A SARS-CoV-2 outbreak in a plastics manufacturing plant.

BACKGROUND: A SARS-CoV-2 outbreak with an attack rate of 14.3% was reported at a plastics manufacturing plant in England. METHODS: Between 23rd March and 13th May 2021, the COVID-OUT team undertook a comprehensive outbreak investigation, including environmental assessment, surface sampling, molecular and serological testing, and detailed questionnaires, to identify potential SARS-CoV-2 transmission routes, and workplace- and worker-related risk factors. RESULTS: While ventilation, indicated using real-time CO2 proxy measures, was generally adequate on-site, the technical office with the highest localized attack rate (21.4%) frequently reached peaks in CO2 of 2100ppm. SARS-CoV-2 RNA was found in low levels (Ct ≥35) in surface samples collected across the site. High noise levels (79dB) were recorded in the main production area, and study participants reported having close work contacts (73.1%) and sharing tools (75.5%). Only 20.0% of participants reported using a surgical mask and/or FFP2/FFP3 respirator at least half the time and 71.0% expressed concerns regarding potential pay decreases and/or unemployment due to self-isolation or workplace closure. CONCLUSIONS: The findings reinforce the importance of enhanced infection control measures in manufacturing sectors, including improved ventilation with possible consideration of CO2 monitoring, utilising air cleaning interventions in enclosed environments, and provision of good-quality face masks (i.e., surgical masks or FFP2/FFP3 respirators) especially when social distancing cannot be maintained. Further research on the impacts of job security-related concerns is warranted.

Surgical Correction of Nonsyndromic Sagittal Craniosynostosis: Concepts and Controversies.

Sagittal craniosynostosis remains the most common type of isolated craniosynostosis, accounting for nearly half of all nonsyndromic cases. The clinical diagnosis is typically made on the basis of a scaphocephalic head shape and is confirmed by computed tomography or magnetic resonance imaging. The current review examines the major surgical options for correction of isolated sagittal craniosynostosis, including their complications and short- and long-term outcomes. Reconstructive techniques have benefited from advances in perioperative anesthesia monitoring and improved safety of blood transfusion. Although extensive calvarial remodeling is considered safe and may confer greater long-term skull shape correction and decreased neuropsychological sequelae, minimally invasive techniques, such as device-assisted expansion of the cranium continue to increase in popularity. This review underscores the need for additional prospective studies comparing different techniques to determine the optimal reconstructive approach for correction of sagittal craniosynostosis.

What works for whom, how and why in mental health education for undergraduate health profession students? A realist synthesis protocol.

INTRODUCTION: It has been shown that mental health education can support positive attitudes of health profession students towards people with mental health challenges, which supports them to provide optimal healthcare to this group. There are many different approaches to designing and delivering mental health education to health profession students. Each has their own advantages and disadvantages, and often mental health education programmes incorporate a multimodal approach in order to reap the benefits of a variety of teaching and learning approaches. The aim of this study is to understand the current landscape of teaching and learning approaches to mental health education for undergraduate health profession students. We will examine the features of successful outcomes for health profession students for:Learning environment.Knowledge development and retention.Confidence. MOTIVATION: Preparedness for professional practice. METHODS: For this, a realist synthesis has been chosen in order to review the literature. Realist synthesis lends itself to the review of complex interventions such as mental health education for undergraduate health profession curricula because it seeks to uncover the range of different mechanisms and context configurations that produce different outcomes. Health profession education and education practice, in general, is complex. A patient and public involvement (PPI) group is involved throughout this study and includes undergraduate health profession students, and members of the St John of Gods Hospital Consumers and Carers Council who are involved at every stage of the research. This study will engage with a stakeholder group who will support the refining of the programme theory. ETHICS AND DISSEMINATION: Ethical approval has been sought and approved by Royal College of Surgeons, Ireland Ethical Committee (REC number: 212622783). We will aim to write up and publish the full synthesis as a journal article. We will also discuss ways of dissemination outside of academia with our PPI group.

Pars plana vitrectomy for vitreomacular traction syndrome: a systematic review and metaanalysis of safety and efficacy.

