Exercise transiently increases the density of incipient blood clots in antiplatelet-treated lacunar stroke patients

INTRODUCTION

Older individuals and, in particular, individuals at risk of recurrent stroke, may be susceptible to thrombosis when participating in exercise, however, this aspect has not been well investigated.

METHODS

Clot microstructure and conventional markers of thrombotic risk were determined in twenty lacunar stroke patients and fifteen healthy age-matched controls before, immediately after and 1 h after a bout of moderate intensity cycling exercise. Data were analyzed using a linear mixed model approach.

RESULTS

At rest, clot microstructure (1.69 ± 0.07 vs. 1.64 ± 0.05, corresponding to a difference of ~ 50% in normalized clot mass; p = 0.009) and thrombocyte count (73%; p < 0.0001) were higher, and activated partial thromboplastin time was lower (18%; p = 0.0001) in stroke patients compared to age-matched controls. Acute exercise increased thrombogenic markers similarly in the two groups: incipient clot microstructure (1.69 ± 0.07 vs. 1.74 ± 0.05; p = 0.0004 and 1.64 ± 0.05 vs. 1.71 ± 0.04; p < 0.0001, for stroke and controls respectively), plasma fibrinogen (12%; p < 0.0001 and 18%; p < 0.0001, for stroke and controls respectively) and the combined coagulation factors II, VII and X (p = 0.0001 and p < 0.0001, for stroke and controls respectively).

CONCLUSION

The results show that exercise transiently increases the risk of blood clot formation in both stroke patients and controls, however, due to the higher baseline thrombogenicity in stroke patients, the post exercise risk of forming blood clots may be higher in this group.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov (NCT03635177).

Effect of short-term abomasal corn starch infusions on postruminal fermentation and blood measures

It is possible that some of the systemic responses to subacute ruminal acidosis (SARA) may be caused by increased intestinal starch fermentation. The objective of this experiment was to evaluate the effect of abomasal infusion of up to 3 g of corn starch/kg body weight (approximately 1.6 kg of starch/d) on fecal measures of fermentation, plasma acute phase proteins, and white blood cell populations. Six ruminally cannulated cows in late lactation were randomly assigned to duplicate 3 × 3 Latin squares with 21-d periods. Cows were fed a 20.6% starch TMR twice daily and during the last 7 d of each period cows were abomasally infused with corn starch at 0 (CON), 1 (ST1), or 3 (ST3) g/kg body weight split into 2 bolus infusions, provided every 12 h. Fecal samples were collected at 0, 6, 12, and 18 h following feeding on d 21 and were analyzed for pH, VFA, lactic acid, and lipopolysaccharide (LPS). Composite fecal samples were used to estimate apparent total-tract nutrient digestibility using undigested neutral detergent fiber as an internal marker. Blood samples were collected at 0 and 6 h relative to feeding on d 14, 18, and 21 of each period. Concentrations of haptoglobin and serum amyloid A in plasma were measured in all samples, 0 h samples on d 14 and 21 were used to measure white blood cell populations, and 0 h samples from d 14, 18, and 21 were used for flow cytometric analysis of γδ T cells. Data were analyzed in SAS using models that included fixed effects of treatment and period and the random effects of cow and square. For blood measures, d 14 samples collected before the initiation of abomasal infusions were included as covariates. Time (d or h) was added as a repeated measure in variables that included multiple samples during the abomasal infusion period. A contrast was used to determine the linear effect of increasing abomasal corn starch. Abomasal corn starch linearly decreased fecal pH and linearly increased fecal total VFA and LPS, but effects were modest, with fecal pH, total VFA, and LPS changing from 6.96, 57.7 mM, and 4.14 log10 endotoxin units (EU) per gram for the CON treatment to 6.69, 64.1 mM, and 4.58 log10 EU/g for the ST3 treatment, respectively. This suggests that we did not induce hindgut acidosis. There were no effects of treatment on apparent total-tract starch digestibility or fecal starch content (mean of 96.9% and 2.2%, respectively). Treatment did not affect serum acute phase proteins or most circulating white blood cells, but the proportion of circulating γδ T cells tended to linearly decrease from 6.69% for CON to 4.61% for ST3. Contrary to our hypothesis, increased hindgut starch fermentation did not induce an inflammatory response in this study.

