Search for exotic decays of the Higgs boson to a pair of pseudoscalars in the μμbb and ττbb final states

A search for exotic decays of the Higgs boson (H ) with a mass of 125Ge V to a pair of light pseudoscalars a 1 is performed in final states where one pseudoscalar decays to two b quarks and the other to a pair of muons or τ leptons. A data sample of proton-proton collisions at s = 13 Te V corresponding to an integrated luminosity of 138fb - 1 recorded with the CMS detector is analyzed. No statistically significant excess is observed over the standard model backgrounds. Upper limits are set at 95% confidence level (CL ) on the Higgs boson branching fraction to μ μ b b and to τ τ b b , via a pair of a 1 s. The limits depend on the pseudoscalar mass m a 1 and are observed to be in the range (0.17-3.3) × 10 - 4 and (1.7-7.7) × 10 - 2 in the μ μ b b and τ τ b b final states, respectively. In the framework of models with two Higgs doublets and a complex scalar singlet (2HDM+S), the results of the two final states are combined to determine upper limits on the branching fraction B ( H → a 1 a 1 → ℓ ℓ b b ) at 95% CL , with ℓ being a muon or a τ lepton. For different types of 2HDM+S, upper bounds on the branching fraction B ( H → a 1 a 1 ) are extracted from the combination of the two channels. In most of the Type II 2HDM+S parameter space, B ( H → a 1 a 1 ) values above 0.23 are excluded at 95% CL for m a 1 values between 15 and 60Ge V .

Laparoscopic cholecystectomy performed by a surgical care practitioner: a review of outcomes

INTRODUCTION

Surgical care practitioners (SCPs) are non-medical workers involved in various aspects of the management of surgical patients. The role includes assisting and performing surgical procedures. More than 60,000 laparoscopic cholecystectomies (LC) are performed annually in the UK. With ever-increasing pressure on waiting lists, it is important to look at fully utilising the skills of our entire workforce. We report what we believe is the first published series of LC performed by an SCP.

METHODS

A retrospective review of a prospectively collected database was performed. The primary outcome was any complication requiring intervention. Secondary outcomes were minor complications, operative time, length of stay, conversion and readmission.

RESULTS

In total, 170 patients were operated on. Indications were biliary colic in 127 (74.7%), cholecystitis in 30 (17.6%) and pancreatitis in 13 (7.6%). Mean operating time was 65min (range 35-152min). Fifty-three operations were assisted by a consultant, 110 by a specialist or associate specialist grade (SAS) doctor and 7 by a core trainee (CT2). Some 139 (81.7%) patients were discharged on the day of surgery and 24 (14.1%) stayed one night in hospital. There were no major complications. Five patients required readmission, three with pain and two with port site infections. There were no conversions or transfusions required.

CONCLUSIONS

There is a paucity of published data on surgical outcomes of procedures performed by SCPs. With a structured, supervised approach, SCPs could be trained to take on more complex procedures and further strengthen the surgical workforce. This study demonstrates that elective LC can be safely performed by an appropriately trained and supervised SCP.

Observation of WWγ Production and Search for Hγ Production in Proton-Proton Collisions at sqrt[s]=13 TeV

The observation of WWγ production in proton-proton collisions at a center-of-mass energy of 13 TeV with an integrated luminosity of 138  fb^{-1} is presented. The observed (expected) significance is 5.6 (5.1) standard deviations. Events are selected by requiring exactly two leptons (one electron and one muon) of opposite charge, moderate missing transverse momentum, and a photon. The measured fiducial cross section for WWγ is 5.9±0.8(stat)±0.8(syst)±0.7(modeling)  fb, in agreement with the next-to-leading order quantum chromodynamics prediction. The analysis is extended with a search for the associated production of the Higgs boson and a photon, which is generated by a coupling of the Higgs boson to light quarks. The result is used to constrain the Higgs boson couplings to light quarks.

New Structures in the J/ψJ/ψ Mass Spectrum in Proton-Proton Collisions at sqrt[s]=13 TeV

A search is reported for near-threshold structures in the J/ψJ/ψ invariant mass spectrum produced in proton-proton collisions at sqrt[s]=13  TeV from data collected by the CMS experiment, corresponding to an integrated luminosity of 135  fb^{-1}. Three structures are found, and a model with quantum interference among these structures provides a good description of the data. A new structure is observed with a local significance above 5 standard deviations at a mass of 6638_{-38}^{+43}(stat)_{-31}^{+16}(syst)  MeV. Another structure with even higher significance is found at a mass of 6847_{-28}^{+44}(stat)_{-20}^{+48}(syst)  MeV, which is consistent with the X(6900) resonance reported by the LHCb experiment and confirmed by the ATLAS experiment. Evidence for another new structure, with a local significance of 4.7 standard deviations, is found at a mass of 7134_{-25}^{+48}(stat)_{-15}^{+41}(syst)  MeV. Results are also reported for a model without interference, which does not fit the data as well and shows mass shifts up to 150 MeV relative to the model with interference.

Search for Scalar Leptoquarks Produced via τ-Lepton-Quark Scattering in pp Collisions at sqrt[s]=13 TeV

The first search for scalar leptoquarks produced in τ-lepton-quark collisions is presented. It is based on a set of proton-proton collision data recorded with the CMS detector at the LHC at a center-of-mass energy of 13 TeV corresponding to an integrated luminosity of 138  fb^{-1}. The reconstructed final state consists of a jet, significant missing transverse momentum, and a τ lepton reconstructed through its hadronic or leptonic decays. Limits are set on the product of the leptoquark production cross section and branching fraction and interpreted as exclusions in the plane of the leptoquark mass and the leptoquark-τ-quark coupling strength.

