Improving care pathways for children with severe illness through implementation of the ASPIRE mHealth primary ETAT package in Malawi

Providing emergency care in low resource settings relies on delivery by lower cadres of health workers (LCHW). We describe the development, implementation and mixed methods evaluation of a mobile health (mHealth) triage algorithm based on the WHO Emergency, Triage, Assessment, and Treatment (ETAT) for primary-level care. We conducted an observational study design of implementation research. Key stakeholders were engaged throughout implementation. Clinicians and LCHW at eight primary health centres in Blantyre district were trained to use an mHealth algorithm for triage. An mHealth patient surveillance system monitored patients from presentation through referral to tertiary and final outcome. A total of 209,174 children were recorded by ETAT between April 2017 and September 2018, and 155,931 had both recorded mHealth and clinician triage outcome data. Concordance between mHealth triage by lower cadres of HCW and clinician assessment was 81·6% (95% CI [81·4, 81·8]) over all outcomes (kappa: 0·535 (95% CI [0·530, 0·539]). Concordance for mHealth emergency triage was 0.31 with kappa 0.42. The most common mHealth recorded emergency sign was breathing difficulty (74·1% 95% CI [70·1, 77·9]) and priority sign was raised temperature (76·2% (95% CI [75·9, 76·6]). A total of 1,644 referrals out of 3,004 (54·7%) successfully reached the tertiary site. Both providers and carers expressed high levels of satisfaction with the mHealth ETAT pathway. An mHealth triage algorithm can be used by LCHWs with moderate concordance with clinician triage. Implementation of ETAT through an mHealth algorithm documented successful referrals from primary to tertiary, but half of referred patients did not reach the tertiary site. Potential harms of such systems, such as cases requiring referral being missed during triage, require further evaluation. The ASPIRE mHealth primary ETAT approach can be used to prioritise acute illness and support future resource planning within both district and national health system.

Impact of individual, household, and area characteristics on health and social care outcomes for people with multimorbidity: Protocol for a multilevel analysis

BACKGROUND

Multimorbidity is one of the greatest challenges facing health and social care systems globally. It is associated with high rates of health service use, adverse healthcare events, and premature death. Despite its importance, little is known about the effects of contextual determinants such as household and area characteristics on health and care outcomes for people with multimorbidity. This study protocol presents a plan for the examination of associations between individual, household, and area characteristics with important health and social care outcomes.

METHODS

The study will use a cross-section of data from the SAIL Databank on 01 January 2019 and include all people alive and registered with a Welsh GP. The cohort will be stratified according to the presence or absence of multimorbidity, defined as two or more long-term conditions. Multilevel models will be used to examine covariates measured for individuals, households, and areas to account for social processes operating at different levels. The intra-class correlation coefficient will be calculated to determine the strength of association at each level of the hierarchy. Model outcomes will be any emergency department attendance, emergency hospital or care home admission, or mortality, within the study follow-up period.

DISCUSSION

Household and area characteristics might act as protective or risk factors for health and care outcomes for people with multimorbidity, in which case results of the analyses can be used to guide clinical and policy responses for effective targeting of limited resources.

Confirmed SARS-CoV-2 infection in Scottish neonates 2020-2022: a national, population-based cohort study

OBJECTIVES

To examine neonates in Scotland aged 0-27 days with SARS-CoV-2 infection confirmed by viral testing; the risk of confirmed neonatal infection by maternal and infant characteristics; and hospital admissions associated with confirmed neonatal infections.

DESIGN

Population-based cohort study.

SETTING AND POPULATION

All live births in Scotland, 1 March 2020-31 January 2022.

RESULTS

There were 141 neonates with confirmed SARS-CoV-2 infection over the study period, giving an overall infection rate of 153 per 100 000 live births (141/92 009, 0.15%). Among infants born to women with confirmed infection around the time of birth, the confirmed neonatal infection rate was 1812 per 100 000 live births (15/828, 1.8%). Two-thirds (92/141, 65.2%) of neonates with confirmed infection had an associated admission to neonatal or (more commonly) paediatric care. Six of these babies (6/92, 6.5%) were admitted to neonatal and/or paediatric intensive care; however, none of these six had COVID-19 recorded as their main diagnosis. There were no neonatal deaths among babies with confirmed infection.

IMPLICATIONS AND RELEVANCE

Confirmed neonatal SARS-CoV-2 infection was uncommon over the first 23 months of the pandemic in Scotland. Secular trends in the neonatal confirmed infection rate broadly followed those seen in the general population, although at a lower level. Maternal confirmed infection at birth was associated with an increased risk of neonatal confirmed infection. Two-thirds of neonates with confirmed infection had an associated admission to hospital, with resulting implications for the baby, family and services, although their outcomes were generally good. Ascertainment of confirmed infection depends on the extent of testing, and this is likely to have varied over time and between groups: the extent of unconfirmed infection is inevitably unknown.

Adeno-associated virus 2 infection in children with non-A-E hepatitis

An outbreak of acute hepatitis of unknown aetiology in children was reported in Scotland1 in April 2022 and has now been identified in 35 countries2. Several recent studies have suggested an association with human adenovirus with this outbreak, a virus not commonly associated with hepatitis. Here we report a detailed case-control investigation and find an association between adeno-associated virus 2 (AAV2) infection and host genetics in disease susceptibility. Using next-generation sequencing, PCR with reverse transcription, serology and in situ hybridization, we detected recent infection with AAV2 in plasma and liver samples in 26 out of 32 (81%) cases of hepatitis compared with 5 out of 74 (7%) of samples from unaffected individuals. Furthermore, AAV2 was detected within ballooned hepatocytes alongside a prominent T cell infiltrate in liver biopsy samples. In keeping with a CD4+ T-cell-mediated immune pathology, the human leukocyte antigen (HLA) class II HLA-DRB1*04:01 allele was identified in 25 out of 27 cases (93%) compared with a background frequency of 10 out of 64 (16%; P = 5.49 × 10-12). In summary, we report an outbreak of acute paediatric hepatitis associated with AAV2 infection (most likely acquired as a co-infection with human adenovirus that is usually required as a 'helper virus' to support AAV2 replication) and disease susceptibility related to HLA class II status.

Comparison of UK paediatric SARS-CoV-2 admissions across the first and second pandemic waves

BACKGROUND

We hypothesised that the clinical characteristics of hospitalised children and young people (CYP) with SARS-CoV-2 in the UK second wave (W2) would differ from the first wave (W1) due to the alpha variant (B.1.1.7), school reopening and relaxation of shielding.

METHODS

Prospective multicentre observational cohort study of patients <19 years hospitalised in the UK with SARS-CoV-2 between 17/01/20 and 31/01/21. Clinical characteristics were compared between W1 and W2 (W1 = 17/01/20-31/07/20,W2 = 01/08/20-31/01/21).

