Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a model-based cost-effectiveness analysis of a pragmatic, cluster-randomised trial in seven low-income and middle-income countries

BACKGROUND

Surgical site infection (SSI) is a major burden on patients and health systems. This study assessed the cost-effectiveness of routine change of sterile gloves and instruments before abdominal wall closure to prevent SSI.

METHODS

A decision-analytic model was built to estimate average costs and outcomes of changing gloves and instruments before abdominal wall closure compared with current practice. Clinical data were obtained from the ChEETAh trial, a multicentre, cluster-randomised trial in seven low-income and middle-income countries (LMICs), and costs were obtained from a study (KIWI) that assessed costs associated with SSIs in LMICs. Outcomes were measured as the percentage of surgeries resulting in SSIs. Costs were measured from a health-care provider perspective and were reported in 2021 US$. The economic analysis used a partially split single-country costing approach, with pooled outcomes data from all seven countries in the ChEETAh trial, and data for resource use and unit costs from India (KIWI); secondary analyses used resource use and costs from Mexico and Ghana (KIWI).

FINDINGS

In the base case, the average cost of the intervention was $259∙92 compared with $261∙10 for current practice (cost difference -$1∙18, 95% CI -4∙08 to 1∙33). In the intervention group, an estimated 17∙6% of patients had an SSI compared with 19∙7% of patients in the current practice group (absolute risk reduction 2∙10%, 95% CI 2∙07-2∙84). At all cost-effectiveness thresholds assumed ($0 to $14 000), the intervention had a higher likelihood of being cost-effective compared with current practice, indicating that the intervention was cost-effective. Similar results were obtained when the analysis using data from India was repeated using resource use and unit cost data from Mexico and Ghana.

INTERPRETATION

Routine sterile glove and instrument change before abdominal wall closure is effective and the costs are similar to those for current practice. Routine change of gloves and instruments before abdominal wall closure should be rolled out in LMICs.

FUNDING

National Institute for Health and Care Research (NIHR) Clinician Scientist Award, NIHR Global Health Research Unit Grant, and Mölnlycke Healthcare.

Accuracy of the Wound Healing Questionnaire in the diagnosis of surgical-site infection after abdominal surgery in low- and middle-income countries

INTRODUCTION

Telemedicine is being adopted for postoperative surveillance but requires evaluation for efficacy. This study tested a telephone Wound Healing Questionnaire (WHQ) to diagnose surgical site infection (SSI) after abdominal surgery in low- and middle-income countries.

METHOD

A multi-centre, international, prospective study was embedded in the FALCON trial; a factorial RCT testing measures to reduce SSI in seven low- and middle-income countries (NCT03700749). It was conducted according to a pre-registered protocol (SWAT126) and reported according to STARD guidelines. The reference test was in-person review by a trained clinician at 30 postoperative days according to US Centres for Disease Control criteria. The index test was telephone administration of an adapted WHQ at 27 to 30 postoperative days by a researcher blinded to the outcome of in-person review. The sum of item response scores generated an overall score between 0 and 29. The primary outcome was the diagnostic accuracy of the WHQ, defined as the proportion of SSI correctly identified by the telephone WHQ, and summarized using the area under the receiving operator characteristic curve (AUROC) and diagnostic test accuracy statistics.

RESULTS

Patients were included from three upper-middle income (396 patients, 13 hospitals), three lower-middle income (746 patients, 19 hospitals), and one low-income country (54 patients, 4 hospitals). 90.3% (1088 of 1196) patients were successfully contacted. Those with non-midline incisions (adjusted odds ratio: 0.36, 95% c.i. 0.17 to 0.73, P=0.005) or a confirmed diagnosis of SSI on in-person assessment (odds ratio: 0.42, 95% c.i. 0.20 to 0.92, P=0.006) were harder to reach. The questionnaire correctly discriminated between most patients with and without SSI (AUROC 0.869, 95% c.i. 0.824 to 0.914), which was consistent across subgroups. A representative cut-off score of ≥4 displayed a sensitivity of 0.701 (0.610-0.792), specificity of 0.911 (0.878-0.943), positive predictive value of 0.723 (0.633-0.814) and negative predictive value of 0.901 (0.867-0.935).

CONCLUSION

SSI can be diagnosed using a telephone questionnaire (obviating in-person assessment) in low resource settings.

Training Traditional Bonesetters in Basic Principles of Fracture Treatment: A Proof of Concept in Ghana

BACKGROUND

Our study assessed the effectiveness of a traditional bonesetter (TBS) educational program that was designed to increase knowledge, reduce complications, and promote the referral of patients to local hospitals by TBSs when necessary.

METHODS

From April to December 2021, TBSs from the Northern Sector (the Northern, Savannah, and North East regions) and the Ashanti region of Ghana underwent a 4-day training course that had been designed to teach basic principles of fracture care with the use of local tools. We assessed the levels of knowledge of the TBSs both before and after training. The change in practice of the trained TBSs also was assessed at 6 months using a structured questionnaire and a checklist.

