Quantitation of propofol metabolites by LC-MS/MS demonstrating long detection window for urine drug monitoring.

Introduction: Chromatographic methods for analysis of propofol and its metabolites have been widely used in pharmacokinetic studies of propofol distribution, metabolism, and clearance. Application of chromatographic methods is also needed in clinical and forensic laboratories for detecting and monitoring propofol misuse. Objective: We report a method for sensitive analysis of propofol, propofol 1-glucuronide (PG), 4-hydroxypropofol 1-glucuronide (1-QG), 4-hydroxypropofol 4-glucuronide (4-QG) and 4-hydroxypropofol 4-sulfate (4-QS) in urine by LC-MS/MS analysis. The method employs a simple dilute-and-analyze sample preparation with stable isotope internal standardization. Results: Validation studies demonstrate a linear calibration model (100-10,000 ng/mL), with dilution integrity verified for the extended range of concentrations experienced in propofol use. Criteria-based validation was achieved, including an average coefficient of variation of 6.5 % and a percent bias of -4.2 ng/mL. The method was evaluated in 12 surgical patients, with monitoring periods lasting up to 30 days following intravenous propofol administrations of 100-3000 mg on the day of surgery. While the concentration ratio of PG to 4-hydroxy propofol metabolite decreased significantly in the days following surgery, PG maintained the highest concentration in all specimens. Both PG and 1-QG were detectable throughout the monitoring periods, including in a patient monitored for 30 days. Lower concentrations were determined for 4-QG and 4-QS, with evidence of detection up to 20 days. Propofol was not detectable in any urine specimens, thereby proving ineffective for identifying drug use. Conclusion: The validated method for quantifying propofol metabolites demonstrates its applicability for the sensitive detection of propofol misuse over a long window of drug-use detection.

Impact of CFTR Modulation on Pseudomonas aeruginosa Infection in People With Cystic Fibrosis.

BACKGROUND: Pseudomonas aeruginosa is a multidrug-resistant pathogen causing recalcitrant pulmonary infections in people with cystic fibrosis (pwCF). Cystic fibrosis transmembrane conductance regulator (CFTR) modulators have been developed that partially correct the defective chloride channel driving disease. Despite the many clinical benefits, studies in adults have demonstrated that while P. aeruginosa sputum load decreases, chronic infection persists. Here, we investigate how P. aeruginosa in pwCF may change in the altered lung environment after CFTR modulation. METHODS: P. aeruginosa strains (n = 105) were isolated from the sputum of 11 chronically colonized pwCF at baseline and up to 21 months posttreatment with elexacaftor-tezacaftor-ivacaftor or tezacaftor-ivacaftor. Phenotypic characterization and comparative genomics were performed. RESULTS: Clonal lineages of P. aeruginosa persisted after therapy, with no evidence of displacement by alternative strains. We identified commonly mutated genes among patient isolates that may be positively selected for in the CFTR-modulated lung. However, classic chronic P. aeruginosa phenotypes such as mucoid morphology were sustained, and isolates remained just as resistant to clinically relevant antibiotics. CONCLUSIONS: Despite the clinical benefits of CFTR modulators, clonal lineages of P. aeruginosa persist that may prove just as difficult to manage in the future, especially in pwCF with advanced lung disease.

Integrating Healthy Nutrition Standards and Practices Into Food Service Contracting in a Large US County Government.

Purpose and Objectives: Although considered a promising model of practice, integrating healthy nutrition standards and practices into a large county government's contracting process with food vendors has not been widely described in empirical literature. We conducted an implementation evaluation project to address this gap. Intervention Approach: County of Los Angeles food vendors provide food or meals annually to more than 100,000 employees and millions of clients and visitors. In 2011, the County of Los Angeles Board of Supervisors adopted a policy to integrate healthy nutrition standards and practices into its requests for proposals (RFPs) and contracting process with food vendors. The policy required all contracts awarded to adhere to these new standards. Evaluation Methods: In 2011, the Los Angeles County Department of Public Health (DPH) began reviewing RFPs for food services for county departments that procured, served, or sold food. From 2011 through 2021, DPH applied a 4-pronged formative-evaluative approach to help county departments implement the Board of Supervisors policy and ensure that nutritional requirements were appropriately integrated into all RFPs for new and renewing contracts with food vendors. We focused our evaluation on understanding the process and tracking the progress of this policy intervention. Our evaluation included 13 key informant interviews, a 2-part survey, reviews of contract data, and synthesis of lessons learned. Results: Based on reviews and subsequent actions taken on more than 20 RFPs, DPH successfully assisted 7 county departments to incorporate healthy nutrition standards and practices into their food vendor contracts. Implementation of the food policy encountered several challenges, including staffing and training constraints and a limited infrastructure. An iterative approach to program improvement facilitated the process. Implications for Public Health: Although the model for integrating healthy nutrition standards and practices into a government contracting process is promising, more work is needed to make it less resource-intensive and to increase user buy-in.