RESULTS

2044 CYP < 19 years from 187 hospitals. 427/2044 (20.6%) with asymptomatic/incidental SARS-CoV-2 were excluded from main analysis. 16.0% (248/1548) of symptomatic CYP were admitted to critical care and 0.8% (12/1504) died. 5.6% (91/1617) of symptomatic CYP had Multisystem Inflammatory Syndrome in Children (MIS-C). After excluding CYP with MIS-C, patients in W2 had lower Paediatric Early Warning Scores (PEWS, composite vital sign score), lower antibiotic use and less respiratory and cardiovascular support than W1. The proportion of CYP admitted to critical care was unchanged. 58.0% (938/1617) of symptomatic CYP had no reported comorbidity. Patients without co-morbidities were younger (42.4%, 398/938, <1 year), had lower PEWS, shorter length of stay and less respiratory support.

CONCLUSIONS

We found no evidence of increased disease severity in W2 vs W1. A large proportion of hospitalised CYP had no comorbidity.

IMPACT

No evidence of increased severity of COVID-19 admissions amongst children and young people (CYP) in the second vs first wave in the UK, despite changes in variant, relaxation of shielding and return to face-to-face schooling. CYP with no comorbidities made up a significant proportion of those admitted. However, they had shorter length of stays and lower treatment requirements than CYP with comorbidities once those with MIS-C were excluded. At least 20% of CYP admitted in this cohort had asymptomatic/incidental SARS-CoV-2 infection. This paper was presented to SAGE to inform CYP vaccination policy in the UK.

Studying the Long-term Impact of COVID-19 in Kids (SLICK). Healthcare use and costs in children and young people following community-acquired SARS-CoV-2 infection: protocol for an observational study using linked primary and secondary routinely collected healthcare data from England, Scotland and Wales

INTRODUCTION

SARS-CoV-2 infection rarely causes hospitalisation in children and young people (CYP), but mild or asymptomatic infections are common. Persistent symptoms following infection have been reported in CYP but subsequent healthcare use is unclear. We aim to describe healthcare use in CYP following community-acquired SARS-CoV-2 infection and identify those at risk of ongoing healthcare needs.

METHODS AND ANALYSIS

We will use anonymised individual-level, population-scale national data linking demographics, comorbidities, primary and secondary care use and mortality between 1 January 2019 and 1 May 2022. SARS-CoV-2 test data will be linked from 1 January 2020 to 1 May 2022. Analyses will use Trusted Research Environments: OpenSAFELY in England, Secure Anonymised Information Linkage (SAIL) Databank in Wales and Early Pandemic Evaluation and Enhanced Surveillance of COVID-19 in Scotland (EAVE-II). CYP aged ≥4 and <18 years who underwent SARS-CoV-2 reverse transcription PCR (RT-PCR) testing between 1 January 2020 and 1 May 2021 and those untested CYP will be examined.The primary outcome measure is cumulative healthcare cost over 12 months following SARS-CoV-2 testing, stratified into primary or secondary care, and physical or mental healthcare. We will estimate the burden of healthcare use attributable to SARS-CoV-2 infections in the 12 months after testing using a matched cohort study of RT-PCR positive, negative or untested CYP matched on testing date, with adjustment for confounders. We will identify factors associated with higher healthcare needs in the 12 months following SARS-CoV-2 infection using an unmatched cohort of RT-PCR positive CYP. Multivariable logistic regression and machine learning approaches will identify risk factors for high healthcare use and characterise patterns of healthcare use post infection.

ETHICS AND DISSEMINATION

This study was approved by the South-Central Oxford C Health Research Authority Ethics Committee (13/SC/0149). Findings will be preprinted and published in peer-reviewed journals. Analysis code and code lists will be available through public GitHub repositories and OpenCodelists with meta-data via HDR-UK Innovation Gateway.

OA43 Development of a national across specialty multi-disciplinary team for management of hyper-inflammatory conditions during the SARS-CoV-2 pandemic

Background/Aims

Effective multi-specialty team working is extremely beneficial in management of children with hyper-inflammatory conditions. With the recognition of paediatric inflammatory multisystem syndrome (PIMS) it became apparent a standardised process for discussion of patients would be beneficial. This includes urgent discussion, with access to multiple specialties, and sharing knowledge and experience in a novel condition. Delivering equitable healthcare including access to expertise, specific treatments and research is challenging in Scotland due to its geography. This is facilitated by successful clinical networks (Scottish Paediatric & Adolescent Rheumatology Network [SPARN] and Scottish Paediatric& Adolescent Infection & Immunology National Managed Clinical Network [SPAIIN]) and a well-established paediatric transport service (ScotSTAR). Our aim was to develop a multi-specialty multi-disciplinary team (MDT) for management of patients with hyper-inflammatory conditions.

Methods

Narrative account of MDT and service development

Results

We identified a core group of individuals with an interest in inflammatory disorders from different centres and specialties across Scotland including Rheumatology, Infectious Diseases, Cardiology, Intensive Care, Academic Paediatrics, Pharmacists and Clinical Nurse Specialists. Three priorities emerged from initial planning stages: urgent discussions around patient management, peer-to-peer learning and information sharing, and effective prioritisation of research. We designed a written framework and referral pathway, including criteria for acute cardiology involvement, ScotSTAR transfer and intensive care. An electronic proforma was designed to guide MDT discussion, medico-legal documentation and audit purposes. Table 1 describes characteristics of the first nine patients discussed. A particular strength was in diagnostics and consideration of differentials; among patients referred we identified those with haematological malignancy, systemic lupus erythematosus and non-accidental injury. Regular peer-review sessions were held, for reflection on cases and their management in both secondary and tertiary care settings. Clinicians throughout Scotland were encouraged to join via SPARN and SPAIIN networks.

Conclusion

This multi-specialty MDT has been and continues to be beneficial for management of hyper-inflammatory patients. We will review the process but hope the MDT will prove to continue to be beneficial for future patients. The authors would like to acknowledge all members of the MDT.

Disclosure

K. McLellan: None. L. Reilly: None. L. Pollock: None. O. Swann: None. C. Anderson: None. N. Martin: None. M. Brennan: None. R. Hague: None. J. Walsh: None.

Investigation into cases of hepatitis of unknown aetiology among young children, Scotland, 1 January 2022 to 12 April 2022

On 31 March 2022, Public Health Scotland was alerted to five children aged 3-5 years admitted to hospital with severe hepatitis of unknown aetiology. Retrospective investigation identified eight additional cases aged 10 years and younger since 1 January 2022. Two pairs of cases have epidemiological links. Common viral hepatitis causes were excluded in those with available results. Five children were adenovirus PCR-positive. Other childhood viruses, including SARS-CoV-2, have been isolated. Investigations are ongoing, with new cases still presenting.

