Enhanced EPIRISK tool for rapid epidemic risk analysis

OBJECTIVES

This study aims to create an enhanced EPIRISK tool in order to correctly predict COVID-19 severity in various countries. The original EPIRISK tool was developed in 2018 to predict the epidemic risk and prioritise response. The tool was validated against nine historical outbreaks prior to 2020. However, it rated many high-income countries that had poor performance during the COVID-19 pandemic as having lower epidemic risk.

STUDY DESIGN

This study was designed to modify EPIRISK by reparameterizing risk factors and validate the enhanced tool against different outbreaks, including COVID-19.

METHODS

We identified three factors that could be indicators of poor performance witnessed in some high-income countries: leadership, culture and universal health coverage. By adding these parameters to EPIRISK, we created a series of models for the calibration and validation. These were tested against non-COVID outbreaks in nine countries and COVID-19 outbreaks in seven countries to identify the best-fit model. The COVID-19 severity was determined by the global incidence and mortality, which were equally divided into four levels.

RESULTS

The enhanced EPIRISK tool has 17 parameters, including seven disease-related and 10 country-related factors, with an algorithm developed for risk level classification. It correctly predicted the risk levels of COVID-19 for all seven countries and all nine historical outbreaks.

CONCLUSIONS

The enhanced EPIRSIK is a multifactorial tool that can be widely used in global infectious disease outbreaks for rapid epidemic risk analysis, assisting first responders, government and public health professionals with early epidemic preparedness and prioritising response to infectious disease outbreaks.

352 A Retrospective Audit to Determine the Appropriateness of Antibiotic Use in Surgical Patients in MKUH

Introduction

This audit’s aim is to determine the appropriateness of antibiotics dispensed in Emergency Surgery Clinic (ESC) for a two-month period in 2020. Antibiotic stewardship promotes appropriate antibiotic use in clinical settings whilst limiting unnecessary use. Appropriate antibiotic use is important in reducing the risk of antibiotic resistance.

Method

We extracted the following details from 801 patients’ electronic notes who attended MKUH ESC: diagnosis, prescription of antibiotics, hospital admission, and re-attendance at the ESC. Prescriptions were analysed as to whether they were in accordance with our microbiology guidelines. Patients were analysed as a collective and within diagnosis sub-specialities (appendicitis, wound infection, gallstones/cholecystitis, testicular pathology, UTI, diverticulitis, renal stones and abscesses).

Results

218 (27%) patients were given antibiotics, 180 (22%) patients re-attended ESC and 111 (14%) were admitted. Only 77 patients (35%) receiving antibiotics were prescribed appropriately. Outcomes also varied by diagnosis. All patients presenting with UTI (n = 15) were treated correctly. In contrast, only 71% of patients with renal stones (n = 68) were incorrectly treated with antibiotics.

Conclusions

Two-thirds of patients receiving antibiotics were inappropriately prescribed. This together with the variation by diagnosis would suggest further measures be introduced to support antibiotic stewardship and mitigate the risk of antibiotic resistance.

Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Commercial Potential for Recycling of Finely Ground Foam in Flexible Polyurethane Foam: A Project of the Polyurethane Recycle and Recovery Council—SPI

Attempts to include ground foam by cryogenic grinding of scrap foams in the production of new flexible polyurethane foams started more than ten years ago. Current work, sponsored by PURRC (Polyurethane Recycle and Recovery Council-SPI), reports on pilot plant and full scale demonstration of the use of foams from a variety of sources, including plant fall off and post consumer foams. Ground foams were produced by cryogenic and mechanical grinding. New foams were produced at two densities and different loading levels while maintaining equal density and IFD to unfilled control foams. The study includes data on dispersion properties of the powders, foam performance and estimated economics.

eRegistries: Electronic registries for maternal and child health

BACKGROUND

The Global Roadmap for Health Measurement and Accountability sees integrated systems for health information as key to obtaining seamless, sustainable, and secure information exchanges at all levels of health systems. The Global Strategy for Women's, Children's and Adolescent's Health aims to achieve a continuum of quality of care with effective coverage of interventions. The WHO and World Bank recommend that countries focus on intervention coverage to monitor programs and progress for universal health coverage. Electronic health registries - eRegistries - represent integrated systems that secure a triple return on investments: First, effective single data collection for health workers to seamlessly follow individuals along the continuum of care and across disconnected cadres of care providers. Second, real-time public health surveillance and monitoring of intervention coverage, and third, feedback of information to individuals, care providers and the public for transparent accountability. This series on eRegistries presents frameworks and tools to facilitate the development and secure operation of eRegistries for maternal and child health.