Genomic characterization of cocirculating Corynebacterium diphtheriae and non-diphtheritic Corynebacterium species among forcibly displaced Myanmar nationals, 2017-2019

Respiratory diphtheria is a serious infection caused by toxigenic Corynebacterium diphtheriae, and disease transmission mainly occurs through respiratory droplets. Between 2017 and 2019, a large diphtheria outbreak among forcibly displaced Myanmar nationals densely settled in Bangladesh was investigated. Here we utilized whole-genome sequencing (WGS) to characterize recovered isolates of C. diphtheriae and two co-circulating non-diphtheritic Corynebacterium (NDC) species - C. pseudodiphtheriticum and C. propinquum. C. diphtheriae isolates recovered from all 53 positive cases in this study were identified as toxigenic biovar mitis, exhibiting intermediate resistance to penicillin, and formed four phylogenetic clusters circulating among multiple refugee camps. Additional sequenced isolates collected from two patients showed co-colonization with non-toxigenic C. diphtheriae biovar gravis, one of which exhibited decreased susceptibility to the first-line antibiotics and harboured a novel 23-kb multidrug resistance plasmid. Results of phylogenetic reconstruction and virulence-related gene contents of the recovered NDC isolates indicated they were likely commensal organisms, though 80.4 %(45/56) were not susceptible to erythromycin, and most showed high minimum inhibition concentrations against azithromycin. These results demonstrate the high resolution with which WGS can aid molecular investigation of diphtheria outbreaks, through the quantification of bacterial genetic relatedness, as well as the detection of virulence factors and antibiotic resistance markers among case isolates.

Impaired fibrinolysis in severe Covid-19 infection is detectable in early stages of the disease

BACKGROUND

A significant degree of mortality and morbidity in Covid-19 is due to thromboembolic disease. Coagulopathy has been well described in critically unwell patients on ICU. There is less clear evidence regarding these changes at the time of presentation to the Emergency Department and the progression of disease over time.

OBJECTIVE

We sought to investigate whether coagulation markers can predict severity and how they change over the disease course.

METHODS

Patients presenting to a single University Teaching Hospital were recruited and followed up if PCR was positive. Alongside routine blood testing, Rotational Thromboelastometry (ROTEM) was performed. Outcome data was recorded for all patients, and ROTEM values were compared across outcome groups.

RESULTS

Extem and Intem Maximum Lysis were significantly reduced in those who died or required an ICU admission, indicating a reduced ability to break down clot mass in the most critically unwell patients.

CONCLUSION

Comparisons between groups demonstrated that one distinguishing feature between those who require ICU admission or die of Covid-19 compared with those who survive a hospital stay to discharge was the extent to which fibrinolysis could occur. Mortality and morbidity in Covid-19 infection appears in part driven by an inability to break down clot mass.

1395 The Influence of Shortened Antimicrobial Courses in Surgical Management of Mid 1/3rd Facial Fractures

Aim

Antimicrobial resistance (AMR) is an increasing issue posing a grave threat to global public health. A prospective pilot study within our OMFS unit investigated the effects a shortened course of perioperative antimicrobial cover had on infective post-operative complications in patients who had surgical management of mid 1/3rd facial fractures.

Method

As per the World Health Organisation (WHO) global action plan on antimicrobial resistance, with our microbiology team we developed and implemented a shortened antimicrobial protocol for use in the surgical management of mid 1/3rd facial fractures. Following protocol implementation, the records of 55 patients who underwent surgery for their mid 1/3 facial fractures between May 2019 and May 2020 were reviewed.

Results

Of 55 patients who underwent surgical management of mid 1/3rd facial fractures 28/55 (50.9%) were prescribed a shortened course of perioperative antimicrobials depending on whether an intra or extra oral surgical approach was used, whilst 27/55 (49.1%) were prescribed a longer course of antimicrobials. Of those given a shortened course of antimicrobials 1/28 (3.6%) experienced infective post-operative complications. Conversely 4/27 (14.8%) of those given a longer course of antibiotics experienced infective post-operative complications.

Conclusions

This data supports growing evidence that shorter courses of antimicrobials are appropriate in the surgical management of facial fractures. As OMFS surgeons we can utilise evidence-based medicine to provide optimal surgical care whilst simultaneously contributing to healthcare professionals’ obligations to tackle the increasing challenge of antimicrobial resistance.

Investigation of a Large Diphtheria Outbreak and Cocirculation of Corynebacterium pseudodiphtheriticum Among Forcibly Displaced Myanmar Nationals, 2017-2019

BACKGROUND

Diphtheria, a life-threatening respiratory disease, is caused mainly by toxin-producing strains of Corynebacterium diphtheriae, while nontoxigenic corynebacteria (eg, Corynebacterium pseudodiphtheriticum) rarely causes diphtheria-like illness. Recently, global diphtheria outbreaks have resulted from breakdown of health care infrastructures, particularly in countries experiencing political conflict. This report summarizes a laboratory and epidemiological investigation of a diphtheria outbreak among forcibly displaced Myanmar nationals in Bangladesh.

METHODS

Specimens and clinical information were collected from patients presenting at diphtheria treatment centers. Swabs were tested for toxin gene (tox)-bearing C. diphtheriae by real-time polymerase chain reaction (RT-PCR) and culture. The isolation of another Corynebacterium species prompted further laboratory investigation.

