Perioperative fluid management and associated complications in children receiving kidney transplants in the UK.

BACKGROUND: Intravenous fluid administration is an essential part of perioperative care for children receiving a kidney transplant. There is a paucity of evidence to guide optimal perioperative fluid management. This study aimed to identify the volume of perioperative fluids administered across 5 UK paediatric kidney transplant centres and explore associations between fluid volume administered, graft function, and fluid-related adverse events. METHODS: Data were collected from five UK paediatric kidney transplant centres on perioperative fluid volumes administered, and incidence of pulmonary oedema, systemic hypertension, and requirement for intensive care support. Children < 18 years of age who received a kidney-only transplant between 1st January 2020 and 31st December 2021 were included. RESULTS: Complete data from 102 children were analysed. The median total volume of fluid administered in 72 h was 377 ml/kg (IQR 149 ml/kg) with a high degree of variability. A negative relationship between total fluid volume administered and day 7 eGFR was noted (p < 0.001). Association between urine volume post-transplant and day 7 eGFR was also negative (p < 0.001). Adverse events were frequent but no significant difference was found in the fluid volume administered to those who developed an adverse event, vs those who did not. CONCLUSIONS: This study describes a high degree of variability in perioperative fluid volumes administered to children receiving kidney transplants. Both fluid volume and urine output were negatively associated with short-term graft function. These data contrast traditional interpretation of high urine output as a marker of graft health, and highlight the need for prospective clinical trials to optimise perioperative fluid administration for this group. A higher resolution version of the Graphical abstract is available as Supplementary information.

An audit of antibiotic prescribing in primary care 2019-2020 in Dunmanway Primary Care Centre.

INTRODUCTION: Antibiotics are often the most common medication prescribed by general practitioners (GPs) and are often expected by patients despite campaigns such as Under the Weather. Antibiotic resistance is increasing in the community. The Health Service Executive (HSE) has issued 'Guidelines for Antimicrobial Prescribing in Primary Care in Ireland' aiming to optimise safe prescribing. This audit aims to analyse change in quality of prescribing after educational intervention. METHODS: GP prescribing patterns were analysed over a week in October 2019 and re-audited in February 2020. Anonymous questionnaires detailed demographics, condition and antibiotic details. Educational intervention included texts, information and review of current guidelines. Data were analysed on a password protected spreadsheet. The HSE Guidelines for Antimicrobial Prescribing in Primary Care were taken as reference standard. A standard of 90% compliance for choice of antibiotic and 70% compliance for dose and course was agreed. RESULTS: FindingsAuditRe-AuditNumber prescriptions4024Number delayed scripts4/40=10%1/24=4.2%Adult37/40=92.5%19/24=79.2%Child3/40=7.5%5/24=20.8%IndicationURTI22.50%25%LRTI10%4%Other RTI37.50%42%UTI20%29%Skin12.50%0%Gynaecological2.50%0%2+ Infections 5%0%Co-amoxiclav17.50%12.50%AdherenceChoice37/40=92.5%22/24=91.7%Dose28/39=71.8%17/24=70.8%Course28/40=70%12/24=50%Discussion: Excellent antibiotic choice and dose concordance with guidelines was noted, with both phases meeting the set standards. Suboptimal course compliance with guidelines occurred in the re-audit. Potential causes include concerns regarding resistance and patient factors not included. This audit included unequal number of prescriptions in each phase but are still of significance and addresses a clinically relevant topic.

Genetic and functional insights into CDA-I prevalence and pathogenesis.