METHODS

In this first paper of the eRegistries Series we have used WHO frameworks and taxonomy to map how eRegistries can support commonly used electronic and mobile applications to alleviate health systems constraints in maternal and child health. A web-based survey of public health officials in 64 low- and middle-income countries, and a systematic search of literature from 2005-2015, aimed to assess country capacities by the current status, quality and use of data in reproductive health registries.

RESULTS

eRegistries can offer support for the 12 most commonly used electronic and mobile applications for health. Countries are implementing health registries in various forms, the majority in transition from paper-based data collection to electronic systems, but very few have eRegistries that can act as an integrating backbone for health information. More mature country capacity reflected by published health registry based research is emerging in settings reaching regional or national scale, increasingly with electronic solutions. 66 scientific publications were identified based on 32 registry systems in 23 countries over a period of 10 years; this reflects a challenging experience and capacity gap for delivering sustainable high quality registries.

CONCLUSIONS

Registries are being developed and used in many high burden countries, but their potential benefits are far from realized as few countries have fully transitioned from paper-based health information to integrated electronic backbone systems. Free tools and frameworks exist to facilitate progress in health information for women and children.

Disease associations in alpha-1-antitrypsin deficiency

INTRODUCTION

In addition to emphysema alpha-1-antitrypsin deficiency (AATD) has been shown to be associated with several inflammatory conditions, including bronchiectasis, vasculitis, (in particular Wegener's granulomatosis), and panniculitis, suggesting neutrophil proteinases also play a role in their pathophysiology. However, it remains unknown whether other inflammatory diseases are also more prevalent in AATD than the general population. The current study describes the prevalence of other co-morbidities in AATD with particular emphasis on inflammatory bowel disease.

METHODS AND RESULTS

The case notes of 651 PiZZ or PiZnull patients attending the UK national centre for AATD between 1996 and 2011 were reviewed. The prevalence of inflammatory bowel disease (1.5%) was higher than that predicted in the UK (0.4%). Ten patients had a confirmed diagnosis of ulcerative colitis, and 1 had Crohn's disease. In 2 cases there was a family history of inflammatory bowel disease and all but 1 patient were ex or never smokers. There was also a higher prevalence of hypothyroidism in this patient group than expected for the UK population - 26 cases (7.2% of females and 1.3% of males).

CONCLUSIONS

The current study of the UK cohort of patients with AATD confirmed a higher prevalence of ulcerative colitis than would be expected in the general population, providing further evidence of a potential link between these 2 conditions. In addition, the data suggested a potential link between hypothyroidism and AATD.

Hope and possibility: envisioning the future in pastoral conversation

Claims that engendering hope is key in all pastoral conversation, because hope is the Christian perspective on every aspect of life--its low points as well as its peaks. Argues that clergy in the pastoral caregiving role need to foster a kind of hope that recognizes actuality (past) but also steps directly into the future by exercising freedom in the present--by taking action. Opines that to do so, pastoral caregivers need to grasp the central importance of thinking about the future and of envisioning hopeful outcomes to human well-being, and they need as well to offer specific care and counseling methods that will nourish hope in troubled people. Presents a series of methods for pastoral conversation that enliven hope, that help people focus on the future and thus engender hope.

Radioactivity in breast milk following 111In-octreotide

The concentration of 111In in breast milk in a 10 weeks postpartum woman was measured at daily intervals up to 72 h post-injection of 5.3 mCi (196 MBq) of 111In-octreotide (OctreoScan). Radiation surveys were also performed at the breast surface. The disappearance of 111In from the breast milk exhibited a bi-exponential pattern with a maximum concentration of 14.2 nCi (0.54 kBq) per 125 ml feeding at 4 h, with lower values thereafter. External surveys at the breast surface also showed a bi-exponential decrease with time. The maximum reading was 8.3 mrem x h(-1) (0.83 mSv x h(-1)) immediately after administration. This rapidly decreased due to 85% urinary excretion by 24 h. Breast milk tracer content and external surveys at the breast surface were determined at 3 h intervals for up to 10 days. If a newborn is nursed for the first 10 days, the internal and external dose equivalents would be 22.97 mrem (0.23 mSv) and 27.86 mrem (0.28 mSv), respectively, for a total of 50.83 mrem (0.5 mSv). The patient was instructed to resume breast-feeding on day 10, when the newborn received a total dose equivalent of 1.55 mrem (0.016 mSv). This dosimetry is based on a very conservative assumption, whereby 100% of the ingested 111In becomes systemic and follows adult bio-behaviour. Oral indium has been shown to be poorly absorbed from the gastrointestinal tract (approximately 0.15%), which suggests the infant's dose could be considerably less. Based on this case report, mathematical relationships are presented for determining the nursing infant's dose equivalent from internal and external exposures relative to time after the maternal administration of 111In-octreotide (OctreoScan).

