656 Making an Effective Ward Round Model in the Department of Trauma and Orthopaedic Surgery for University Hospitals of Birmingham Trust

Background

Ward rounds in hospitals are crucial for decision-making in the context of patient treatment processes.

Objectives

Improve the standard of ward rounds with a review of care and planning.

Method

6 key elements were established using the Modern ward rounds report by the Royal College of Physicians and Nursing. This includes daily ward rounds which will be multidisciplinary, documented clearly and handed over to relevant staff; consisting of a board, bedside ward round and debrief; using Prompts in the form of REMIND mnemonic : R = Respect form, E = Electronic Prescribing, M = Mental Capacity, mobility status, I = Investigations, N = Nutrition and Hydration, NBM status, D=DVT assessment and Thromboprophylaxis; with practices being audited.

Results

After running a successful pilot in Respiratory in August 2021 the quality improvement project (QIP) was introduced in Trauma and Orthopaedic surgery.

88 patients were included in the initial audit prior to implementation and 91 in the re-audit. There was a 85% improvement seen in completion of respect and dementia forms with a 90% improvement in electronic prescribing. There was an 75% improvement in documentation of mobility status, investigations performed and NBM status. Fluid prescription, DVT assessment and LMWH prescription also improved by 85%.

Conclusions

A successful Pilot in Respiratory and Trauma and Orthopaedic Surgery shows the feasibility of the QIP in other departments. However, Education should also include Consultant and nurses. We are overcoming this but establishing a virtual module that can be made mandatory for induction of junior doctors, consultants, and nurses.

354 Virtual Consultation in Vascular Practice: The New Normal

Aim

Face to face vascular clinics were suspended at a major trauma centre at the beginning of the COVID-19 pandemic, however Royal Stoke Hospital Vascular team were still undertaking emergency vascular operations. Consequently, virtual telephone consultations were set up and delivered to facilitate post-operative follow ups. The objective of this improvement study is to compare the virtual clinic documentation against The Royal College of Surgeons of England (RCS Eng) Best Practice Guidance on Conducting Virtual Consultations, which was published in June 2020. This is important as good documentation is vital to patient care as well as being a medico-legal document.

Method

We retrospectively identified 30 vascular patients operated between May 2021 and June 2021; 10 of which had had a virtual telephone clinic and the majority underwent an amputation. We audited the clinic note documentation against the RCS Eng guidelines.

Results

Total of 9 RCS Eng guidelines were identified and audited. The first cycle revealed poor areas in documentation of the surgeon introducing themselves, confirmation of patient details, obtaining consent to proceed, summary of consult and plan discussed.

Findings were presented at the trust governance meeting. Areas which required improvement in documentation were highlighted. In addition to education of surgeons, it was decided to introduce a checklist as a requirement.

Conclusions

Clinic note documentation is of paramount importance as it has legal and medical ramifications. The education of surgeons and introduction of a checklist to ensure compliance with RCS Eng guidelines and we will re-audit to ensure improvement.

Brain function and clinical characterization in the Boston adolescent neuroimaging of depression and anxiety study

We present a Human Connectome Project study tailored toward adolescent anxiety and depression. This study is one of the first studies of the Connectomes Related to Human Diseases initiative and is collecting structural, functional, and diffusion-weighted brain imaging data from up to 225 adolescents (ages 14-17 years), 150 of whom are expected to have a current diagnosis of an anxiety and/or depressive disorder. Comprehensive clinical and neuropsychological evaluations and longitudinal clinical data are also being collected. This article provides an overview of task functional magnetic resonance imaging (fMRI) protocols and preliminary findings (N = 140), as well as clinical and neuropsychological characterization of adolescents. Data collection is ongoing for an additional 85 adolescents, most of whom are expected to have a diagnosis of an anxiety and/or depressive disorder. Data from the first 140 adolescents are projected for public release through the National Institutes of Health Data Archive (NDA) with the timing of this manuscript. All other data will be made publicly-available through the NDA at regularly scheduled intervals. This article is intended to serve as an introduction to this project as well as a reference for those seeking to clinical, neurocognitive, and task fMRI data from this public resource.