PURPOSE: To determine the safety and efficacy of pars plana vitrectomy for vitreomacular traction. METHODS: Articles reporting visual acuity change before and after pars plana vitrectomy were selected using a systematic literature review with predefined eligibility criteria. Visual acuities were converted to logarithm of the minimum angle of resolution (logMAR), weighted for study size, and pooled across studies. Safety outcomes were also pooled across studies. RESULTS: Twenty-one of 460 articles were eligible. Mean (±standard deviation) logMAR visual acuity improved from 0.67 ± 0.55 to 0.42 ± 0.45 (n = 259 eyes) after pars plana vitrectomy (from 20/94 to 20/53 Snellen). In series of at least 20 eyes, mean visual acuity improved in all 5 studies (sign test, P = 0.0625). Of 392 eyes, 9.2% lost visual acuity, 11.7% were unchanged, and 64.3% improved; 32.9% of 217 eyes gained ≥2 Snellen lines. The most common postoperative complications were cataract (34.7% of 304 eyes; 63.2% of 68 phakic eyes), epiretinal membrane (5.7% of 348 eyes), and retinal detachment (4.6% of 348 eyes). Cataract surgery was undertaken in 10.5% of eyes. CONCLUSION: The visual acuity gains after pars plana vitrectomy for vitreomacular traction are relatively modest, but visual acuity change may not fully reflect symptomatic relief.

Transporting Lazarus: physicians, the state, and the creation of the modern paramedic and ambulance, 1955-73.

In 1966, morticians provided 50 percent of ambulance services in the United States; today advanced care by trained medical professionals en route to the hospital is considered a basic standard of care. The creation of emergency medical services (EMS) provides an important case study for how physicians acting as "experts" helped to shape the creation of federal policy in the post-World War II years. This paper challenges a narrative of the development of EMS that has emphasized technology, individual agency, and the role of fortuitous chance as the prime movers of EMS development. Instead it argues that a key factor in EMS development was the National Academy of Science-National Research Council's Committee on Emergency Medical Services. Using the examples of paramedic training and ambulance design, this paper argues that members of the committee utilized complex mix of local experimentation and professional networking to suggest directions for the federal government's efforts to create national standards and guidelines for EMS. The NAS-NRC Committee retained a prominent role in EMS development until the passage of the Emergency Medical Services Systems Act of 1973, when federal interest in EMS largely shifted from prehospital transport to an emphasis on in hospital care and regional trauma systems planning.

Epimacular brachytherapy for previously treated neovascular age-related macular degeneration: month 36 results of the MERLOT randomised controlled trial.

BACKGROUND/AIM: To assess the long-term safety and efficacy of epimacular brachytherapy (EMB) for chronic, active, neovascular age-related macular degeneration (nAMD). METHODS: This pivotal, randomised, controlled surgical device trial recruited patients with chronic nAMD receiving intravitreal ranibizumab from 24 UK hospitals. Participants were randomised to either pars plana vitrectomy with 24 Gray EMB and pro re nata (PRN) ranibizumab (n=224) or PRN ranibizumab monotherapy (n=119). Although masking was not possible, masked clinicians assessed best-corrected visual acuity (BCVA) and imaging. After month 24, participants reverted to standard care, with either ranibizumab or aflibercept, returning for a month 36 study visit. RESULTS: Of 363 participants, 309 (85.1%) completed month 36. The number of injections was 12.1±8.1 in the EMB group versus 11.4±6.1 in the ranibizumab group (difference 0.7, 95% CI of difference -0.9 to 2.3, p=0.41) between months 1 and 36, and 3.6±3.3 (n=200) versus 3.9±2.7 (n=102) (difference -0.3, 95% CI of difference -1.0 to 0.4, p=0.43) between months 25 and 36 (standard care). Over 36 months, BCVA change was -19.7±18.5 letters in the EMB group and -4.8±12.5 in the ranibizumab group (difference -14.9, 95% CI of difference -18.5 to -11.2, p<0.0001). The month 36 BCVA of 20 EMB-treated participants with microvascular abnormalities (MVAs) at month 24 was similar to EMB-treated participants without MVAs (-21.8 vs -19.4 letters, p=0.65). CONCLUSION: EMB does not reduce the number of anti-vascular endothelial growth factor (VEGF) injections, either within or outside of a trial setting, and is associated with worse BCVA than anti-VEGF monotherapy. TRIAL REGISTRATION NUMBER: NCT01006538.