RESULTS

Among 382 patients, 153 (40%) tested tox positive for C. diphtheriae by RT-PCR; 31 (20%) PCR-positive swabs were culture confirmed. RT-PCR revealed 78% (298/382) of patients tested positive for C. pseudodiphtheriticum. Of patients positive for only C. diphtheriae, 63% (17/27) had severe disease compared to 55% (69/126) positive for both Corynebacterium species, and 38% (66/172) for only C. pseudodiphtheriticum.

CONCLUSIONS

We report confirmation of a diphtheria outbreak and identification of a cocirculating Corynebacterium species. The high proportion of C. pseudodiphtheriticum codetection may explain why many suspected patients testing negative for C. diphtheriae presented with diphtheria-like symptoms.

The treatment effect of rivaroxaban on clot characteristics in patients who present acutely with first time deep vein thrombosis

BACKGROUND

The acute vascular disease deep vein thrombosis (DVT) requires oral anticoagulants to prevent progression. Monitoring therapeutic efficacy of direct oral anticoagulants (DOAC), including rivaroxaban, is problematic as no reliable test is available. Advances in rheometry have led to the development of a functional coagulation biomarker using Gel Point (GP) analysis which assesses clot structure formation. The biomarker measures incipient clot formation time (TGP) and quantifies fibrin clot structure in terms of fractal dimension (df).

OBJECTIVE

This study aimed to investigate clot structure formation in first time DVT and the effect of rivaroxaban treatment.

METHODS

This prospective observational cohort study measured the GP and standard laboratory markers at three sample points: pre-treatment and at 20 and 60 days following 15 mg BD and 20 mg OD rivaroxaban respectively.

RESULTS

Forty DVT patients (mean age 64 years [SD±14.8]; 23 males, 17 female) were recruited. The results show that DVT vs non-DVT patients did not have a significantly different GP profile (df: 1.72±0.06 vs 1.70±0.06 and TGP: 267±68 sec vs 262±73 sec) with both within the defined healthy index. In addition, rivaroxaban therapy increased TGP to 392 s (±135 s) after 20 days, and subsequently increased to 395 s (±194 s) at 60 days but did not significantly increase df (from 1.69±0.05 to 1.71±0.06).

CONCLUSIONS

The results indicate in this cohort of DVT patients there was no underlying hypercoagulable effect as determined by gel point analysis. Furthermore, the anticoagulant effect of rivaroxaban prolonged clotting, suggesting a protective effect against clot formation, without significantly reducing clot microstructural properties.

Evaluating the effects of Lactobacillus animalis and Propionibacterium freudenreichii on performance and rumen and fecal measures in lactating dairy cows

Two experiments evaluated the effect of supplementation with a bacterial direct-fed microbial on performance and apparent total-tract nutrient digestion of dairy cows. In experiment 1, 30 multiparous cows (75 ± 32 d in milk) were randomly assigned to 1 of 2 treatments fed for 10 wk. All cows were fed a diet containing 23.8% starch. Treatments were top dressed to rations twice daily and consisted of a combination of Lactobacillus animalis (1 × 10⁹ cfu/d) and Propionibacterium freudenreichii (2 × 10⁹ cfu/d; LAPF) or carrier alone (CON). In experiment 2, 6 ruminally cannulated cows (123 ± 129 d in milk) were randomly assigned to a crossover design with two 6-wk periods. Cows received the same CON or LAPF treatment as in experiment 1. Cows were fed the same 23.8% starch diet as experiment 1 during wk 1 through 5 of each period, and then cows were abruptly switched to a 31.1% starch diet for wk 6. For both experiments, intake and milk yield were measured daily, and milk samples were collected weekly. In experiment 1, fecal grab samples were collected every 6 h on d 7 of experimental wk 1, 2, 4, 6, 8, and 10. Fecal consistency was scored, and fecal starch was measured in daily composite samples. Fecal composites from a subset of 7 cows per treatment were used to measure apparent total-tract nutrient digestion. In experiment 2, rumen pH was continuously recorded during wk 5 and 6. On d 7 of wk 5 (the final day of feeding the 23.8% starch ration), d 1 of wk 6 (the day of diet transition), and d 7 of wk 6 (the final day of feeding the 31.1% starch ration), rumen in situ digestion was determined. Samples of rumen fluid and feces were collected every 6 h on those days for measurement of fecal starch (composited by cow within day), rumen volatile fatty acids, and fecal pH. Rumen and fecal samples were collected at one time point on those days for microbiota assessment. In experiment 1, treatment did not affect intake, milk yield, milk composition, or fecal score. The LAPF treatment decreased fecal starch percentage and tended to increase starch digestion compared with CON, but the differences were very small (0.59 vs. 0.78% and 98.74 vs. 98.46%, respectively). Digestion of other nutrients was unaffected. In experiment 2, LAPF increased rumen pH following the abrupt switch to the high-starch diet, but milk yield was lower for LAPF compared with CON (35.7 vs. 33.2 kg/d). Contrary to the decrease in fecal starch with LAPF observed in experiment 1, fecal starch tended to be increased by LAPF following the abrupt ration change in experiment 2 (2.97 vs. 2.15%). Few effects of treatment on rumen and fecal microbial populations were detectable. Under the conditions used in our experiments, addition of the bacterial direct-fed microbials did not have a marked effect on animal performance, ruminal measures, or total-tract nutrient digestion.