Alternative migratory locust phenotypes are associated with differences in the expression of genes encoding the methylation machinery

Despite the importance of locust density-dependent polyphenism as a model system for understanding phenotypic plasticity, there is still much to be learnt about its underlying molecular control. Here we describe the first investigation into the expression of genes encoding the DNA methylation machinery in the migratory locust (Locusta migratoria). We show that the alternative solitarious and gregarious phenotypic states induced by different locust rearing densities are associated with significant differences in the expression of the target genes DNA methyltransferase 1, DNA methyltransferase 2 and methyl-CpG-binding domain protein 2/3. This variation was most pronounced in the embryos of solitarious vs. gregarious mothers. We mapped the embryonic methylation profiles of several intragenic regions and a Long Interspersed Nuclear Element (LINE), each of which is known to be differentially expressed between alternative locust phenotypes or has been directly implicated in phase change. LmI and three genes, adenyl cyclase-associated binding protein 2, choline kinase alpha-like and henna, were methylated. Our results set the stage for future studies investigating the specific role of DNA methylation in the maternal transfer of migratory locust phase polyphenism.

Taxonomic status of the intracellular bacterium Wolbachia pipientis

Wolbachia pipientis is a maternally inherited, intracellular bacterium found in more than 20 % of all insects, as well as numerous other arthropods and filarial nematodes. It has been the subject of a growing number of studies in recent decades, because of the remarkable effects it has on its arthropod hosts, its potential as a tool for biological control of arthropods of agricultural and medical importance and its use as a target for treatment of filariasis. W. pipientis was originally discovered in cells of the mosquito Culex pipiens and is the only formally described member of the genus. Molecular sequence-based studies have revealed a number of phylogenetically diverse strains of W. pipientis. Owing to uncertainty about whether W. pipientis comprises more than one species, researchers in the field now commonly refer to W. pipientis simply as Wolbachia. In this note, we briefly review higher-level phylogenetic and recombination studies of W. pipientis and propose that all the intracellular symbionts known to cluster closely with the type strain of W. pipientis, including those in the currently recognized supergroups (A–H), are officially given this name.

Phylogeny of Australian Coptotermes (Isoptera: Rhinotermitidae) species inferred from mitochondrial COII sequences

Six Australian species of Coptotermes are traditionally recognized, but recent cuticular hydrocarbon studies suggest that some of these may represent more than one species. An understanding of the phylogenetic diversity of Australian Coptotermes, particularly the pest species, is likely to be important for the improvement of termite management strategies. A study of phylogenetic relationships among species of this genus was performed, based on the mitochondrial cytochrome oxidase (COII) gene, comparing the data with recent data from Asian species. Representatives of the species C. lacteus (Froggatt), C. frenchi Hill and C. michaelseni Silvestri were each found to form closely related monophyletic groups, however representatives of C. acinaciformis (Froggatt) were not. For C. acinaciformis, representatives from northern mound-building populations were found to form a distinct group to southern, tree-nesting forms. Among southern C. acinaciformis, two Western Australian representatives were found to be divergent from other populations. The results suggest that C. acinaciformis probably represents a complex of species rather than one, as has been suggested previously. One unidentified Coptotermes sp. taxon from Melbourne was found to be divergent from other taxa. Notably, some Australian species were more closely related to Asian species than other Australian species.