RESULTS

In total, 157 TBSs were trained in 5 training sessions over a 9-month period. There was an improvement in knowledge in all of the modules of training, with an overall knowledge gain of 19.7% (from 67.2% to 86.9%). At 6 months of follow-up, the practices of TBSs that had most improved were record-keeping, hand hygiene, and patient rehabilitation. As a result of the referral system that was established by the training project, a total of 37 patients were referred to local hospitals in the 6 months following the training.

CONCLUSIONS

Formal training for TBSs that was provided by a multidisciplinary team with use of a locally developed curriculum and tools was effective in improving the practice and outcomes of treatment by TBSs. There was marked knowledge retention by the trained TBSs at 6 months after training in fracture management.

CLINICAL RELEVANCE

Education, training, and the establishment of referral pathways between TBSs and local hospitals could improve trauma care in Ghana.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Strategies to minimise and monitor biases and imbalances by arm in surgical cluster randomised trials: evidence from ChEETAh, a trial in seven low- and middle-income countries

BACKGROUND

Cluster randomised controlled trials (cRCT) present challenges regarding risks of bias and chance imbalances by arm. This paper reports strategies to minimise and monitor biases and imbalances in the ChEETAh cRCT.

METHODS

ChEETAh was an international cRCT (hospitals as clusters) evaluating whether changing sterile gloves and instruments prior to abdominal wound closure reduces surgical site infection at 30 days postoperative. ChEETAh planned to recruit 12,800 consecutive patients from 64 hospitals in seven low-middle income countries. Eight strategies to minimise and monitor bias were pre-specified: (1) minimum of 4 hospitals per country; (2) pre-randomisation identification of units of exposure (operating theatres, lists, teams or sessions) within clusters; (3) minimisation of randomisation by country and hospital type; (4) site training delivered after randomisation; (5) dedicated 'warm-up week' to train teams; (6) trial specific sticker and patient register to monitor consecutive patient identification; (7) monitoring characteristics of patients and units of exposure; and (8) low-burden outcome-assessment.

RESULTS

This analysis includes 10,686 patients from 70 clusters. The results aligned to the eight strategies were (1) 6 out of 7 countries included ≥ 4 hospitals; (2) 87.1% (61/70) of hospitals maintained their planned operating theatres (82% [27/33] and 92% [34/37] in the intervention and control arms); (3) minimisation maintained balance of key factors in both arms; (4) post-randomisation training was conducted for all hospitals; (5) the 'warm-up week' was conducted at all sites, and feedback used to refine processes; (6) the sticker and trial register were maintained, with an overall inclusion of 98.1% (10,686/10,894) of eligible patients; (7) monitoring allowed swift identification of problems in patient inclusion and key patient characteristics were reported: malignancy (20.3% intervention vs 12.6% control), midline incisions (68.4% vs 58.9%) and elective surgery (52.4% vs 42.6%); and (8) 0.4% (41/9187) of patients refused consent for outcome assessment.

CONCLUSION

cRCTs in surgery have several potential sources of bias that include varying units of exposure and the need for consecutive inclusion of all eligible patients across complex settings. We report a system that monitored and minimised the risks of bias and imbalances by arm, with important lessons for future cRCTs within hospitals.

Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a pragmatic, cluster-randomised trial in seven low-income and middle-income countries

BACKGROUND

Surgical site infection (SSI) remains the most common complication of surgery around the world. WHO does not make recommendations for changing gloves and instruments before wound closure owing to a lack of evidence. This study aimed to test whether a routine change of gloves and instruments before wound closure reduced abdominal SSI.

METHODS

ChEETAh was a multicentre, cluster randomised trial in seven low-income and middle-income countries (Benin, Ghana, India, Mexico, Nigeria, Rwanda, South Africa). Any hospitals (clusters) doing abdominal surgery in participating countries were eligible. Clusters were randomly assigned to current practice (42) versus intervention (39; routine change of gloves and instruments before wound closure for the whole scrub team). Consecutive adults and children undergoing emergency or elective abdominal surgery (excluding caesarean section) for a clean-contaminated, contaminated, or dirty operation within each cluster were identified and included. It was not possible to mask the site investigators, nor the outcome assessors, but patients were masked to the treatment allocation. The primary outcome was SSI within 30 days after surgery (participant-level), assessed by US Centers for Disease Control and Prevention criteria and on the basis of the intention-to-treat principle. The trial has 90% power to detect a minimum reduction in the primary outcome from 16% to 12%, requiring 12 800 participants from at least 64 clusters. The trial was registered with ClinicalTrials.gov, NCT03700749.

