Novel method to plan and design services. Using software to optimise the head and neck cancer patient's commute to hospital

Travelling for hospital appointments represents a significant burden to patients. We have developed a computer programme that accurately evaluates patient commutes between their home and treatment hospital in public and private transport. This has been applied to a cohort of Head and Neck Cancer (HNC) patients to plan the locations of satellite hospitals and assess their impact on patients' commutes. Patients diagnosed with HNC were identified from our hospital's database between December 2019 and January 2022. Using Python, commuting distances from patients' postcodes to our tertiary referral hospital were calculated. These commutes incorporated routes along defined roads, traffic data, and were calculated using public and private transport. Patient commutes from their postcodes to four satellite hospitals were also calculated. We identified their closest hospital and compared that journey to the patients' journey to our tertiary centre. We included 709 patients in our analysis. Patients would have a significantly shorter journey distance and time in both public and private transport if satellite hospitals were used for appointments alongside our tertiary centre. Average travel times would reduce by 10 minutes in private and 25 minutes in public transport. Furthermore, 70% of patients required ≥2 forms of public transport to get to our hospital. This would drop to 44.1% of patients if satellite hospitals were included in our service. Our programme would allow the most accessible sites to be identified for establishing outreach clinics at appropriate satellite hospitals, therefore improving patient access to healthcare.

Predicting methane emissions of individual grazing dairy cows from spectral analyses of their milk samples

Data on the enteric methane emissions of individual cows are useful not just in assisting management decisions and calculating herd inventories but also as inputs for animal genetic evaluations. Data generation for many animal characteristics, including enteric methane emissions, can be expensive and time consuming, so being able to extract as much information as possible from available samples or data sources is worthy of investigation. The objective of the present study was to attempt to predict individual cow methane emissions from the information contained within milk samples, specifically the spectrum of light transmittance across different wavelengths of the mid-infrared (MIR) region of the electromagnetic spectrum. A total of 93,888 individual spot measures of methane (i.e., individual samples of an animal's breath when using the GreenFeed technology) from 384 lactations on 277 grazing dairy cows were collapsed into weekly averages expressed as grams per day; each weekly average coincided with a MIR spectral analysis of a morning or evening individual cow milk sample. Associations between the spectra and enteric methane measures were performed separately using partial least squares regression or neural networks with different tuning parameters evaluated. Several alternative definitions of the enteric methane phenotype (i.e., average enteric methane in the 6 d preceding or 6 d following taking the milk sample or the average of the 6 d before and after the milk sample, all of which also included the enteric methane emitted on the day of milk sampling), the candidate model features (e.g., milk yield, milk composition, and milk MIR) as well as validation strategy (i.e., cross-validation or leave-one-experimental treatment-out) were evaluated. Irrespective of the validation method, the prediction accuracy was best when the average of the milk MIR from the morning and evening milk sample was used and the prediction model was developed using neural networks; concurrently including milk yield and days in milk in the prediction model generated superior predictions relative to just the spectral information alone. Furthermore, prediction accuracy was best when the enteric methane phenotype was the average of at least 20 methane spot measures across a 6-d period flanking each side of the milk sample with associated spectral data. Based on the strategy that achieved the best accuracy of prediction, the correlation between the actual and predicted daily methane emissions when based on 4-fold cross-validation varied per validation stratum from 0.68 to 0.75; the corresponding range when validated on each of the 8 different experimental treatments focusing on alternative pasture grazing systems represented in the dataset varied from 0.55 to 0.71. The root mean square error of prediction across the 4-folds of cross-validation was 37.46 g/d, whereas the root mean square error averaged across all folds of leave-one-treatment-out was 37.50 g/d. Results suggest that even with the likely measurement errors contained within the MIR spectrum and gold standard enteric methane phenotype, enteric methane can be reasonably well predicted from the infrared spectrum of milk samples. What is yet to be established, however, is whether (a) genetic variation exists in this predicted enteric methane phenotype and (b) selection on estimates of genetic merit for this phenotype translate to actual phenotypic differences in enteric methane emissions.