Does prophylactic use of topical gelatin-thrombin matrix sealant affect postoperative drainage volume and hematoma formation following microendoscopic spine surgery? A randomized controlled trial.

BACKGROUND CONTEXT: Microendoscopic spinal surgery has demonstrated efficacy and is increasingly utilized as a minimally invasive approach to neural decompression, but there is a theoretical concern that bleeding and postoperative epidural hematoma (PEH) may occur with increased frequency in a contained small surgical field. Hemostatic agents, such as topical gelatin-thrombin matrix sealant (TGTMS), are routinely used in spine surgery procedures, yet there has been no data on whether PEH is suppressed by these agents when administered in microendoscopic spine surgery. PURPOSE: The purpose of this study was to investigate the effect of TGTMS on bleeding and PEH formation in lumbar micoroendoscopic surgery. STUDY DESIGN: This is a randomized controlled trial (RCT) with additional prospective observational cohort. PATIENT SAMPLE: Patients were registered from July 2017 to September 2018 and a hundred and three patients undergoing microendoscopic laminectomy for lumbar spinal stenosis at a single institution were enrolled in this study. OUTCOME MEASURES: The primary outcome was the drainage volume within 48 hours after surgery. Secondary outcomes were the numerical rating scale (NRS) of leg pain on the second (NRS2) and seventh day (NRS7) after surgery and the hematoma area ratio (HAR) in horizontal images on magnetic resonance image (MRI). METHODS: In the RCT, 41 cases that received TGTMS (F group) were compared with 41 control group cases (C group) that did not receive TGTMS at the end of the procedure. Drainage volume, NRS2, NRS7, and HAR on MRI were evaluated. Nineteen cases were excluded from the RCT (I group) due to difficulty of hemostasis during surgery and the intentional use of TGTMS for hemostasis. I group was compared with C group in the drainage volume and NRS of leg pain as a prospective observational study. RESULTS: The RCT demonstrated no statistically significant difference in drainage volume between those receiving TGTMS (117.0±71.7; mean±standard deviation) and controls (125.0±127.0; p=.345). The NRS2 and NRS7 was 3.5±2.6 and 2.8±2.5 in the F group, respectively, and 3.1±2.6 and 2.1±2.3 in the C group, respectively. The HAR on MRI was 0.19±0.19 in the F group and 0.17±0.13 in the C group. There was no significant difference in postoperative leg pain and HAR (p=.644 for NRS2, p=.129 for NRS7, and p=.705 for HAR). In the secondary observational cohort, the drainage volume in the I group was 118.3±151.4, and NRS2 and NRS7 was 3.5±2.0 and 2.6±2.6, respectively. There were no statistically significant differences in drainage volume (p=.386) or postoperative NRS of leg pain between these two groups (p=.981 and .477 for NRS2 and NRS7, respectively). CONCLUSIONS: The prophylactic use of TGTMS in patients undergoing microendoscopic laminotomy for lumbar spinal stenosis did not demonstrate any difference in postoperative bleeding or PEH. Nonetheless, for patients that had active bleeding that required the use of TGTMS, there was no evidence of difference in postoperative clinical outcomes relative to controls.

High-Grade Lumbar Spondylolisthesis.

Most high-grade spondylolistheses are resultant from isthmic spondylolisthesis, as complete discontinuity of the pars is typically necessary to allow for this degree of anterior vertebral translation, although can occur less commonly in other scenarios. Higher-grade slips can affect the global sagittal balance of the patient and often result in altered gait patterns and compensatory posturing. Management usually entails surgical decompression and fusion with instrumentation. The addition of anterior column support carries many advantages, including greater surface area for fusion, dynamic compression load sharing at the lumbosacral junction, and a powerful adjunct for deformity correction.