Widespread distribution and high prevalence of an alpha-proteobacterial symbiont in the tick Ixodes ricinus

The tick Ixodes ricinus is responsible for the transmission of a number of bacterial, protozoan and viral diseases to humans and animals in Europe and Northern Africa. Female I. ricinus from England, Switzerland and Italy have been found to harbour an intracellular alpha-proteobacterium, designated IricES1, within the cells of the ovary. IricES1 is the only prokaryote known to exist within the mitochondria of any animal or multicellular organism. To further examine the distribution, prevalence and mode of transmission of IricES1, we performed polymerase chain reaction screening of I. ricinus adults from 12 countries across its geographic distribution, including tick colonies that have been maintained in the laboratory for varying periods of time. IricES1 was detected in 100% of field-collected female ticks from all countries examined (n = 128), while 44% of males were found to be infected (n = 108). Those males that are infected appear to harbour fewer bacteria than females. Sequencing of fragments of the 16S rRNA and gyrB genes revealed very low nucleotide diversity among various populations of IricES1. Transmission of IricES1 from engorged adult females to eggs was found to be 100% (n = 31). In tick colonies that had been maintained in the laboratory for several years, a relatively low prevalence was found in females (32%; n = 25). To our knowledge, IricES1 is the most widespread and highly prevalent of any tick-associated symbiont.

Phylogeny of Wolbachia pipientis based on gltA, groEL and ftsZ gene sequences: clustering of arthropod and nematode symbionts in the F supergroup, and evidence for further diversity in the Wolbachia tree

Current phylogenies of the intracellular bacteria belonging to the genus Wolbachia identify six major clades (A–F), termed ‘supergroups’, but the branching order of these supergroups remains unresolved. Supergroups A, B and E include most of the wolbachiae found thus far in arthropods, while supergroups C and D include most of those found in filarial nematodes. Members of supergroup F have been found in arthropods (i.e. termites), and have previously been detected in the nematode Mansonella ozzardi, a causative agent of human filariasis. To resolve the phylogenetic positions of Wolbachia from Mansonella spp., and other novel strains from the flea Ctenocephalides felis and the filarial nematode Dipetalonema gracile, the authors generated new DNA sequences of the Wolbachia genes encoding citrate synthase (gltA), heat-shock protein 60 (groEL), and the cell division protein ftsZ. Phylogenetic analysis confirmed the designation of Wolbachia from Mansonella spp. as a member of the F supergroup. In addition, it was found that divergent lineages from Dip. gracile and Cte. felis lack any clear affiliation with known supergroups, indicating further genetic diversity within the Wolbachia genus. Finally, although the data generated did not permit clear resolution of the root of the global Wolbachia tree, the results suggest that the transfer of Wolbachia spp. from arthropods to nematodes (or vice versa) probably occurred more than once.

A symbiont of the tick Ixodes ricinus invades and consumes mitochondria in a mode similar to that of the parasitic bacterium Bdellovibrio bacteriovorus

We have recently performed molecular characterisation of an intracellular alpha-proteobacterium, named IricES1, which resides in the ovarian tissue of female Ixodes ricinus ticks from Italy. A unique characteristic of this bacterium is its ability to invade the mitochondria of the cells in which it resides. Although some ultrastructural studies have been performed on close relatives of this bacterium from I. ricinus in England and Switzerland, a number of questions remain about its movement within ovarian tissues and mitochondria. We have performed the first detailed ultrastructural examination of IricES1 in engorged female adult I. ricinus. Among our findings was that the bacterium enters mitochondria in a similar way to that employed by the 'predatory' bacterium Bdellovibro bacteriovorus, that is, between the inner and outer membranes. It then appears to multiply, with the new 'colony' consuming the mitochondrial matrix. Despite having many of their mitochondria consumed, oocytes appear to develop normally, and the bacteria are likely to be vertically transferred to all eggs.

[Emerging rickettsioses]