Dialister pneumosintes and aortic graft infection - a case report

BACKGROUND

Dialister pneumosintes is an anaerobic, Gram negative bacillus, found in the human oral cavity and associated with periodontitis. It has also been isolated from gastric mucosa and stool samples. Recent case reports implicate D. pneumosintes in local infection such as dental root canals, sinusitis, Lemierres syndrome and brain abscesses, as well as distal infections of the liver and lung through haematogenous spread.

CASE PRESENTATION

We present a novel case of aortic graft infection and aortoenteric fistula (AEF) in a 75 year old Caucasian male, associated with D. pneumosintes bacteraemia. Microbiological evaluation of septic emboli in the lower limbs revealed other gastrointestinal flora. This suggests either AEF leading to graft infection and subsequent distal emboli and bacteraemia, or a dental origin of infection which seeded to the graft, resulting in AEF and systemic infection. To our knowledge this is the first report of D. pneumosintes associated aortic graft infection. The patient underwent surgical explantation, oversew of the aorta and placement of extra-anatomical bypass graft in conjunction with antimicrobial therapy, making a good recovery with discharge home after a 35-day hospital admission.

CONCLUSION

We report a case of Dialister pneumosintes bacteraemia associated with aortic graft infection. To our knowledge, vascular graft-associated infection with D. pneumosintes has not been reported before.

Extra-mandibular Osteoradionecrosis after the Treatment of Head and Neck Cancer

AIMS

Osteoradionecrosis (ORN) is a serious toxicity of head and neck radiotherapy. It predominantly affects the mandible. Extra-mandibular ORN is rare. The aim of this study was to report the incidence and outcomes of extra-mandibular ORNs from a large institutional database.

MATERIALS AND METHODS

In total, 2303 head and neck cancer patients were treated with radical or adjuvant radiotherapy. Of these, extra-mandibular ORN developed in 13 patients (0.5%).

RESULTS

Maxillary ORNs (n = 8) were a consequence of the treatment of various primaries (oropharynx = 3, sinonasal = 2, maxilla = 2, parotid = 1). The median interval from the end of radiotherapy to the development of ORN was 7.5 months (range 3-42 months). The median radiotherapy dose in the centre of the ORN was 48.5 Gy (range 22-66.5 Gy). Four patients (50%) healed in 7, 14, 20 and 41 months. All temporal bone ORNs (n = 5) developed after treatment to the parotid gland (of a total of 115 patients who received radiotherapy for parotid gland malignancy). The median interval from the end of radiotherapy to the development of ORN was 41 months (range 20-68 months). The median total dose in the centre of the ORN was 63.5 Gy (range 60.2-65.3 Gy). ORN healed in only one patient after 32 months of treatment with repeated debridement and topical betamethasone cream.

CONCLUSION

Extra-mandibular ORN is a rare late toxicity and this current study provides useful information on its incidence and outcome. The risk of temporal bone ORN should be considered in the treatment of parotid malignancies and patients should be counselled. More research is required to determine the optimal management of extra-mandibular ORN, particularly on the role of the PENTOCLO regimen.

The psychological burden associated with Ehlers-Danlos syndromes: a systematic review

CONTEXT

Ehlers-Danlos syndromes (EDS) are disorders of connective tissue that lead to a wide range of clinical presentations. While we are beginning to understand the association between EDS and psychological manifestations, it is critical that we further elucidate the relationship between the two. Understanding the correlation between EDS and mental health will better ensure swift diagnosis and effective treatment for patients.

OBJECTIVES

This study aims to systematically examine and report the prevalence of psychiatric disorders in the EDS population.

METHODS

The PubMed database was searched on June 14, 2021 for articles published from January 2011 to June 2021. We included original, evidence-based, peer-reviewed journal articles in English that reported information on psychiatric disorders among EDS patients. Psychiatric disorders and psychological conditions were limited to those included in the "psychology" and "mental disorders" Medical Subject Headings (MeSH) search terms defined by the National Library of Medicine. Publications identified utilizing this search strategy by M.K. were imported into the Covidence system, where they first underwent a title and abstract screening process by three independent reviewers (M.K., K.L., H.G.). During the full-text review, two independent reviewers read the full text of the questionable articles to assess their eligibility for inclusion. Studies were excluded if they did not meet our target objective or if they were not in English or if they were opinion pieces, conference abstracts, or review articles. Data were extracted from the shortlisted studies by reviewers. During the data extraction phase, the quality and risk of publication bias were assessed by two independent reviewers utilizing the National Institutes of Health (NIH) Study Quality Assessment Tools. Any disagreements in study selection, data extraction, or quality assessment were adjudicated via discussion between the two reviewers, utilizing a third reviewer as a decider if necessary.