FINDINGS

Between June 24, 2020 and March 31, 2022, 81 clusters were randomly assigned, which included a total of 13 301 consecutive patients (7157 to current practice and 6144 to intervention group). Overall, 11 825 (88·9%) of 13 301 patients were adults, 6125 (46·0%) of 13 301 underwent elective surgery, and 8086 (60·8%) of 13 301 underwent surgery that was clean-contaminated or 5215 (39·2%) of 13 301 underwent surgery that was contaminated-dirty. Glove and instrument change took place in 58 (0·8%) of 7157 patients in the current practice group and 6044 (98·3%) of 6144 patients in the intervention group. The SSI rate was 1280 (18·9%) of 6768 in the current practice group versus 931 (16·0%) of 5789 in the intervention group (adjusted risk ratio: 0·87, 95% CI 0·79-0·95; p=0·0032). There was no evidence to suggest heterogeneity of effect across any of the prespecified subgroup analyses. We did not anticipate or collect any specific data on serious adverse events.

INTERPRETATION

This trial showed a robust benefit to routinely changing gloves and instruments before abdominal wound closure. We suggest that it should be widely implemented into surgical practice around the world.

FUNDING

National Institute for Health Research (NIHR) Clinician Scientist Award, NIHR Global Health Research Unit Grant, Mölnlycke Healthcare.

Knowledge and awareness of mitochondrial diseases among physicians in the tertiary hospitals in Ghana

BACKGROUND

Mitochondrial diseases/disorders (MDs), for decades, have been identified as a key underlying condition for many chronic diseases globally. However, data on the knowledge and prevalence of MDs in many countries in sub-Saharan Africa are lacking. This study assessed the knowledge, and awareness, of MDs among senior medical doctors in the five tertiary hospitals in Ghana.

METHOD

Data were collected from one hundred and twenty-eight (128) medical doctors in the five Tertiary Hospitals in Ghana using both closed and open-ended questionnaires and analysed using descriptive statistics.

RESULTS

Of the 128 respondents, 70.32% were senior medical officers and above, 87% of them indicated that they were aware of MDs and over 90% said physicians do not often diagnose MDs in Ghana. About 81% indicated that MDs are associated with chronic illnesses whilst 72% said the disease is diagnosed in both males and females. About 45% of the respondents alluded to the fact that MDs are difficult to diagnose, are associated with mutations in both the mitochondrial and the nuclear DNA, and are non-infectious diseases. Approximately 85% said nervous system dysfunction and muscle weakness are some of the symptoms associated with MDs whilst 77% said fatigue is also one of the symptoms. About 38% of the respondents specified that they encounter myopathies. A majority (70%) did not know about the availability of any consensus or standard diagnostic procedure and/or drugs for MDs.

CONCLUSION

There is a high level of knowledge and awareness of MDs among the respondents. However, there is a low disease encounter, which could be due to a lack of diagnostic protocols or a low disease prevalence. It is, therefore recommend that a patient perspective study, which looks at clinical records and laboratory data be conducted to fully ascertain the prevalence of MDs in Ghana and that appropriate educational strategies and interventions aimed at improving the diagnosis of mitochondrial diseases in Ghana be put in place.

SARS-COV-2 antibody responses to AZD1222 vaccination in West Africa

Real-world data on vaccine-elicited neutralising antibody responses for two-dose AZD1222 in African populations are limited. We assessed baseline SARS-CoV-2 seroprevalence and levels of protective neutralizing antibodies prior to vaccination rollout using binding antibodies analysis coupled with pseudotyped virus neutralisation assays in two cohorts from West Africa: Nigerian healthcare workers (n = 140) and a Ghanaian community cohort (n = 527) pre and post vaccination. We found 44 and 28% of pre-vaccination participants showed IgG anti-N positivity, increasing to 59 and 39% respectively with anti-receptor binding domain (RBD) IgG-specific antibodies. Previous IgG anti-N positivity significantly increased post two-dose neutralizing antibody titres in both populations. Serological evidence of breakthrough infection was observed in 8/49 (16%). Neutralising antibodies were observed to wane in both populations, especially in anti-N negative participants with an observed waning rate of 20% highlighting the need for a combination of additional markers to characterise previous infection. We conclude that AZD1222 is immunogenic in two independent West African cohorts with high background seroprevalence and incidence of breakthrough infection in 2021. Waning titres post second dose indicates the need for booster dosing after AZD1222 in the African setting despite hybrid immunity from previous infection.

Strengths, disconnects and lessons in local and central governance of the response to the first wave of COVID-19 in Ghana

Objectives

To explore governance, coordination and implementation actors, structures and processes, facilitators, and barriers within local government and between central and local government in Ghana's COVID-19 response during the first wave of the outbreak.

Design

Cross-sectional single case study. Data collection involved a desk review of media, policy and administrative documents and key informant in-depth interviews.

Setting

Two municipalities in the Greater Accra region of Ghana.

Participants

Local government decentralised decision makers and officials of decentralised departments.