The effect of the acute inflammatory response of burns and its treatment on clot characteristics and quality: A prospective case controlled study

INTRODUCTION

Burns are known to have an effect on coagulation in the early period after burn. Current coagulation tests have been criticised in acute burns due to their inherent limitations. This study aims to investigate the potential for a new quantitative functional biomarker of clot quality, fractal dimension, to identify changes in clot microstructure as a result of the burn inflammatory response and its treatment.

METHODS

A total of fifty-eight burn patients were included in this prospective case-controlled study. The control group (29 patients mean TBSA 1%), and case group (29 patients mean TBSA 30%) were compared at baseline and the case group investigated further over four time points (baseline, 12h, 24h and 5-7 days). Fractal analysis was performed, as well as current markers of coagulation, inflammatory markers and point-of-care tests, Thromboelastography and Multiplate analysis.

RESULTS

Fractal dimension did not differ between groups at admission (1.73±0.06 and 1.72±0.1), and fell within the healthy index normal range (1.74±0.7), suggesting a normal clot microstructure in the early period after burn. Fractal dimension significantly reduced from baseline over the first 24h following injury (1.59±0.03 p<0.005), indicating a significant reduction in mechanical clot strength and functionality consistent with a hypocoagulable state, not identified with other markers.

CONCLUSIONS

This is the first study to quantify the changes in clot microstructure following burn injury. This study confirms clot microstructure is significantly altered during the first 24h after burn, with the production of a weaker, more porous fibrin clot, consistent with a hypocoagulable state.

ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes: protocol for the ELECTRIC randomised trial

BACKGROUND

Urinary incontinence (UI) is highly prevalent in nursing and residential care homes (CHs) and profoundly impacts on residents' dignity and quality of life. CHs predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous posterior tibial nerve stimulation (TPTNS) is a non-invasive, safe and low-cost intervention with demonstrated effectiveness for reducing UI in adults. However, the effectiveness of TPTNS to treat UI in older adults living in CHs is not known. The ELECTRIC trial aims to establish if a programme of TPTNS is a clinically effective treatment for UI in CH residents and investigate the associated costs and consequences.

METHODS

This is a pragmatic, multicentre, placebo-controlled, randomised parallel-group trial comparing the effectiveness of TPTNS (target n = 250) with sham stimulation (target n = 250) in reducing volume of UI in CH residents. CH residents (men and women) with self- or staff-reported UI of more than once per week are eligible to take part, including those with cognitive impairment. Outcomes will be measured at 6, 12 and 18 weeks post randomisation using the following measures: 24-h Pad Weight Tests, post void residual urine (bladder scans), Patient Perception of Bladder Condition, Minnesota Toileting Skills Questionnaire and Dementia Quality of Life. Economic evaluation based on a bespoke Resource Use Questionnaire will assess the costs of providing a programme of TPTNS. A concurrent process evaluation will investigate fidelity to the intervention and influencing factors, and qualitative interviews will explore the experiences of TPTNS from the perspective of CH residents, family members, CH staff and managers.

DISCUSSION

TPTNS is a non-invasive intervention that has demonstrated effectiveness in reducing UI in adults. The ELECTRIC trial will involve CH staff delivering TPTNS to residents and establish whether TPTNS is more effective than sham stimulation for reducing the volume of UI in CH residents. Should TPTNS be shown to be an effective and acceptable treatment for UI in older adults in CHs, it will provide a safe, low-cost and dignified alternative to the current standard approach of containment and medication.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03248362. Registered on 14 August 2017. ISRCTN, ISRCTN98415244. Registered on 25 April 2018. https://www.isrctn.com/.

Specificity of personality relationships to particular forms of concurrent substance use among methadone maintenance therapy clients

OBJECTIVE

A mainstay treatment for opioid addiction in North America is methadone maintenance therapy (MMT) - a form of opiate agonist therapy (OAT). While efficacious for treating opioid addiction, MMT fails to address the concurrent polysubstance use that is common among opioid dependent clients. Moreover, psychosocial approaches for addressing polysubstance use during MMT are lacking. Our study's goals were to validate the use of the four-factor personality model of substance use vulnerability in MMT clients, and to demonstrate theoretically-relevant relationships of personality to concurrent substance use while receiving MMT.