BACKGROUND: Congenital dyserythropoietic anaemia type I (CDA-I) is a hereditary anaemia caused by biallelic mutations in the widely expressed genes CDAN1 and C15orf41. Little is understood about either protein and it is unclear in which cellular pathways they participate. METHODS: Genetic analysis of a cohort of patients with CDA-I identifies novel pathogenic variants in both known causative genes. We analyse the mutation distribution and the predicted structural positioning of amino acids affected in Codanin-1, the protein encoded by CDAN1. Using western blotting, immunoprecipitation and immunofluorescence, we determine the effect of particular mutations on both proteins and interrogate protein interaction, stability and subcellular localisation. RESULTS: We identify six novel CDAN1 mutations and one novel mutation in C15orf41 and uncover evidence of further genetic heterogeneity in CDA-I. Additionally, population genetics suggests that CDA-I is more common than currently predicted. Mutations are enriched in six clusters in Codanin-1 and tend to affect buried residues. Many missense and in-frame mutations do not destabilise the entire protein. Rather C15orf41 relies on Codanin-1 for stability and both proteins, which are enriched in the nucleolus, interact to form an obligate complex in cells. CONCLUSION: Stability and interaction data suggest that C15orf41 may be the key determinant of CDA-I and offer insight into the mechanism underlying this disease. Both proteins share a common pathway likely to be present in a wide variety of cell types; however, nucleolar enrichment may provide a clue as to the erythroid specific nature of CDA-I. The surprisingly high predicted incidence of CDA-I suggests that better ascertainment would lead to improved patient care.

Supporting a Learning System in Pediatric Emergency Pathways: Using Organizational Comparisons, Serious Incidents, and Near-Miss Events to Improve the Diagnosis and Treatment of Testicular Torsion.

BACKGROUND: Scrotal pain is a common presentation to the emergency department requiring prompt investigation and management to identify testicular torsion and increase the opportunity for testicular salvage. Using national data obtained from the NHS Improvement, we aim to identify key suboptimal areas in the acute diagnosis and management of testicular torsion with a view to learning from these and improving outcomes. METHODS: A freedom of information request was made to all 134 hospital groups in England and Wales that manage testicular torsion. Serious incidents experienced by these hospitals were analyzed to see whether those with pediatric emergency departments fared better than those without. In addition, a qualitative thematic analysis of the NHS Improvement National Reporting and Learning System database over a 12-year period (2007-2019) was undertaken, to identify common themes associated with orchidectomies and "near-miss" events in the pediatric population. RESULTS: Three hundred four patient safety incidents were returned and divided into 62 orchidectomies and 242 near-miss events. The most common factor in the orchidectomy group was individual factors (83.9%). Misdiagnosis of symptomatic testicle was not significant when comparing ED to specialist surgeons (odds ratio = 1.46, P = 0.3842). Atypical presentation resulting in orchidectomy was significant when comparing ED with specialists (odds ratio = 6, P = 0.0355). Near-miss events, not leading to orchidectomy, are often due to a wider variety of factors. A Mann-Whitney U test showed that there was no statistical significance in incidents when comparing general ED units caring for all ages with pediatric EDs in terms of incidents ( U = 807.5, z = -1.124, P = 0.261). CONCLUSIONS: There is a need for education in ED about atypical presentation of testicular torsion and examination of scrotum in cases of lower abdominal pain. It is also vital that specialist teams are cognizant of the standard operating procedures relevant to scrotal pain and testicular within the organization and the wider clinical network. Finally, there should be a drive for annual collation of data in urology and ED units with regards to testicular torsion as patient safety incidents may be underreported.

Recapitulation of erythropoiesis in congenital dyserythropoietic anaemia type I (CDA-I) identifies defects in differentiation and nucleolar abnormalities.