Interventions

None.

Main Outcome Measures

None.

Results

Coordination between the national and local government involved the provision of directives, guidelines, training, and resources. Most of the emergency response structures at the municipal level were functional except for some Public Health Emergency Management Committees. Inadequate resources challenged all aspects of the response. Coordination between local government and district health directorates in risk communication was poor. During the distribution of relief items, a biased selection process and a lack of a bottom-up approach in planning and implementation were common and undermined the ability to target the most vulnerable beneficiaries.

Conclusions

Adequate financing and equipping of frontline health facilities and workers for surveillance, laboratory and case management activities, transparent criteria to ensure effective targeting and monitoring of the distribution of relief items, and a stronger bottom-up approach to the planning and implementation of interventions need to be given high priority in any response to health security threats such as COVID-19.

Funding

This work is funded by International Development Research Centre Grant No. 109479, Exploring and learning from evidence, policy and systems responses to COVID-19 in West and Central Africa.

Trends in type 1 diabetes diagnosis in Ghana

BACKGROUND

Despite the fact that the rate of type 1 diabetes (T1D) is increasing worldwide, there exists a dearth of information on the disease in most sub-Saharan African countries. The goal of this study was to determine the enrolment trend of T1D using data compiled over 28 y from a teaching hospital in Kumasi, Ghana.

METHODS

Information collected included sex, age at diagnosis and date of T1D diagnosis. We identified trends from 1992 to 2018, divided into 3 y intervals.

RESULTS

From 1992 to 2018, 1717 individuals with T1D were enrolled in the diabetes clinic at the Komfo Anokye Teaching Hospital. The male:female ratio was 1:1.2. The number of individuals diagnosed with T1D decreased among the 10-19 y age group during the 1992-1994 period, followed by a progressive increase within the same age group during the subsequent period (from 35.4% in 1995-1997 to 63.2% in 2016-2018). There was a decline in the proportion of children 0-9 y of age diagnosed during the study period (from 5.1% in 1992-1994 to 3.6% in 2016-2018).

CONCLUSIONS

In our study population, a decreasing trend of T1D enrolments was observed in general while among adolescents an increasing trend was observed.

Self-medication practices of pregnant women attending antenatal clinic in northern Ghana: An analytical cross-sectional study

In Ghana, despite the dangers that self-medication poses to maternal and fetal health, there has been limited examination of self-medication among pregnant women. This study examines the practice of self-medication among pregnant women in Wa Municipality, Ghana. An analytical cross-sectional survey of 367 pregnant women was conducted in three health facilities. The prevalence of self-medication practice was 74.1%. The majority (68.4%) of pregnant women obtained unprescribed medicines from chemical shops; others utilized leftover drugs from previous hospital visits (15.8%) or herbal medications (9.9%), while others took unprescribed drugs from relatives or friends (5.9%). Analgesics (76.1%), antibiotics (24.6%), and antimalarials (16.2%) were the most frequently self-medicated drugs. The most common illnesses or symptoms for which pregnant women self-medicated were headaches (34.2%), back pain (33.1%), waist pain (32.7%), lower abdominal pain (20.6%), and malaria (16.2%). After adjusting for potential confounders, easy access to medication without prescription (AOR= 8.4), illness perceived as minor (AOR=4.1), availability of health facilities (AOR=4.2), and frequent lack of medicines at health facilities (AOR=1.7) were significantly associated with self-medication. Enforcing legislation to prevent the stocking and sale of certain analgesics and antibiotics, increasing service points, and improving service quality at antenatal clinics, outpatient departments and pharmacies could reduce self-medication.

Diagnostics for COVID-19: A case for field-deployable, rapid molecular tests for community surveillance

Across the globe, the outbreak of the COVID-19 pandemic is causing distress with governments doing everything in their power to contain the spread of the novel coronavirus (SARS-CoV-2) to prevent morbidity and mortality. Actions are being implemented to keep health care systems from being overstretched and to curb the outbreak. Any policy responses aimed at slowing down the spread of the virus and mitigating its immediate effects on health care systems require a firm basis of information about the absolute number of currently infected people, growth rates, and locations/hotspots of infections. The only way to obtain this base of information is by conducting numerous tests in a targeted way. Currently, in Ghana, there is a centralized testing approach, that takes 4–5 days for samples to be shipped and tested at central reference laboratories with results communicated to the district, regional and national stakeholders. This delay in diagnosis increases the risk of ongoing transmission in communities and vulnerable institutions. We have validated, evaluated and deployed an innovative diagnostic tool on a mobile laboratory platform to accelerate the COVID-19 testing. A preliminary result of 74 samples from COVID-19 suspected cases has a positivity rate of 12% with a turn-around time of fewer than 3 hours from sample taking to reporting of results, significantly reducing the waiting time from days to hours, enabling expedient response by the health system for contact tracing to reduce transmission and additionally improving case management.

