The SelfSTarT intervention for low back pain patients presenting to first contact physiotherapists: A mixed methods service evaluation

INTRODUCTION

Globally, back pain is the leading cause of years of disability. In the United Kingdom, over 20 million people live with musculoskeletal (MSK) pain, with low back pain being one of the most common causes. National strategies promote self-management and the use of digital technologies to empower populations.

AIMS

To evaluate the uptake and impact of providing the SelfSTart approach (STarT Back and SelfBACK App) when delivered by a First Contact Physiotherapist (FCP) to people presenting with low back pain in primary care.

METHODS

Patients presenting with a new episode of low back pain underwent routine assessment and completion of a STarT Back questionnaire. Patients with low/medium scores were offered the SelfBACK App. A control population was provided by the MIDAS-GP study. Patient Experience, outcome measures, healthcare utilisation and retention were captured through the app and clinical systems (EMIS). Interviews with five FCPs explored the experiences of using the SelfSTart approach.

RESULTS

SelfSTarT was taken up by almost half (48%) of those to whom it was offered. Compared to MIDAS-GP, users were more likely to be younger, male, in work, and with higher health literacy. SelfSTarT users reported significant improved experiences relating to receiving an agreed care plan and receiving sufficient information. There were no significant differences in treatments offered. FCPs were positive about the app and felt it had value but wanted feedback on patient progress. They recognised that a digital solution would not be suitable for all.

CONCLUSION

This approach offers an opportunity to empower and support self-management, using robustly evaluated digital technology.

Profiling volatile organic compounds from human plasma using GC×GC-ToFMS

Volatile organic compounds (VOCs) originating from human metabolic activities can be detected in, for example, breath, urine, feces, and blood. Thus, attention has been given to identifying VOCs from the above matrices. Studies identifying and measuring human blood VOCs are limited to those focusing on monitoring specific pollutants, or blood storage and/or decomposition. However, a comprehensive characterization of VOCs in human blood collected for routine diagnostic testing is lacking. In this study, 72 blood-derived plasma samples were obtained from apparently healthy adult participants. VOCs were extracted from plasma using solid-phase microextraction and analyzed using comprehensive two-dimensional gas chromatography tandem time-of-flight mass spectrometry (GC×GC-ToFMS). Chromatographic data were aligned, and putative compound identities were assigned via spectral library comparison. All statistical analysis, including contaminant removal, data normalization and transformation were performed using R. We identified 401 features which we called the pan volatilome of human plasma. Of the 401 features, 34 were present in all the samples with less than 15% variance (core molecules), 210 were present in ≥10% but <100% of the samples (accessory molecules) and 157 were present in less than 10% of the samples (rare molecules). The core molecules, consisting of aliphatic, aromatic and carbonyl compounds were validated using 25 additional samples. The validation accuracy was 99.9%. Of the 34 core molecules, two molecules (octan-2-one and 4-methylheptane) have been identified from the plasma samples for the first time. Overall, our data describes the baseline VOC profile in human plasma and will serve as a resource for blood-derived VOCs that can complement future biomarker studies using different matrices.

Co-production in public health research grant writing: engaging underserved migrant mothers in the UK

Background

In the UK, one in three births is to a non-UK born woman, but there is a gap in co-produced research to explore their experiences. The National Institute for Health and Care Research (NIHR) defines co-production as ‘an approach in which researchers, practitioners, and members of the public work together, sharing power and responsibility'. This project co-produced a grant proposal to improve maternity care for underserved migrant women in the UK. We reflect on transferrable learning for engaging those whose voices are less often heard in grant writing.

Methods

An expert by experience, an underserved migrant woman who gave birth in the UK, joined the research team. Four online engagement workshops were conducted; two involved only migrant women, two were multi-disciplinary. 26 underserved migrant women attended. NIHR INVOLVE public involvement guidance was consulted.