Baculovirus-derived hemagglutinin vaccines protect against lethal influenza infections by avian H5 and H7 subtypes

Baculoviruses were engineered to express hemagglutinin (HA) genes of recent avian influenza (AI) isolates of the H5 and H7 subtypes. The proteins were expressed as either intact (H7) or slightly truncated versions (H5). In both cases purified HA proteins from insect cell cultures retained hemagglutination activity and formed rosettes in solution, indicating proper folding. Although immunogenic in this form, these proteins were more effective when administered subcutaneously in a water-in-oil emulsion. One or two-day-old specific pathogen free (SPF) White Rock chickens, free of maternal AI antibodies, responded with variable serum HI titers, but in some cases the titers were comparable to those achieved using whole virus preparations. Vaccination of three-week-old chickens with 1.0 microg of protein per bird generated a more consistent serum antibody response with an average geometric mean titer (GMT) of 121 (H5) and 293 (H7) at 21 days postvaccination. When challenged with highly pathogenic strains of the corresponding AI subtypes, the vaccinated birds were completely protected against lethal infection and in some cases exhibited reduced or no cloacal shedding at 3 days postinfection. Vaccine protocols employing these recombinant HA proteins will not elicit an immune response against internal AI proteins and thus will not interfere with epidemiological surveys of natural influenza infections in the field.

Molecular characterization of the hemagglutinin gene and oral immunization with a waterfowl-origin avian influenza virus

Vaccination against highly pathogenic (HP) subtypes of avian influenza (AI) virus in poultry has been prohibited in the United States. Recently, policy has been changed to potentially allow use of inactivated vaccines in emergency programs to control HP H5 and H7 AI. Vaccination with inactivated virus against non-highly pathogenic AI viruses has been allowed in the U.S. turkey industry since 1979 (1) but requires expensive handling of individual birds for parenteral inoculation. Oral immunization would provide a less expensive method to protect commercial poultry from AI. Prime candidates for oral vaccines are waterfowl-origin (WFO) isolates, which have a tropism for the alimentary tract. One WFO isolate, A/mallard/Ohio/556/1987 (H5N9) (MOh87), was characterized by determining the complete nucleotide sequence of its hemagglutinin (HA) gene. The HA protein of this isolate possessed a deduced amino acid sequence nearly identical to the consensus amino acid sequence for all published H5 genes, indicating that it has potential as a broadly effective vaccine. Experimental results demonstrated measurable serum antibody responses to orally delivered live and inactivated preparations of MOh87. Oral vaccination also protected chickens from diverse, lethal H5 AI virus challenge strains and blocked cloacal shedding of challenge virus.

In ovo vaccination of chicken embryos with experimental Newcastle disease and avian influenza oil-emulsion vaccines

Inactivated oil-emulsion (OE) Newcastle disease (ND) and avian influenza (AI) vaccines were injected into 18-day-old white rock (WR) and white leghorn (WL) chicken embryos to evaluate their immunologic efficacy and their effects on hatchability. Embryonating eggs were inoculated at 1.5 inches depth with various vaccine volumes and antigen concentrations. Serum hemagglutination-inhibition (HI) titers were first detected in chickens at 2 wk posthatch. Protection against morbidity and mortality was demonstrated in all of 10 chickens vaccinated as embryos and challenged with viscerotropic velogenic ND virus at 53 days of age and also in all of eight in ovo- vaccinated chickens challenged with highly pathogenic AI virus at 34 days of age. All of five unvaccinated control chickens for each respective ND- and AI-vaccinated group died. In pooled groups from successive hatches, the hatchability of WR or WL embryos injected with 100 microliters of vaccine was not significantly different (P > 0.05) from unvaccinated hatchmate controls when needle gauges of 22, 20, and 18 were used. Seroconversion rates of chickens vaccinated as embryos ranged from 27% to 100% with ND vaccination and 85% to 100% for AI vaccination. For ND, geometric mean HI titers of chickens per vaccine group ranged from 11 to 733, and in pooled groups, the range was 49 to 531. Titers for AI vaccine groups ranged from 156 to 1178. This study demonstrated that acceptable hatchability, seroconversion rates, and protective immunity can be attained with in ovo inoculation of ND or AI OE vaccines if the vaccines are prepared with sufficient antigen and administered properly.

Non-metallothionein cadmium binding proteins

In this review we discuss cadmium binding proteins which are similar to equine metallothionein but have significant differences and also binding proteins which appear to be totally unrelated.