Rethinking Surgical Treatment of Lumbar Spondylolisthesis: Anatomic Considerations.

The goal was to develop a classification of degenerative spondylolisthesis (DS) and concurrent lumbar spinal stenosis (LSS) based on pathologic stage and determine how these subtypes of DS affect outcomes for minimally invasive decompression. Patients who underwent microendoscopic laminotomy for single-level LSS with DS were included. Degenerative spondylolisthesis pathologic staging was defined as early, advanced, or end stage, based on percent slippage (10% slippage), degree of dynamic instability (3 mm), and disc height. Less than 10% required additional surgery; 5% required subsequent fusion, and all these patients were in the advanced stage DS group.

Microendoscopic Decompression for Lumbar Spinal Stenosis With Degenerative Spondylolisthesis: The Influence of Spondylolisthesis Stage (Disc Height and Static and Dynamic Translation) on Clinical Outcomes.

STUDY DESIGN: This study was a retrospective subgroup analysis of prospective cohort data. OBJECTIVE: The main objectives of this study were to develop a classification of degenerative spondylolisthesis (DS) and concurrent lumbar spinal stenosis (LSS) based on pathologic stage, and to determine how these subtypes of DS affect outcomes for minimally invasive (MIS) decompression SUMMARY OF BACKGROUND DATA:: DS with LSS is a common clinical scenario, yet there is no consensus on optimal treatment. Natural history of DS is described as early degenerative damage, followed by instability, and eventual restabilization via spondylotic changes. MIS decompression surgery has become increasingly popular, but the effect of DS subtypes on clinical outcomes after MIS decompression is unknown. PATIENTS AND METHODS: From 2008 to 2013, all patients who underwent microendoscopic laminotomy for single-level LSS with DS were included. In total, 218 patients (91 male, 127 female individuals) were reviewed. DS pathologic staging was defined as early, advanced, or end stage, based on percent slippage (10% slippage), degree of dynamic instability (3 mm), and disc height. The following variables were evaluated preoperatively and >2 years postoperatively and compared among groups: Japanese Orthopaedic Association (JOA) score, JOA recovery rate, and Visual Analog Scale low back pain. RESULTS: In total, 173 patients were included in final analysis. Final follow-up period was 2.3 years. Average JOA recovery rate was 63.8%. There were no significant differences in JOA recovery and Visual Analog Scale among 3 DS stages (P>0.05). In total, 9.8% of patients required additional spine surgery, with 5% requiring subsequent fusion. All patients who required subsequent fusion were in the advanced stage DS group. CONCLUSIONS: Microendoscopic decompression is an effective treatment for patients with DS and concurrent LSS, with only 5% of patients requiring subsequent fusion at over 2-year follow-up, and another 5% requiring revision or adjacent segment decompression. The advanced stage DS group, indicating a >10% anterolisthesis and/or >3 mm of dynamic instability, was more likely to require additional surgery.

UK vaccines network: Mapping priority pathogens of epidemic potential and vaccine pipeline developments.

During the 2013-2016 Ebola outbreak in West Africa an expert panel was established on the instructions of the UK Prime Minister to identify priority pathogens for outbreak diseases that had the potential to cause future epidemics. A total of 13 priority pathogens were identified, which led to the prioritisation of spending in emerging diseases vaccine research and development from the UK. This meeting report summarises the process used to develop the UK pathogen priority list, compares it to lists generated by other organisations (World Health Organisation, National Institutes of Allergy and Infectious Diseases) and summarises clinical progress towards the development of vaccines against priority diseases. There is clear technical progress towards the development of vaccines. However, the availability of these vaccines will be dependent on sustained funding for clinical trials and the preparation of clinically acceptable manufactured material during inter-epidemic periods.

Early versus delayed kyphoplasty for thoracolumbar osteoporotic vertebral fractures: The effect of timing on clinical and radiographic outcomes and subsequent compression fractures.