METHOD

Respondents included 138 daily-witnessed MMT clients (65.9% male, 79.7% Caucasian), mean age (SD) 40.18 (11.56), recruited across four Canadian MMT clinics. Bayesian confirmatory factor analysis was used to establish the structural validity of the four-factor personality model of substance use vulnerability (operationalized with the Substance Use Risk Profile Scale [SURPS]) in MMT clients. SURPS personality scores were then used as predictors for specific forms of recent (past 30-day) substance use.

RESULTS

Using a latent hierarchal model, hopelessness was associated with recent opioid use; anxiety sensitivity with recent tranquilizer use; and sensation seeking with recent alcohol, cannabis, and stimulant use.

CONCLUSION

Personality is associated with substance use patterns and may be an appropriate target for intervention for those undergoing MMT to reduce opioid use, and potentially dangerous concurrent use of other drugs, while receiving methadone.

Hay Fever Treatment in General Practice: A Randomised Controlled Trial Comparing Standardised Western Acupuncture with Sham Acupuncture

The effect of standardised, Western acupuncture on hay fever symptoms was investigated in a randomised, controlled, single-blind trial in comparison with “sham” acupuncture. Three general practices, in Oxfordshire (rural), Lincolnshire (semi-rural), and Peterborough (urban), recruited 102 patients aged 16 or over with long-standing, moderate or severe hay fever symptoms that had required continuous therapy for at least one month of the year for three or more consecutive years.

The patients were asked to keep a diary to record: the amount of medication used daily; a daily symptom score (using a ten-point scale), from which was derived a weekly remission of symptoms score; and their assessment of the effect of acupuncture on the hay fever symptoms. Symptom scores and use of medication were similar in the two groups. In the four-week period following each patient's first treatment, remission of symptoms was reported by 39.0% in the active treatment group and 45.2% in the sham group; mean weekly symptom scores were 18.4 and 17.6 respectively; and mean units of medication used were 4.1 and 5.0 respectively. Sixteen out of 43 patients in the active treatment group and 14 out of 43 in the sham group felt that the acupuncture had had an excellent or very good effect on their hay fever. The treatments were simple, safe, reproducible and perceived as equally effective. Whether this represented an acupuncture effect, a placebo effect, or natural variation in a fluctuating condition, is not clear.

Increasing body mass index and abdominal subcutaneous fat thickness are associated with increased skin-to-epidural space distance in pregnant women

BACKGROUND

Body mass index does not indicate the distribution of adipose tissue. Central adiposity may be measured using ultrasound measurement of subcutaneous fat thickness. This study determined if the abdominal subcutaneous fat thickness measured correlated with skin-to-epidural space distance at delivery, and compared this with the booking body mass index.

METHODS

We analysed a sub-set of participants from a single-centre, prospective cohort study that assessed the relationship between subcutaneous fat thickness and maternity outcomes. Abdominal subcutaneous fat thickness measurements were obtained during the routine fetal anomaly scan. The skin-to-epidural space distance was obtained in those having epidural or combined spinal-epidural analgesia. Linear regression was used to test for strength of association and adjusted R² values calculated to determine if subcutaneous fat thickness or body mass index was more strongly associated with skin-to-epidural space distance.

RESULTS

The 463 women had a median (IQR) booking body mass index of 25.0 kg/m² (21.8-29.3) and subcutaneous fat thickness of 16.2 mm (13.0-21.0). The median (IQR) skin-to-epidural space distance was 5.0 cm (4.5-6.0). Both parameters significantly correlated with skin-to-epidural space distance (r=0.53 and 0.68 respectively, P <0.001). Adjusted linear regression coefficient (95% CI) for subcutaneous fat thickness was 0.09 (0.08 to 0.11), R²=0.30 and for body mass index 0.12 (0.11 to 0.13), R²=0.47.

CONCLUSIONS

Booking body mass index had a stronger relationship with skin-to- epidural space distance at delivery than subcutaneous fat thickness, explaining 47% of the variation in the skin-to-epidural distance.

