents completed questionnaires at least once during treatment.

RESULTS

At each time point, generic HRQoL was significantly lower than equivalent norm scores for healthy children. HRQoL decreased significantly at the start of treatment, before recovering gradually (but remained below pre-treatment levels). Parents reported that older children worried more about side effects and their appearance, but showed less procedural anxiety than younger children. Concern for appearance was greater among girls than boys. Compared to Regimen B (i.e. additional doxorubicin during induction and additional cyclophosphamide and cytarabine during consolidation chemotherapy), patients receiving Regimen A had fewer problems with pain and nausea. There were no statistically significant differences in HRQoL by number of DI blocks received.

INTERPRETATION

HRQoL is compromised at all stages of treatment, and is partly dependent on age. The findings increase understanding of the impact of therapy on children's HRQoL and parental care-giving burden, and will contribute to the design of future trials.

Exploring the potential duty of care in clinical genomics under UK law

Genome-wide sequencing technologies are beginning to be used in projects that have both clinical diagnostic and research components. The clinical application of this technology, which generates a huge amount of information of varying diagnostic certainty, involves addressing a number of challenges to establish appropriate standards. In this article, we explore the way that UK law may respond to three of these key challenges and could establish new legal duties in relation to feedback of findings that are unrelated to the presenting condition (secondary, additional or incidental findings); duties towards genetic relatives as well as the patient and duties on the part of researchers and professionals who do not have direct contact with patients. When considering these issues, the courts will take account of European and international comparisons, developing guidance and relevant ethical, social and policy factors. The UK courts will also be strongly influenced by precedent set in case law.

Could It Be Snowing Microbes on Enceladus? Assessing Conditions in Its Plume and Implications for Future Missions

We analyzed Cassini Imaging Science Subsystem (ISS) images of the plume of Enceladus to derive particle number densities for the purpose of comparing our results with those obtained from other Cassini instrument investigations. Initial discrepancies in the results from different instruments, as large as factors of 10-20, can be reduced to ∼2 to 3 by accounting for the different times and geometries at which measurements were taken. We estimate the average daily ice production rate, between 2006 and 2010, to be 29 ± 7 kg/s, and a solid-to-vapor ratio, S/V > 0.06. At 50 km altitude, the plume's peak optical depth during the same time period was τ ∼ 10^-3; by 2015, it was ∼10^-4. Our inferred differential size distribution at 50 km altitude has an exponent q = 3. We estimate the average geothermal flux into the sea beneath Enceladus' south polar terrain to be comparable to that of the average Atlantic, of order 0.1 W/m². Should microbes be present on Enceladus, concentrations at hydrothermal vents on Enceladus could be comparable to those on Earth, ∼10⁵ cells/mL. We suggest the well-known process of bubble scrubbing as a means by which oceanic organic matter and microbes may be found in the plume in significantly enhanced concentrations: for the latter, as high as 10⁷ cells/mL, yielding as many as 10³ cells on a 0.04 m² collector in a single 50 km altitude transect of the plume. Mission design can increase these numbers considerably. A lander mission, for example, catching falling plume particles on the same collector, could net, over 100 Enceladus days without bubble scrubbing, at least 10⁵ cells; and, if bubble scrubbing is at work, up to 10⁸ cells. Key Words: Enceladus-Microbe-Organic matter-Life detection. Astrobiology 17, 876-901.

Could It Be Snowing Microbes on Enceladus? Assessing Conditions in Its Plume and Implications for Future Missions

We analyzed Cassini Imaging Science Subsystem (ISS) images of the plume of Enceladus to derive particle number densities for the purpose of comparing our results with those obtained from other Cassini instrument investigations. Initial discrepancies in the results from different instruments, as large as factors of 10-20, can be reduced to ∼2 to 3 by accounting for the different times and geometries at which measurements were taken. We estimate the average daily ice production rate, between 2006 and 2010, to be 29 ± 7 kg/s, and a solid-to-vapor ratio, S/V > 0.06. At 50 km altitude, the plume's peak optical depth during the same time period was τ ∼ 10^-3; by 2015, it was ∼10^-4. Our inferred differential size distribution at 50 km altitude has an exponent q = 3. We estimate the average geothermal flux into the sea beneath Enceladus' south polar terrain to be comparable to that of the average Atlantic, of order 0.1 W/m². Should microbes be present on Enceladus, concentrations at hydrothermal vents on Enceladus could be comparable to those on Earth, ∼10⁵ cells/mL. We suggest the well-known process of bubble scrubbing as a means by which oceanic organic matter and microbes may be found in the plume in significantly enhanced concentrations: for the latter, as high as 10⁷ cells/mL, yielding as many as 10³ cells on a 0.04 m² collector in a single 50 km altitude transect of the plume. Mission design can increase these numbers considerably. A lander mission, for example, catching falling plume particles on the same collector, could net, over 100 Enceladus days without bubble scrubbing, at least 10⁵ cells; and, if bubble scrubbing is at work, up to 10⁸ cells. Key Words: Enceladus-Microbe-Organic matter-Life detection. Astrobiology 17, 876-901.

Training in general internal medicine: what do trainees want and what can we deliver?

General internal medicine (GIM) training, usually as part of a dual accreditation programme, is increasingly challenging to deliver as a result of increased numbers of acute admissions, changes to consultant input into medical 'on call' and the reduction in the numbers of units taking unselected medical patients. GIM has become synonymous with acute medical take, reducing the scope of programmes to deliver a true general medical experience. The role of the 'medical registrar' is reported to be increasingly unpopular with trainees. Differing models of the delivery of training are in place. We have carried out a two-stage questionnaire in order to determine the views of both trainees and trainers on different models of training and their deliverability. The first stage defined the key areas of concern for trainees and the second focused on these areas and the ability of local education providers to deliver an expanded GIM programme. Our data suggest that trainees would value a face-to-face annual review of competence progression (ARCP) for GIM, separate from their specialty ARCP, and would support more structured blocks of GIM training in order to allow later specialty-focused training. However, -significant concerns were raised about the ability of many units to deliver such training beyond the acute medical 'take'.