Plasma rotavirus-specific IgA and risk of rotavirus vaccine failure in infants in Malawi

BACKGROUND

Rotavirus vaccine efficacy is reduced in low-income populations, but efforts to improve vaccine performance are limited by lack of clear correlates of protection. While plasma rotavirus (RV)-specific IgA appears strongly associated with protection against rotavirus gastroenteritis in high-income countries, weaker association has been observed in low-income countries. We tested the hypothesis that lower RV-specific IgA is associated with rotavirus vaccine failure in Malawian infants.

METHODS

In a case-control study we recruited infants presenting with severe rotavirus gastroenteritis following monovalent oral rotavirus vaccination (RV1 vaccine failures). Conditional logistic regression was used to determine the odds of rotavirus seronegativity (RV-specific IgA<20 U/mL) in these cases compared 1:1 with age-matched, vaccinated, asymptomatic community controls. Plasma RV-specific IgA was determined by ELISA for all participants at recruitment, and for cases at 10 days post symptom onset. Rotavirus infection and genotype were determined by antigen testing and RT-PCR respectively.

RESULTS

In 116 age-matched pairs, infants with RV1 vaccine failure were more likely to be RV-specific IgA seronegative than controls: OR 3.1 (95%CI 1.6-5.9), p=0.001. In 60 infants with convalescent serology, 42/45 (93%, 95%CI 81-98%) infants seronegative at baseline became seropositive. Median rise in RV-specific IgA concentration following acute infection was 112.8 (IQR 19.1-380.6) fold.

CONCLUSIONS

In this vaccinated population with high residual burden of rotavirus disease, RV1 vaccine failure was associated with lower RV-specific IgA, providing further evidence of RV-specific IgA as a marker of protection. Robust convalescent RV-specific IgA response in vaccine failures suggests differences in wild-type and vaccine-induced immunity, which informs future vaccine development.

Community transmission of rotavirus infection in a vaccinated population in Blantyre, Malawi: a prospective household cohort study

BACKGROUND

Rotavirus vaccine effectiveness is reduced among children in low-income countries. Indirect (transmission-mediated) effects of rotavirus vaccine might contribute to the total population effect of vaccination. We aimed to examine risk factors for transmission of rotavirus to household contacts in Blantyre, Malawi, and estimated the effectiveness of rotavirus vaccine in preventing transmission of infection to household contacts.

METHODS

In this prospective household cohort study, we recruited children born after Sept 17, 2012, and aged at least 6 weeks (vaccine-eligible children) with acute rotavirus gastroenteritis and their household contacts, in four government health facilities in Blantyre, Malawi. Clinical data, a bulk stool sample, and 1-2 mL of serum were collected from case children at presentation. Clinical data and stool samples were also prospectively collected from household contacts over 14 days from presentation. A single stool sample was collected from control households containing asymptomatic children who were frequency age-matched to case children. Samples were tested for rotavirus using semi-quantitative real-time PCR and for anti-rotavirus IgA using a semi-quantitative sandwich ELISA. Risk factors for household transmission of rotavirus infection and clinical disease, including disease severity and faecal shedding density, were identified using mixed effects logistic regression. Vaccine effectiveness against transmission was estimated as 1 minus the ratio of secondary attack rates in vaccinated and counterfactual unvaccinated populations, using vaccine effectiveness estimates from the associated diarrhoeal surveillance platform to estimate the counterfactual secondary attack rate without vaccination.

FINDINGS

Between Feb 16, 2015, and Nov 11, 2016, we recruited 196 case households (705 members) and 55 control households (153 members). Household secondary attack rate for rotavirus infection was high (434 [65%] of 665 individuals) and secondary attack rate for clinical disease was much lower (37 [5%] of 698). Asymptomatic infection in control households was common (40 [28%] of 144). Increasing disease severity in an index child (as measured by Vesikari score) was associated with increased risk of transmission of infection (odds ratio 1·17 [95% CI 1·06-1·30) and disease (1·28 [1·08-1·52]) to household contacts. Estimated vaccine effectiveness against transmission was 39% (95% CI 16-57).

INTERPRETATION

Rotavirus vaccine has the potential to substantially reduce household rotavirus transmission. This finding should be considered in clinical and health economic assessments of vaccine effectiveness.

FUNDING

Wellcome Trust, US National Institutes of Health, and US National Institute of Allergy and Infectious Diseases.

Duration and Density of Fecal Rotavirus Shedding in Vaccinated Malawian Children With Rotavirus Gastroenteritis

Quantifying rotavirus shedding among vaccinated individuals will aid understanding of vaccine indirect effects. Serial stool samples were collected from 196 children who presented with rotavirus gastroenteritis to health facilities in Blantyre, Malawi, and were tested for rotavirus using a VP6 semi-quantitative, real-time polymerase chain reaction. The median duration of fecal shedding was 28 days (95% CI, 19–28). The median copy numbers for peak shedding were 1.99 × 10⁷ (interquartile range, 3.39 × 10⁶ to 6.37 × 10⁷). The fecal viral load was positively associated with disease severity and negatively associated with serum anti-rotavirus immunoglobin A. High and persistent rotavirus shedding among vaccinated children with breakthrough disease may contribute to ongoing transmission in this setting.

Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study

OBJECTIVE

To characterise the clinical features of children and young people admitted to hospital with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the UK and explore factors associated with admission to critical care, mortality, and development of multisystem inflammatory syndrome in children and adolescents temporarily related to coronavirus disease 2019 (covid-19) (MIS-C).

DESIGN

Prospective observational cohort study with rapid data gathering and near real time analysis.

SETTING

260 hospitals in England, Wales, and Scotland between 17 January and 3 July 2020, with a minimum follow-up time of two weeks (to 17 July 2020).

PARTICIPANTS

651 children and young people aged less than 19 years admitted to 138 hospitals and enrolled into the International Severe Acute Respiratory and emergency Infections Consortium (ISARIC) WHO Clinical Characterisation Protocol UK study with laboratory confirmed SARS-CoV-2.

MAIN OUTCOME MEASURES

Admission to critical care (high dependency or intensive care), in-hospital mortality, or meeting the WHO preliminary case definition for MIS-C.