OBJECTIVE: Osteoporotic vertebral body fractures (OVFs) represent a significant medical and socioeconomic burden. There is ongoing debate concerning the role of cement augmentation versus conservative management, but we are increasingly recognizing the longer-term effects of kyphotic vertebral alignment on functional outcomes, pain, and subsequent fracture rates. The purpose of this study was to determine the effect of timing of intervention with percutaneous balloon kyphoplasty (BKP) for OVF on clinical and radiographic outcomes. PATIENTS AND METHODS: 51 patients (mean age, 75.5 years) who underwent BKP for OVF were analyzed. Patients were divided into two groups based on timing of BKP: early (<4 weeks) or late (>4 weeks). Multiple factors were assessed preoperatively and throughout follow up and compared between groups using bivariate testing, including: focal kyphosis, subsequent vertebral fracture, and low back pain. RESULTS: This was a retrospective sub-group analysis. There were 32 patients in the early group and 19 patients in the late group. There was no significant difference in preoperative bone density between groups. Mean follow-up was 1.2 years. Local kyphosis at final follow-up was significantly greater in the late group (-28.4°) than in the early group (-9.5°; p < 0.001). There was no significant difference in local kyphosis between preoperative measurement and final follow-up in the early (p = 0.741) or late cohort (p = 0.794). Patients treated with early BKP demonstrated significantly better LBP scores (p < 0.05) and a lower rate of subsequent vertebral fracture (p < 0.05). CONCLUSION: BKP is able to prevent progressive collapse and kyphosis after OVF, but not effectively restore alignment, and as a result, patients who undergo early BKP (<4 weeks) demonstrate better alignment, better LBP scores, and reduced rates of subsequent fracture at an average of 1.2 years following treatment.

On an infrastructure to support sharing and aggregating pre- and post-publication systems biology research data.

The move towards in silico experimentation has resulted in the use of computational models, in addition to traditional experimental models, to generate the raw data that is analysed and published as research findings. This change requires new methods to be introduced to facilitate independent validation of the underlying models and the reported results. The promotion of co-operative research has the potential to help to both validate results and explore wider problem areas. In this paper we leverage and extend two existing software frameworks to develop an infrastructure that has the potential to both promote the sharing of data between researchers pre-publication and enable access to the data for interested parties post-publication. The pre-publication sharing of data would enable larger problem spaces to be explored by distributed research groups; enabling access to the data post-publication would allow reviewers and the wider community to independently verify the published results which would, in the longer term, help to increase confidence in published results. The framework is used to perform reproducible and numerically validated individual-based computational experiments into the onset of colorectal cancer. Existing results are verified and new insights into the top-down versus bottom-up hypothesis of colorectal crypt invasion are given.

The biotechnology-value chain: development of Sm14 as a schistosomiasis vaccine.

In the 1990s, WHO/TDR created a product development program and initiated collaborations with other major international donors to promote rapid vaccine development and other tools for the control of endemic diseases. This "push strategy" was chosen to achieve effective research projects fostering innovation in the context of rapid product development. In the field of vaccine development, the aim was to bring forth ways and means to immunize against the most important human parasite diseases. Although the malaria vaccine projects scored initial successes it has been difficult to move forward decidedly. With regard to schistosomiasis, more than 10 important antigens with strong potential as vaccines candidates emerged from the several 100 scientific projects supported by international donor agencies and national research programs over the last few decades. Among those still seriously pursued, the Fatty Acid-Binding Protein (FABP)-14 kDa Schistosoma mansoni (Sm14) antigen stands out, both due to its steady progress towards field trials and because it represents the sole vaccine candidate to emerge from an endemic country. Work has now progressed to the scale-up level and an industrial production process has successfully been put in place. The very special feature of Sm14 is its strong immunological reactivity with an antigen shared between two different important parasites, which give this vaccine candidate the potential to be used against more than one infection. It has been demonstrated that it has effect not only against S. mansoni in humans but also against Fasciola hepatica, a parasite that causes disease in cattle and sheep leading to annual losses over 3 $US billion to the food industry worldwide. The Sm14 patents, granted to Oswaldo Cruz Foundation (FIOCRUZ), a Brazilian scientific institution directly linked to the Brazilian Ministry of Health, have been licensed to a private company which has the intention to lead the Sm14 project to success, both in the veterinary and in the human field. The objective is to provide economic performance by fostering scientific and economic progress and thus reach the global market. Sm14 is at present at the stage of planning clinical trials under a private-public partnership (PPP) initiative in collaboration with FIOCRUZ which has recently received significant financial support from FINEP, a public Brazilian Financial Agency.