Results

Women said they were often asked about negative experiences which felt disempowering, and rarely asked about solutions. Thus, we shifted the focus of our work to co-designing solutions. Women said that having an expert by experience co-host workshops encouraged engagement, so we integrated this into our methods. Some women were uncomfortable in professional groups. Thus, our proposed steering and focus groups will have an expert by experience subgroup with elected members attending multi-disciplinary groups. We will engage mostly online as women preferred this to enable flexibility with childcare. The lead expert by experience helped form the proposal through brainstorming, co-drafting, and feedback; experts by experience commented on the draft via email and workshops. The lead expert by experience wished to gain further experience of research methods, for which we requested additional funding.

Conclusions

This project highlights the immense potential for co-production in public health research, and the value of adapting research planning to maximise the voices of the less often heard.

Key messages

• Engaging experts by experiences in public health research planning is key to ensuring our work addresses the needs of underserved communities.

• Co-Production of research requires determination to involve those whose voices are less often heard from the beginning of the research process, and to commit to joined working throughout.

New evidence on the prevalence and risk of peripartum mental illness amongst migrant women: A global review of the literature

Migration is known to affect an individual's health and social status, and migrant women who are pregnant or postpartum are known to be at high risk of adverse health and social outcomes. They are at particularly high risk of mental disorders, especially perinatal depression (PND). Previous studies have demonstrated the prevalence of PND may be higher amongst migrant women when compared to the general population. The determinants of perinatal mental disorders amongst migrant women are complex and may include social isolation, discrimination, poor healthcare access, and low levels of emotional and practical support. The consequences of perinatal mental disorders include a high risk of suicidality and depression in the woman, as well as adverse outcomes for the child including a high risk of low birth weight, diarrhoeal disease, and poorer cognitive outcomes. We will present updated data on the prevalence and risk factors for perinatal mental illness (depression, anxiety, post-traumatic stress disorder, psychosis) amongst migrant women (refugee women, and internally displaced women) at a global level. We will synthesize the available evidence which is available to date, and create consensus on the prevalence and risk of perinatal mental illness amongst migrant women. We expect that migrant woman will be at significantly higher risk of perinatal mental illness when compared to the general population. We will discuss appropriate health system responses which may address the health care needs for migrant women in fragile or conflict-affected settings.

Cross-validation of ELISA and a portable surface plasmon resonance instrument for IgG antibody serology with SARS-CoV-2 positive individuals

We report on the development of surface plasmon resonance (SPR) sensors and matching ELISAs for the detection of nucleocapsid and spike antibodies specific against the novel coronavirus 2019 (SARS-CoV-2) in human serum, plasma and dried blood spots (DBS). When exposed to SARS-CoV-2 or a vaccine against SARS-CoV-2, the immune system responds by expressing antibodies at levels that can be detected and monitored to identify the fraction of the population potentially immunized against SARS-CoV-2 and support efforts to deploy a vaccine strategically. A SPR sensor coated with a peptide monolayer and functionalized with various sources of SARS-CoV-2 recombinant proteins expressed in different cell lines detected human anti-SARS-CoV-2 IgG antibodies in clinical samples. Nucleocapsid expressed in different cell lines did not significantly change the sensitivity of the assays, whereas the use of a CHO cell line to express spike ectodomain led to excellent performance. This bioassay was performed on a portable SPR instrument capable of measuring 4 biological samples within 30 minutes of sample/sensor contact and the chip could be regenerated at least 9 times. Multi-site validation was then performed with in-house and commercial ELISA, which revealed excellent cross-correlations with Pearson's coefficients exceeding 0.85 in all cases, for measurements in DBS and plasma. This strategy paves the way to point-of-care and rapid testing for antibodies in the context of viral infection and vaccine efficacy monitoring.

Early-cannulation arteriovenous grafts are safe and effective in avoiding recurrent tunneled central catheter infection

Objective

Tunneled central venous catheter infection (TCVCi) is a common complication that often necessitates removal of the TCVC and a further TCVC. Theoeretically, insertion of an early-cannualtion graft (ecAVG) early after TCVC infection is possible but not widely practiced with concerns over safety and infection in the ecAVG. With 8 years of ecAVG experience, the aim of this study was to compare the outcomes following TCVC infection, comparing replacement with TCVC (TCVCr) versus immediate ecAVG (ecAVGr).