RESULTS

Median age was 4.6 (interquartile range 0.3-13.7) years, 35% (225/651) were under 12 months old, and 56% (367/650) were male. 57% (330/576) were white, 12% (67/576) South Asian, and 10% (56/576) black. 42% (276/651) had at least one recorded comorbidity. A systemic mucocutaneous-enteric cluster of symptoms was identified, which encompassed the symptoms for the WHO MIS-C criteria. 18% (116/632) of children were admitted to critical care. On multivariable analysis, this was associated with age under 1 month (odds ratio 3.21, 95% confidence interval 1.36 to 7.66; P=0.008), age 10-14 years (3.23, 1.55 to 6.99; P=0.002), and black ethnicity (2.82, 1.41 to 5.57; P=0.003). Six (1%) of 627 patients died in hospital, all of whom had profound comorbidity. 11% (52/456) met the WHO MIS-C criteria, with the first patient developing symptoms in mid-March. Children meeting MIS-C criteria were older (median age 10.7 (8.3-14.1) v 1.6 (0.2-12.9) years; P<0.001) and more likely to be of non-white ethnicity (64% (29/45) v 42% (148/355); P=0.004). Children with MIS-C were five times more likely to be admitted to critical care (73% (38/52) v 15% (62/404); P<0.001). In addition to the WHO criteria, children with MIS-C were more likely to present with fatigue (51% (24/47) v 28% (86/302); P=0.004), headache (34% (16/47) v 10% (26/263); P<0.001), myalgia (34% (15/44) v 8% (21/270); P<0.001), sore throat (30% (14/47) v (12% (34/284); P=0.003), and lymphadenopathy (20% (9/46) v 3% (10/318); P<0.001) and to have a platelet count of less than 150 × 109/L (32% (16/50) v 11% (38/348); P<0.001) than children who did not have MIS-C. No deaths occurred in the MIS-C group.

CONCLUSIONS

Children and young people have less severe acute covid-19 than adults. A systemic mucocutaneous-enteric symptom cluster was also identified in acute cases that shares features with MIS-C. This study provides additional evidence for refining the WHO MIS-C preliminary case definition. Children meeting the MIS-C criteria have different demographic and clinical features depending on whether they have acute SARS-CoV-2 infection (polymerase chain reaction positive) or are post-acute (antibody positive).

STUDY REGISTRATION

ISRCTN66726260.

Clenbuterol: a new toxic substance in paediatrics

A 13-year-old girl presented to the emergency department with acute onset of chest pain, nausea and tremor. The patient denied drug ingestion, and urine toxicology was negative. ECG demonstrated sinus tachycardia, prolonged QTc (541 ms) and ST depression. Laboratory testing demonstrated metabolic acidosis, hypokalaemia, hypophosphataemia and hyperglycaemia. She was commenced on continuous cardiac monitoring and treated with intravenous fluids and electrolyte replacement. Presenting features and laboratory abnormalities resolved within 48 hours. The National Poisons Information Service and Clinical Biochemistry were integral to her management, advising the clinical team on the likeliest aetiology. Five weeks after discharge, urine toxicology, using mass spectrometry, identified clenbuterol. Clenbuterol is an oral β2-agonist with anabolic and lipolytic effects that is misused as a performance and image enhancing drug. Clinicians must be aware of the increasing availability of these drugs and their potential for causing harm in children and adolescents.

Etiology of Diarrhea Among Hospitalized Children in Blantyre, Malawi, Following Rotavirus Vaccine Introduction: A Case-Control Study

Despite rotavirus vaccination, diarrhea remains a leading cause of child mortality. We collected stool specimens from 684 children <5 years of age hospitalized with diarrhea (cases) and 527 asymptomatic community controls for 4 years after rotavirus vaccine introduction in Malawi. Specimens were tested for 29 pathogens, using polymerase chain reaction analysis. Three or more pathogens were detected in 71% of cases and 48% of controls. Pathogens significantly associated with diarrhea included rotavirus (in 34.7% of cases and 1.5% of controls), enteric adenovirus (in 29.1% and 2.7%, respectively), Cryptosporidium (in 27.8% and 8.2%, respectively), heat-stable enterotoxin-producing Escherichia coli (in 21.2% and 8.5%, respectively), typical enteropathogenic E. coli (in 18.0% and 8.3%, respectively), and Shigella/enteroinvasive E. coli (in 15.8% and 5.7%, respectively). Additional interventions are required to prevent diarrhea due to rotavirus and other common causal pathogens.

Infrequent Transmission of Monovalent Human Rotavirus Vaccine Virus to Household Contacts of Vaccinated Infants in Malawi

Horizontal transmission of rotavirus vaccine virus may contribute to indirect effects of rotavirus vaccine, but data are lacking from low-income countries. Serial stool samples were obtained from Malawian infants who received 2 doses of monovalent human rotavirus vaccine (RV1) (days 4, 6, 8, and 10 after vaccination) and from their household contacts (8–10 days after vaccine). RV1 vaccine virus in stool was detected using semiquantitative real-time reverse-transcription polymerase chain reaction. RV1 fecal shedding was detected in 41 of 60 vaccinated infants (68%) and in 2 of 147 household contacts (1.4%). Horizontal transmission of vaccine virus within households is unlikely to make a major contribution to RV1 indirect effects in Malawi.

4 Effects on Hospital Admissions from the Completion of Good Quality Treatment Escalation Plans in Care Homes

Topic

Some care home residents are admitted to hospital when they either do not wish for admission or will not benefit from admission. Meeting residents and their next of kin to explore the person’s goals and priorities can facilitate the completion of a good quality Treatment Escalation Plan (TEP).

Intervention

A pilot service was commenced in November 2018 to complete and review TEPs in the top ten admitting care homes to Musgrove Park Hospital. A small team of clinicians (1.5 full time equivalent) worked in the selected care homes completing and reviewing TEPs, with an aim to see 80% of residents. Clinicians met residents and their next of kin to discuss the person’s wishes. Completed TEPs were left in the care home, shared with GPs and uploaded to the IT system in the acute hospital. The number of Emergency Department (ED) attendances and inpatient admissions from care homes were recorded and compared to data from 2017/18.

Improvement

Over 5 months, 492 residents had TEPs reviewed or completed by the team; this was 76% of the total bed base of the selected care homes. Data were compared to the same period a year earlier. During the final two months of the pilot, attendances to ED from care homes with the intervention were reduced by 24%, whilst the control group saw an 8% decrease. In the same period, inpatient admissions from the intervention group were reduced by 35%, compared to an 11% decrease in the control care homes.

Discussion

Whilst there are too few data to provide conclusive evidence, early indications suggest that facilitating the discussion of good quality TEPs in care homes reduces attendances to ED and inpatient admissions. Further evaluation is required as the service continues. There were challenges to the implementation of the pilot; these included communication and engagement with GPs, in addition to access to GP IT systems.

