SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes.

OBJECTIVES: To understand SARS-Co-V-2 infection and transmission in UK nursing homes in order to develop preventive strategies for protecting the frail elderly residents. METHODS: An outbreak investigation involving 394 residents and 70 staff, was carried out in 4 nursing homes affected by COVID-19 outbreaks in central London. Two point-prevalence surveys were performed one week apart where residents underwent SARS-CoV-2 testing and had relevant symptoms documented. Asymptomatic staff from three of the four homes were also offered SARS-CoV-2 testing. RESULTS: Overall, 26% (95% CI 22-31) of residents died over the two-month period. All-cause mortality increased by 203% (95% CI 70-336) compared with previous years. Systematic testing identified 40% (95% CI 35-46) of residents as positive for SARS-CoV-2, and of these 43% (95% CI 34-52) were asymptomatic and 18% (95% CI 11-24) had only atypical symptoms; 4% (95% CI -1 to 9) of asymptomatic staff also tested positive. CONCLUSIONS: The SARS-CoV-2 outbreak in four UK nursing homes was associated with very high infection and mortality rates. Many residents developed either atypical or had no discernible symptoms. A number of asymptomatic staff members also tested positive, suggesting a role for regular screening of both residents and staff in mitigating future outbreaks.

The clinical and cost effectiveness of a virtual fracture clinic service: An interrupted time series analysis and before-and-after comparison.

OBJECTIVES: To assess the clinical and cost-effectiveness of a virtual fracture clinic (VFC) model, and supplement the literature regarding this service as recommended by The National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association (BOA). METHODS: This was a retrospective study including all patients (17 116) referred to fracture clinics in a London District General Hospital from May 2013 to April 2016, using hospital-level data. We used interrupted time series analysis with segmented regression, and direct before-and-after comparison, to study the impact of VFCs introduced in December 2014 on six clinical parameters and on local Clinical Commissioning Group (CCG) spend. Student's t-tests were used for direct comparison, whilst segmented regression was employed for projection analysis. RESULTS: There were statistically significant reductions in numbers of new patients seen face-to-face (140.4, sd 39.6 versus 461.6, sd 61.63, p < 0.0001), days to first orthopaedic review (5.2, sd 0.66 versus 10.9, sd 1.5, p < 0.0001), discharges (33.5, sd 3.66 versus 129.2, sd 7.36, p < 0.0001) and non-attendees (14.82, sd 1.48 versus 60.47, sd 2.68, p < 0.0001), in addition to a statistically significant increase in number of patients seen within 72-hours (46.4% 3873 of 8345 versus 5.1% 447 of 8771, p < 0.0001). There was a non-significant increase in consultation time of 1 minute 9 seconds (14 minutes 53 seconds sd 106 seconds versus 13 minutes 44 seconds sd 128 seconds, p = 0.0878). VFC saved the local CCG £67 385.67 in the first year and is set to save £129 885.67 annually thereafter. CONCLUSIONS: We have shown VFCs are clinically and cost-effective, with improvement across several clinical performance parameters and substantial financial savings for CCGs. To our knowledge this is the largest study addressing clinical practice implications of VFCs in England, using robust methodology to adjust for pre-existing trends. Further studies are required to appreciate whether our results are reproducible with local variations in the VFC model and payment tariffs.Cite this article: A. McKirdy, A. M. Imbuldeniya. The clinical and cost effectiveness of a virtual fracture clinic service: An interrupted time series analysis and before-and-after comparison. Bone Joint Res 2017;6:-269. DOI: 10.1302/2046-3758.65.BJR-2017-0330.R1.

PP060. Matrix metalloproteinases-2 and -9 and their inhibitors: A role in the development of pre-eclampsia?

INTRODUCTION: Pre-eclampsia (PE) is a common and potentially life-threatening condition, affecting 3-10% pregnancies[1]. Placentation has been shown to be deficient in PE and this may be a result of impaired trophoblast invasion [1]. Matrix metalloproteinases (MMPs) are zinc-dependent enzymes which may be important in trophoblast invasion. The activity of MMPs is regulated by tissue inhibitors (TIMPs) and it has been proposed that alterations in MMP/TIMP levels may alter net MMP activity and play a part in both the early and late pathophysiology of pre-eclampsia [2]. Previous studies have largely looked at both active and latent MMP-9 and there is a need for more studies looking specifically at the active forms of these enzymes. OBJECTIVES: The aims of this study were to characterise active MMP-9 expression throughout normal gestation by immunohistochemical localisation, and to compare the levels of MMP-2, -9 (both pro and active) and TIMP-2 in normal and pre-eclamptic term placentae. METHODS: Immunohistochemical localisation of active MMP-9 was carried out on a gestational series of normal placentae from 6-41 weeks' gestation. Quantification of MMP and TIMP levels in term healthy (n=12), pre-eclamptic (n=16) and IUGR (n=12) placental homogenates was done by gelatin-substrate zymography and ELISA. Placentae from IUGR and healthy pregnancies were used as controls to allow us to identify and PE-specific alterations. RESULTS: Using immunohistochemical localisation, we demonstrated a negative relationship between gestational age and active MMP-9 expression throughout normal gestation (p=0.012). The zymographic and ELISA results showed no significant difference in MMP-2, MMP-9 or TIMP-2 levels in placenta from the healthy, pre-eclamptic and IUGR groups (p>0.05). CONCLUSION: To our knowledge, this is the first report using immunohistochemistry to specifically localise the active form of MMP-9 in a gestational series of this size. Our findings demonstrate that there may be high MMP-9 activity during early gestation, which is consistent with a key role for this enzyme in the process of placentation. Thus, it is important to determine if MMP-9 activity is abnormal in PE. In term placentae no difference was found in protein levels of MMPs and TIMPs between control and PE samples; further studies are ongoing to study the MMP and TIMP mRNA expression in these samples.

Clinical and biochemical abnormalities in coppersmiths exposed to cadmium.

5(18.5%) of a group 27 coppersmiths exposed to cadmium fume had stone disease. When compared with a control group of assembly workers in the same factory they had evidence of renal impairment as shown by blood biochemistry and proteinuria. A greater tendency to liver damage was found in the coppersmiths. There was evidence that restrictive airways disease was more common in the coppersmiths than in the control group. Blood-cadmium concentrations were significantly higher in the coppersmiths and in the assembly workers than in a reference population.