RESULTS

Out of 73 articles identified, there were no duplicates. A total of 73 records were screened, but only 40 articles were assessed in full text for eligibility. A total of 23 articles were ultimately included, which collectively discussed 12,298 participants. Ten (43.5%) of the included studies were cross-sectional in design, three (13.0%) were case reports, and three (13.0%) were retrospective chart reviews. The remaining seven (30.4%) articles were either case-control, cohort, qualitative, controlled observational, or validation studies. Twelve (52.2%) of the studies reported data on depression disorders, six of which reported prevalence data. Nine (39.1%) of the studies reported data on anxiety disorders, five of which reported prevalence data. Studies that reported nonprevalence data presented odds-ratio, mean scores on psychiatric evaluations, and other correlation statistics. Psychiatric disorders that were most reported in these articles were mood disorders (n=11), anxiety disorders (n=9), and neurodevelopmental disorders (n=7). Although the reports varied, the highest psychiatric prevalence reports in EDS patients involved language disorders (63.2%), attention-deficit/hyperactivity disorder (ADHD) (52.4%), anxiety (51.2%), learning disabilities (42.4%), and depression (30.2%).

CONCLUSIONS

Although mood disorders were cited in more articles, the highest reported prevalence was for language disorders and ADHD. This discrepancy highlights the importance of performing more research to better understand the relationship between EDS and psychiatric disorders.

Real world radiation exposure in left atrial appendage occlusion device implantation performed in a high volume center

 

Left atrial appendage occlusion (LAAO) is an established and effective treatment to reduce the risk of thromboembolic stroke derived from the LAA in patient with non valvular atrial fibrillation. Per-cutaneous closure of the LAA is typically guided by fluoroscopic and echocardiographic guidance.

The purpose of our study is to ascertain real world radiation exposure during the LAAO performed in our institution and the interplay of different variables and patient characteristics.

Our study retrospectively analyzed all consecutive LAAO procedures performed at our Tertiary level Teaching Hospital. Data was collected using Hospital electronic records and cardiac catherization laboratory records.

A total of 261 patients who underwent LAAO were identified, 28% were female. Average age at the time of procedure was 77 years (range 54–93 years). Mean fluoroscopy time was 10.2 minutes (±7.0), average Radiation dose was 67 gy/cm2 (±73). Interestingly, gy/cm2 per minute of fluoroscopy averaged at 6.69 (±5.0).

Subgroup analysis focused on the effect of Body mass index (BMI) on radiation dose. Since the recent introduction of a partial electronic health record system, BMI data was only available on 161 patients. The cohort with BMI <30 had a mean radiation dose of 57±62 gy/cm2, whereas for BMI >30 mean dose was 96.8±68, p=0.0025 (95% CI (65 to 14)).

Analysis by the four different device types (Watchman, Watchman Flx, Wavecrest and ACP) were used for LAAO, with highest number been watchman (n=189). Upon comparing the radiation exposure in our study cohort watchman device had the least Dose adjusted Product (DAP) at 62gy/cm2 but the newer watchman flx (n=25) had slightly lower gy/cm2 per minute of fluoroscopy time 6.58±3.41 versus 6.83±5.56.

In addition, operator volume between our two implanters was assessed. Our highest volume operator implanted the majority of devices (n=235) whilst the Watchman Flx was predominantly implanted by our newer implanter (n=26). Despite the relatively modest numbers of the Watchman Flx, there was minimal difference in exposure time in favor of the more senior interventionist.

In conclusion, LAAO in our center has encouraging radiation safety data, which is comparable to previously published data in internationally recognized high volume centers. Normal BMI patients had the least radiation exposure, with the dose increasing with rising BMI.