Ticks are known to carry and transmit a number of microbial agents that cause diseases in humans and animals. Among these are members of the order Rickettsiales (alpha-proteobacteria), which include the genera Rickettsia and Ehrlichia. The most common and well-known Rickettsial human disease in Europe is Mediterranean Spotted Fever (MSF), caused by Rickettsia conorii. In recent years, a number of new Rickettsia species have been discovered in Europe, some of which have been shown to be pathogenic to humans. These discoveries have been facilitated by use of sequence-based molecular identification techniques. In Italy, it is generally believed that R. conorii is the only Rickettsia species present, and clinical tests for MSF rely on antigens raised against this bacterium. We are currently undertaking a molecular screening study of Rickettsiales-bacteria in ticks from various regions of Italy, to check for the potential presence of species from this order recently discovered in other parts of Europe. So far, we have identified a number of additional species in ticks collected from northern, central and southern regions. These include the known pathogens R. helvetica and R. slovaca as well as two species which may or may not be of medical relevance: R. monacensis and R. sp. IRS4. As a part of this survey, we have identified a novel alphaproteobacterium from the medically important tick Ixodes ricinus. This bacterium, tentatively named IricES1, has the unusual property of existing within the mitochondria, as well as the cytoplasm, of ovarian cells. To our knowledge, this is the only known example of a bacterium that is able to enter the mitochondria of animals. Our recently published electron microscopic data indicates that the bacterium enters mitochondria between the inner and outer membranes, and then proceeds to consume the inner mitochondrial matrix. We will present further data on this bacterium, including: 1) its phylogenetic position based on various molecular sequences, 2) its localization within the tick based on in situ hybridization; 3) its distribution among tick populations in Europe; 4) preliminary data on attempts at culturing this bacterium in a variety of cell types. Possible interactions between the bacterium and its host will be discussed. Ticks are known to carry and transmit a number of microbial agents that cause diseases in humans and animals. Among these are members of the order Rickettsiales (alpha-proteobacteria), which include the genera Rickettsia and Ehrlichia. The most common and well-known Rickettsial human disease in Europe is Mediterranean Spotted Fever (MSF), caused by Rickettsia conorii. In recent years, a number of new Rickettsia species have been discovered in Europe, some of which have been shown to be pathogenic to humans. These discoveries have been facilitated by use of sequence-based molecular identification techniques. In Italy, it is generally believed that R. conorii is the only Rickettsia species present, and clinical tests for MSF rely on antigens raised against this bacterium. We are currently undertaking a molecular screening study of Rickettsiales-bacteria in ticks from various regions of Italy, to check for the potential presence of species from this order recently discovered in other parts of Europe. So far, we have identified a number of additional species in ticks collected from northern, central and southern regions. These include the known pathogens R. helvetica and R. slovaca as well as two species which may or may not be of medical relevance: R. monacensis and R. sp. IRS4. As a part of this survey, we have identified a novel alphaproteobacterium from the medically important tick Ixodes ricinus. This bacterium, tentatively named IricES1, has the unusual property of existing within the mitochondria, as well as the cytoplasm, of ovarian cells. To our knowledge, this is the only known example of a bacterium that is able to enter the mitochondria of animals. Our recently published electron microscopic data indicates that the bacterium enters mitochondria between the inner and outer membranes, and then proceeds to consume the inner mitochondrial matrix. We will present further data on this bacterium, including: 1) its phylogenetic position based on various molecular sequences, 2) its localization within the tick based on in situ hybridization; 3) its distribution among tick populations in Europe; 4) preliminary data on attempts at culturing this bacterium in a variety of cell types. Possible interactions between the bacterium and its host will be discussed.

[Epidemiology, prognosis and prevention of choriocarcinoma in University Hospital of Dakar]

The objective of this study was to define epidemiological profile of choriocarcinoma in Senegal, to evaluate its prognosis and to submit a better strategy of prevention. It's a retrospective cases-control study; all choriocarcinoma diagnosed from January 1st to December 31st 2000 at Dakar University Teaching Hospital. The control were chosen among patients who had molar abortion during the same time than the cases and did not developed the pathology after at least 12 months of medical follow up. The stability of association is checked by calculating 95 confidence interval by Miettinen method, and using Chi 2 test of Pearson with a p value of 5% or Fischer test; the prognosis survival factors was compared using logrank test. Among 1098 patients with medical care follow up of post molar abortion, 61 choriocarcinoma were diagnosed with an incidence of 5.5%. The epidemiological profile is a great multipare 40 years old or more with low socio-economical status, 51% of diagnosed cases was in metastasis stage. The prognosis was marked by a complete remission in 37.7% and by global lethality in 49.2%; the average survival was about 48 months. The risk factors of choriocarcinoma among patients who had a molar abortion are represented by an age superior or equal 40 years old, high multipare and preservation of the uterus after molar abortion. To improve the prognosis we recommend to widen preventive hysterectomy indications after molar abortion among patients with risk factors of choriocarcinoma.