The investigation of inherited disorders of erythropoiesis has elucidated many of the principles underlying the production of normal red blood cells and how this is perturbed in human disease. Congenital Dyserythropoietic Anaemia type 1 (CDA-I) is a rare form of anaemia caused by mutations in two genes of unknown function: CDAN1 and CDIN1 (previously called C15orf41), whilst in some cases, the underlying genetic abnormality is completely unknown. Consequently, the pathways affected in CDA-I remain to be discovered. To enable detailed analysis of this rare disorder we have validated a culture system which recapitulates all of the cardinal haematological features of CDA-I, including the formation of the pathognomonic 'spongy' heterochromatin seen by electron microscopy. Using a variety of cell and molecular biological approaches we discovered that erythroid cells in this condition show a delay during terminal erythroid differentiation, associated with increased proliferation and widespread changes in chromatin accessibility. We also show that the proteins encoded by CDAN1 and CDIN1 are enriched in nucleoli which are structurally and functionally abnormal in CDA-I. Together these findings provide important pointers to the pathways affected in CDA-I which for the first time can now be pursued in the tractable culture system utilised here.

Testicular Pain Pathway in Children: Investigating Where Missed Torsion Occurs Most Often.

OBJECTIVES: Acute scrotal pain in children is a common presenting complaint in hospital, and it is imperative that cases of testicular torsion are identified and managed promptly. We aim to identify the most influential points in the pathway in determining whether patients are managed in the appropriate time frame, so these areas can be targeted to improve salvage rates. METHODS: Using quality improvement principles, the pediatric scrotal pain pathway was mapped out, commencing with initial symptom onset and ending with definitive surgical management. We retrospectively reviewed data on all patients between 0 and 18 years of age attending the emergency department at Whipps Cross University Hospital with acute scrotal pain between October 2010 and October 2013. RESULTS: Over the 3-year period, 238 patients 18 years or younger presented to casualty with scrotal pain. Of the patients assessed initially by an emergency department physician, 52.8% (n = 67) were discharged without referral. To our knowledge, none of these patients presented later with a missed torsion. Torsion was diagnosed in 23.2% of the patients operated on (n = 22), of which 5 required orchidectomy, comprising 2.1% of all patients presenting with scrotal pain. In this group, 4 were due to late presentation by the patient. CONCLUSIONS: We demonstrate the value of different stages of the pathway, as more than half of patients seen in A&E were correctly discharged without referral. In the context of our study, late presentation to hospital appears to be the most significant factor leading to orchidectomy. To target this issue, awareness among both children and parents must be improved.

National comparative audit of blood transfusion: 2014 audit of transfusion services and practice in children and adults with sickle cell disease.

OBJECTIVES: To determine the organisational resources in place; what blood was being transfused, why, how, where, when and by whom; whether laboratory support and policies met standards for patients with sickle cell disease (SCD). BACKGROUND: SCD affects 14 000 people in the United Kingdom (UK). Standards and guidelines do not cover all aspects of transfusion in SCD and there are no data on their use; people may become very sick without warning presenting to non-specialist hospitals; blood services are increasingly supplying units for transfusion in SCD with little data on their use. METHODS: A retrospective audit of transfusion services/practice for people with SCD who had received a transfusion in January-July 2014 in participating hospitals in the UK and Republic of Ireland (ROI). RESULTS: Eighty-four hospitals submitted 1290 cases, 75% of cases came from 18 hospitals submitting 25 or more cases. Transfusions (91.2% [1164/1276]) were administered to patients with HbSS, 60% (732/1227) of patients needed Rh CE negative blood. Transfusion episodes (4528) were recorded, of which 84% were elective. Stroke prevention accounted for 42% of all transfusions; adults received 56% of transfusions of which 50% were automated red cell exchange (RCE), children received 44% of transfusions of which 87% were simple transfusions. CONCLUSIONS: There was a paucity of appropriate clinical management protocols, adequately trained staff and network arrangements. The high numbers of children being transfused, disparity in transfusion modality between children and adults and the high frequency of the CE negative Rh phenotype were noted.

Thermal and aqueous stability improvement of graphene oxide enhanced diphenylalanine nanocomposites.