Funding Acknowledgement

Type of funding sources: None. Bar Graph, radiation dose vs BMIScatter Plot, radiation dose vs BMI

1312 Characteristics of Those Who Present with Self-Inflicted Burns: A Burns Unit Service Evaluation Which Challenges Stereotypes

Introduction

Self-harm rates in the UK are increasing. Healthcare professionals’ beliefs regarding repeat attendance; attention-seeking; and poor treatment compliance may contribute to patients’ stigma. Self-inflicted burns (SIB) constitute a minority of burns cases, but require disproportionate healthcare input, yet little is known about these patients. Our aim was to evaluate presentations, compliance and outcomes in this patient group.

Method

A retrospective audit of outpatients with SIBs attending a UK Burns Unit over four years (Jan 2016-Dec 2019).

Results

Over the study period, 58 patients presented with 94 burn wounds. Incidence doubled over one year (2018-2019). Most patients were female (85%) with a median age of 29 years (range 19-62). The most commonly associated psychiatric diagnosis was personality disorder. On presentation 22% (n = 21) were admitted under the Mental Health Act. For 83% (n = 48) it was their first presentation with a SIB, although 74% had previously presented with non-burn self-harm. Median burn size was 0.5% TBSA, the most common mechanism was contact (48%) and 77% were deep (n = 77). 92% were compliant with treatment and did not tamper with their wounds or dressings.

Conclusions

The majority, 70% (n = 41), of patients only presented once to the Burns Department during the study period. This challenges the commonly held stereotype that those who self-harm will also seek attention through repeat presentation. Ongoing education among health professionals may dispel some myths regarding these individuals. Further, larger investigations, may permit rigorous comparison of treatment outcomes with non-SIB patients.

Hemoptysis associated with percutaneous transthoracic needle biopsy: Development of critical events checklist and procedure outcomes

BACKGROUND

A percutaneous transthoracic needle biopsy (PTNB) is performed to obtain tissue for a pathologic diagnosis. A PTNB is necessary prior to the initiation of many cancer treatments. There is a risk of hemoptysis, the expectoration of blood, with the possibility for adverse, life-threatening outcomes. A critical event checklist is a cognitive aid used in an emergency to ensure critical steps are followed. To date, there are no known checklists published for management of PTNB-related, life-threatening hemoptysis. The purpose of this report is to describe the development and implementation of a critical event checklist and the adoption of the checklist into hemoptysis management.

METHODS

In March 2017, a process improvement team convened to evaluate the hemoptysis response using the Plan-Do-Study-Act (PDSA) methodology. The checklist was evaluated and updated through September 2019. The team educated Interventional Radiology (IR) clinicians on the new checklist and conducted simulations on its use. A retrospective chart review was performed on hemoptysis events between the ten-year period of October 1, 2008 and September 30, 2018 to evaluate the adoption of the checklist into practice.

RESULTS

There were 231 hemoptysis events occurring in 229 patients (2 with repeat biopsies). Prior to implementing the protocol and checklist, there were 166 (71.9%) hemoptysis events. After implementation there were 65 (28.1%) events. The median amount of documented blood expectorated with hemoptysis was 100 mL (IQR 20.0-300.0). Twenty-six patients were admitted after PTNB for reasons related to the hemoptysis event (11.3%). During the procedure, four (1.7%) patients with hemoptysis suffered a cardiac arrest. Prior to implementation of the protocol and critical events checklist, nurses positioned patients in the lateral decubitus (LD) position in 40 out of 162 (24.7%) cases. After implementation of the critical events checklist, nurses positioned patients in the LD position 42 out of 65 cases (64.6%) (OR=5.57(95% CI 2.99-10.367), p<0.001).

DISCUSSION

Interventional Radiology nurses successfully adopted the checklist into management of hemoptysis events. The reported incidence of hemoptysis suggests a need for IR teams to prepare for and simulate hemoptysis events. Future research is needed to evaluate the change in patient outcomes before and after critical events checklist implementation.

Gaps in maternal, newborn, and child health research: a scoping review of 72 years in Ethiopia

Background

Despite significant reductions in maternal and child mortality over the past few decades, a disproportionate number of global deaths occur in low and middle-income country settings, such as Ethiopia. To prioritize research questions that would generate policy recommendations for better outcomes, we conducted a scoping review that gathers the current knowledge of maternal, newborn, and child health (MNCH) and illustrates remaining gaps in Ethiopia.