Methods

Retrospective comparison of two cohorts, who underwent replacement of an infected TCVC either by an early cannulation graft (n = 18) or by a further central catheter (n = 39).

Data were abstracted from a prospectively completed electronic patient record and collected on patient demographics, TCVC insertion, duration and infection, including culture proven bacteriaemia and subsequent access interventions.

Results

18/299 patients identified from 2012-2020 had an ecAVG implanted as treatment for a TCVCi. In a one-year time-period (1/1/2015 -31/12/2015) out of 222 TCVC inserted, 39 were as a replacement following a TCVCi. No patient with an ecAVGr developed an immediate infection, nor complication from the procedure. The rate of subsequent vascular access infection was significantly more frequent for those with TCVCr than with an ecAVGr (0.6 vs. 0.1/patient/ 1000 HD days, p &lt; 0.000). The number of further TCVC required was significantly higher in the TCVCr group (7.1 vs. 0.4/patient/ 1000 HD days, p = 0.000).

Conclusion

An ecAVG early following a TCVC infection is safe, reduces the incidence of subsequent infectious complications and reduces the number of TCVC required, with a better functional patency.

Early-Cannulation Arteriovenous Grafts Are Safe and Effective in Avoiding Recurrent Tunneled Central Catheter Infection

OBJECTIVES

Tunneled central venous catheter infection (TCVCi) is a common complication that often necessitates removal of the TCVC and replacement by a further TCVC. Theoretically, insertion of an early - cannulation graft (ecAVG) early after TCVC infection is possible but not widely practiced with concerns over safety and infection in the ecAVG. With 8 years of ecAVG experience, the aim of this study was to compare the outcomes following TCVC infection, comparing replacement with TCVC (TCVCr) versus immediate ecAVG (ecAVGr).

DESIGN

Retrospective comparison of 2 cohorts, who underwent replacement of an infected TCVC either by an early cannulation graft (n = 18) or by a further central catheter (n = 39).

METHODS

Data were abstracted from a prospectively completed electronic patient record and collected on patient demographics, TCVC insertion, duration and infection, including culture proven bacteriaemia and subsequent access interventions.

RESULTS

Eighteen of 299 patients identified from 2012 to 2020 had an ecAVG implanted as treatment for a TCVCi. In a 1-year time-period (January 1, 2015-December 31, 2015) out of 222 TCVC inserted, 39 were as a replacement following a TCVCi. No patient with an ecAVGr developed an immediate infection, nor complication from the procedure. The rate of subsequent vascular access infection was significantly more frequent for those with a TCVCr than with an ecAVGr (0.6 vs. 0.1/patient/1000 HD days, P< 0.000). The number of further TCVC required was significantly higher in the TCVCr group (7.1 vs. 0.4/patient/1000 HD days, P= 0.000).

CONCLUSIONS

An ecAVG early following a TCVC infection is safe, reduces the incidence of subsequent infectious complications and reduces the number of TCVC required, with a better functional patency.

Health Science Students as PPE Coaches in the Emergency Department - a Pandemic Pilot Project

PPE is an integral part of reducing transmission of COVID-19. We assessed a 5-week pilot project of utilising health science student volunteers as PPE coaches in the adult and paediatric emergency department (ED) during the pandemic. PPE coaches were provided with training, PPE checklist, area for written observations, and feedback surveys. Overall, correct PPE use improved over time. Coaches felt safe, that training was adequate, and part of the team. Factors that contributed to project effectiveness included institutional support, role clarification, and continuous feedback from staff. Our findings support the utilisation of students in IPC projects.

A pilot study evaluating GSK1070806 inhibition of interleukin-18 in renal transplant delayed graft function

INTRODUCTION

Delayed graft function (DGF) following renal transplantation is a manifestation of acute kidney injury (AKI) leading to poor long-term outcome. Current treatments have limited effectiveness in preventing DGF. Interleukin-18 (IL18), a biomarker of AKI, induces interferon-γ expression and immune activation. GSK1070806, an anti-IL18 monoclonal antibody, neutralizes activated (mature) IL18 released from damaged cells following inflammasome activation. This phase IIa, single-arm trial assessed the effect of a single dose of GSK1070806 on DGF occurrence post donation after circulatory death (DCD) kidney transplantation.