Search for Inelastic Dark Matter in Events with Two Displaced Muons and Missing Transverse Momentum in Proton-Proton Collisions at sqrt[s]=13 TeV

A search for dark matter in events with a displaced nonresonant muon pair and missing transverse momentum is presented. The analysis is performed using an integrated luminosity of 138  fb^{-1} of proton-proton (pp) collision data at a center-of-mass energy of 13 TeV produced by the LHC in 2016-2018. No significant excess over the predicted backgrounds is observed. Upper limits are set on the product of the inelastic dark matter production cross section σ(pp→A^{'}→χ_{1}χ_{2}) and the decay branching fraction B(χ_{2}→χ_{1}μ^{+}μ^{-}), where A^{'} is a dark photon and χ_{1} and χ_{2} are states in the dark sector with near mass degeneracy. This is the first dedicated collider search for inelastic dark matter.

Luminosity determination using Z boson production at the CMS experiment

The measurement of Z boson production is presented as a method to determine the integrated luminosity of CMS data sets. The analysis uses proton-proton collision data, recorded by the CMS experiment at the CERN LHC in 2017 at a center-of-mass energy of 13Te V . Events with Z bosons decaying into a pair of muons are selected. The total number of Z bosons produced in a fiducial volume is determined, together with the identification efficiencies and correlations from the same data set, in small intervals of 20pb - 1 of integrated luminosity, thus facilitating the efficiency and rate measurement as a function of time and instantaneous luminosity. Using the ratio of the efficiency-corrected numbers of Z bosons, the precisely measured integrated luminosity of one data set is used to determine the luminosity of another. For the first time, a full quantitative uncertainty analysis of the use of Z  bosons for the integrated luminosity measurement is performed. The uncertainty in the extrapolation between two data sets, recorded in 2017 at low and high instantaneous luminosity, is less than 0.5%. We show that the Z boson rate measurement constitutes a precise method, complementary to traditional methods, with the potential to improve the measurement of the integrated luminosity.

Probing Small Bjorken-x Nuclear Gluonic Structure via Coherent J/ψ Photoproduction in Ultraperipheral Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

Quasireal photons exchanged in relativistic heavy ion interactions are powerful probes of the gluonic structure of nuclei. The coherent J/ψ photoproduction cross section in ultraperipheral lead-lead collisions is measured as a function of photon-nucleus center-of-mass energies per nucleon (W_{γN}^{Pb}) over a wide range of 40 Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

Posterior stabilised total knee arthroplasty is associated with improved post-operative knee specific function, health related quality of life and greater satisfaction when compared to cruciate retaining protheses

PURPOSE

To assess whether there were differences in knee specific function, health related quality of life (HRQoL), and satisfaction between patients with a cruciate retaining (CR) or a posterior stabilised (PS) total knee arthroplasty (TKA) at 1 and 2 years postoperatively.

METHODS

A retrospective review of TKA (CR and PS) patients from a prospectively collected arthroplasty database. Patient demographics, body mass index and ASA grade, Oxford knee score (OKS) and EuroQol 5-dimension (EQ-5D) 3-level, which was used to assess HRQoL, were collected preoperatively and 1 year and 2 years postoperatively. Regression was used to adjust for confounding factors.

RESULTS

The sample included 3122 TKA, of which 1009 (32.3%) were CR and 2112 (67.7%) were PS. The PS group were more likely to be female (odd ratio (OR) 1.26, p = 0.003) and undergo resurfacing of the patella (OR 6.63, p < 0.001). There was a significantly greater improvement in the 1 year OKS in the PS group (mean difference (MD) 0.9, p = 0.016). The PS TKA was independently associated with a greater 1 year (MD 1.1, 95% CI 0.4 to 1.9, p = 0.001) and 2 years (MD 0.8, p = 0.037) post-operative improvements in OKS. PS TKA was also independently associated with a greater 1 year (MD 0.021, p = 0.024) and 2 years (MD 0.022, p = 0.025) post-operative and change in EQ-5D utility compared to the CR group. The PS group was more likely to be satisfied with their outcome at 1 year (OR 1.75, p < 0.001) and at 2 years (OR 1.38, p = 0.001) when adjusting for confounders.

CONCLUSION

PS TKA was associated with a better knee specific function and HRQoL when compared to CR, but the clinical significance of this is not clear. However, the PS group was more likely to be satisfied with their outcome compared to the CR group.

A search for decays of the Higgs boson to invisible particles in events with a top-antitop quark pair or a vector boson in proton-proton collisions at s=13TeV

A search for decays to invisible particles of Higgs bosons produced in association with a top-antitop quark pair or a vector boson, which both decay to a fully hadronic final state, has been performed using proton-proton collision data collected at s = 13 Te V by the CMS experiment at the LHC, corresponding to an integrated luminosity of 138fb - 1 . The 95% confidence level upper limit set on the branching fraction of the 125Ge V Higgs boson to invisible particles, B ( H → inv ) , is 0.54 (0.39 expected), assuming standard model production cross sections. The results of this analysis are combined with previous B ( H → inv ) searches carried out at s = 7 , 8, and 13Te V in complementary production modes. The combined upper limit at 95% confidence level on B ( H → inv ) is 0.15 (0.08 expected).

Emotional eating among adults with healthy weight, overweight and obesity: a systematic review and meta-analysis

BACKGROUND

Emotional eating (EE) is a disordered eating behaviour which may lead to overeating. It is not clear whether EE presents to an equal degree among adults, regardless of their body mass index (BMI) status. The aim of this study was to assess whether there is a difference in degree of EE between adults with healthy weight, overweight and obesity.

METHODS

MEDLINE and APA PsycINFO databases were searched from inception up to January 2022 for studies that reported EE scores from validated questionnaires. The quality of all included studies was assessed using the AXIS tool. Meta-analysis used random effects and standardised mean difference (SMD). Heterogeneity was investigated using I2 statistics and sensitivity analyses.

RESULTS

A total of 11 studies with 7207 participants were included in the meta-analysis. Degree of EE was greater in adults with a BMI above the healthy range, compared to adults with a healthy BMI (SMD 0.31, 95% CI 0.17 to 0.45; I2  = 85%). However, subgroup analysis found that degree of EE was greater only in adults with obesity (SMD 0.61, 95% CI 0.41 to 0.81; I2  = 62%), and there was no difference in degree of EE between adults with overweight and those with a healthy BMI.