Methods

We conducted a search strategy from 1946-2018 in PubMed/MEDLINE, EMBASE, and the WHO African Index Medicus. The study team of reviewers independently screened titles, abstracts, and full-texts; abstracted data; and reconciled differences in pairs. Descriptive analyses were conducted.

Results

We identified 7,829 unique articles of which 2,170 were included. Most MNCH publications in Ethiopia (70.0%) were published in the last decade, 2010-2018. Most studies included children aged one to less than 10 years old (30.5%), women of reproductive age (22.0%), and pregnant women (21.9%); fewer studies included newborns (7.0%), infants (6.6%), and postpartum women (2.9%). Research topics included demographics and social determinants of health (43.4%), nutrition (15.3%), and infectious diseases (13.0%). There were limited studies on violence (1.4%), preterm birth (0.8%), antenatal/postpartum depression (0.7%), stillbirths (0.1%), and accidents (0.1%). Most study designs were cross-sectional (53.6%). A few study designs included prospective cohort studies (5.5%) and randomized control trials (2.3%).

Conclusions

This is the first scoping review to describe the landscape of MNCH research in Ethiopia. Understanding the depth of existing knowledge will support the prioritization and development of future research questions. Additional studies are needed to focus on the neonatal, infant, and postpartum populations as well as preterm and stillbirth outcomes.

406 Bioabsorbable Screws in Scaphoid Fractures; a systematic review

Background

Scaphoid fractures account for 90% carpal injury. Due to the limited vascular supply achieving adequate reduction and healing is important to avoid complications including avascular necrosis. Recent technological advances have led to renewed vigour in bioabsorbable material research to develop devices which could be used without the need for removal and complications including stress shielding and suboptimal imaging.

Method

A systematic review was made using PubMed, Ovid Medline, and Google Scholar databases according to PRISMA guidelines.

Results

Initial search results yielded 852 studies. 124 studies were screened, resulting in 7 studies which were included in this review. The level of evidence of studies ranged between III-IV of low power. Analysis demonstrated mixed findings with generally comparable outcomes to traditionally used screws. Heterogeneity of studies prevented a meta-analysis.

Conclusions

Development in bioabsorbable materials has yielded promising results in orthopaedic studies, however there is a dearth in research using these devices in the scaphoid. Further robust research is needed to establish the efficacy and applicability of bioabsorbable devices in the scaphoid bone.

Osteoradionecrosis after treatment of head and neck cancer: a comprehensive analysis of risk factors with a particular focus on role of dental extractions

In head and cancer (HNC), osteoradionecrosis (ORN) is one of the most significant complications of radiotherapy (RT). With an absence of effective non-surgical treatment, prevention of the development of ORN is the best approach. The purpose of this study was to identify the risk factors for the development of ORN in HNC. Records of 1,118 patients with HNC treated with radical RT (≥55Gy) from January 2010 to December 2019 were reviewed. After applying the exclusion criteria, 935 patients were included in the final analysis. In patients with confirmed ORN, exact RT doses were mapped. In total, 91 patients were found (9.7%) with a median (range) time of eight (3-89) months to the development of ORN. Smoking, having a primary site in the oropharynx, bone surgery before adjuvant RT, the addition of concurrent chemotherapy, the presence of xerostomia, dental extraction pre-RT, the time ≤20 days between dental extraction and start of RT, and receiving >55Gy RT dose were significant factors for its development. This comprehensive analysis including the precise RT dose mapping has shown the risk factors for the development of ORN. In practice, every effort should be made to avoid these risk factors without compromising the oncology treatment. The findings of this analysis may provide a basis for future prospective research on this topic.

Modeling aerosol transmission of SARS-CoV-2 in multi-room facility

The versatile and computationally attractive FATE™ facility software package for analyzing the transient behavior of facilities during normal and off-normal conditions is applied to the problem of SARS-CoV-2 virus transmission in single-and multi-room facilities. Subject to the justifiable assumptions of non-interacting virus droplets, room-wide spatially homogeneous virus droplet aerosols and droplet sedimentation in accordance with Stokes law; the FATE code tracks the virus aerosol from a human source through a facility with a practical ventilation system which reconditions, filters, and recycles the air. The results show that infection risk can be reduced by 50 percent for increased facility airflow, 70 percent for increased airflow and the inclusion of a HEPA filter on recirculated ventilation air, and nearly 90 percent for increased airflow, inclusion of a HEPA filter, and wearing a mask. These results clearly indicate that there are operational changes and engineering measures which can reduce the potential infection risk in multi-room facilities.