On the origin of termite workers: weighing up the phylogenetic evidence

Resolving the phylogenetic history of a 'true' worker caste in termites is essential to our understanding of termite eusocial evolution. Whether this caste is ancient and monophyletic or derived and polyphyletic will have a tremendous impact on our interpretation of termite eusocial history and remains an outstanding question in termite biology. Recent work has begun to re-examine this question in light of new phylogenetic information, but new questions have now arisen about how best to model character state changes in termite caste systems. In the present paper, we compare the models of Grandcolas and D'Haese [J. Evol. Biol. 15 (2002) 885] and Thompson et al. [J. Evol Biol. 13 (2000) 8691 and attempt to make explicit how these proposals differ with respect to the number of, and homology between, character states. We highlight the support each model has for the two principal, but competing, evolutionary hypotheses outlined above.

[Choriocarcinoma in Senegal: epidemiology, prognosis and prevention]

OBJECTIVE

The objective of this study was to define the epidemiological profile of choriocarcinoma in Senegal, to evaluate its prognosis and to submit a better way of prevention of this pathology in an area with poor medical care.

MATERIAL AND METHOD

It was a retrospective case-control study of all choriocarcinomas diagnosed from January 1st to December 31st 2000 at Dakar university teaching hospital. The witnesses were chosen among patients who had had molar abortion at the same time as the cases at study and had not developed the pathology after at least 12 months of aftercare. The stability of association was checked by calculating the confidence interval in 95% by Miettinen method and using Chi 2 test of Pearson with a risk factor alpha under 5% or Fischer test; the prognosis survival factors were compared by using logrank test.

RESULTS

Among the 1098 patients in follow-up treatment after molar abortion, 61 choriocarcinomas were diagnosed with an incidence of 5.5%. The epidemiological profile was a great multiparous (40 years old or more) with low socio-economical level, 51% of the diagnosed cases are made in the metastasis stage. The prognosis was marked by a complete remission in 37.7% and by global lethality in 49.2%; the average survival was about 48 months.

DISCUSSION AND CONCLUSION

The risk factors of choriocarcinoma among patients who had a molar abortion were represented by an age superior or equal to 40 years old, high multiparity and preservation of the uterus after molar abortion. To improve the prognosis in a country with low medical care, we recommend to widen preventive hysterectomy indications after molar abortion among patients with risk factors of choriocarcinoma.

Evidence from multiple gene sequences indicates that termites evolved from wood-feeding cockroaches

Despite more than half a century of research, the evolutionary origin of termites remains unresolved [1] [2] [3]. A clear picture of termite ancestry is crucial for understanding how these insects evolved eusociality, particularly because they lack the haplodiploid genetic system associated with eusocial evolution in bees, ants, wasps and thrips [4] [5]. Termites, together with cockroaches and praying mantids, constitute the order Dictyoptera, which has been the focus of numerous conflicting phylogenetic studies in recent decades [6] [7] [8] [9] [10] [11] [12]. With the aim of settling the debate over the sister-group of termites, we have determined the sequences of genes encoding 18S ribosomal RNA, mitochondrial cytochrome oxidase subunit II (COII) and endogenous endo-beta-1, 4-glucanase (EG) from a diverse range of dictyopterans. Maximum parsimony and likelihood analyses of these sequences revealed strong support for a clade consisting of termites and subsocial, wood-feeding cockroaches of the genus Cryptocercus. This clade is nested within a larger cockroach clade, implicating wood-feeding cockroaches as an evolutionary intermediate between primitive non-social taxa and eusocial termites.