Nanocomposites of diphenylalanine (FF) and carbon based materials provide an opportunity to overcome drawbacks associated with using FF micro- and nanostructures in nanobiotechnology applications, in particular their poor structural stability in liquid solutions. In this study, FF/graphene oxide (GO) composites were found to self-assemble into layered micro- and nanostructures, which exhibited improved thermal and aqueous stability. Dependent on the FF/GO ratio, the solubility of these structures was reduced to 35.65% after 30 min as compared to 92.4% for pure FF samples. Such functional nanocomposites may extend the use of FF structures to e.g. biosensing, electrochemical, electromechanical or electronic applications.

Complete genome of an inhibitor-resistant blaTEM-30 encoding Escherichia coli sequence type 127 isolate identified in human saliva with a high genotypic virulence load.

OBJECTIVES: Escherichia coli sequence type (ST) 127 is a pandemic lineage that belongs to the extraintestial pathogenic (ExPEC) family, mainly associated with urinary tract infections and bloodstream infections. Here, we report the complete genome of an E. coli ST 127 isolate which was identified in the saliva of a patient with treatment-resistant schizophrenia (TRS) exhibiting no signs of infection. The objective of this work is to determine the mobile genetic elements (MGEs), antibiotic resistance genes (ARGs), and virulence factors (VFs) that contribute to the pathogenicity of such ST127 isolates. METHODS: Whole-genome sequencing (WGS) of isolate GABEEC10 was performed using DNABseq and Nanopore MinION platforms. Hybrid assembly of GABEEC10 was conducted with Unicycler v. 0.5.0. and annotated using PROKKA v1.14.5. Comparative genomics and phylogenomics were conducted using average nucleotide identity (ANI) and approximately-maximum-likelihood phylogenetic inference. ARGs, VFs, and serotyping were identified with Abricate v1.0.0 using CARD, vfdb, and EcOH databases, respectively. RESULTS: Escherichia coli salivary isolate GABEEC10 was identified to belong to phylogroup B2 and have a serotype of O6 H31 with a total genome length of 4,940,530 bp and a mean guanine-cytosine (GC) content of 50.40 %. GABEEC10 was identified to have a highly virulent genotype with the presence of 84 VFs in addition to 44 ARGs, including an acquired blaTEM-30. The strain was identified to additionally carry four mobilisable plasmids. CONCLUSION: We report the complete genome of E. coli GABAEEC10 that can be used for gaining insights into the pathogenicity, drug resistance mechanisms, and dissemination patterns of the emerging pandemic lineage ST 127.

High-Frequency Electroporation and Chemotherapy for the Treatment of Cutaneous Malignancies: Evaluation of Early Clinical Response.

High-frequency electroporation (HF-EP) with chemotherapy is a novel therapy proposed for both curative and palliative treatment of cutaneous malignancies. The use of high-frequency biphasic pulses is thought to reduce the painful muscle contractions associated with traditional electrochemotherapy (ECT), allowing treatment administration under local anaesthesia. This proof-of-concept study investigated the efficacy and tolerability of HF-EP protocols on a variety of cutaneous malignancies. A total of 97 lesions of five different histological subtypes were treated across 25 patients. At 12 weeks post-treatment, a 91.3% overall lesion response rate was observed (complete response: 79%; partial response: 12.3%), with excellent intraprocedural patient tolerability under local anaesthetic. HF-EP with chemotherapy shows promising results regarding tumour response rates for cutaneous malignancies of varying histological subtypes when compared to traditional ECT protocols. Improved patient tolerability is important, increasing the possibility of treatment delivery under local anaesthesia and potentially broadening the treatment envelope for patients with cutaneous malignancies.

Rural healthcare delivery and maternal and infant outcomes for diabetes in pregnancy: A systematic review.