Determination of Patulin in Apple Juice by Liquid Chromatography: Collaborative Study

An AOAC International-International Union of Pure and Applied Chemistry-International Fruit Juice Union (AOAC-IUPAC-IFJU) collaborative study was conducted to evaluate a liquid chromatographic (LC) procedure for determination of patulin in apple juice. Patulin is a mold metabolite found naturally in rotting apples. Patulin is extracted with ethyl acetate, treated with sodium carbonate solution, and determined by reversed-phase LC with UV detection at 254 or 276 nm. Water, water-tetrahydrofuran, or water-acetonitrile was used as mobile phase. Levels determined in spiked test samples were 20, 50,100, and 200 μg/L. A test sample naturally contaminated at 31 μg/L was also included. Twenty-two collaborators in 10 countries analyzed 12 test samples of apple juice. Recoveries averaged 96%, with a range of 91-108%. Repeatability relative standard deviations (RSDr) ranged from 10.9 to 53.8%. The reproducibility relative standard deviation (RSDR) ranged from 15.1 to 68.8%. The LC method for determination of patulin in apple juice has been adopted first action by AOAC INTERNATIONAL.

Working Health Services Scotland: a 4-year evaluation

Background

Working Health Service Scotland (WHSS) supports the self-employed and employees of small and medium-sized enterprises (SMEs) in Scotland with a health condition affecting their ability to work, who are either absent or at risk of becoming absent due to it.

Aims

To evaluate the impact on health and work outcomes of WHSS clients over a 4-year period.

Methods

Data were collected at enrolment, entry, discharge and follow-up at 3 and 6 months after discharge. Clients completed up to three validated health questionnaires at entry and discharge-EuroQol five dimensions (EQ-5D) and visual analogue scale (VAS); Hospital Anxiety and Depression Scale (HADS); and Canadian Occupational Performance Measure (COPM).

Results

A total of 13463 referrals occurred in the 4-year period; 11748 (87%) were eligible and completed entry assessment and 60% of the latter completed discharge paperwork. The majority of referrals were due to musculoskeletal conditions (84%) while 12% were referred with mental health conditions. Almost a fifth (18%) of cases were absent at entry and back at work at discharge. Work days lost while in WHSS was associated with age, length of absence prior to entering WHSS, primary health condition and time in programme. All health measures showed significant improvements from entry to discharge. Improvement in general health was sustained at 3- and 6-month follow-up.

Conclusions

The WHSS evaluation findings indicate that participation was associated with positive changes to health and return-to-work. The extent of the positive change in health measures and work ability can be highly important economically for employees and employers.

Integration of novel hybrid composite discharge electrode with semi-pilot novel cross-flow electrostatic precipitator

Wet electrostatic precipitators (WESPs) are modern-era pollution control systems specifically designed to capture ultrafine particles as well as acid mist, highly resistive and sticky particles; however, this requires the use of expensive corrosion-resistant metal alloys. The work presented here is part of a continuing study at Ohio University aimed at reducing the cost of WESPs by using a novel combination of a polymer collector surfaces with a hybrid composite discharge electrode. In this study, a hybrid composite discharge electrode was tested, for the first time, inside a semi-pilot-scale experimental setup, with collection surfaces consists of a vertical array of strands. Particle laden gases were passed through this array of polymer ropes, which were kept wet by a small flow of water. The discharge electrodes were composite laminates of carbon fibers in a polymer matrix enclosing a metal mesh. The preliminary results showed that this new integrated system of composite discharge electrode and polymer collector surfaces can match or exceed the performance of a conventional metal alloy electrostatic precipitator (ESP) with metal discharge electrodes. There are additional advantages due to the system being compact, lightweight, and highly corrosion resistant. Implications: This study focused on integrating and assessing performance of a novel hybrid composite electrode (HCE) inside semi-pilot novel cross-flow electrostatic precipitator at conditions typically observed in coal-fired power plant exhausts. The results were collected for particulate collection efficiencies and were compared with a rigid metal electrode. The HCE outperformed metal electrode by showing higher particulate collection efficiency. This result showcases substantial potential for these two new technologies (HCE and cross-flow system) as a substitute for conventional metal based wet ESPs.