Seeking healthcare at their 'right' time; the iterative decision process for women with breast cancer

Background

About 85% of breast cancer patients attending Komfo Anokye Teaching Hospital (KATH), Ghana, present with stage III/IV disease. In spite of great investments into the early diagnosis and management of breast cancer, late presentation persists and poses a barrier to realising the possible benefits of the gains made in breast cancer management. This study assessed the symptom appraisal and medical health seeking behaviour of women with either locally advanced or metastatic breast cancer attending breast clinic at KATH.

Method

In-depth interviews of women presenting with clinical stage III/IV breast cancer were conducted to explore the women’s care seeking pathways after symptom identification until arrival at KATH from May 2015 to March 2016. Thematic data analysis was conducted using the Andersen behavioural model for health service use.

Results

Fifteen women aged 24–79 years were interviewed. The time from symptom identification to reporting to KATH was 4–24 months. The initial symptom was a breast lump or breast swelling which all the women identified themselves. These were initially appraised as not serious because most importantly, they did not interfere with their daily function. Symptom progression such as prevented them from undertaking their usual economic, social and family function triggered seeking care from health facilities. The availability of money to pay for care and diagnostic investigations influenced the time taken to navigate the referral pathway. While the women initially deferred healthcare for reasons related to their ability to perform economic, family and social roles, ultimately, aggressively pursuing healthcare was also for the same economic, family and social reasons or goals.

Conclusion

Deciding to seek care and pursue treatment for breast cancer symptoms may be much more complicated than it appears. Economic, family and social function significantly drive the health seeking process both at the personal and health facility phases of health seeking. Breast cancer education messages must be adapted to incorporate these functional goals and their influence on symptom appraisal and decision making to seek help and not just focus on the breast symptom as an isolated entity.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

The utility of the Sports Concussion Assessment Tool in hospitalized traumatic brain injury patients

The Sports Concussion Assessment Tool 3rd version is a sports screening tool that is often used to support return to play decisions following a head injury. The Sports Concussion Assessment Tool 3rd version is presumed to identify brain dysfunction (implying a degree of brain injury); however, the Sports Concussion Assessment Tool has never been validated with patients with definite acute brain injury. In this study, we found that all three Sports Concussion Assessment Tool 3rd version domains – symptoms, cognitive and balance assessments – were sensitive in discriminating traumatic brain injury patients (all with abnormal acute neuroimaging) from healthy controls. Through a correlation matrix (Bonferroni corrected), we found no correlation between the subjective (symptoms) and objective (examination) Sports Concussion Assessment Tool 3rd version assessments, e.g. complaints of imbalance and memory dysfunction were not correlated, respectively, with performance on testing balance and memory function. When relaxing the correction for multiple comparisons we found that of all Sports Concussion Assessment Tool 3rd version symptoms, a feeling of ‘pressure in the head’ had the largest number of co-correlations (including affective symptoms) and overwhelmingly in a pattern indicative of migraine. Taken together, that objective and subjective assessments in the Sports Concussion Assessment Tool 3rd version are poorly correlated, could suggest that symptoms in the Sports Concussion Assessment Tool 3rd version poorly reflect brain injury but rather indicate non-brain injury processes such as migraine. It follows that the current prominent orthodoxy of resting athletes following a head injury until their symptoms settle for fear of exacerbating brain injury may be unfavourable for their recovery – at least in some cases. Prospective clinical studies would be required to assess patient recovery from concussion with early active investigation and treatment versus rest – a notion supported by recent international consensus.

Educational Text Messages Decreased Emergency Department Utilization Among Infant Caregivers: A Randomized Trial

OBJECTIVE

To determine the feasibility and effectiveness of text messages as an educational tool to reduce the prevalence of nonurgent emergency department (ED) visits among a population with high levels of low health literacy.

METHODS

This prospective, randomized experiment conducted in a large, urban, academic pediatric primary care practice enrolled 231 caregivers of infants into 2 groups: enhanced standard of care materials at well-child visits through 6 months (n = 99 completing), and enhanced standard of care and 4 text messages a week through 6 months (n = 108 completing). Use of the ED and visit urgency were compared between groups via chart review at 1 year of age.

RESULTS

Of the 230 included in the analysis, 84.2% (n = 194 of 230) were racial or ethnic minorities, 69.7% (n = 142 of 204) reported yearly incomes of less than $20,000 per year, and 70.4% (n = 142 of 204) were identified as having likely or probable limited health literacy. Participants who received text messages had fewer visits to the ED in their first year (2.14 visits in the control group to 1.47 visits in the intervention group who received text messages; P < .05).

CONCLUSIONS

Sending educational text messages to caregivers is effective in reducing the number of visits to the ED. Given the accessibility and small expense of sending text messages, these findings have direct implications on the cost of health care, in addition to improving continuity and quality of care for pediatric patients.