CONCLUSIONS

Degree of EE is greater among adults living with obesity, compared to adults with a healthy BMI, indicating a need for behavioural support to support EE among people living with obesity seeking weight management. Future research should examine the long-term effectiveness of interventions for EE.

Measurement of the Dependence of the Hadron Production Fraction Ratios f_{s}/f_{u} and f_{d}/f_{u} on B Meson Kinematic Variables in Proton-Proton Collisions at sqrt[s]=13 TeV

The dependence of the ratio between the B_{s}^{0} and B^{+} hadron production fractions, f_{s}/f_{u}, on the transverse momentum (p_{T}) and rapidity of the B mesons is studied using the decay channels B_{s}^{0}→J/ψϕ and B^{+}→J/ψK^{+}. The analysis uses a data sample of proton-proton collisions at a center-of-mass energy of 13 TeV, collected by the CMS experiment in 2018 and corresponding to an integrated luminosity of 61.6  fb^{-1}. The f_{s}/f_{u} ratio is observed to depend on the B p_{T} and to be consistent with becoming asymptotically constant at large p_{T}. No rapidity dependence is observed. The ratio of the B^{0} to B^{+} meson production fractions, f_{d}/f_{u}, is also measured, for the first time in proton-proton collisions, using the B^{0}→J/ψK^{*0} decay channel. The result is found to be within 1 standard deviation of unity and independent of p_{T} and rapidity, as expected from isospin invariance.

Observation of the Rare Decay of the η Meson to Four Muons

A search for the rare η→μ^{+}μ^{-}μ^{+}μ^{-} double-Dalitz decay is performed using a sample of proton-proton collisions, collected by the CMS experiment at the CERN LHC with high-rate muon triggers during 2017 and 2018 and corresponding to an integrated luminosity of 101  fb^{-1}. A signal having a statistical significance well in excess of 5 standard deviations is observed. Using the η→μ^{+}μ^{-} decay as normalization, the branching fraction B(η→μ^{+}μ^{-}μ^{+}μ^{-})=[5.0±0.8(stat)±0.7(syst)±0.7(B_{2μ})]×10^{-9} is measured, where the last term is the uncertainty in the normalization channel branching fraction. This work achieves an improved precision of over 5 orders of magnitude compared to previous results, leading to the first measurement of this branching fraction, which is found to agree with theoretical predictions.

"Is it time to throw out the weighing scales?" Implicit weight bias among healthcare professionals working in bariatric surgery services and their attitude towards non-weight focused approaches

BACKGROUND

People living with overweight or obesity (PLwO) can be stigmatised by healthcare professionals (HCPs). Reducing focus on weight is a proposed strategy to provide less threatening healthcare experiences. Given the lack of research on weight bias within obesity services, this study aimed to explore implicit bias among obesity specialist HCPs and explore views on non-weight focused approaches.

METHODS

Obesity specialist HCPs were invited to a webinar, "An exploration of non-weight focused approaches within bariatric services", held in October 2021. Implicit weight bias was examined using the BiasProof mobile device test, based on the Implicit Association Test. Poll data was analysed descriptively, and qualitative data was analysed using framework analysis.

FINDINGS

82 of the 113 HCPs who attended the webinar consented to contribute data to the study. Over half (51%) had an implicit weight bias against PLwO. Most (90%) agreed/strongly agreed that obesity services are too weight focused and that patients should not be weighed at every appointment (86%). Perceived benefits of taking a non-weight focused approach included patient-led care, reducing stigma and supporting patient wellbeing, while perceived barriers included loss of objectivity, inducing risk and difficulty demonstrating effectiveness.

INTERPRETATION

Our findings indicate that half of obesity specialists HCPs in our sample of 82 providers, who are primarily dieticians and psychologists, have an implicit weight bias against PLwO. HCPs feel that a weight-focused approach within services was a barrier to patient care, but that there is a lack of alternative non-weight focused measures. Further research is needed into substitute outcome measures for clinical practice, also seeking the views of PLwO, and into interventions to address implicit weight bias.

FUNDING

Johnson & Johnson funded the BiasProof licence and publication open access charge.

A pre-registered short-term forecasting study of COVID-19 in Germany and Poland during the second wave

Disease modelling has had considerable policy impact during the ongoing COVID-19 pandemic, and it is increasingly acknowledged that combining multiple models can improve the reliability of outputs. Here we report insights from ten weeks of collaborative short-term forecasting of COVID-19 in Germany and Poland (12 October-19 December 2020). The study period covers the onset of the second wave in both countries, with tightening non-pharmaceutical interventions (NPIs) and subsequently a decay (Poland) or plateau and renewed increase (Germany) in reported cases. Thirteen independent teams provided probabilistic real-time forecasts of COVID-19 cases and deaths. These were reported for lead times of one to four weeks, with evaluation focused on one- and two-week horizons, which are less affected by changing NPIs. Heterogeneity between forecasts was considerable both in terms of point predictions and forecast spread. Ensemble forecasts showed good relative performance, in particular in terms of coverage, but did not clearly dominate single-model predictions. The study was preregistered and will be followed up in future phases of the pandemic.

Experiences and perceptions of dietitians for obesity management: a general practice qualitative study

BACKGROUND

Multi-component lifestyle interventions are the first line treatment for obesity. Dietitians are ideally placed healthcare professionals to deliver such interventions. However, only a small proportion of patients with obesity are referred by general practice to dietitians, and the reasons for this are not clear. The present study aimed to explore general practice healthcare professionals' (GPHCPs) experiences and perceptions of dietitians in the context of obesity management.

METHODS

A convenience sample of GPHCPs practicing in the UK was recruited via a targeted social media strategy, using virtual snowball sampling. Data were collected using semi-structured interviews and analysed using framework analysis.

RESULTS

In total, 20 participants were interviewed (11 general practice nurses and nine general practitioners). Experiences of referring patients with obesity for dietetic intervention resulted in two main themes: (i) access barriers and (ii) the dietetic consult experience. Three themes emerged from participants' perceptions of a role for general practice dietitians: (i) utilising dietetic expertise; (ii) access to dietitian; and (iii) time. Participants experienced barriers to accessing dietitians for obesity management and felt that having a dietitian working within their general practice team would help address this. Having a dietitian embedded within their general practice team was perceived to have the potential to alleviate GPHCPs' clinical time pressures, offer opportunities for upskilling, and may improve patient engagement with obesity management.