Sterilization wrap inspections do not adequately evaluate instrument sterility.

Orthopaedic procedures rely on strict sterilization techniques to prevent surgical site infections. Surgical instrument trays are wrapped for sterilization, and these wraps routinely are inspected by operating room personnel to evaluate for breaches before using the contained instruments. The sensitivity of this practice for detecting wrap defects has not been established. We divided 90 sterilization wraps into groups with no defect and with six sizes of defects ranging from 1.1 to 10.0 mm in diameter. Puncture-type defects were created using nails of known diameter. All wraps were evaluated by medical personnel for evidence of a breach. Detection rates ranged from 6.7% to 96.7% from the smallest to largest defects, respectively. The potential for bacterial transmission through wrap defects also was evaluated, and contaminated nails of the smallest size transmitted bacterial contaminants through the wrap during the creation of puncture defects. Thus, substantial perforations in sterilization wraps frequently are missed when evaluated with commonly used techniques. Defects with a diameter approximately that of a pencil (6.7 mm) were missed 18% of the time, although contamination can be transmitted by a nail with the diameter of a pin (1.1 mm). These results raise questions about a common screening method.

Open-label randomized trial of oral trimethoprim-sulfamethoxazole, doxycycline, and chloramphenicol compared with trimethoprim-sulfamethoxazole and doxycycline for maintenance therapy of melioidosis.

Melioidosis (infection caused by Burkholderia pseudomallei) requires a prolonged course of oral antibiotics following initial intravenous therapy to reduce the risk of relapse after cessation of treatment. The current recommendation is a four-drug regimen (trimethoprim [TMP], sulfamethoxazole [SMX], doxycycline, and chloramphenicol) and a total treatment time of 12 to 20 weeks. Drug side effects are common; the aim of this study was to compare the efficacy and tolerance of the four-drug regimen with a three-drug regimen (TMP-SMX and doxycycline). An open-label, randomized trial was conducted in northeast Thailand. A total of 180 adult Thai patients were enrolled, of which 91 were allocated to the four-drug regimen and 89 to the three-drug regimen. The trial was terminated early due to poor drug tolerance, particularly of the four-drug regimen. The culture-confirmed relapse rates at 1 year were 6.6% and 5.6% for the four- and three-drug regimens, respectively (P = 0.79). The three-drug regimen was better tolerated than the four-drug regimen; 36% of patients receiving four drugs and 19% of patients receiving three drugs required a switch in therapy due to side effects (P = 0.01). The duration of oral therapy was significantly associated with relapse; after adjustment for confounders, patients receiving less than 12 weeks of oral therapy had a 5.7-fold increase of relapse or death. A combination of TMP-SMX and doxycycline is as effective as and better tolerated than the conventional four-drug regimen for the oral treatment phase of melioidosis.

Projeto Genoma Humano e suas implicaçöes para a saúde humana: visäo geral e contribuiçäo brasileira para o projeto / Human Genome Project and its implications to human health: general view and Brazilian contribution to the project

A informaçäo derivada do Projeto Genoma Humano, um esforço internacional para elucidar e caracterizar a seqüência completa de 3X109 pares de bases do genoma humano, vai revolucionar a prática da medicina no séc. XXI por prover instrumentos para determinar o componente genético de virtualmente todas as doenças. As conseqüências para a prática da medicina deveräo ser profundas, tais como a geraçäo de medidas que possam prever o risco, permitir o diagnóstico precoce e promover estratégias de tratamento mais efetivas. Discutem-se as aplicaçöes potenciais do conhecimento adquirido com o HGP, bem como a contribuiçäo brasileira a esse projeto