Molecular phylogeny and geographic distribution of wood-feeding cockroaches in East Asian Islands

Molecular phylogenetic relationships of the wood-feeding cockroach genera Salganea and Panesthia (Blaberidae; Panesthiinae) in East Asian Islands (Ryukyu archipelago and Taiwan Island) were analyzed based on the DNA sequence of the complete mitochondrial cytochrome oxidase II gene. Unweighted parsimony analysis resulted in high bootstrap support for relationships within Panesthia taxa; however, some nodes were unresolved between members of Salganea. Comparison of the number of transitions and transversions with genetic distance at each codon position suggested that saturation of third-codon substitutions has occurred between certain pairs of taxa. Consequently, differential weighting of substitutions at these sites was performed, which resulted in a substantial increase in resolution of Salganea relationships. The inferred phylogenies for both genera displayed good correspondence to the geographical locations of populations but however did not agree with previous subspecies designations based on morphological characters. It appears that both cockroach genera invaded the Ryukyu archipelago from the Taiwan region via a land-bridge present in the Miocene period. Invasion of the main islands of Japan by these cockroaches most likely occurred before the formation of the Tokara Tectonic Strait. Our study suggests that several barriers to gene flow have arisen and persisted over the past approximately 10 million years, which have caused segregation and vicariant speciation of the cockroach taxa of this region.

Metazoan cellulase genes from termites: intron/exon structures and sites of expression

Endogenous endo-beta-1,4-glucanase (EGase, EC 3.2.1.4) cDNAs were cloned from representatives of the termite families Termitidae and Rhinotermitidae. These EGases are all composed of 448 amino acids and belong to glycosyl hydrolase family 9 (GHF9), sharing high levels of identity (40-52%) with selected bacterial, mycetozoan and plant EGases. Like most plant EGases, they consist of a single catalytic domain, lacking the ancillary domains found in most microbial cellulases. Using a PCR-based strategy, the entire sequence of the coding region of NtEG, a gene putatively encoding an EGase from Nasutitermes takasagoensis (Termitidae), was determined. NtEG consists of 10 exons interrupted by 9 introns and contains typical eukaryotic promoter elements. Genomic fragments of EGase genes from Reticulitermes speratus (Rhinotermitidae) were also sequenced. In situ hybridization of N. takasagoensis guts with an antisense NtEG RNA probe demonstrated that expression occurs in the midgut, which contrasts to EGase expression being detected only in the salivary glands of R. speratus. NtEG, when expressed in Escherichia coli, was shown to have in vitro activity against carboxymethylcellulose.

On the respiratory quotient (RQ) of termites (Insecta: Isoptera)

The respiratory quotient (RQ) at 28 degrees C was determined by Warburg manometry in 23 species of termites from the Mbalmayo Forest Reserve (Cameroon) and three sub-tropical species cultured under laboratory conditions in the U.K. or freshly collected in Australia. The data are tabulated with other recently reported RQs (determined by manometry or GC) and with measured CH(4) emission rates to provide a survey of 29 species covering both lower and higher termites in all major trophic (functional) categories. In all species, except the wood-feeding Coptotermes acinaciformis and the soil-feeding Cubitermes fungifaber, the observed mean values (with manometry corrected for known fluxes of H(2) and CH(4)) were at or well above 1.00. Soil-feeding forms (except C. fungifaber) generally showed a high apparent RQ (not corrected for H(2)), with nine species (out of 13) above 1.20 and six species above 1.30. Well-replicated laboratory experiments with Reticulitermes lucifugus showed that there was a tendency for RQ to fall with time over a 4-h incubation, although remaining greater than 1.00.The observed RQs are consistent with carbohydrate being the principal substrate supporting respiration in all trophic and taxonomic categories, with little or no contribution from the degradation of lignin or other polyaromatic materials. However, in many species (especially soil-feeders), the observed RQ is greater than that expected from known fluxes of O(2), CO(2) and CH(4) on the assumption that carbohydrate is the respiratory substrate. This presupposes that there is a large hydrogen sink (additional to CH(4) production), possibly the emission of H(2) gas, and/or the existence of unresolved digestive mechanisms or electron routings. Uncertainties in the use of manometry with termites are discussed.