CONCLUSIONS

GPHCPs perceived that embedding a dietitian within their general practice team would be valuable and beneficial for obesity management. Our findings provide support for the funding of general practice dietitian roles in the UK.

Group versus one-to-one multi-component lifestyle interventions for weight management: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Multi-component lifestyle interventions that incorporate diet, physical activity and behaviour change are effective for weight management. However, it is not clear whether delivery in a group or one-to-one format influences weight loss efficacy. The present study aimed to systematically review the evidence of the effectiveness of group compared to one-to-one multi-component lifestyle interventions for weight management.

METHODS

MEDLINE, EMBASE, CINAHL, CENTRAL and ISRCTN databases were searched from inception up to February 2020 for randomised controlled trials comparing group versus one-to-one multi-component lifestyle interventions for weight loss in adults with a body mass index ≥ 25 kg m^-2 . The primary outcome was weight loss (kg) at 12 months and the secondary outcome was attainment of ≥5% weight loss at 12 months. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Meta-analysis used random effects and estimated risk ratios and continuous inverse variance methods. Heterogeneity was investigated using I² statistics and sensitivity analyses.

RESULTS

Seven randomised controlled trials with 2576 participants were included. Group interventions were favoured over one-to-one interventions for weight loss at 12 months (-1.9 kg, 95% confidence interval = -1.3 to -2.6; I²  = 99%). Participants of group interventions were more likely to attain ≥5% weight loss at 12 months relative to one-to-one interventions (relative risk = 1.58, 95% confidence interval = 1.25-2.00; I²  = 60%).

CONCLUSIONS

Group multi-component lifestyle interventions are superior for weight loss compared to one-to-one interventions with respect to adult weight management. Further research is required to determine whether specific components of group interventions can explain the superiority of weight loss outcomes in group interventions.

Xenopus pitx3 target genes lhx1 and xnr5 are identified using a novel three-fluor flow cytometry-based analysis of promoter activation and repression

BACKGROUND

Pitx3 plays a well understood role in directing development of lens, muscle fiber, and dopaminergic neurons; however, in Xenopus laevis, it may also play a role in early gastrulation and somitogenesis. Potential downstream targets of pitx3 possess multiple binding motifs that would not be readily accessible by conventional promoter analysis.

RESULTS

We isolated and characterized pitx3 target genes lhx1 and xnr5 using a novel three-fluor flow cytometry tool that was designed to dissect promoters with multiple binding sites for the same transcription factor. This approach was calibrated using a known pitx3 target gene, Tyrosine hydroxylase.

CONCLUSIONS

We demonstrate how flow cytometry can be used to detect gene regulatory changes with exquisite precision on a cell-by-cell basis, and establish that in HEK293 cells, pitx3 directly activates lhx1 and represses xnr5. Developmental Dynamics 246:657-669, 2017. © 2017 Wiley Periodicals, Inc.

Abstract P2-04-19: Elucidating the tumor immune microenvironment phenotype in early stage untreated BRCA mutated breast cancer patients

Background: Increased stromal tumor infiltrating lymphocytes (TILs) are predictive and prognostic for improved outcomes from neoadjuvant or adjuvant chemotherapy in triple negative breast cancer. Increased tumor mutational burden may promote neoantigens causing immune system upregulation. Microsatellite instability in gastrointestinal cancer predicts for response to checkpoint inhibition and is associated with inherited cancer predisposition. The immune system response in BRCA mutated breast cancer has not been described. The purpose of this study is to assess tumor infiltrating immune cells in early stage breast cancer patients with and without BRCA gene mutations.

Methods: We retrospectively investigated 124 early stage breast cancer patients with BRCA mutations (n=62, BRCA+) and without BRCA mutations (n=62, BRCA WT). The %TILs was measured manually by H&E. Our control group consisted of age, stage, and receptor status matched early stage untreated breast cancer patients who were deemed BRCA WT by extended gene panel testing or were negative for BRCA 1/2 and had a posttest probability of harboring an autosomal dominant mutated gene of ≤ 1% using the Bayes-Mendel algorithm. We used a two-sample binomial arcsin approximation to detect a 20% difference in TILs between cohorts to attain 80% power with a one-side alpha of 0.05. Wilcoxon Rank-Sums test was used to compare differences in the central tendencies for continuous variables. We used the Nanostring PanCancer immune profiling panel to immunophenotype a portion of the BRCA+ and BRCA WT cohorts and used nSolver for quality control, normalization, and bioinformatics analyses.

Results: Here we report TILs from the first 21 patients of our study. Thirteen patients harbored BRCA mutations and eight patients did not. All patients were HER2 negative. Eight (61%) and four (50%) patients were hormone receptor positive (HR+) in the BRCA+ and BRCA WT cohorts, respectively. Median %TILs were not significantly different between the BRCA+ (15, range 0-70) and BRCA WT (17.5, range 5-60; p=0.7) groups. Median %TILs in the HR+/BRCA+ (12.5, range 0-50) and HR-/BRCA+ (15, range 5-70) cohorts were not statistically different when compared to HR+/BRCA WT (10, range 5-15; p=0.4) and HR-/BRCA WT (30, range 20-60; p=0.2) cohorts, respectively. There were 2 patients with lymphocyte predominant breast cancer (n=1, HR-/BRCA+; n=1, HR-/BRCA WT).

Conclusions: This is the first study to characterize TILs and a tumor immune microenvironment phenotype in early stage breast cancer patients with BRCA mutations. These results suggest harboring a BRCA mutation is not associated with increased TILs in early stage untreated breast cancer patients. This conclusion stayed true regardless of hormone receptor status. However, a trend of decreased TILs was seen in HR-/BRCA+ patients when compared to those with HR-/BRCA WT disease. Moreover, the median and range of TILs were higher in the HR+/BRCA+ group compared to the HR+/BRCA WT group. This suggests increased TILs may exist in some HR+ patients with a BRCA mutation. Further investigation of TILs and immune profiling of early stage untreated breast cancer patients with and without BRCA mutations is warranted.