Vaccine Effectiveness against DS-1-Like Rotavirus Strains in Infants with Acute Gastroenteritis, Malawi, 2013-2015

Atypical DS-1-like G1P[8] rotaviruses emerged in 2013 in Malawi after rotavirus vaccine introduction. Vaccine effectiveness among infants hospitalized with acute DS-1-like G1P[8] rotavirus gastroenteritis was 85.6% (95% CI 34.4%-96.8%). These findings suggest that vaccine provides protection against these strains despite their emergence coinciding with vaccine introduction.

Nonsecretor Histo-blood Group Antigen Phenotype Is Associated With Reduced Risk of Clinical Rotavirus Vaccine Failure in Malawian Infants

BACKGROUND

Histo-blood group antigen (HBGA) Lewis/secretor phenotypes predict genotype-specific susceptibility to rotavirus gastroenteritis (RVGE). We tested the hypothesis that nonsecretor/Lewis-negative phenotype leads to reduced vaccine take and lower clinical protection following vaccination with G1P[8] rotavirus vaccine (RV1) in Malawian infants.

METHODS

A cohort study recruited infants receiving RV1 at age 6 and 10 weeks. HBGA phenotype was determined by salivary enzyme-linked immunosorbent assay (ELISA). RV1 vaccine virus shedding was detected by quantitative real-time polymerase chain reaction (qRT-PCR) in stool collected on alternate days for 10 days post-immunization. Plasma rotavirus-specific immunoglobulin A was determined by ELISA pre- and post-immunization. In a case-control study, HBGA phenotype distribution was compared between RV1-vaccinated infants with RVGE and 1:1 age-matched community controls. Rotavirus genotype was determined by RT-PCR.

RESULTS

In 202 cohort participants, neither overall vaccine virus fecal shedding nor seroconversion differed by HBGA phenotype. In 238 case-control infants, nonsecretor phenotype was less common in infants with clinical vaccine failure (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.20-0.75). Nonsecretor phenotype was less common in infants with P[8] RVGE (OR, 0.12; 95% CI, 0.03-0.50) and P[4] RVGE (OR, 0.17; 95% CI, 0.04-0.75). Lewis-negative phenotype was more common in infants with P[6] RVGE (OR, 3.2; 95% CI, 1.4-7.2).

CONCLUSIONS

Nonsecretor phenotype was associated with reduced risk of rotavirus vaccine failure. There was no significant association between HBGA phenotype and vaccine take. These data refute the hypothesis that high prevalence of nonsecretor/Lewis-negative phenotypes contributes to lower rotavirus vaccine effectiveness in Malawi.

Direct and possible indirect effects of vaccination on rotavirus hospitalisations among children in Malawi four years after programmatic introduction

INTRODUCTION

Despite increased use of vaccine in routine immunisation, rotavirus remains a major cause of acute gastroenteritis (AGE) in low-income countries. We describe rotavirus prevalence and hospitalisation in Malawi pre and four years post vaccine introduction; provide updated vaccine effectiveness (VE) estimates; and assess rotavirus vaccine indirect effects.

METHODS

Children under five years of age presenting to a referral hospital in Blantyre with AGE were recruited. Stool samples were tested for rotavirus using Enzyme Immunoassay. The change in rotavirus prevalence was evaluated using Poisson regression. Time series analysis was used to further investigate trends in prevalence over time. VE against rotavirus diarrhoea of any severity was estimated using logistic regression. Indirect effects were estimated by evaluating rotavirus prevalence in unvaccinated children over time, and by comparing observed reductions in incidence of rotavirus hospitalisation to those expected based on vaccine coverage and trial efficacy estimates.

RESULTS

2320 children were included. Prevalence of rotavirus in hospitalised infants (<12 months) with AGE decreased from 69/139(49.64%) prior to vaccine introduction to 197/607(32.45%) post-vaccine introduction (adjusted RR 0.67[95% CI 0.55, 0.82]). Prevalence in children aged 12-23 months demonstrated a less substantial decline: 15/37(40.54%) pre- and 122/352(34.66%) post-vaccine introduction (adjusted RR 0.85, 95% CI 0.57, 1.28). Adjusted VE was 61.89%(95% CI 28.04-79.82), but lower in children aged 12-23 months (31.69% [95% CI -139.03 to 80.48]). In hospitalised infants with rotavirus disease, the observed overall effect of the vaccine was 9% greater than expected according to vaccine coverage and efficacy estimates. Rotavirus prevalence among unvaccinated infants declined post-vaccine introduction (RR 0.70[95% CI 0.55-0.80]).

CONCLUSIONS

Following rotavirus vaccine introduction in Malawi, prevalence of rotavirus in hospitalised children with AGE has declined significantly, with some evidence of an indirect effect in infants. Despite this, rotavirus remains an important cause of severe diarrhoea in Malawian children, particularly in the second year of life.

Population Impact and Effectiveness of Monovalent Rotavirus Vaccination in Urban Malawian Children 3 Years After Vaccine Introduction: Ecological and Case-Control Analyses

BACKGROUND

Rotavirus vaccines have been introduced in many low-income African countries including Malawi in 2012. Despite early evidence of vaccine impact, determining persistence of protection beyond infancy, the utility of the vaccine against specific rotavirus genotypes, and effectiveness in vulnerable subgroups is important.

METHODS

We compared rotavirus prevalence in diarrheal stool and hospitalization incidence before and following rotavirus vaccine introduction in Malawi. Using case-control analysis, we derived vaccine effectiveness (VE) in the second year of life and for human immunodeficiency virus (HIV)-exposed and stunted children.

RESULTS

Rotavirus prevalence declined concurrent with increasing vaccine coverage, and in 2015 was 24% compared with prevaccine mean baseline in 1997-2011 of 32%. Since vaccine introduction, population rotavirus hospitalization incidence declined in infants by 54.2% (95% confidence interval [CI], 32.8-68.8), but did not fall in older children. Comparing 241 rotavirus cases with 692 test-negative controls, VE was 70.6% (95% CI, 33.6%-87.0%) and 31.7% (95% CI, -140.6% to 80.6%) in the first and second year of life, respectively, whereas mean age of rotavirus cases increased from 9.3 to 11.8 months. Despite higher VE against G1P[8] than against other genotypes, no resurgence of nonvaccine genotypes has occurred. VE did not differ significantly by nutritional status (78.1% [95% CI, 5.6%-94.9%] in 257 well-nourished and 27.8% [95% CI, -99.5% to 73.9%] in 205 stunted children;P= .12), or by HIV exposure (60.5% [95% CI, 13.3%-82.0%] in 745 HIV-unexposed and 42.2% [95% CI, -106.9% to 83.8%] in 174 exposed children;P= .91).

CONCLUSIONS

Rotavirus vaccination in Malawi has resulted in reductions in disease burden in infants <12 months, but not in older children. Despite differences in genotype-specific VE, no genotype has emerged to suggest vaccine escape. VE was not demonstrably affected by HIV exposure or stunting.