Screening for Food Insecurity in Pediatric Clinical Settings: Opportunities and Barriers

Food insecurity is a serious health concern among children in the United States with 15.3 million children living in food insecure households. The American Academy of Pediatrics recommends that pediatricians screen for food insecurity at health maintenance visits as identifying children at risk is a crucial step in the amelioration of food insecurity. Two surveys were administered in a Midwest pediatric clinic. A cross-sectional survey was electronically distributed to pediatric providers to assess perceptions of food insecurity among patients, provider readiness to conduct food security screenings, and barriers to conducting those screenings. A cross-sectional caregiver survey was administered to assess demographics, household food security status, participation in nutrition assistance programs, and barriers to getting enough food to eat. Descriptive statistics and odds ratios were calculated. Eighty-eight percent of physicians believe that food insecurity is a challenge for some of their patients. Only 15 % of providers reported screening for food insecurity, while 80 % were willing to screen. Physicians were most concerned with knowing how to handle a positive screen. Among caregivers, 57 % screened positive for food insecurity. Those experiencing food insecurity were more likely to be non-white, participate in SNAP and to feel discomfort towards the idea of talking to a doctor or nurse about food needs. Caregivers reporting food insecurity were significantly less likely to have a personal vehicle. Effective food insecurity screening requires addressing caregiver and health provider barriers in order to increase the likelihood of identifying households most at risk.

Demonstration of single-crystal self-seeded two-color x-ray free-electron lasers

A scheme for generating two simultaneous hard-x-ray free-electron laser pulses with a controllable difference in photon energy is described and then demonstrated using the self-seeding setup at the Linac Coherent Light Source (LCLS). The scheme takes advantage of the existing LCLS equipment, which allows two independent rotations of the self-seeding diamond crystal. The two degrees of freedom are used to select two nearby crystal reflections, causing two wavelengths to be present in the forward transmitted seeding x-ray pulse. The free-electron laser system must support amplification at both desired wavelengths.

Effects of Wheat streak mosaic virus on Root Development and Water-Use Efficiency of Hard Red Winter Wheat

Greenhouse and field studies were conducted to determine the effects of Wheat streak mosaic virus (WSMV), a member of the family Potyviridae, on root development and water-use efficiency (WUE) of two hard red winter wheat (Triticum aestivum) cultivars, one susceptible and one resistant to WSMV. In the greenhouse studies, wheat cultivars were grown under three water regimes of 30, 60, and 80% soil saturation capacity. After inoculation with WSMV, plants were grown for approximately 4 weeks and then harvested. Root and shoot weights were measured to determine the effect of the disease on biomass. In all water treatments, root biomass and WUE of inoculated susceptible plants were significantly less (P < 0.05) than those of the noninoculated control plants. However, in the resistant cultivar, significance was only found in the 30 and 60% treatments for root weight and WUE, respectively. Field studies were also conducted under three water regimes based on reference evapotranspiration rates. Significant reductions in forage, grain yield, and crop WUE were observed in the inoculated susceptible plots compared with the noninoculated plots. Both studies demonstrated that wheat streak mosaic reduces WUE, which is a major concern in the Texas Panhandle because of limited availability of water.

An exploratory study of the association between reactive attachment disorder and attachment narratives in early school-age children

OBJECTIVE

To explore attachment narratives in children diagnosed with reactive attachment disorder (RAD).

METHOD

We compared attachment narratives, as measured by the Manchester Child Attachment Story Task, in a group of 33 children with a diagnosis of RAD and 37 comparison children.

RESULTS

The relative risk (RR) for children with RAD having an insecure attachment pattern was 2.4 (1.4-4.2) but 30% were rated as securely attached. Within the RAD group, children with a clear history of maltreatment were more likely to be Insecure-Disorganised than children without a clear history of maltreatment.

CONCLUSIONS

Reactive attachment disorder is not the same as attachment insecurity, and questions remain about how attachment research informs clinical research on attachment disorders.

X-ray diffuse scattering measurements of nucleation dynamics at femtosecond resolution

Femtosecond time-resolved small and wide angle x-ray diffuse scattering techniques are applied to investigate the ultrafast nucleation processes that occur during the ablation process in semiconducting materials. Following intense optical excitation, a transient liquid state of high compressibility characterized by large-amplitude density fluctuations is observed and the buildup of these fluctuations is measured in real time. Small-angle scattering measurements reveal snapshots of the spontaneous nucleation of nanoscale voids within a metastable liquid and support theoretical predictions of the ablation process.

Carrier-density-dependent lattice stability in InSb

The ultrafast decay of the x-ray diffraction intensity following laser excitation of an InSb crystal has been utilized to observe carrier dependent changes in the potential energy surface. For the first time, an abrupt carrier dependent onset for potential energy surface softening and the appearance of accelerated atomic disordering for a very high average carrier density have been observed. Inertial dynamics dominate the early stages of crystal disordering for a wide range of carrier densities between the onset of crystal softening and the appearance of accelerated atomic disordering.