Citation Format: Force J, Abbott S, Broadwater G, Kimmick G, Westbrook K, Hwang S, Kauff N, Stashko I, Weinhold K, Nair S, Hyslop T, Blackwell K, Castellar E, Marcom PK. Elucidating the tumor immune microenvironment phenotype in early stage untreated BRCA mutated breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-04-19.

Intestinal lymphoma--a review of the management of emergency presentations to the general surgeon

INTRODUCTION

Intestinal non-Hodgkin's lymphoma (NHL) is uncommon but not rare. This paper aims to review the recent evidence for the management of perforated NHL of the intestine, consider when chemotherapy should be commenced and examine the likely outcomes and prognosis for patients presenting as surgical emergencies with this condition.

METHODS

MEDLINE and Cochrane databases were searched using intestinal lymphoma, clinical presentation, perforation, management and prognosis. The full text of relevant articles was retrieved and reference lists checked for additional articles.

FINDINGS

Emergency surgery was required at disease presentation for between 11 and 64% of intestinal NHL cases. Perforation occurs in 1-25% of cases, and also occurs whilst on chemotherapy for NHL. Intestinal bleeding occurs in 2-22% of cases. Obstruction occurs more commonly in small bowel (5-39%) than large bowel NHL and intussusceptions occur in up to 46%. Prognosis is generally poor, especially for T cell lymphomas.

CONCLUSIONS

There is a lack of quality evidence for the elective and emergency treatment of NHL involving the small and large intestine. There is a lack of information regarding the impact an emergency presentation has on the timing of postoperative chemotherapy and overall prognosis. It is proposed that in order to develop evidence-based treatment protocols, there should be an intestinal NHL registry.

Outcomes following treatment for pelvic floor mesh complications

INTRODUCTION AND HYPOTHESIS

Our aim was to determine symptoms and degree of improvement in a cohort of women who presented following treatment for vaginal mesh complications.

METHODS

This study was a follow-up to a multicenter, retrospective study of women who presented to four tertiary referral centers for management of vaginal-mesh-related complications. Study participants completed a one-time follow-up survey regarding any additional treatment, current symptoms, and degree of improvement from initial presentation.

RESULTS

Two hundred and sixty women received surveys; we had a response rate of 41.1 % (107/260). Complete data were available for 101 respondents. Survey respondents were more likely to be postmenopausal (p = 0.006), but otherwise did not differ from nonrespondents. Fifty-one percent (52/101) of women underwent surgery as the primary intervention for their mesh complication; 8 % (4/52) underwent a second surgery; 34 % (17/52) required a second nonsurgical intervention. Three patients required three or more surgeries. Of the 30 % (30/101) of respondents who reported pelvic pain prior to intervention, 63 % (19/30) reported improvement, 30 % (9/30) were worse, and 7 % (2/30) reported no change. Of the 33 % (33/101) who reported voiding dysfunction prior to intervention, 61 % (20/33) reported being at least somewhat bothered by these symptoms.

CONCLUSIONS

About 50 % of women with mesh complications in this study underwent surgical management as treatment, and <10 % required a second surgery. Most patients with pain preintervention reported significant improvement after treatment; however, almost a third reported worsening pain or no change after surgical management. Less than half of patients with voiding dysfunction improved after intervention.

Predictors of outcome in palliative colonic stent placement for malignant obstruction

BACKGROUND

Emergency surgery for large bowel obstruction carries significant morbidity and mortality. After initially promising results, concerns have been raised over complication rates for self-expandable metal stents (SEMS) in both the palliative and bridge-to-surgery settings. This article documents the technique used at the authors' institution, and reports on success and complication rates, as well as identifying predictors of endoscopic reintervention or surgical treatment.

METHODS

Data were collected for a prospective cohort of consecutive patients undergoing attempted colonoscopic SEMS insertion at a single institution between 1998 and 2013. Multivariable logistic models were fitted to assess possible predictors of endoscopic reintervention and surgical treatment.

RESULTS

Palliative SEMS insertion was attempted in 146 patients. Primary colorectal cancer was the most common cause of obstruction (95.2 per cent). The majority of patients (77.4 per cent) were treated in an acute setting, with a high technical success rate of 97.3 per cent. The perforation rate was 4.8 per cent and the 30-day procedural mortality rate 2.7 per cent. No predictors of early complications were identified, although patients with metastases and those who received chemotherapy were more likely to have late complications. Some 30.8 per cent of patients required at least one further intervention, with 11.0 per cent of the cohort requiring a stoma. Endoscopic reintervention was largely successful.

CONCLUSION

SEMS offer a valid alternative to operative intervention in the palliative management of malignant large bowel obstruction. Patients receiving chemotherapy are more likely to receive endoscopic reintervention, which is largely successful.

A methodological study to compare survey-based and observation-based evaluations of organisational and safety cultures and then compare both approaches with markers of the quality of care

BACKGROUND

Patient safety concerns have focused attention on organisational and safety cultures, in turn directing attention to the measurement of organisational and safety climates.

OBJECTIVES

First, to compare levels of agreement between survey- and observation-based measures of organisational and safety climates/cultures and to compare both measures with criterion-based audits of the quality of care, using evidence-based markers drawn from national care standards relating to six common clinical conditions. (This required development of an observation-based instrument.) Second, to examine whether observation-based evaluations could replace or augment survey measurements to mitigate concerns about declining response rates and increasing social desirability bias. Third, to examine mediating factors in safety and organisational climate scores.

DESIGN

The study had three strands: (A) a postal questionnaire survey to elicit staff perceptions of organisational and safety climates, using six prevalidated scales; (B) semistructured non-participant observation of clinical teams; and (C) a retrospective criterion-based audit carried out by non-clinical auditors to minimise hindsight bias. Standardised summary scores were created for each strand, and pairs of measurements were compared (strand A with strand B, strand A with strand C, and strand B with strand C) using Bland-Altman plots to evaluate agreement. Correlations were also examined. Multilevel modelling of Strand A scores explored mediating factors.