Management of persistent purulent pericarditis using streptokinase for intrapericardial fibrinolysis

Purulent pericarditis (PP) is a very serious condition with almost 100% mortality if untreated. Intrapericardial fibrinolysis is a preferred alternative to pericardectomy in the treatment of persistent PP, but there are no consensus guidelines on the standard protocol for this procedure in children. A 9-year-old boy was referred to the Medical Research Council Unit in The Gambia (MRC). He had been unwell for 18 days with a high continuous fever, cough, fast breathing, and dyspnoea on exertion. Prior to referral he had been treated for malaria and pneumonia with no improvement. At the MRC, he was diagnosed with purulent pericarditis caused by Staphylococcus aureus and after admission he was managed for 4 weeks with intravenous antibiotics, pericardial aspirations followed by saline lavage of the pericardium and intrapericardial antibiotic instillation. Despite these measures, massive re-accumulation of the purulent pericardial effusion continued. Once daily intrapericardial instillation of streptokinase at a dose of 18,000 i.u/kg diluted in 50 ml of normal saline, and saline washout of the pericardium after 2 hours was commenced on the 29th day of admission, in addition to the antibiotics. This technique of fibrinolysis employed for 2 days was effective in managing the persistent purulent pericarditis when pericardial aspiration and intravenous and intrapericardial antibiotics failed.

The relationship between concentration of specific antibody at birth and subsequent response to primary immunization

BACKGROUND AND AIMS

Trans-placentally acquired antibodies can protect infants from infection in the first months of life. However, high concentrations of antibody at birth may impact the infant's own immune response to primary immunization. We examine the relationship between concentration of specific antibody to Bordetella pertussis, Haemophilus influenzae type b (Hib), tetanus toxoid and pneumococcal antigens at birth and following primary immunization.

METHODS

Healthy mother-infant pairs were recruited from a UK maternity unit. Peripheral blood samples were obtained at birth and 4 weeks after primary immunization. Specific antibody concentrations were determined using enzyme-linked immunosorbent assays. Pertussis antibody concentrations >50 IU/ml, Tetanus antibody levels >0.1 IU/ml and Hib antibody levels >0.15 mg/l were regarded as protective.

RESULTS

Following primary immunization, 35/36 (97%) infants had specific antibody concentrations associated with protection against Hib, 32/36 (89%) against pertussis and 36/36 (100%) against tetanus. Concentrations of all specific antibodies were significantly higher than at birth (p<0.0001), except anti-tetanus toxoid, p=0.41. However, there was an inverse correlation between infant antibody concentration at birth and fold-increase in antibody concentration post-immunization for tetanus: rs -0.86 (95%CI -0.93 to -0.74), p<0.0001; pneumococcus: rs -0.82 (95% CI -0.91 to -0.67), p<0.0001; pertussis: rs -0.77 (95% CI -0.89 to -0.58), p<0.0001 and Hib: rs -0.66 (95%CI -0.82 to -0.42), p<0.0001. The highest concentrations of specific IgG at birth were associated with lower concentrations post-immunization for tetanus (p=0.009) and pneumococcus (p=0.03). This association was not observed for Hib (p=0.88) or pertussis (p=0.14).

CONCLUSION

Higher antibody concentration at birth appeared to inhibit the response to infant immunization for tetanus and pneumococcus; the effect was less marked for Hib and pertussis. However, the majority of infants achieved high antibody levels post-immunization. This supports maternal immunization, as high levels of maternally derived antibody at birth may not inhibit infants' immunization responses in a clinically relevant manner.

How to use: interferon γ release assays for tuberculosis

Diagnosis and treatment of latent tuberculosis infection (LTBI) is important to reduce risk of progression to active tuberculosis (TB) disease. For the past century the tuberculin skin test (TST) has been used as a measure of exposure to Mycobacterium tuberculosis (MTB), but this test has limitations in test performance, sensitivity and specificity. Interferon γ release assays (IGRA), like TST, measure host immune response to MTB. IGRA are designed to be more specific for the diagnosis of LTBI than TST in patients with previous BCG or exposure to non-tuberculous mycobacteria, detecting interferon γ generated by T cells in response to antigens more specific to MTB. Although developed as an alternative to TST, recent data, particularly in children, suggest IGRA have their own limitations. Superiority to TST as a diagnostic test in children has not been demonstrated. Neither test discriminates between current or past MTB infection, or between latent infection and active disease. This article reviews the current literature on sensitivity and specificity of IGRA in the diagnosis of LTBI, and summarises current NICE recommendations for the use of IGRA in combination with TST. Although not developed for this purpose, in clinical practice IGRA have also been used as a diagnostic test for active TB. The gold standard for diagnosis of active TB disease is microbiological confirmation by culture of MTB. This article discusses the utility of IGRA as an adjunct to diagnosis of active TB disease, but emphasises that IGRA do not have sufficient sensitivity or specificity to exclude or confirm active TB disease.

Specific antibodies against vaccine-preventable infections: a mother-infant cohort study

OBJECTIVES

To determine maternal and neonatal specific antibody levels to selected vaccine-preventable infections (pertussis, Haemophilus influenzae type b (Hib), tetanus and pneumococcus).

DESIGN

Prospective cohort study.

SETTING

A UK secondary care maternity unit (March 2011-January 2012).

PARTICIPANTS

Mothers and infants within 72 h of delivery were eligible. Unwell individuals, mothers less than 18 years of age, and infants born at less than 36 weeks gestation, or weighing less than 2500 g, were excluded. HIV-infected mothers were included. 112 mother-infant pairs were recruited. Samples from 111 mothers and 109 infants (108 pairs) were available for analysis.

OUTCOME MEASURES

Specific antibody levels were determined using standard commercial ELISAs. Specific antibody to pertussis antigens (PT and FHA) of >50 IU/ml, defined as 'positive' by the test manufacturer, were interpreted as protective. Antitetanus antibody titres >0.1 IU/ml and anti-Hib antibody titres >1 mg/l were regarded as protective.

RESULTS

Only 17% (19/111) of women exhibited a protective antibody response against pertussis. 50% (56/111) of women had levels of antibody protective against Hib and 79% (88/111) against tetanus. There was a strong positive correlation between maternal-specific and infant-specific antibodies' responses against pertussis (rs=0.71, p<0.001), Hib (rs=0.80, p<0.001), tetanus (rs=0.90, p<0.001) and pneumococcal capsular polysaccharide (rs=0.85, p<0.001). Only 30% (33/109) and 42% (46/109) of infants showed a protective antibody response to pertussis and Hib, respectively. Placental transfer (infant:mother ratio) of specific IgG to pertussis, Hib, pneumococcus and tetanus was significantly reduced from HIV-infected mothers to their HIV-exposed, uninfected infants (n=12 pairs) compared with HIV-uninfected mothers with HIV-unexposed infants (n=96 pairs) by 58% (<0.001), 61% (<0.001), 28% (p=0.034) and 32% (p=0.035), respectively.