Cell wall microstructure, pore size distribution and absolute density of hemp shiv

This paper, for the first time, fully characterizes the intrinsic physical parameters of hemp shiv including cell wall microstructure, pore size distribution and absolute density. Scanning electron microscopy revealed microstructural features similar to hardwoods. Confocal microscopy revealed three major layers in the cell wall: middle lamella, primary cell wall and secondary cell wall. Computed tomography improved the visualization of pore shape and pore connectivity in three dimensions. Mercury intrusion porosimetry (MIP) showed that the average accessible porosity was 76.67 ± 2.03% and pore size classes could be distinguished into micropores (3-10 nm) and macropores (0.1-1 µm and 20-80 µm). The absolute density was evaluated by helium pycnometry, MIP and Archimedes' methods. The results show that these methods can lead to misinterpretation of absolute density. The MIP method showed a realistic absolute density (1.45 g cm^-3) consistent with the density of the known constituents, including lignin, cellulose and hemi-cellulose. However, helium pycnometry and Archimedes' methods gave falsely low values owing to 10% of the volume being inaccessible pores, which require sample pretreatment in order to be filled by liquid or gas. This indicates that the determination of the cell wall density is strongly dependent on sample geometry and preparation.

Octopus engineering, intentional and inadvertent

We previously published a description of discovery of a site where octopuses live in an unusually dense collection of individual dens near one another in a bed of scallop shells amid a rock outcrop. We believe the shell bed is an extended midden, accumulated over time by individual octopuses returning to their dens with food. Here we consider what aspects of material collection, den maintenance, and aggregation are intentional for the octopuses, versus inadvertent consequences of individual decisions. Collection of prey items, transport of prey to the den, den excavation, and collection and use of non-prey materials at the den appear to be intentional behaviors. The occurrence of many dens in close aggregation appears to be an inadvertent outcome of the availability of food and the risk of predation in the habitat. Popular media reports have described this site as an ‘city’ designed by octopuses, but that is not an accurate description of the site.

Controlled comparison of two crisis resolution and home treatment teams

Aims and method

To compare an existing crisis resolution service with a new crisis resolution team (CRT) in Wales. The impact of the new team was measured by changes in bed days and admissions. A random sample of patients from each service was assessed for service satisfaction, social functioning and quality of life after first presentation.

Results

The total number of bed days was reduced following the introduction of the new CRT (27.3%). The frequency and duration of compulsory admissions increased by 31% in the CRT between the first and second years and by 7% in the control service, offset by a greater reduction in informal admissions in the CRT (23.5%) compared with the control group (13.3%); overall bed usage was unchanged. Service satisfaction, social functioning and quality of life showed no important differences between the services.

Clinical implications

Crisis resolution teams may reduce informal admissions in the short term but at the cost of more compulsory admissions later.

The effects of inbreeding on sperm morphometry of captive-bred endangered mammals

Captive breeding is used for the conservation of endangered species, but inbreeding can result when a small number of founders are used to establish populations. Inbreeding can reduce the proportion of normal sperm in an ejaculate, but may also have effects on sperm size and shape (morphometry). We investigated the effects of inbreeding on sperm morphometry of black-footed ferrets (Mustela nigripes (Audubon and Bachman, 1851)) and red wolves (Canis rufus Audubon and Bachman, 1851) from captive breeding programs to determine if more inbred males produced sperm of poor quality (bulky head, small midpiece, short tail). We measured sperm head length, head width, midpiece length, midpiece width, and tail length on 10 sperm from each male of both species. A negative relationship between variation in sperm tail length and inbreeding coefficient (f) was found in black-footed ferret, suggesting that more inbred individuals will have reduced genetic and phenotypic variation. Analyses indicated a negative relationship between sperm head width and f and a positive relationship between sperm tail length and f in red wolf, suggesting that more inbred male red wolves could have faster sperm. These results indicate that inbreeding affects functionally important aspects of sperm morphometry, but that these effects may not be entirely negative.

Mindfulness-based stress reduction in Parkinson's disease: a systematic review

BACKGROUND

Mindfulness based stress reduction (MBSR) is increasingly being used to improve outcomes such as stress and depression in a range of long-term conditions (LTCs). While systematic reviews on MBSR have taken place for a number of conditions there remains limited information on its impact on individuals with Parkinson's disease (PD).

METHODS

Medline, Central, Embase, Amed, CINAHAL were searched in March 2016. These databases were searched using a combination of MeSH subject headings where available and keywords in the title and abstracts. We also searched the reference lists of related reviews. Study quality was assessed based on questions from the Cochrane Collaboration risk of bias tool.

RESULTS

Two interventions and three papers with a total of 66 participants were included. The interventions were undertaken in Belgium (n = 27) and the USA (n = 39). One study reported significantly increased grey matter density (GMD) in the brains of the MBSR group compared to the usual care group. Significant improvements were reported in one study for a number of outcomes including PD outcomes, depression, mindfulness, and quality of life indicators. Only one intervention was of reasonable quality and both interventions failed to control for potential confounders in the analysis. Adverse events and reasons for drop-outs were not reported. There was also no reporting on the costs/benefits of the intervention or how they affected health service utilisation.