Fasting Versus a Heart-Healthy Diet Before Cardiac Catheterization: A Randomized Controlled Trial.

BACKGROUND: Patients undergoing cardiac catheterization are ordered to take nothing by mouth after midnight before their procedure with no evidence to support this practice. OBJECTIVE: To identify best practice for fasting requirements before cardiac catheterization through comparative evaluation in a prospective randomized controlled study. METHODS: The study included a convenience sample of 197 patients undergoing elective cardiac catheterization in a progressive inpatient cardiac unit at a regional heart institute in the midwestern United States. The patients were randomized into 2 groups. Patients in the heart-healthy diet group could eat a specified diet with low-acid options until the scheduled procedure. Patients in the fasting group were restricted to nothing by mouth after midnight except for sips of water with medications until the scheduled procedure. Outcome measures included patient-reported satisfaction and complications. RESULTS: Compared with patients in the fasting group, those in the heart-healthy diet group had significantly more satisfaction with the preprocedural diet. Patients in the heart-healthy diet group had less thirst and hunger before and after the procedure. No patients experienced pneumonia, aspiration, intubation, or hypoglycemia after the procedure. Fatigue, glucose level, gastrointestinal issues, and loading dose of antiplatelet medication did not differ between the groups. CONCLUSIONS: Allowing patients to eat before elective cardiac catheterization posed no safety risk and benefited patient satisfaction and overall care. The results of this study may help identify best practice for allowing patients to eat before elective procedures using conscious sedation.

Confirmation of cannabinoids in forensic toxicology casework by isomer-selective UPLC-MS-MS analysis in urine.

Confirmation of cannabinoid use by forensic toxicology testing in urine has been traditionally focused on ∆9-tetrahydrocannabinol (∆9-THC) with analysis of its major metabolite, 11-nor-9-carboxy-∆9-THC (∆9-cTHC), in free and conjugated forms. Legalization of hemp, however, has led to the widespread production and sale of cannabidiol (CBD) derivatives with psycho-activity, including ∆8-THC and ∆10-THC isomers. The increasing availability and growing use of isomer derivatives necessitate an expanded scope of cannabinoid confirmation test protocols. We report a quantitative, isomer-selective method of cannabinoid confirmation by liquid chromatography-tandem mass spectrometry determination of parent drug isomers (∆8-THC, ∆9-THC, ∆10-THC and CBD) as well as isomeric metabolites (∆8-cTHC and ∆9-cTHC). An efficient C18 phase chromatography on 1.6-µm solid core particles was used with a step gradient for near isocratic separation of both early-eluting THC metabolite isomers and later-eluting CBD and THC isomers. A rapid method of hydrolysis, dilution and analysis was employed for the quantitative co-determination of free and conjugated analytes, using stable isotope internal standardization. Method validation is reported, along with interference assessment from a prior confirmation method. Casework experience with the isomer-selective method revealed a 14% prevalence of ∆8-cTHC positive cases with a pattern of concomitant ∆8-THC and ∆9-THC use. A comparison of ∆8-cTHC and ∆9-cTHC phase two metabolism is also reported.

UV irradiance effects on komodo dragon (Varanus komodoensis) vitamin D3, egg production, and behavior: A case study.