Face mask sampling reveals antimicrobial resistance genes in exhaled aerosols from patients with chronic obstructive pulmonary disease and healthy volunteers

Introduction

The degree to which bacteria in the human respiratory tract are aerosolised by individuals is not established. Building on our experience sampling bacteria exhaled by individuals with pulmonary tuberculosis using face masks, we hypothesised that patients with conditions frequently treated with antimicrobials, such as chronic obstructive pulmonary disease (COPD), might exhale significant numbers of bacteria carrying antimicrobial resistance (AMR) genes and that this may constitute a previously undefined risk for the transmission of AMR.

Methods

Fifteen-minute mask samples were taken from 13 patients with COPD (five paired with contemporaneous sputum samples) and 10 healthy controls. DNA was extracted from cell pellets derived from gelatine filters mounted within the mask. Quantitative PCR analyses directed to the AMR encoding genes: blaTEM (β-lactamase), ErmB (target methylation), mefA (macrolide efflux pump) and tetM (tetracycline ribosomal protection protein) and six additional targets were investigated. Positive signals above control samples were obtained for all the listed genes; however, background signals from the gelatine precluded analysis of the additional targets.

Results

9 patients with COPD (69%), aerosolised cells containing, in order of prevalence, mefA, tetM, ErmB and blaTEM, while three healthy controls (30%) gave weak positive signals including all targets except blaTEM. Maximum estimated copy numbers of AMR genes aerosolised per minute were mefA: 3010, tetM: 486, ErmB: 92 and blaTEM: 24. The profile of positive signals found in sputum was not concordant with that in aerosol in multiple instances.

Discussion

We identified aerosolised AMR genes in patients repeatedly exposed to antimicrobials and in healthy volunteers at lower frequencies and levels. The discrepancies between paired samples add weight to the view that sputum content does not define aerosol content. Mask sampling is a simple approach yielding samples from all subjects and information distinct from sputum analysis. Our results raise the possibility that patient-generated aerosols may be a significant means of AMR dissemination that should be assessed further and that consideration be given to related control measures.

Human Alzheimer's disease gene expression signatures and immune profile in APP mouse models: a discrete transcriptomic view of Aβ plaque pathology

Background

Alzheimer’s disease (AD) is a chronic neurodegenerative disease with pathological hallmarks including the formation of extracellular aggregates of amyloid-beta (Aβ) known as plaques and intracellular tau tangles. Coincident with the formation of Aβ plaques is recruitment and activation of glial cells to the plaque forming a plaque niche. In addition to histological data showing the formation of the niche, AD genetic studies have added to the growing appreciation of how dysfunctional glia pathways drive neuropathology, with emphasis on microglia pathways. Genomic approaches enable comparisons of human disease profiles between different mouse models informing on their utility to evaluate secondary changes to triggers such as Aβ deposition.

Methods

In this study, we utilized two animal models of AD to examine and characterize the AD-associated pathology: the Tg2576 Swedish APP (KM670/671NL) and TgCRND8 Swedish plus Indiana APP (KM670/671NL + V717F) lines. We used laser capture microscopy (LCM) to isolate samples surrounding Thio-S positive plaques from distal non-plaque tissue. These samples were then analyzed using RNA sequencing.

Results

We determined age-associated transcriptomic differences between two similar yet distinct APP transgenic mouse models, known to differ in proportional amyloidogenic species and plaque deposition rates. In Tg2576, human AD gene signatures were not observed despite profiling mice out to 15 months of age. TgCRND8 mice however showed progressive and robust induction of lysomal, neuroimmune, and ITIM/ITAM-associated gene signatures overlapping with prior human AD brain transcriptomic studies. Notably, RNAseq analyses highlighted the vast majority of transcriptional changes observed in aging TgCRND8 cortical brain homogenates were in fact specifically enriched within the plaque niche samples. Data uncovered plaque-associated enrichment of microglia-related genes such as ITIM/ITAM-associated genes and pathway markers of phagocytosis.