CONCLUSION

This systematic review found limited and inconclusive evidence of the effectiveness of MBSR for PD patients. Both of the included interventions claimed positive effects for PD patients but significant outcomes were often contradicted by other results. Further trials with larger sample sizes, control groups and longer follow-ups are needed before the evidence for MBSR in PD can be conclusively judged.

Intracranial hypertension secondary to high dose cytosine arabinoside - A case study

We report a rare case of intracranial hypertension following high dose cytosine arabinoside (HiDAC) in a 20-year-old man, with precursor B-cell acute lymphoblastic leukemia (ALL). A five drug induction protocol for ALL was initiated; post induction consolidation was with HiDAC (3 g/m² IV every 12 h on days 1, 3 and 5). Post consolidation, cytogenetic remission was attained and he received an intensification and maintenance regimen for ALL, for a period of approximately 24 months. Four months following the completion of his treatment, the patient relapsed within the central nervous system (CNS). Intravenous salvage chemotherapy was initiated using a combination of fludarabine 30 mg/m², followed by cytarabine 2 g/m² 4 h later on days 1 through 5 (FA). On day # 23 of FA, he developed a severe headache. A gadolinium-enhanced brain magnetic resonance imaging (MRI) revealed increased intracranial pressure. On day # 25, ophthalmology examination suggested bilateral papilledema. He was started on acetazolamide 250 mg twice daily. He had spontaneous resolution of his symptoms. The patient had no recurrence of papilledema or any other neurological symptoms. Intracranial hypertension secondary to HiDAC, is an exceedingly rare complication and is not regularly associated as a common side effect of cytarabine administration. Prompt action in diagnosing and treating intracranial hypertension will save the patient from consequences, such as loss of vision, that are prevalent in this condition.

Enhancing evidence use in public health nutrition policymaking: theoretical insights from a New Zealand case study

Background

Enhancing the use of evidence in policymaking is critical to addressing the global burden of nutrition-related disease. Whilst the public health nutrition community has embraced evidence-informed policymaking, their approach of defining relevant evidence and evaluating policy has not brought about major shifts in policymaking. This article uses a public health nutrition case study to refine a novel theory-informed framework for enhancing the use of evidence in government public health nutrition policymaking. Our aim is to contribute insights from evidence-informed policy to the emerging paradigm in public health nutrition policymaking.

Methods

An enquiry framework informed by three groups of theories underpinning evidence-informed policy was used to explore the role of socially mediated processes on the use of evidence. A public health nutrition case study on food marketing to New Zealand children was conducted to refine the framework. Interview data collected from 54 individuals representing four key policy stakeholder groups, policymakers, academics, and food industry and non-government organisations were analysed using deductive and inductive thematic analysis. To enhance theoretical robustness, an alternative hypothesis of political explanations for evidence use was explored alongside the enquiry framework.

Results

We found the prevailing political climate influenced the impact of advocacy for evidence inclusive processes at the meta-policy and policymaking process levels and in policy community relationships. Low levels of awareness of the impact of these processes on evidence use and uncoordinated advocacy resulted in the perpetuation of ad hoc policymaking. These findings informed refinements to the enquiry framework.

Conclusion

Our study highlights the role advocates can play in shifting government public health nutrition policymaking systems towards enhanced use of evidence. Our Advocacy for Evidence Use framework argues for a three-channel approach to advocacy for using evidence in the public interest. The framework provides a means for building a constituency for evidence use in public health nutrition and adds understanding about advocacy to the field of evidence-informed policy. Future research should examine the impact of coordinated advocacy on public health nutrition policymaking systems.

Electronic supplementary material

The online version of this article (doi:10.1186/s12961-016-0154-8) contains supplementary material, which is available to authorized users.

Upregulation of Haploinsufficient Gene Expression in the Brain by Targeting a Long Non-coding RNA Improves Seizure Phenotype in a Model of Dravet Syndrome

Dravet syndrome is a devastating genetic brain disorder caused by heterozygous loss-of-function mutation in the voltage-gated sodium channel gene SCN1A. There are currently no treatments, but the upregulation of SCN1A healthy allele represents an appealing therapeutic strategy. In this study we identified a novel, evolutionary conserved mechanism controlling the expression of SCN1A that is mediated by an antisense non-coding RNA (SCN1ANAT). Using oligonucleotide-based compounds (AntagoNATs) targeting SCN1ANAT we were able to induce specific upregulation of SCN1A both in vitro and in vivo, in the brain of Dravet knock-in mouse model and a non-human primate. AntagoNAT-mediated upregulation of Scn1a in postnatal Dravet mice led to significant improvements in seizure phenotype and excitability of hippocampal interneurons. These results further elucidate the pathophysiology of Dravet syndrome and outline a possible new approach for the treatment of this and other genetic disorders with similar etiology.