Modifications to UV irradiance for indoor housed herpetofauna can affect behavior and physiology. Low ultraviolet B (UVB) irradiance can result in vitamin D3 deficiency resulting in calcium metabolism disorders including metabolic bone disease and immune suppression. High UVB can result in skin and eye issues, which can be severe enough to cause shock and death. Using tools available for the assessment of UV light, including Ferguson zones and the UV working tool designed by the British and Irish Association of Zoos and Aquaria, we redesigned lighting in our indoor komodo dragon (Varanus komodoensis) habitat to better suit the UV requirements of this species, while studying changes in behavior and physiology. We measured serum vitamin 25-hydroxy D3 values in one male and one female komodo dragon before and after they were housed in indoor and outdoor habitats. We also measured behavior changes in our male komodo as he moved from an outdoor habitat, to an indoor habitat with changing UV irradiance. Our female komodo showed a 98% increase in vitamin D3 values after being moved outdoors, and laid her first clutch of eggs. Our male dragon's vitamin D3 remained consistent 200 days after moving inside. He did show increased activity when higher UV irradiance was available. Importantly, we found the UV lamps we used stopped producing desired UV irradiance within 3.5 months of regular use. We suggest all animal care facilities develop UV monitoring programs to research output and longevity of UVB lamps used in indoor herpetofauna habitats.

Anti-Migratory and Cytotoxic Activities of [Ga(8-hydroxyquinolinato)3 ]: Roles of Endogenous Cu(II) and Drug-Induced Phenotypic Changes.

As shown by IncuCyte Zoom imaging proliferation assays, invasive triple-negative human breast MDA-MB-231 cancer cells treated with sub-toxic doses (5.0-20 µM, 72 h) of [GaQ3 ] (Q=8-hydroxyquinolinato) caused profound morphological changes and inhibition of cell migration, which were likely due to terminal cell differentiation or similar phenotypical change. This is the first demonstration of potential use of a metal complex in differentiation anti-cancer therapy. Additionally, a trace amount of Cu(II) (0.20 µM) added to the medium dramatically increased [GaQ3 ] cytotoxicity (IC50 ~2 µM, 72 h) due to its partial dissociation and the action of the HQ ligand as a Cu(II) ionophore, as shown with electrospray mass spectrometry and fluorescence spectroscopy assays in the medium. Hence, cytotoxicity of [GaQ3 ] is strongly linked to ligand binding of essential metal ions in the medium, for example, Cu(II). Appropriate delivery mechanisms of such complexes and their ligands could enable a powerful new triple therapeutic approach for cancer chemotherapy, including cytotoxicity against primary tumour, arrest of metastases, and activation of innate and adaptive immune responses.

Novel Matrix Normalization Technique for Accurate LC-ESI-MS/MS Detection and Quantification of Drugs and Their Metabolites in Toxicology Research and Practice.

Accurate identification and quantification of drugs and their metabolites (analytes) in biological matrices is an analytical foundation of clinical and forensic toxicology. For decades, liquid chromatography interfaced by electrospray ionization with tandem mass spectrometry (LC-ESI-MS/MS) has been a widely used technology for analysis in the field of toxicology, as well as in many other fields of bioscience. It is also known that ion response in LC-ESI-MS/MS analysis is influenced by coeluting biological compounds and that preanalytical sample clean-up is often insufficient in removing these interferences. As a result, a normalization technique is commonly used for assessment and compensation of matrix effects encountered in routine analysis. Internal standardization with a stable isotope analog of the analyte is the predominant normalization technique used in LC-ESI-MS/MS analysis. The technique, however, requires commercial availability or costly custom synthesis of an isotopic analog specific for each analyte. Here we describe an alternative technique for matrix normalization for use in high-volume, multianalyte testing without the need for isotope analogs. The technique involves analysis of the original sample (neat analysis) followed by analysis of a second sample aliquot (spike analysis) that has been fortified with a controlled amount of reference analyte. A calibration procedure similar to internal standardization is employed, using an ion response ratio of neat to fortified analyte. As a demonstration of the technique in multianalyte testing, we provide a detailed protocol for simultaneous detection and quantification of 102 drugs and drug metabolites in human urine. We also provide a support protocol for addition of new analytes to the multianalyte panel, allowing convenient collection of the validation data during routine testing. The matrix normalization technique and testing principles may be applicable to a wide range of analytes and biological matrices, not only those encountered in toxicology but also in other fields of bioscience. © 2023 Wiley Periodicals LLC. Basic Protocol: Detection and quantification of 102 toxicology analytes in urine by LC-ESI-MS/MS analysis using the threshold accurate calibration technique Support Protocol: Method for addition and validation of new analytes to expand the Basic Protocol.