SETTING AND PARTICIPANTS

Eight emergency departments and eight maternity units in England, UK.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Examination of feasibility, correlation and agreement.

RESULTS

Strand A: the overall response rate was 27.6%, whereas site-specific rates ranged from 9% to 47%. We identified more mediating factors than previous studies; variable response rates had little effect on the results. Organisational and safety climate scores were strongly correlated (r = 0.845) and exhibited good agreement [standard deviation (SD) differences 0.449; 14 (88%) within ± 0.5; one large difference]. Two commonly used scales had high levels of positive responses, suggesting positive climates or social desirability bias. Strand B: scoring on a four-point scale was feasible. Observational evaluation of teamwork culture was good but too limited for evaluating organisational culture. Strand C: a total of 359-399 cases were audited per condition. The results varied widely between different markers for the same condition, so selection matters. Each site performed well on some markers but not others, with few consistent patterns. Some national guidelines were contested. Comparisons: the comparison of safety climate (survey) and teamwork culture (observation) revealed a moderately low correlation (r = 0.316) and good agreement [SD differences 1.082; 7 (44%) within ±0.5; one large difference]. The comparison of safety climate (survey) and performance (audit) revealed lower correlation (r = 0.150, i.e. relationship not linear) but reasonably good agreement [SD differences 0.992; 9 (56%) within ± 0.5; two large differences]. Comparisons between performance (audit) and both organisational climate (survey) and teamwork culture (observation) showed negligible correlations (< 0.1) but moderately good agreement [SD differences 1.058 and 1.241; 6 (38%) and 7 (44%) within ± 0.5; each with two large differences (at different sites)]. Field notes illuminated large differences.

CONCLUSIONS

Climate scores from staff surveys are not unduly affected by survey response rates, but increasing use risks social desirability bias. Safety climate provides a partial indicator of performance, but qualitative data are needed to understand discrepant results. Safety climate (surveys) and, to a lesser degree, teamwork culture (observations) are better indicators of performance than organisational climate (surveys) or attempts to evaluate organisational culture from time-limited observations. Scoring unobtrusive, time-limited observations to evaluate teamwork culture is feasible, but the instrument developed for this study needs further testing. A refined observation-based measure would be useful to augment or replace surveys.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Conservation of Piping Plover (Charadrius melodus) in North America: science, successes, and challenges1This review is part of the virtual symposium “Flagship Species – Flagship Problems” that deals with ecology, biodiversity and management issues, and climate impacts on species at risk and of Canadian importance, including the polar bear (Ursus maritimus), Atlantic cod (Gadus morhua), Piping Plover (Charadrius melodus), and caribou (Rangifer tarandus)

There are only about 8000 Piping Plovers ( Charadrius melodus Ord, 1834) in existence. Because they depend on environments that are under intense human pressures and controls in both their breeding and wintering grounds, these birds and their habitats are highly managed in many areas across their range. Efforts to recover this endangered and threatened species have engaged thousands of people from Newfoundland to the Caribbean, and have provoked a ground-swell of public support and, at times, fury, as well as a considerable body of research. Although populations have increased substantially in the U.S. Atlantic and U.S. Great Lakes, this is not true of all regions. Significant issues still exist with respect to the efficacy of predator management; need for more accurate model input information; effects of climate, pollutants, and water management; habitat loss and degradation from recreation and development; and whether the cost and effort of management for this species can be maintained or increased where needed.

The third generation superconducting 28 GHz electron cyclotron resonance ion source VENUS (invited)

VENUS is a third generation electron cyclotron resonance (ECR) ion source, which incorporates a high field superconducting NbTi magnet structure, a 28 GHz gryotron microwave source and a state of the art closed cycle cryosystem. During the decade from initial concept to regular operation, it has demonstrated both the feasibility and the performance levels of this new generation of ECR ion sources and required innovation on magnet construction, plasma chamber design, and beam transport. In this paper, the development, performance, and major innovations are described as well as a look to the potential to construct a fourth generation ECR ion source.

Multisystemic abscesses in African green monkeys (Chlorocebus aethiops) with invasive Klebsiella pneumoniae--identification of the hypermucoviscosity phenotype

Invasive Klebsiella pneumoniae is an emerging disease of humans characterized by abscesses in the liver or other sites involving bacteria with the unique hypermucoviscosity phenotype. Over several months, 7 African green monkeys in our research colony developed abscess formation in multiple locations and succumbed to disease. K. pneumoniae was identified by bacterial culture in 6 monkeys and immunohistochemistry in 1 additional monkey. All monkeys had been housed in, or had contact with monkeys housed in, 1 animal room in our facility. All affected monkeys had 1 or more abscesses, most notably in the abdomen, but also affecting the lungs, cerebellum, and skin. Abdominal abscesses and associated adhesions entrapped loops of bowel, forming palpable masses. Abdominal masses were located at the root of the mesentery, the ileocecocolic junction, or the pelvic inlet. In 1 case, culture, serotyping, and polymerase chain reaction (PCR) analysis of the bacterial isolate identified K. pneumoniae expressing the hypermucoviscosity phenotype and capsular serotype K2 and determined that the K. pneumonia was genetically rmpA(+)/magA(-).

Community nurses and self-management of blood glucose

Self-monitoring of blood glucose (SMBG) is commonly recommended to patients with diabetes, although the rationale for this is unclear. This small research project was designed to explore the reasons why nurses working in the community recommend SMBG. Seven interviews were carried out with community nurses caring primarily for housebound patients. Those interviewed believed that a sound evidence-base supported the recommendation that patients test their blood, but not urine, for glucose levels. Though nurses believed in the importance of patient choice and empowerment, the scope for these was limited among housebound patients. There was no evidence that patients understood how to respond to test results, or that comprehensive care planning was normal practice. Although small, this study suggests that nurses working in community settings may need to update their knowledge. It also suggests that a national debate is necessary to disseminate better the evidence about SMBG, and its implications for nursing practice.