Ultrafast bond softening in bismuth: mapping a solid's interatomic potential with X-rays

Intense femtosecond laser excitation can produce transient states of matter that would otherwise be inaccessible to laboratory investigation. At high excitation densities, the interatomic forces that bind solids and determine many of their properties can be substantially altered. Here, we present the detailed mapping of the carrier density-dependent interatomic potential of bismuth approaching a solid-solid phase transition. Our experiments combine stroboscopic techniques that use a high-brightness linear electron accelerator-based x-ray source with pulse-by-pulse timing reconstruction for femtosecond resolution, allowing quantitative characterization of the interatomic potential energy surface of the highly excited solid.

Observation of structural anisotropy and the onset of liquidlike motion during the nonthermal melting of InSb

The melting dynamics of laser excited InSb have been studied with femtosecond x-ray diffraction. These measurements observe the delayed onset of diffusive atomic motion, signaling the appearance of liquidlike dynamics. They also demonstrate that the root-mean-squared displacement in the [111] direction increases faster than in the [110] direction after the first 500 fs. This structural anisotropy indicates that the initially generated fluid differs significantly from the equilibrium liquid.

Atomic-Scale Visualization of Inertial Dynamics

The motion of atoms on interatomic potential energy surfaces is fundamental to the dynamics of liquids and solids. An accelerator-based source of femtosecond x-ray pulses allowed us to follow directly atomic displacements on an optically modified energy landscape, leading eventually to the transition from crystalline solid to disordered liquid. We show that, to first order in time, the dynamics are inertial, and we place constraints on the shape and curvature of the transition-state potential energy surface. Our measurements point toward analogies between this nonequilibrium phase transition and the short-time dynamics intrinsic to equilibrium liquids.

Clocking femtosecond X rays

Linear-accelerator-based sources will revolutionize ultrafast x-ray science due to their unprecedented brightness and short pulse duration. However, time-resolved studies at the resolution of the x-ray pulse duration are hampered by the inability to precisely synchronize an external laser to the accelerator. At the Sub-Picosecond Pulse Source at the Stanford Linear-Accelerator Center we solved this problem by measuring the arrival time of each high energy electron bunch with electro-optic sampling. This measurement indirectly determined the arrival time of each x-ray pulse relative to an external pump laser pulse with a time resolution of better than 60 fs rms.

Increasing the accuracy of operative coding

INTRODUCTION

Operative codes provide a readily retrievable record of operative procedures and interventions and are invaluable in performance of clinical audit and research. In most hospitals, coding is performed by coding clerks who depend on legible complete operative notes for coding. In others, coding is by the operator/surgeon. The aim of this audit was to determine the impact of hand-written and typed operative notes on accuracy of coding as well as deciding if the operator is the better coder.

METHODS

A total of 200 operations/procedures performed by one surgical firm were randomised, prospectively, into hand-written (HN, 100) and template-based typed (TN, 100) operation notes. Each procedure was coded by the operator/surgeon as well as by the coding clerk. The results were compared for error, incomplete and complete codes.

RESULTS

Coding clerks were found to be better coders with 97% of TN and 85% of HN coded completely compared to 48% and 62%, respectively, by operators. There were more incomplete codes for HN compared to TN (15% versus 6% for coders and 62% versus 53% for operators). There were no error codes for both groups.

CONCLUSIONS

These results suggest that the quality of coded information is poorer if operation notes are hand-written rather than typed, with template-based mandatory fields in typed notes possibly acting as an aide-memoir in generating complete, accurate notes. In the absence of formal training for clinicians, coding of procedures should probably be left to coding clerks.

Future possibilities of the Linac Coherent Light Source

A study of the potential for the development of the Linac Coherent Light Source (LCLS) beyond the specifications of the baseline design is presented. These future developments include delivery of X-ray pulses in the 1 fs regime, extension of the spectral range, increase of the FEL power, exploitation of the spontaneous emission, and a more flexible time structure. As this potential is exploited, the LCLS can maintain its role as a world-leading instrument for many years beyond its commissioning in 2008 and initial operation as the world's first X-ray free-electron laser.

An alternate targeting pathway for procathepsin L in mouse fibroblasts

In transformed mouse fibroblasts, a significant proportion of the lysosomal cysteine protease cathepsin L remains in cells as an inactive precursor which associates with membranes by a mannose phosphate-independent interaction. When microsomes prepared from these cells were resolved on sucrose gradients, this procathepsin L was localized in dense vesicles distinct from those enriched for growth hormone, which is secreted constitutively when expressed in fibroblasts. Ultrastructural studies using antibodies directed against the propeptide to avoid detection of the mature enzyme in lysosomes revealed that the proenzyme was concentrated in dense cores within small vesicles and multivesicular endosomes which labeled with antibodies specific for CD63. Consistent with the resemblance of these cores to those of regulated secretory granules, secretion of procathepsin L from fibroblasts was modestly stimulated by phorbol, 12-myristate, 13-acetate. When protein synthesis was blocked with cycloheximide and lysosomal proteolysis inhibited with leupeptin, procathepsin L was found to gradually convert to the active single-chain protease. The data suggest that when synthesis levels are high, a portion of the procathepsin L is packaged in dense cores within multivesicular endosomes localized near the plasma membrane. Gradual activation of this proenzyme achieves targeting of the proenzyme to lysosomes by a mannose phosphate receptor-independent pathway.