Draft Genome Sequence of Pseudomonas protegens Strain MWU12-2233, Isolated from Wild Cranberry Fruit in Provincetown, Massachusetts.

Pseudomonas protegens strain MWU12-2233 was isolated from wild cranberry fruit surfaces in Provincetown, MA. The genome contains putative hydrogen cyanide synthase and type VI secretion systems which can act symbiotically on plant health by suppressing competitors, indicating a role in indigenous microfloral disease and insect pest suppression.

Clinical status, biochemical profile and management of a single cohort of patients with arginase deficiency.

Arginase deficiency is a rare autosomal recessive urea cycle disorder (UCD) caused by mutations in the ARG1 gene encoding arginase that catalyses the hydrolysis of arginine to ornithine and urea. Patients have hyperargininaemia and progressive neurological impairment but generally suffer fewer metabolic decompensations compared to other UCDs. The objective is to describe the clinical features, biochemical profile, neuroradiological findings and experience of managing children with arginase deficiency. Twenty-year retrospective review of patient medical records at a single metabolic centre was performed. Six patients from three unrelated families were identified. Mean age at first symptom was 3.3 (1.5-9.0) years, while mean age at diagnosis was 8.8 (0.16-15.92) years. Four patients developed spastic diplegia and two of six with spastic quadriplegia with classical features including hyperreflexia, clonus and toe walking. This resulted in gait abnormalities that have been monitored using the GAITRite system and required Achilles tendon release in five children. Generalised tonic-clonic seizures and/or absences were present in three of six children and were controlled with anticonvulsants. All patients had moderate learning difficulties. Neuroimaging showed cerebral/cerebellar atrophy in four patients and basal ganglia abnormalities in two. Arginine levels were universally elevated throughout follow-up despite protein restriction, essential amino acid supplementation and ammonia scavengers, and neurological outcome was generally poor. Two patients died following severe metabolic decompensation in adolescence. Children with arginase deficiency continue to present a management challenge of what appears to be an inexorable course of neurocognitive impairment. Further insight into disease mechanisms may provide insight into novel treatment strategies.

Blisters and Calluses from Rowing: Prevalence, Perceptions and Pain Tolerance.

Background and Objectives: Rowing is a sport that involves constant gripping, pulling/pushing, and rotational movements of the hands, in a cyclic periodic manner with every stroke, with hundreds of strokes being taken within a short period of time. Dermatological issues on rowers' hands (fingers and palms) in the form of blisters and calluses are common knowledge within the community, but their prevalence and the rower's perceptions and pain tolerance to them has never been systematically evaluated. This work addresses these lacunae. Materials and Methods: Analysis of data collected from a survey on a sample of competitive (117) and noncompetitive rowers (28) who row on-water (total 145). Results: It was found that approximately 69% of rowers participating in this study have calluses on their hands for most of their time (considered by them as not painful). The incidence of blisters was found to be lower (but perceived as more painful). Their incidence was found to be fairly independent of the frequency and intensity of training, but they seem to affect most rowers equally at the beginning of season or during a change of position (nonconditioned hands). Blisters and calluses were reported to be mainly located on the proximal phalanges and metacarpo-phalangeal joint area of both hands, i.e., on the lower parts of the fingers and the upper inner palms. Conclusions: Rowers demonstrated a sense of acceptance of these dermatological issues, even a sense of pride in what they represent. The incidence of blisters becoming infected was estimated to be so low that most rowers would not have encountered such serious, albeit rare, consequences.

Improved Patient Safety and Quality Outcomes With Amiodarone Infusions.