Variations in the social inclusion of people with intellectual disabilities in supported living schemes and residential settings

BACKGROUND

The social inclusion of tenants living in two forms of supported living schemes - those clustered on one site and those dispersed in neighbourhoods - is contrasted with more traditional provision found on the island of Ireland, namely, small group homes, residential homes and campus-style settings.

METHODS

A standard pro forma based on measures used in past research was completed by the key-worker for each tenant or resident. In all, data were obtained on 620 persons, representing nearly all tenants in clustered schemes in Northern Ireland and over 40% of those in dispersed schemes.

RESULTS

People in either form of supported living tended to have greater levels of social inclusion as measured by their use of community amenities and social contacts than did those in small group homes or residential homes, with participants from campus-style settings having the lowest levels of social inclusion. Moreover, multivariate analyses confirmed that the accommodation variable was a significant influence in addition to the social competence of the person.

CONCLUSIONS

Although there were few differences between the two models of supported living, further research could usefully focus on decisions to place persons in either form of accommodation and their impact on wider indicators of social inclusion.

What sort of networks are public health networks?

BACKGROUND

Re-organization of the English National Health Service (NHS) has fragmented the public health workforce, relocating teams from about 100 health authorities into over 300 primary care trusts (PCTs). The UK Government announced the setting up of public health networks (PHNs) as a solution to the problems created by fragmentation.

METHODS

Fifty-seven semi-structured telephone interviews were held with key players in PHNs in all strategic health authority areas in England in early 2003.

RESULTS

PHNs appeared to be primarily networks of public health professionals rather than of organizations. Informants were unsure about PCTs' commitment to public health. Predominantly, members were those NHS personnel with a clear and explicit public health role. Most PHNs intended to include others later (e.g. health visitors, environmental health officers), although a few thought that inclusivity was essential from the start. Continuing professional development for public health personnel dominated the work being undertaken, with some collaborative work across PCTs. PHNs were seen as a compulsory reconfiguration of existing networks, and informants doubted that they were appropriate for the many levels of networking that public health work requires.

CONCLUSION

The formation of PHNs does not appear to have been either necessary or sufficient. However, the public health community has a well-established tradition of networking, and therefore has the skills to use PHNs advantageously.

A multi-state outbreak of Salmonella serotype Thompson infection from commercially distributed bread contaminated by an ill food handler

Foodborne transmission is estimated to account for 95% of non-typhoidal Salmonella infections reported in the United States; however, outbreaks of salmonellosis are rarely traced to food handlers. In August 2000, an increase in Salmonella serotype Thompson infection was noted in Southern California; most of the cases reported eating at a restaurant chain (Chain A) before illness onset. A case-control study implicated the consumption of burgers at Chain A restaurants. The earliest onset of illness was in a burger bun packer at Bakery B who had not eaten at Chain A but had worked while ill. Bakery B supplied burger buns to some Chain A restaurants in Southern California and Arizona. This outbreak is notable for implicating a food handler as the source of food contamination and for involving bread, a very unusual outbreak vehicle for Salmonella . Inadequate food-handler training as well as delayed reporting to the health department contributed to this outbreak.

Developing a speciality: regearing the specialist public health workforce

OBJECTIVES

To identify issues surrounding the future training needs of the specialist public health workforce following the most recent restructuring of the National Health Service (NHS) in England.

METHODS

All directors of public health (DsPH) based in strategic health authorities and nine senior staff working in public health at the regional level were invited to participate in a semi-structured telephone interview.

RESULTS

Twenty-six people were interviewed. Many interviewees expressed concern that because consultants and specialists in public health will be working in much smaller teams than hitherto, they will have to generalize their skills to cover a much wider range of functions (including board-level duties). This may result in a loss of specialist expertise. Successful public health practice in the new structures will require new ways of interorganizational working that will add an administrative burden to specialists in public health. Also, the creation of a board-level post in each primary care trust (PCT) has resulted in more time spent on corporate responsibilities and less on public health for DsPH, who are often the only fully trained specialist in public health in their PCT. Furthermore, interviewees expressed their anxiety about the lack of diversity in the posts available to specialists in public health and particularly to those newly completing their specialist training. Generally, interviewees felt that traditional public health roles and responsibilities were being eclipsed by corporate and managerial ones. Professional development activities were being carried out, but in a rather ad-hoc fashion. Interviewees were hopeful that public health networks would lead professional development initiatives once they were more established.

CONCLUSIONS

It is important that excellence in public health is maintained through a set of accreditable standards, whilst corporate skills, essential to successful public health practice in the new UK NHS, are developed among specialists in public health.

Specialist public health capacity in England: working in the new primary care organizations

OBJECTIVES

To determine the capacity and development needs, in relation to key areas of competency and skills, of the specialist public health workforce based in primary care organizations following the 2001 restructuring of the UK National Health Service.

STUDY DESIGN

Questionnaire survey to all consultants and specialists in public health (including directors of public health) based in primary care trusts (PCTs) and strategic health authorities (SHAs) in England.

RESULTS

Participants reported a high degree of competency. However, skill gaps were evident in some areas of public health practice, most notably "developing quality and risk management" and in relation to media communication, computing, management and leadership. In general, medically qualified individuals were weaker on community development than non-medically qualified specialists, and non-medically qualified specialists were less able to perform tasks that require epidemiological or clinical expertise than medically qualified specialists. Less than 50% of specialists felt that their links to external organizations, including public health networks, were strong. Twenty-nine percent of respondents felt professionally isolated and 22% reported inadequate team working within their PCT or SHA. Approximately 21% of respondents expressed concerns that they did not have access to enough expertise to fulfil their tasks and that their skills were not being adequately utilized.

CONCLUSIONS

Some important skill gaps are evident among the specialist public health workforce although, in general, a high degree of competency was reported. This suggests that the capacity deficit is a problem of numbers of specialists rather than an overall lack of appropriate skills. Professional isolation must be addressed by encouraging greater partnership working across teams.