Nature of e(g) electron order in La(1-x)Sr(1+x)MnO(4)

X-ray scattering measurements of the low-temperature structure of La(1-x)Sr(1+x)MnO(4) ( 0.33< or =x< or =0.67) indicate the existence of three distinct regions: a disordered phase (x<0.4), a charge-ordered phase (x> or =0.5), and a mixed phase (0.4< or =x<0.5). For x>0.5, the modulation vector associated with the charge order is incommensurate with the lattice and depends linearly on the concentration of e(g) electrons. The primary superlattice reflections are strongly suppressed along the modulation direction and the higher harmonics are weak, implying the existence of a largely transverse and nearly sinusoidal structural distortion, consistent with a charge-density wave of the e(g) electrons.

When is reduced-compression bandaging safe and effective?

During a one-year period 44 patients were treated with reduced-compression bandaging in the vascular unit at a district general hospital. Twenty patients with venous ulcers were referred from community leg ulcer clinics because they could not tolerate standard compression bandaging (group 1). A further 24 patients had mixed aetiology leg ulcers (group 2), and high-compression bandaging was not attempted because of significant peripheral vascular disease (ankle brachial pressure index < 0.8). Forty-two patients tolerated reduced-compression bandaging without discomfort or skin pressure changes. Healing was achieved in 32 patients (13 in group 1 and 19 in group 2). All non-healed ulcers were considered smaller at the time of final follow-up, and had less exudate. Reduced-compression bandaging has been shown to be effective and well tolerated by patients with venous ulcers who cannot comply with high-compression bandaging. With close supervision, it is safe to use in patients with significant peripheral vascular disease.

A study of primary neuronal infection by mutants of herpes simplex virus type 1 lacking dispensable and non-dispensable glycoproteins

Cultures of primary rat dorsal root ganglia neurones were inoculated with various doses of herpes simplex virus mutants deficient in glycoproteins B, D, H, C, G, E, I or J, and the proportion of infected neurones was determined. The behaviour of these mutants on primary neurones was broadly similar to their behaviour on fibroblasts or epithelial cells. Thus, virions lacking the 'nondispensable' glycoproteins B, D or H were incapable of infecting primary neurones, whereas mutants lacking glycoproteins G, E, I or J infected primary neurones with the same efficiency as wild-type virions. Two independently derived mutants lacking gC displayed a marginal phenotype, infecting neurones with a five- to tenfold reduced efficiency relative to wild-type virus and relative to non-neuronal cells in the same cultures. We conclude that the virion glycoprotein requirements for infection of mammalian neurones are similar to those required for infection of fibroblasts and epithelial cells but that glycoprotein C may enhance infection of neurones.

Transduction of murine and human tumors using recombinant adenovirus vectors

BACKGROUND

Most cytokine-based cancer gene therapy clinical trials have used labor-intensive, retrovirus-mediated strategies resulting in unpredictable gene expression. Recombinant AdV vectors were evaluated for easier, more reproducible gene transfer into 12 human melanoma, 2 murine fibrosarcomas, and 8 other tumor cell lines.

METHODS

AdV vectors contained a reporter (Escherichia coli beta-galactosidase or firefly luciferase) or cytokine gene (human interleukin-2 [IL-2] or IL-7). Transduction efficiencies and expression levels were assessed by histochemical staining, flow cytometry, polymerase chain reaction, fluorometry, and enzyme-linked immunosorbent assay. Tumorigenicity was determined by subcutaneous injection of cells into syngeneic mice.

RESULTS

All cell lines studied were transduced with AdV. Most cell lines exhibited 100% transduction efficiencies (by flow cytometry) at multiplicities of infection (MOI) epsilon 10. Gene expression correlated linearly with MOI, but a cytopathic effect was observed at MOI > 100 with all vectors. Nanogram gene expression levels were routinely achieved. Irradiation (30 Gy) minimally affected expression levels. Tumorigenicity of AdV-IL-2-transduced fibrosarcoma cells in mice was inversely related to IL-2 production. A majority of mice that rejected their tumor challenge were immune to tumor rechallenge.

CONCLUSIONS

E1-deleted AdV vectors may prove useful in generating tumor vaccines ex vivo with high, transient cytokine expression levels.