BACKGROUND: Amiodarone is a common intravenous medication and a known irritant to the vessel wall when administered peripherally. LOCAL PROBLEM: Nurses identified an increase in phlebitis associated with peripheral amiodarone leading to multiple catheter replacements and interruptions in drug therapy. Central venous access is recommended by the manufacturer but not practical for a short-term infusion based on the risk to the patient, time, and cost. METHODS: A 4-phased approach was used to identify a more suitable peripheral intravenous catheter. INTERVENTIONS: A collaborative effort between bedside nurses and the vascular access team evolved to look at alternative products for peripheral intravenous catheters. RESULTS: The extended dwell peripheral catheter decreased phlebitis from 54% to 5%. It also decreased interruptions in drug therapy and improved patient comfort and satisfaction. CONCLUSIONS: A practice change was implemented utilizing extended dwell peripheral catheters for intravenous amiodarone and disseminated to other units.

Application and Clinical Value of Definitive Drug Monitoring in Pain Management and Addiction Medicine.

OBJECTIVE: To assess routine application and clinical value of definitive urine drug monitoring (UDM) for drug detection, inconsistent drug use, and prescription adherence, along with a comparison to immunoassay screening (IAS). METHODS: Direct-to-definitive UDM performance was analyzed retrospectively in 5000 patient specimens. Drug findings, medication inconsistencies, and detection sensitivity were assessed, and definitive UDM versus IAS monitoring was studied. RESULTS: Definitive testing resulted in 18,793 drug findings with 28,403 positive drug and metabolite tests. Definitive testing expanded monitoring with 11,396 drug findings that would not be tested by IAS. The opioids accounted for the highest frequency of inconsistent positive drug-use findings, at 12%. Conversely, inconsistent negative drug findings, used as an index of prescription non-adherence, were determined in 1,751 of 15,409 monitored medications and included a high frequency of antidepressants and antipsychotics inconsistencies. Direct comparison of definitive UDM and IAS showed false-positives by IAS as well as a high rate of false-negatives that would be missed using current confirmation protocols. CONCLUSIONS: Results from routine application of direct-to-definitive UDM demonstrate the clinical value of drug-use identification and the objective evaluation of inconsistencies in drug misuse and medication adherence in pain management and addiction medicine practice. Without conversion to direct-to-definitive UDM, continuing use of IAS will limit the scope of drugs being tested, will result in an indeterminate rate of false negatives and will require confirmation testing to eliminate the reporting of false-positive IAS tests. The findings in this study provide evidence-based support for recommended use of a direct-to-definitive drug testing protocol.

Physiotherapy for epidermolysis bullosa: clinical practice guidelines.

Epidermolysis bullosa (EB) is characterized by skin fragility with blister formation occurring spontaneously or following minor trauma such as gentle pressure or friction. Current physiotherapy practice is based on anecdotal care, clinical expertise and creative problem solving with caregivers and individuals with EB. Evidence based intervention is needed to establish a foundation of knowledge and to guide international practitioners to create and improve standards of care to effectively work with individuals living with EB. This clinical practice guideline (CPG) was created for the purpose of providing evidence based interventions and best clinical practices for the physiotherapy management of individuals with EB. A survey was conducted within the EB community and six outcomes were identified as a priority to address in physiotherapy management, including (1) attaining developmental motor milestones, (2) identifying safe and functional mobility in the natural environment, (3) encouraging ambulation endurance, (4) supporting safe ability to bear weight, (5) improving access to physiotherapy services, and (6) optimizing interaction with the community. A systematic literature review was conducted and articles were critically analyzed by an international panel consisting of thirteen members: healthcare professionals (including physiotherapist, doctors, and occupational therapist), caregivers, and individuals with EB. Recommendations were formulated from evidence and panel consensus. An external panel of twelve were invited to improve the quality and gather feedback on draft manuscript and recommendations. This CPG describes the development of recommendations for physiotherapy management including several best practice interventions. This guideline lays the foundational work for physiotherapist throughout the world to provide high quality services while improving and maintaining functional mobility and independence within the EB community. The CPG outlines limitations in the evidence available and possible future research needed to improve physiotherapy practice.

Matrix Normalization Techniques for Definitive Urine Drug Testing.