CONCLUSIONS

Low baseline antibody levels against pertussis in this cohort suggest the recently implemented UK maternal pertussis immunisation programme has potential to be effective.

Steady-state nevirapine, lamivudine and stavudine levels in Malawian HIV-infected children on antiretroviral therapy using split Triomune 30 tablets

BACKGROUND

Children remain under-represented in national antiretroviral treatment (ART) programmes in settings with limited resources and high HIV prevalence. In Malawi, an increasing number of HIV-infected children have been started on ART with split tablets of an adult fixed-dose combination drug in the past few years. In 2006, the national paediatric ART regime was changed from Triomune 40 (T40) to Triomune 30 (T30).

METHODS

This was a cross-sectional study conducted at the paediatric ART clinic in Blantyre (Malawi) from September 2006 to July 2007. Children taking T30 for > 6 weeks from each dosing weight band (<5, 5-<8, 8-<12, 12-<14, 14-<19, 19-<26, 26-<30 and > or = 30 kg) were recruited. Plasma drug concentration, CD4+ T-cell count and HIV viral load were measured.

RESULTS

A total of 74 children were analysed. The median nevirapine (NVP) concentration was 7.35 mg/l. A therapeutic NVP plasma level > 3 mg/l was found in 62 (87.8%) children. A subtherapeutic NVP level (< 3 mg/l) occurred significantly more often in children treated with T30 doses between one-quarter tablet once daily and one-half tablet twice daily (P=0.035). Median prescribed NVP dose was 342 mg/m(2)/day, but 13 (17.6%) children received a dose below the recommended dose of 300 mg/m(2)/day. Compared with a historical control, the median prescribed NVP dose was increased (from 243 to 342 mg/m(2)/day).

CONCLUSIONS

Our findings indicate that with the Malawian T30-based ART regime, the majority (87.8%) of children in the study group achieved a therapeutic NVP level. However, treatment remains suboptimal especially for young children receiving T30 dosages less than or equal to one-half tablets twice daily and child appropriate formulations are warranted.

Pharmacokinetics of nevirapine in HIV-infected children with and without malnutrition receiving divided adult fixed-dose combination tablets

OBJECTIVES

To determine the relationship between nutritional status and nevirapine exposure by comparing the pharmacokinetics of nevirapine in HIV-infected children of different ages with and without malnutrition receiving divided tablets of Triomune 30 (stavudine + lamivudine + nevirapine) in accordance with Malawi National Guidelines.

METHODS

Children were recruited in weight-based dosage bands and nutritional status classified according to weight for height. Total and unbound plasma nevirapine concentrations were measured over a full dosing interval. Multivariate linear and logistic regression analyses were performed to determine the effects of malnutrition, age, dose and other factors on nevirapine exposure and likelihood of achieving therapeutic nevirapine trough concentrations.

RESULTS

Forty-three children were recruited (37 included for analysis). Mild to moderate malnutrition was present in 12 (32%) children; 25 (68%) were of normal nutritional status. There was no effect of malnutrition on any measure of total drug exposure or on the unbound fraction of nevirapine. Nevirapine exposure was strongly related to dose administered (P = 0.039) and to age (for every yearly increase in age there was an approximately 88% increase in the odds of achieving a therapeutic nevirapine concentration; P = 0.056, 95% confidence interval 0.983-3.585).

CONCLUSIONS

Use of divided adult Triomune 30 tablets in treating young children results in significant underdosing. No independent effect of malnutrition on total and unbound nevirapine exposures was observed. These data support the use of bespoke paediatric antiretroviral formulations.

Experiences in providing training and education in aquatic animal health

The Institute of Aquaculture brings together cross-disciplinary researchers to meet the wide range of training challenges faced as the global aquaculture industry grows. The Institute offers training in a range of academic levels from short courses, aimed at farm operatives, to BSc (Hons), MSc and PhD levels. The focus of training at the Institute is on promoting a holistic approach, emphasising the importance of understanding the aquatic production system as a whole as well as detailed knowledge of specific pathogens. To make training more accessible, the Institute has made the provision of Continuing Professional Development (CPD) a strategic objective and provides distance learning and flexible study options.

Person first: what people with enduring mental disorders value about community psychiatric nurses and CPN services

Based on a Scottish study, this article presents findings from qualitative analysis of interview data, on views of people with enduring mental disorders (people) regarding services provided by community psychiatric nurses (CPNs) and what these people value in working with CPNs. Thirteen people took part in semi-structured interviews, and data were analysed using strategies including thematic analysis. The main finding was that people value their interpersonal relationship with CPNs. This relationship has a specific function in the individual's overall social network. The CPN-person relationship forms the context of 'purposeful talk', and is shaped and developed through the talk. It provides comfort and a greater sense of confidence with which people can cope with daily life. A valued feature of the personalized relationship with CPNs is continuity, associated with regularity of contact with CPNs, accessibility (both physical and emotional) and respect for and commitment to people as individuals. We interpret CPNs, as they appear in these accounts given by people with enduring mental disorders, as 'beings-in-between', bridging symbolically the worlds of hospital and community. They are figures between 'friends' and professionals, to whom people who have been ill can relate and show feelings which would, if otherwise expressed, compromise participation in community. CPNs help sustain people experiencing 'illness in the context of life' and enhance their potential for participation in the community. In doing so they contribute to public health. Viability of sustaining relationships and personal care, valued at the micro-level of interaction, depends on support at the meso-level by managers, and at the macro-level by policy makers and funders. Health service managers who play a key role in instigating and managing service changes should engage in regular dialogue with CPNs about the impact of change on the ability of CPNs to maintain sustaining relationships with people. The adaptability of CPNs to the situation and the person-in-the-situation needs to be facilitated, not compromised, by the requirements of record-keeping and accounting systems. Practice described in this study indicates the possibility of CPNs relating to the person in ways consistent with a 'community development approach'. Limitations of the study are noted. Our findings are highly contextualized and based on a small sample. Nonetheless, they are consistent with findings from other studies also based on listening to service users' accounts of problems of living with enduring mental disorder. Implications of the analysis of peoples' perceptions of the role of CPNs are considered, with attention to service providers, policy makers and future research.