Epidemiological features of a newly described serotype of Shigella boydii

We report the clinical, microbiological, and epidemiological features of an emerging serotype, Shigella boydii 20. We interviewed patients about symptoms, and history of travel and visitors during the week before illness onset. Seventy-five per cent of the 56 patients were Hispanic. During the week before illness onset, 18 (32%) travelled abroad; 17 (94%) had visited Mexico. Eight (21%) out of 38 who had not travelled had foreign visitors. There were eight closely related patterns by PFGE with XbaI. S. boydii 20 may be related to travel to Mexico and Hispanic ethnicity. Prompt epidemiological investigation of clusters of S. boydii 20 infection may help identify specific vehicles and risk factors for infection.

Alfalfa sprouts and Salmonella Kottbus infection: a multistate outbreak following inadequate seed disinfection with heat and chlorine

Raw sprouts have been implicated in a number of foodborne disease outbreaks. Because contaminated seeds are usually responsible, many sprout producers attempt to disinfect seeds before germination and detect sprout contamination during production. In March 2001, we detected an increased number of Salmonella serotype Kottbus isolates in California. Overall, we identified 31 cases from three western states. To identify the cause, we conducted a case-control study with the first 10 identified case-patients matched to 20 controls by age, sex, and residential area. Our case-control study found illness to be statistically associated with alfalfa sprout consumption. The traceback investigation implicated a single sprouter, where environmental studies yielded Salmonella Kottbus from ungerminated seeds and floor drains within the production facility. Pulsed-field gel electrophoresis patterns of all patient, seed, and floor drain Salmonella Kottbus isolates were indistinguishable. Most implicated sprouts were from seeds that underwent heat treatment and soaking with a 2,000-ppm sodium hypochlorite solution rather than the Food and Drug Administration (FDA)-recommended 20,000-ppm calcium hypochlorite soak. Other implicated seeds had been soaked in a calcium hypochlorite solution that, when tested, measured only 11,000 ppm. The outbreak might have been averted when screening tests of sprout irrigation water detected Salmonella in January; however, confirmatory testing of these samples was negative (but testing improperly utilized refrigerated irrigation water). Producers should use the enrichment broth of positive screening samples, not refrigerated irrigation water, for confirmatory testing. Until other effective disinfection technologies are developed, producers should adhere to FDA recommendations for sprout seed disinfection.

Escherichia coli O157 and Salmonella infections associated with sprouts in California, 1996-1998

BACKGROUND

In California, from 1996 through 1998, more than 50% of multicounty outbreaks with confirmed food vehicles were related to alfalfa or clover sprouts.

OBJECTIVE

To summarize investigations of sprout-associated outbreaks.

DESIGN

Matched case-control studies.

SETTING

California.

PATIENTS

Outbreak-associated patients and matched population controls.

MEASUREMENTS

Matched odds ratios and 95% CIs; traceback and environmental investigations of sprout and seed growers; and pulsed-field gel electrophoresis of isolates from patients, sprouts, and seeds.

RESULTS

Five sprout-associated outbreaks of salmonellosis and one outbreak of infection with nonmotile Shiga toxin-producing Escherichia coli O157 occurred. Six hundred patients had culture-confirmed disease, and two died. It is estimated that these outbreaks caused 22 800 cases of gastrointestinal illness or urinary tract infection. In the case-control studies, odds ratios for the association between illness and alfalfa sprout consumption ranged from 5.0 to infinity (all were statistically significant). Three sprout growers were implicated, and each was associated with two outbreaks. Outbreak strains of Salmonella were isolated from sprouts supplied by two sprout growers and from seeds used by the third sprout grower.

CONCLUSIONS

As currently produced, sprouts can be a hazardous food. Seeds can be contaminated before sprouting, and no method can eliminate all pathogens from seeds. Seed and sprout growers should implement measures to decrease contamination. The general public should recognize the risks of eating sprouts, and populations at high risk for complications from salmonellosis or E. coli O157 infection should avoid sprout consumption.

An outbreak of Salmonella serotype Thompson associated with fresh cilantro

An outbreak of Salmonella serotype Thompson in California was identified through laboratory-based surveillance and investigated with case-control, traceback, and laboratory studies. There were 35 "sporadic" cases and a restaurant-associated outbreak of 41 cases with onset between 6 March and 31 March 1999. Three case patients were hospitalized. A case-control study found a significant association between illness and eating cilantro at a restaurant (63% of case patients vs. 34% of control subjects; odds ratio, 3.5; 95% confidence interval, 1.1-11.4). Although common distributors of cilantro were identified, inadequate records prohibited the identification of a single farm supplying cilantro. At room temperature, Salmonella Thompson grew more rapidly and to a higher concentration on chopped cilantro, compared with whole-leaf cilantro. Freshly made salsa (pH 3.4) supported growth of Salmonella Thompson. Cilantro should be served promptly after chopping. Accurate records of the distribution of produce should be available, and bacterial contamination of produce should be prevented in retail and wholesale establishments, in packing sheds, and on farms.

Participation in arranging continuing health care packages: experiences and aspirations of service users

AIMS

This paper examines patients' and carers' experiences of receiving community health services, and considers the degree of patients' participation in the management of their continuing care.

BACKGROUND

Care management, advocated for many years as a way of ensuring appropriate and coordinated care, emphasizes the involvement of patients and carers in care planning. Evidence suggests that such involvement is unusual.

METHODS

Semi-structured interviews were carried out with 99 continuing health care patients and/or their carers.

FINDINGS

A few informants had willingly chosen to be active in arranging and coordinating their care, and a few others, who did not take an active role, were very satisfied with the services which they received. The majority, however, were not satisfied, feeling unclear about how their needs had been assessed and how services had been arranged. They were mostly disappointed by the absence of information and by the lack of regular contact with NHS and/or Social Services personnel. Some had felt compelled to become proactive in order to ensure that the care provided was adequate.

CONCLUSIONS

Community nurses are valued by patients, and are well placed to be care managers. However, less qualified staff are also able to offer the regular support and information which patients want and value.