Analytical performance of stable isotope-labeled internal standardization (SIL-IS) and threshold accurate calibration (TAC) methods of matrix normalization are compared for quantitation of 51 drugs and metabolites (analytes) in urine with analysis by ultra performance liquid chromatography with tandem mass spectrometry (UPLC-MS-MS). Two SIL-IS methods of analysis were performed, one method using analyte-specific internal standardization (ASIL-IS) and another method using a shared stable isotope from another analyte for internal standardization (SSIL-IS). Variance in inter-specimen matrix effect, without the use of a matrix normalization method, was studied by UPLC-MS-MS analysis of 338 urine donor samples and showed >200% variation in ion response for some analytes. Matrix normalization methods were evaluated for precision, accuracy, calibration, multi-matrix recovery and positive casework quantitation. Acceptable calibration and quality control criteria were achieved for all methods when calibrators and controls were prepared from the same urine matrix pool. Quantitative accuracy, determined by the addition of analytes to multi-donor urine pools at two concentration levels, resulted in acceptable percent relative standard deviation (%RSD) and bias for TAC and ASIL-IS methods. SSIL-IS method quantitations in analyte-supplemented donor pools revealed a %RSD ranging from 20% to 60% for >30% of the analytes and a method bias that ranged up to 87%, with a differential matrix effect on analyte and shared internal standard accounting for the imprecision and bias. Analyte quantitation in 162 authentic case samples showed close agreement for TAC and ASIL-IS methods, with greater variance in the SSIL-IS method. The study demonstrates effective matrix normalization by ASIL-IS and TAC methods and a matrix-caused bias in the SSIL-IS method.

Interspecific introgression reveals a role of male genital morphology during the evolution of reproductive isolation in Drosophila.

Rapid divergence in genital structures among nascent species has been posited to be an early-evolving cause of reproductive isolation, although evidence supporting this idea as a widespread phenomenon remains mixed. Using a collection of interspecific introgression lines between two Drosophila species that diverged approximately 240,000 years ago, we tested the hypothesis that even modest divergence in genital morphology can result in substantial fitness losses. We studied the reproductive consequences of variation in the male epandrial posterior lobes between Drosophila mauritiana and Drosophila sechellia and found that divergence in posterior lobe morphology has significant fitness costs on several prefertilization and postcopulatory reproductive measures. Males with divergent posterior lobe morphology also significantly reduced the life span of their mates. Interestingly, one of the consequences of genital divergence was decreased oviposition and fertilization, which suggests that a sensory bias for posterior lobe morphology could exist in females, and thus, posterior lobe morphology may be the target of cryptic female choice in these species. Our results provide evidence that divergence in genitalia can in fact give rise to substantial reproductive isolation early during species divergence, and they also reveal novel reproductive functions of the external male genitalia in Drosophila.

Interprofessional Health Care Delivery: Perceptions of oral health care integration in a Federally Qualified Health Center.

Purpose: The purpose of this qualitative ethnographic case study was to explore the perceptions of a team of interprofessional healthcare providers regarding how oral health care was integrated into health care provided within a Federally Qualified Health Center (FQHC) in Brighton, Colorado.Methods: Data were gathered through one-on-one, semi-structured personal interviews, which were recorded and professionally transcribed for evaluation. Purposive sampling included physicians, physician assistants, dentists, and dental hygienists. Descriptive analysis was used to describe the sample demographics. An inductive and deductive approach was utilized to assess the qualitative data and subsequently develop themes. Validity was established using triangulation, member checks, and peer review of data and themes by co-investigators.Results: Eight participants (n=8) were interviewed. Subjects were between the ages of 31 and 58 and had been practicing between 5 and 30 years with an average of 13.6 years and had been employed by the FQHC an average of 6.8 years. Thematic analysis revealed seven themes: interprofessional collaboration supports patient care, immediate consultations lead to improved outcomes for all, shared expertise to optimize care delivery, oral health is health, increased communication through collocation, role clarity does not impede team functioning, and mission driven to provide excellent care. These themes support the domains of patient centered care, communication, and the role clarity of the Interprofessional Care Competency Framework and Team Assessment Toolkit (ICCFTAT).Conclusion: Findings from this study can aid FQHC's in the implementation of integrated oral health care delivery systems. Further research is needed to understand how interprofessional health care collaboration (IPHC) affects the team dynamic in FQHC settings.