Screening of cervical cytological samples using coherent optical processing. Part 1

Coherent optical signal processing methods for screening Pap smears were evaluated and are presented in a three-part sequence. In Part 1, 2-D Fourier spectra of normal and abnormal cells generated from many high resolution cell photographs are presented. Each cell spectrum was measured with a coherent optical data processing system containing a special geometry detector and automated data collection capability. Several parameters, determined from weighted measures of the cell transform intensity variations, were tested as feature discriminators to separate normal from abnormal cells. An analysis of the experimental data demonstrates that several transform features are good discriminators of normal/abnormal cells (using standard Baysian decision algorithms with quadratic decision rules). In Part 2, mathematical model studies to guide and validate the experimental work show certain transform parameters to be functionally related to cell and nucleus diameter and optical density. Other parameters appear to be related to cell characteristics such as clumping of nuclear deoxyribonucleic acid (DNA). The model studies also show that the photographic variables play a key role in cell image preprocessing prior to Fourier analysis. Part 3 discusses an optical transducer that was used as a film replacement to modulate a laser beam spatially with a cell image. Several of the feature discriminators used in Part 1 with photographic film images served also to separate normal and malignant cell types when the cell Fourier spectrum was obtained from a transducer image. Based on an understanding of the procedure from the model studies and the demonstrated ability to separate normal and malignant cells using certain transform features, a coherent optical processing system to screen Pap smears from cell or slide photographs is feasible and appears practical in terms of the number of cells to be processed. A high-speed optical transducer would be required for processing large numbers of cells without photography in a reasonable time interval.

Potential new artificial sweetener from study of structure-taste relationships

4-(Methoxymethyl)-1,4-cyclohexadiene-1-carboxaldehyde syn-oxime is a new sweetening agent developed by systematic synthesis and taste evaluation of 80 new oximes analogous to the little-used osime sweetener, perillartine.

Coherent optical processing of cervical cytologic samples

Earlier research using a very limited data base gave encouraging results for the automated screening of exfoliated cytologic samples using coherent optical processing techniques to examine individual isolated cells. A more thorough investigation involving a larger data base has confirmed our initial results. This investigation was performed using a specially designed Fourier spectrum analyzer and a solid state optical detector array. An analysis was made to determine the performance of a screening system using such a cell-by-cell discriminating device. This analysis indicated that less than 20,000 cells would have to be examined to obtain a system performance level of 1% false negative and 10% false positive error rates with a 1% probability of occurrence of malignant cells in a malignant sample. This performance figure was inferred from measured statistical performance characteristics of a laboratory cell-by-cell screening device using optically generated Fourier transfrom techniques for cell discrimination. The performance of the system was shown to be much more sensitive to cell-by-cell false error rates than false negative error rates. It was also found that the majority of false positive errors were due to misclassifying parabasal cells as malignant. By eliminating parabasal cells, which comprised more than 25% of our normal cell data base, the number of cells needed to be screened dropped by an order of magnitude. It was also shown that there is an inverse quadratic relationship between the percentage of malignant cells in a malignant sample and the number of cells that must be screened to achieve any desired system performance.

The use of coherent optical processing techniques for the automatic screening of cervical cytologic samples

Coherent optical signal processing techniques applied to the screening of exfoliated cytologic cervical samples were evaluated. The two-dimensional Fourier spectrum of some 80 isolated cells was obtained from high resolution cell photographs and recorded. Quantitative spectrum data were collected on a training set consisting of 15 categorized malignant cells taken from slides diagnosed as malignant and 10 categorized normal cells taken from slides diagnosed as normal. A variety of transform parameters were measured and certain combinations of them were found which separated completely the normal from malignant cells. Certain parameters were shown to be functionally related to the cell diameter, nuclear diameter and nuclear density. Other parameters were found which appear to be related to other cell features such as clumping of nuclear deoxyribonucleic acid. When they were used in combination with the previous parameters, they greatly enhanced the discriminatory capabilities. Computer model studies formed the basis for our experimental design and parameter selection and have validated much of our experimental results. Although the sample size to date is admittedly small, our results have been very encouraging.

The birth of a child with Down's syndrome. A medico-social study of thirty-one children and their families

In a study of 31 children with Down's syndrome and their families in the Glasgow area, medico-social help was found to be adequate in dealing with the major physical problems (especially congenital heart disease) of the child, and in providing genetic advice to those families in whom recurrence was a major anxiety.

Help was deficient in catering for the emotional and social needs of many of the families of these children.

It is suggested that these findings reflect the narrow medical concept of Down's syndrome as an isolated pathological entity, and that a major shift of emphasis of medical attention from the child on to the family unit is required to effect changes in the standards of care of such children and their families.

Studies Concerning the Effects of Various Hormones Upon Renal Structure

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