METHODS

The 3 mg/kg intravenous dose was selected based on prior studies and physiologically based pharmacokinetic (PBPK) modeling, indicating the high likelihood of a rapid and high level of IL18 target engagement when administered prior to kidney allograft reperfusion. Utilization of a Bayesian sequential design with a background standard-of-care DGF rate of 50% based on literature, and confirmed via extensive registry data analyses, enabled a statistical efficacy assessment with a minimal sample size. The primary endpoint was DGF frequency, defined as dialysis requirement ≤7 days post transplantation (except for hyperkalemia). Secondary endpoints included safety, pharmacokinetics and pharmacodynamic biomarkers.

RESULTS

GSK1070806 administration was associated with IL18-GSK1070806 complex detection and increased total serum IL18 levels due to IL18 half-life prolongation induced by GSK1070806 binding. Interferon-γ-induced chemokine levels declined or remained unchanged in most patients. Although the study was concluded prior to the Bayesian-defined stopping point, 4/7 enrolled patients (57%) had DGF, exceeding the 50% standard-of-care rate, and an additional two patients, although not reaching the protocol-defined DGF definition, demonstrated poor graft function. Six of seven patients experienced serious adverse events (SAEs), including two treatment-related SAEs.

CONCLUSION

Overall, using a Bayesian design and extensive PBPK dose modeling with only a small sample size, it was deemed unlikely that GSK1070806 would be efficacious in preventing DGF in the enrolled DCD transplant population.

TRIAL REGISTRATION

NCT02723786.

Cortisol/cortisone levels and quality of life in individuals with pulmonary arterial hypertension

Individuals with pulmonary arterial hypertension experience debilitating symptoms and psychological distress which may influence their cortisol regulation. We describe associations between diurnal salivary cortisol/cortisone levels and quality of life in adults with pulmonary arterial hypertension. Findings suggest potential clinical utility of cortisol/cortisone assessment as applied to a pulmonary arterial hypertension population.

Anomalously High Proton Conduction of Interfacial Water

Water at the solid-liquid interface exhibits an anomalous ionic conductivity and dielectric constant compared to bulk water. Both phenomena still lack a detailed understanding. Here, we report radio-frequency measurements and analyses of the electrodynamic properties of interfacial water confined in nanoporous matrices formed by diamond grains of various sizes, ranging from 5 nm to 0.5 μm in diameter. Contrary to bulk water, the charge-carrying protons/holes in interfacial water are not mutually screened, allowing for higher mobility in the external electric field. Thus, the protonic conductivity reaches a maximum value, which can be 5 orders of magnitude higher than that of bulk water. Our results aid in the understanding of physical and chemical properties of water confined in porous materials and pave the way to the development of new type of highly efficient proton-conductive materials for applications in electrochemical energy systems, membrane separations science, and nanofluidics.

Has the Expansion in Extended Criteria Deceased Donors Led to a Different Type of Delayed Graft Function and Poorer Outcomes?

OBJECTIVES

There has been considerable change in the practice of deceased kidney transplantation in the past 15 years, with more extreme phenotypes implanted. The aim of this study was to determine whether increased use of expanded criteria donors (extended criteria donors and donors after circulatory death) affected clinical outcomes, including the incidence and pattern of delayed graft function.

METHODS AND MATERIALS

A retrospective analysis of 1359 renal transplants was performed over 15 years. The first 10 years of data (group 1) were compared with the subsequent 5 years (group 2). Outcomes were analyzed at 6 months and 12 months in addition to serum creatinine and patterns of delayed graft function (posttransplant times: on hemodialysis, to peak creatinine, for creatinine to half, and for creatinine to fall within 10% of baseline).