A case review to describe variation in care following diagnosis of Perthes' disease.

AIMS: Perthes' disease is a condition which leads to necrosis of the femoral head. It is most commonly reported in children aged four to nine years, with recent statistics suggesting it affects around five per 100,000 children in the UK. Current treatment for the condition aims to maintain the best possible environment for the disease process to run its natural course. Management typically includes physiotherapy with or without surgical intervention. Physiotherapy intervention often will include strengthening/stretching programmes, exercise/activity advice, and, in some centres, will include intervention, such as hydrotherapy. There is significant variation in care with no consensus on which treatment option is best. The importance of work in this area has been demonstrated by the British Society for Children's Orthopaedic Surgery through the James Lind Alliance's prioritization of work to determine/identify surgical versus non-surgical management of Perthes' disease. It was identified as the fourth-highest priority for paediatric lower limb surgery research in 2018. METHODS: Five UK NHS centres, including those from the NEWS (North, East, West and South Yorkshire) orthopaedic group, contributed to this case review, with each entre providing clinical data from a minimum of five children. Information regarding both orthopaedic and physiotherapeutic management over a two-year post-diagnosis period was reviewed. RESULTS: Data were extracted from the clinical records of 32 children diagnosed with Perthes' disease; seven boys and 25 girls. The mean age of the children at diagnosis was 6.16 years (standard deviation (SD) 3.001). In all, 26 children were referred for physiotherapy. In the two-year period following diagnosis, children were seen a median of 7.5 times (interquartile range (IQR) 4.25 to 11) by an orthopaedic surgeon, and a median of 9.5 times (IQR 8 to 18.25) by a physiotherapist. One centre had operated on all of their children, while another had operated on none. Overall, 17 (53%) of the children were managed conservatively in the two-year follow-up period, and 15 (47%) of the children underwent surgery in the two-year follow-up period. CONCLUSION: The results of this case review demonstrate a variation of care provided to children in the UK with Perthes' disease. Further national and international understanding of current care is required to underpin the rationale for different treatment options in children with Perthes' disease.Cite this article: Bone Joint Open 2020;1-11:691-695.

Current infection control practices used in Australian and New Zealand cystic fibrosis centers.

BACKGROUND: The 2013 update of the Infection Prevention and Control (IP&C) Guideline outlined recommendations to prevent the spread of CF respiratory pathogens. We aimed to investigate the current infection control practices used in Australian and New Zealand (NZ) CF centers. METHODS: Two online surveys were distributed to Australian and NZ CF centers regarding the uptake of selected IP&C recommendations. One survey was distributed to all the Medical Directors and Lead CF Nurses and the second survey was distributed to all the Lead CF Physiotherapists. RESULTS: The response rate was 60% (60/100) for medical/nursing and 58% (14/24) for physiotherapy. Over 90% (55/60) of CF centers followed CF-specific infection control guidelines and consistent infection control practices were seen in most CF centers; 76% (41/54) had implemented segregation strategies for ambulatory care and no CF centers housed people with CF in shared inpatient accommodation. However, the application of contact precautions (wearing gloves and apron/gown) by healthcare professionals when reviewing a CF person was variable between CF center respondents but was most often used when seeing CF persons with MRSA infection in both ambulatory care and hospital admission (20/50, 40% and 42/45, 93% of CF centers, respectively). Mask wearing by people with CF was implemented into 61% (36/59) of centers. Hospital rooms were cleaned daily in 79% (37/47) of CF centers and the ambulatory care consult rooms were always cleaned between consults (49/49, 100%) and at the end of the clinic session (51/51, 100%); however the staff member tasked with cleaning changed with 37% (18/49) of CF centers responding that CF multidisciplinary team (MDT) members cleaned between patients whereas at the end of the clinic session, only 12% (6/51) of the CF MDT cleaned the consult room. CONCLUSIONS: Overall, Australian and NZ CF centers have adopted many recommendations from the IP&C. Although, the application of contact precautions was inconsistent and had overall a low level of adoption in CF centers. In ~ 25% of centers, mixed waiting areas occurred in the ambulatory care. Given the variability of responses, additional work is required to achieve greater consistency between centers.