Conclusion

This work may help guide improved translational value of APP mouse models of AD, particularly for strategies aimed at targeting neuroimmune and neurodegenerative pathways, by demonstrating that TgCRND8 more closely recapitulates specific human AD-associated transcriptional responses.

Electronic supplementary material

The online version of this article (10.1186/s12974-018-1265-7) contains supplementary material, which is available to authorized users.

Failing to meet the needs of generations of care home residents with diabetes: a review of the literature and a call for action

In residential care homes and aged-care facilities globally, between one in three and one in four residents may have diabetes, an often complex highly co-morbid illness that leads to frailty, dependency, disability and reduced life expectancy. Residents with diabetes also have a high risk of hypoglycaemia, avoidable hospital admissions, and represent one of the most difficult challenges to health professionals and care staff in optimizing their diabetes and medical care. This detailed review examines the literature relating to care home diabetes over the last 25 years to assess what has been achieved in characterizing residents with diabetes, and what we know about the various but limited intervention studies that have been carried out internationally. The guidance and guidelines that have been published to assist clinicians in planning effective and safe care for this rather vulnerable group of people with diabetes are also reviewed. The review presents the first diagrammatic representation of a likely physiological cascade depicting the mainly irreversible functional decline a resident with diabetes might experience, provides modern principles of care for each resident with diabetes, and identifies what priority recommendations are required to be implemented if diabetes care is to improve. The review concludes that action is required since diabetes care still remains fragmented, sub-optimal, and in need of investment, otherwise care home residents with diabetes will continue to have their needs unfulfilled.

Clinicopathological features of squamous cell carcinoma of the oral cavity and oropharynx in young patients

Our aim was to examine the clinicopathological features of squamous cell carcinoma (SCC) of the oral cavity and oropharynx in a group of young patients who were dignosed during a 15-year period (2000-2014). Patients' clinical details, risk factors, and survival were obtained from medical records. Formalin-fixed, paraffin-embedded, tissue was tested for high-risk human papillomavirus (HPV). The results were compared with those of a matching group of older patients. We identified 91 patients who were younger than 45 years old, and the 50 youngest patients were studied in detail. The male:female ratio was 2:1, with more tumours located in the oral cavity than in the oropharynx (35 compared with 15). HPV-related SCC was restricted to the oropharynx. When matched for site, stage and HPV status, five-year overall survival was similar in young and matched older patients (log-rank test, p=0.515). Our findings suggest that young patients with oral SCC have a disease profile similar to that of older patients with the condition. It is plausible that prognostic information generally available for oral cancers is applicable to young patients with the disease.

Intravenous fosfomycin for pulmonary exacerbation of cystic fibrosis: Real life experience of a large adult CF centre

BACKGROUND

The increased prevalence of multi-drug resistant strains of P.aeruginosa and allergic reactions among adult patients with cystic fibrosis (CF) limits the number of antibiotics available to treat pulmonary exacerbations. Fosfomycin, a unique broad spectrum bactericidal antibiotic, might offer an alternative therapeutic option in such cases.

AIM

To describe the clinical efficacy, safety and tolerability of intravenous fosfomycin in combination with a second anti-pseudomonal antibiotic to treat pulmonary exacerbations in adult patients with CF.

METHOD

A retrospective analysis of data captured prospectively, over a 2-years period, on the Unit electronic medical records for patients who received IV fosfomycin was performed. Baseline characteristics in the 12 months prior treatment, lung function, CRP, renal and liver function and electrolytes at start and end of treatment were retrieved.

RESULTS

54 patients received 128 courses of IV fosfomycin in combination with a second antibiotic, resulting in improved FEV1 (0.94 L vs 1.24 L, p < 0.01) and reduced CRP (65 mg/L vs 19.3 mg/L, p < 0.01). Renal function pre- and post-treatment remained stable. 4% (n = 5) of courses were complicated with AKI at mid treatment, which resolved at the end of the course. Electrolyte supplementation was required in 18% of cases for potassium and magnesium and 7% for phosphate. Nausea was the most common side effect (48%), but was well controlled with anti-emetics.

CONCLUSION

Antibiotic regimens including fosfomycin appear to be clinically effective and safe. Fosfomycin should, therefore, be considered as an add-on therapy in patients who failed to respond to initial treatment and with multiple drug allergies.