A Simple Method for the Size Controlled Synthesis of Stable Oligomeric Clusters of Gold Nanoparticles under Ambient Conditions

Reducing dilute aqueous HAuCl4 with sodium thiocyanate (NaSCN) under alkaline conditions produces 2 to 3 nm diameter nanoparticles. Stable grape-like oligomeric clusters of these yellow nanoparticles of narrow size distribution are synthesized under ambient conditions via two methods. The delay-time method controls the number of subunits in the oligoclusters by varying the time between the addition of HAuCl₄ to alkaline solution and the subsequent addition of reducing agent, NaSCN. The yellow oligoclusters produced range in size from ~3 to ~25 nm. This size range can be further extended by an add-on method utilizing hydroxylated gold chloride (Na(+)[Au(OH₄-x)Clx](-)) to auto-catalytically increase the number of subunits in the as-synthesized oligocluster nanoparticles, providing a total range of 3 nm to 70 nm. The crude oligocluster preparations display narrow size distributions and do not require further fractionation for most purposes. The oligoclusters formed can be concentrated >300 fold without aggregation and the crude reaction mixtures remain stable for weeks without further processing. Because these oligomeric clusters can be concentrated before derivatization they allow expensive derivatizing agents to be used economically. In addition, we present two models by which predictions of particle size can be made with great accuracy.

Stable oligomeric clusters of gold nanoparticles: preparation, size distribution, derivatization, and physical and biological properties

Reducing dilute aqueous HAuCl4 with NaSCN under alkaline conditions produces 2-3 nm diameter yellow nanoparticles without the addition of extraneous capping agents. We here describe two very simple methods for producing highly stable oligomeric grape-like clusters (oligoclusters) of these small nanoparticles. The oligoclusters have well-controlled diameters ranging from ∼5 to ∼30 nm, depending mainly on the number of subunits in the cluster. Our first ["delay-time"] method controls the size of the oligoclusters by varying from seconds to hours the delay time between making the HAuCl4 alkaline and adding the reducing agent, NaSCN. Our second ["add-on"] method controls size by using yellow nanoparticles as seeds onto which varying amounts of gold derived from "hydroxylated gold", Na(+)[Au(OH4-x)Clx](-), are added-on catalytically in the presence of NaSCN. Possible reaction mechanisms and a simple kinetic model fitting the data are discussed. The crude oligocluster preparations have narrow size distributions, and for most purposes do not require fractionation. The oligoclusters do not aggregate after ∼300-fold centrifugal-filter concentration, and at this high concentration are easily derivatized with a variety of thiol-containing reagents. This allows rare or expensive derivatizing reagents to be used economically. Unlike conventional glutathione-capped nanoparticles of comparable gold content, large oligoclusters derivatized with glutathione do not aggregate at high concentrations in phosphate-buffered saline (PBS) or in the circulation when injected into mice. Mice receiving them intravenously show no visible signs of distress. Their sizes can be made small enough to allow their excretion in the urine or large enough to prevent them from crossing capillary basement membranes. They are directly visible in electron micrographs without enhancement, and can model the biological fate of protein-like macromolecules with controlled sizes and charges. The ease of derivatizing the oligoclusters makes them potentially useful for presenting pharmacological agents to different tissues while controlling escape of the reagents from the circulation.

Four-month outbreak of invasive meningococcal disease caused by a rare serogroup B strain, identified through the use of molecular PorA subtyping, England, 2013

Molecular PorA subtyping provides information that increasingly requires the adaptation of standard public health approaches to outbreak management. We report an outbreak of a rare subtype of meningococcal infection not previously identified in the United Kingdom (UK). The outbreak occurred in the Warwickshire area in England between February and June 2013. Molecular subtyping allowed the identification of additional cases, prompting an enhanced public health response that included efforts to identify potential social networks that might benefit from chemoprophylaxis. It also prompted swabbing to define nasopharyngeal carriage in the focal nursery and helped explain the unusual epidemiological pattern. Without subtyping to identify a link, the additional cases would have been managed as sporadic cases in accordance with current UK guidance.

Monitoring the health-related labelling of foods and non-alcoholic beverages in retail settings

Food labelling on food packaging has the potential to have both positive and negative effects on diets. Monitoring different aspects of food labelling would help to identify priority policy options to help people make healthier food choices. A taxonomy of the elements of health-related food labelling is proposed. A systematic review of studies that assessed the nature and extent of health-related food labelling has been conducted to identify approaches to monitoring food labelling. A step-wise approach has been developed for independently assessing the nature and extent of health-related food labelling in different countries and over time. Procedures for sampling the food supply, and collecting and analysing data are proposed, as well as quantifiable measurement indicators and benchmarks for health-related food labelling.