RESULTS

There was a significant increase in the percentage of expanded criteria donor allografts used in group 2 with a significant increase in the incidence of delayed graft function. Despite this, serum creatinine and the incidence of biopsy-proven acute rejection had both improved in group 2. Group 2 expanded criteria donor kidneys had a significantly lower incidence of type 1 delayed graft function and a significantly higher incidence of types 3 and 4 delayed graft function. Time for creatinine to half in both groups was the best predictor of a serum creatinine <180 μmol/L at 1 year.

CONCLUSION

The increased use of expanded criteria donor kidneys has led to a higher incidence of delayed graft function, but the pattern has shown that the requirement for hemodialysis has significantly reduced.

Culture phenotypes and molecular characterization of Mycobacterium avium subsp. paratuberculosis isolates from small ruminants

In this study the suitability of different solid media was investigated for the isolation of Mycobacterium avium subsp. paratuberculosis (Map) in order to identify the optimum single or combination of media to permit the isolation of all strain types from small ruminants. A subset of these Map strains was then further characterized by molecular typing methods to assess the genetic diversity of Map strains in the study area (Northern Greece). Map strains were isolated from tissues and faeces of infected goats (n=52) and sheep (n=8) and were analysed for polymorphisms in IS1311 to classify the strain type as Type C or S. The study found that M7H11 supplemented with mycobactin j, OADC and new born calf serum (M7H11+Mj) is the best single choice of medium for the primary isolation of Map of both Type C and S from small ruminants. The combination of M7H11+Mj and Herrolds egg yolk medium supplemented with mycobactin j and sodium pyruvate allowed the detection of all Map isolates in this study. Nineteen Map isolates were characterised by pulsed-field gel electrophoresis and the isolates demonstrated significant genetic diversity. Twelve different SnaBI and 16 distinct SpeI profiles were detected of which 25 have not been described previously and are new profiles. The combination of both enzyme profiles gave 13 different multiplex profiles. Ten different multiplex profiles were detected in goats and three in sheep. One ovine isolate gave the same multiplex profile as a caprine isolate and two different profiles were found within a single goat herd.

Search for lepton flavour violation in the eμ continuum with the ATLAS detector in [Formula: see text]pp collisions at the LHC

This paper presents a search for the t-channel exchange of an R-parity violating scalar top quark ([Formula: see text]) in the e±μ∓ continuum using 2.1 fb-1 of data collected by the ATLAS detector in [Formula: see text]pp collisions at the Large Hadron Collider. Data are found to be consistent with the expectation from the Standard Model backgrounds. Limits on R-parity-violating couplings at 95 % C.L. are calculated as a function of the scalar top mass ([Formula: see text]). The upper limits on the production cross section for pp→eμX, through the t-channel exchange of a scalar top quark, ranges from 170 fb for [Formula: see text] to 30 fb for [Formula: see text].

Measurement of the ZZ production cross section and limits on anomalous neutral triple gauge couplings in proton-proton collisions at sqrt[s] = 7 TeV with the ATLAS detector

A measurement of the ZZ production cross section in proton-proton collisions at sqrt[s] = 7 TeV using data corresponding to an integrated luminosity of 1.02 fb(-1) recorded by the ATLAS experiment at the LHC is presented. Twelve events containing two Z boson candidates decaying to electrons and/or muons are observed, with an expected background of 0.3 ± 0.3(stat)(-0.3)(+0.4)(syst) events. The cross section measured in a phase-space region with good detector acceptance and for dilepton masses within the range 66 to 116 GeV is σ(ZZ → ℓ+ ℓ- ℓ+ ℓ-)(fid) = 19.4(-5.2)(+6.3)(stat)(-0.7)(+0.9)(syst) ± 0.7(lumi) fb. The resulting total cross section for on-shell ZZ production, σ(ZZ)(tot) = 8.5(-2.3)(+2.7)(stat)(-0.3)(+0.4)(syst) ± 0.3(lumi) pb, is consistent with the standard model expectation of 6.5(-0.2)(+0.3) pb calculated at the next-to-leading order in QCD. Limits on anomalous neutral triple gauge boson couplings are derived.