AIM: The aim of this systematic review was to examine the literature regarding rural healthcare delivery for women with any type of diabetes in pregnancy, and subsequent maternal and infant outcomes. METHODS: Eight databases were searched in September 2020, including Medline, EMCare, CINAHL, EMBASE, Maternity and Infant Care, Cochrane, Rural and Remote Health and Aboriginal and Torres Strait Islander Health bibliography. Studies from high-income countries in rural, regional or remote areas with interventions conducted during the antenatal period were included. Intervention details were reported using the template for intervention description and replication template. Two reviewers independently assessed for risk of bias using the RoB2 and ROBINS I tools. RESULTS: Three articles met the inclusion criteria: two conducted in Australia and one in the United States. A multidisciplinary approach was reported in two of the included studies, which were modified specifically for their respective rural settings. All three studies reported rates of caesarean section, birthweight (grams) and gestational age at birth as maternal and infant outcomes. One study was considered at moderate risk of bias, and two studies were at serious risk of bias. CONCLUSION: There is a significant gap in research relating to healthcare delivery for women with diabetes in pregnancy in rural areas. This lack of research is concerning given that 19% of individuals in high-income countries reside rurally. Further research is required to understand the implications of healthcare delivery models for diabetes in pregnancy in rural areas.

A combined experimental inelastic neutron scattering, Raman and ab initio lattice dynamics study of α-lithium amidoborane.

A combination of inelastic neutron scattering (INS) spectroscopy and Raman spectroscopy with periodic density functional theory calculations is used to provide a complete assignment of the vibrational spectra of α-lithium amidoborane (α-LiNH(2)BH(3)). The Born charge density and the atomic motion up to the decomposition temperature have been modelled. These models not only explain the nature of bonding in α-LiNH(2)BH(3) but also provide an insight into the atomic mechanisms of its decomposition. The (INS) measurements were performed in the range of 0-4000 cm(-1) on the high-resolution time-of-flight TOSCA INS spectrometer at the ISIS Spallation Neutron Source at the Rutherford Appleton Laboratory.

Routine management, healthcare resource use and patient and carer-reported outcomes of patients with transfusion-dependent ß-thalassaemia in the United Kingdom: A mixed methods observational study.

Objectives: We evaluated routine healthcare management, clinical status and patient- and carer-reported outcomes in UK paediatric and adult patients with transfusion-dependent ß-thalassaemia (TDT). Methods: A multi-centre, observational mixed-methodology study evaluated 165 patients (50% male; median age 24.1 [interquartile range (IQR)] 11.8-37.2] years) from nine UK centres. Results: Patients had a mean of 13.7 (standard deviation [SD] ±3.2) transfusion episodes/year (mean retrospective observation period 4.7 [±0.7] years). The median (IQR) for iron overload parameters at the last assessment during the observation period were: serum ferritin (n = 165) 1961.0 (1090.0-3003.0) µg/L (38% > 2500 µg/L); R2 liver iron (n = 119) 5.4 (2.9-11.6) mg/g (16% ≥15 mg/g); T2* cardiac iron (n = 132) 30.3 (22.0-37.1) ms (10% < 10 ms). All patients received ≥1 iron chelator during the observation period; 21% received combination therapy. Patients had a mean of 7.8 (±8.1) non-transfusion-related hospital attendances or admissions/year. Adult patients' mean EQ-5D utility score was 0.69 (±0.33; n = 94 [≥16 years]) and mean Transfusion-dependent quality of life score was 58.6 (±18.4; n = 94 [≥18 years]). For Work Productivity and Activity impairment, mean activity impairment for patients ≥18 years (n = 88) was 48% (±32%) and for carers (n = 29) was 28% (±23%). Conclusions: TDT presents significant burden on patients, carers and healthcare resources.

Potassium(I) amidotrihydroborate: structure and hydrogen release.

Potassium(I) amidotrihydroborate (KNH(2)BH(3)) is a newly developed potential hydrogen storage material representing a completely different structural motif within the alkali metal amidotrihydroborate group. Evolution of 6.5 wt % hydrogen starting at temperatures as low as 80 degrees C is observed and shows a significant change in the hydrogen release profile, as compared to the corresponding lithium and sodium compounds. Here we describe the synthesis, structure, and hydrogen release characteristics of KNH(2)BH(3).