Progress's Pilgrim: a critical narrative of research in progress

There is increasing interest in the use of stories to develop nursing and health care practice. This paper reports on how we used story to understand and develop research on nursing practice. Story (or narrative) and science can be seen as distinct but complementary paradigms. We have found that a story framework can help researchers to reflect on a process of social scientific investigation, and to consider how to 'go on' in that process. In a study on 'Community psychiatric nurses' empowerment of people with enduring mental disorders in the community: involving users to develop services' we have encountered a number of interesting and challenging issues related to design and use of methods. We present these issues within a framework of story analysis, focusing on issues related to empowerment. This analysis draws on Burke's 'pentad' of story elements as a framework for narrative analysis. We present the elements of the 'story of the study-as-funded' and as it was carried out through the pilot stage, and outline the story of developments in the main study. 'Trouble' in a story centres on a problematic 'ratio' of story elements. The 'trouble' at this stage in the progress of our study relates to lack of fit between some parts of the instruments (the methods) and the goal (empowerment), and to the status of the CPNs as actors or agents. Narrative analysis sensitizes us to these issues of 'trouble' and provides a means of addressing them. Like John Bunyan's Pilgrim, we have learned through our progress; unlike Pilgrim, we know not our end.

Discourses on empowerment

The discourse community of British psychiatric and mental health nursing is a contested realm. The 'Big Stories' of policy and planning of services are clearly articulated in disputes in journals, but the 'Little Stories' of nurses' work and patients' or users' experiences may be ignored or under-valued. This paper illustrates how the Big Story of a central theme in current policy--empowerment--is articulated in the realm of research funding and design, and how it is articulated by practitioners. The paper focuses attention on the responsibilities faced by researchers, in relating the Little Stories of practice and the Big Story of policy. It reports early and tentative findings from a study of community psychiatric nurses' empowerment of people with enduring mental disorders. The paper suggests ways in which strategies for analysis of qualitative data from interviews with CPNs may be informed by ideas drawn from the field of discourse analysis; reflexively examining how researchers' discourses relate to those of policy makers and mental health nursing practitioners. This paper is based on a presentation at the Network for Psychiatric Nursing Research Conference, Napier University, Edinburgh, 17 September 1997.

Reality and danger in psychoanalytic treatment

In recent papers there has been considerable interest in the disclosure of the analyst's erotic countertransference. In our view this discussion touches a more fundamental issue: must something "real" take place between analyst and patient in order for real change to occur? And if what takes place is "real," will it not be dangerous and potentially destructive? Tracing the history of psychoanalytic understandings of what is "real" in the patient's life and what is "real" in the transference, we explore these questions in a clinical vignette and discuss the implications of this issue for our understanding of the process of psychoanalytic treatment.

Use of self-collected vaginal specimens for detection of Chlamydia trachomatis infection

OBJECTIVE

To evaluate the efficacy of a self-collected vaginal introital specimen, obtained by women using only an instruction booklet as a guide, for the detection of Chlamydia trachomatis using polymerase chain reaction (PCR).

METHODS

Comparison analysis in an Urban hospital clinic, using a convenience sample of 101 women undergoing screening or treatment for C trachomatis infection. Subjects were given an illustrated instruction booklet and were asked to collect a single specimen from the vaginal introitus using the Amplicor collection kit. Cervical and introital specimens then were obtained by clinicians. The presence of C trachomatis in patient-collected versus clinician-collected samples was determined by PCR. Discordant specimens were retested by PCR, using primer pairs to the C trachomatis major outer membrane protein gene, and were screened for the presence of PCR assay inhibitors.

RESULTS

Ninety-nine subjects completed the self-collection. Sixty-two percent were adolescents and 17% spoke English as their second language. Forty-three percent had never used tampons, and 36% had never looked at their own genitals. Twenty-eight cervical specimens (28%), 32 clinician-collected introital specimens (32%), and 33 self-collected introital specimens (33%) were positive for C trachomatis infection. All clinician-collected introital specimens that were positive for C trachomatis and all cervical specimens that were positive for C trachomatis were positive on self-test. Compared with clinician-collected introital specimens, self-collected specimens had a sensitivity of 100% and a specificity of 98.5%. Compared with cervical specimens, self-collected specimens had a sensitivity of 100% and a specificity of 93.4%. After discrepant analysis, self-test had a sensitivity of 100% and a specificity of 94.6% for detection of C trachomatis cervical infection.

CONCLUSION

Self-collection of introital samples is both sensitive and specific in screening for C trachomatis.

The clinical role of the nurse teacher: an exploratory study of the nurse teacher's present and ideal role in the clinical area

This paper describes a study which aimed to explore the present and ideal role of the nurse teacher in the clinical area from the perspective of: nurse teachers; ward sisters/charge nurses; staff nurses and students nurses undertaking the 'traditional' and Project 2000 programmes of training. The study adopted a qualitative design. Findings from this study demonstrate that the clinical role of the nurse teacher lacks clarity, however, clear criteria emerged as to how trained nurses and student nurses perceived the ideal role. Nurse teachers' role in assuring the quality of the clinical learning environment emerged as a major area of criticism. It was suggested that, if nurse teachers adopted a clinical role that was primarily concerned with supporting clinically based nurses in their teaching role, this served to assure the quality of students' clinical learning experience. In conclusion, it is suggested that for nurse teachers to meet the needs of trained nurses and student nurses in the clinical area, the role must be diverse and flexible. Attempts to prescribe a unimodel approach to deliver the service should be avoided. Rather, the role must be negotiated between teachers, clinical nurses and students, and constructed in a way that best meets the needs of all parties concerned.

Desmin expression in rhabdomyosarcoma: influence of the desmin clone and immunohistochemical method

AIM

To determine which, if any, of five commercially available desmin clones is most reliable at labelling desmin filaments and whether the enhanced polymer one step (EPOS) method of labelling is of any advantage in the routine diagnostic laboratory.

METHODS

Thirty four rhabdomyosarcomas from the files at The Hospital for Sick Children, Great Ormond Street, London, were studied. Four different desmin clones, DE-R-11, D33, DE-U-10, and PDE, were applied to each using the conventional extravidin biotin peroxidase method. The D33 clone was also applied using the EPOS method.

RESULTS

The EPOS method incorporating D33 persistently scored more cells as desmin positive and was positive in four cases which were negative on staining with the other clones.

CONCLUSIONS

The D33 desmin clone used with the EPOS method is more reliable for identifying desmin filaments in tumours than other desmin antibodies tested. Different desmin clones using a routine technique label different rhabdomyosarcoma cells and therefore it is justifiable to use more than one clone.

Childhood soft tissue chondroma: a case report

In this paper we draw attention to the existence of soft tissue chondromas in childhood. This entity is well recognized in adults, where over 90% of the recorded cases have occurred in the hands and feet. Our case is unusual in that the child was only 10 years of age and the lesion was on the back, not in the extremity. The importance of recognizing this condition is that these chondromas may exhibit increased cellularity and mitoses and should not be mistaken for a malignant condition.