Mycobacterium avium subsp. hominissuis Infection in a captive-bred kiang (Equus kiang)

Equids are considered highly resistant to mycobacterial infections and clinical cases have been described in domestic horses only. Mycobacterium bovis is the most common species reported, although a single report exists of disease due to definitively diagnosed infection with Mycobacterium avium subsp. hominissuis in two domestic horses. This is the first report of a mycobacterial infection in a kiang (Equus kiang), or indeed any wild equid. The animal had chronic loss of condition and serum biochemical changes suggestive of liver disease and chronic infection. Further investigation showed a chronic granulomatous enteritis, lymphadenitis and hepatitis with focal granulomatous pneumonia due to systemic infection with M. avium subsp. hominissuis. The distribution and severity of the lesions suggested that the route of infection was alimentary.

Oral epithelial dysplasia and squamous cell carcinoma following allogeneic hematopoietic stem cell transplantation: clinical presentation and treatment outcomes

Background

Late complications of allogeneic hematopoietic stem cell transplantation (HSCT) include a risk of secondary malignancies, including oral cancers. Optimization of best clinical practices for early diagnosis and treatment of oral premalignant or malignant lesions requires an assessment of potential predisposing risk factors as well as treatment outcomes.

Methods

The medical records of patients who developed oral epithelial dysplasia (OED) and oral squamous cell carcinoma (OSCC) following allogeneic HSCT were reviewed. Data on demographics, HSCT course, chronic graft-versus-host disease (cGVHD), smoking and alcohol consumption, oral lesion characteristics, mode of therapy and clinical outcome were recorded; landmark survival was calculated.

Results

Twenty-six patients with OED (n = 8) and OSCC (n = 18) were identified with a median follow-up of 26.5 and 21.5 months, respectively. Premalignant and malignant oral lesions were diagnosed at a median time of 2.5 and 8 years after HSCT, respectively. Chronic GVHD was present in 96% of patients and of these, 96% had oral involvement. Multifocal oral cancer was found in 28% of cases, and localized recurrence was observed in 44% of cases. Five-year overall survival was 75% and 70% for OED and OSCC, respectively.

Conclusions

These results suggest that oral cGVHD may be considered a potential risk factor for the development of OSCC following allogeneic HSCT. The observation that oral cancers were frequently multifocal and recurred locally supports the concept of field cancerization and suggests that these cancers may be more aggressive compared with the non-HSCT population. Vigilant follow-up and coordination of care between hematologists and oral health specialists are critical to minimize morbidity and mortality.

The provision of anaesthesia for children by non-subspecialist anaesthetists: expectations of newly qualified consultant anaesthetists and their prospective employers in Victoria

We surveyed newly qualified consultant anaesthetists and their prospective employers in Victoria, regarding their expectations for the provision of paediatric anaesthesia by anaesthetists who have not completed subspecialty training in paediatric anaesthesia (generally-trained anaesthetists). Responses were received from 15 of 19 (79%) eligible Directors and 26 of 37 (70%) newly qualified Australian and New Zealand College of Anaesthetists (ANZCA) Fellows. Of those responding, 80% of Directors and 82% of Fellows would expect a generally-trained anaesthetist to anaesthetise children two years of age or older Regional Directors expected generally-trained anaesthetists to anaesthetise younger children than metropolitan Directors, and Directors' expectations were not influenced by their own practice. Testing these age limits with a series of simple case descriptions showed there is recognition from both Directors and Fellows that the stated age limits would be modified in both directions by case complexity and comorbidities. The new consultants who responded were significantly less confident than Directors in their ability to resuscitate and stabilise a critically ill child prior to transfer if required. Only 50% agreed they still met all the requirements of the ANZCA paediatric module and only 37.5% had the level of confidence they achieved during their paediatric rotations. We suggest that current training provides capacity to routinely anaesthetise well children two years of age or older However it appears more training would be required for most anaesthetists undertaking anaesthesia for younger patients or more complex paediatric cases. This raises the question of subspecialty endorsements within ANZCA Fellowship.