Scottish Index of Multiple Deprivation (SIMD) indicators as predictors of mortality among patients hospitalised with COVID-19 disease in the Lothian Region, Scotland during the first wave: a cohort study.

BACKGROUND: Sars-CoV-2, the causative agent of COVID-19, has led to more than 226,000 deaths in the UK and multiple risk factors for mortality including age, sex and deprivation have been identified. This study aimed to identify which individual indicators of the Scottish Index of Multiple Deprivation (SIMD), an area-based deprivation index, were predictive of mortality. METHODS: This was a prospective cohort study of anonymised electronic health records of 710 consecutive patients hospitalised with Covid-19 disease between March and June 2020 in the Lothian Region of Southeast Scotland. Data sources included automatically extracted data from national electronic platforms and manually extracted data from individual admission records. Exposure variables of interest were SIMD quintiles and 12 indicators of deprivation deemed clinically relevant selected from the SIMD. Our primary outcome was mortality. Age and sex adjusted univariable and multivariable analyses were used to determine measures of association between exposures of interest and the primary outcome. RESULTS: After adjusting for age and sex, we found an increased risk of mortality in the more deprived SIMD quintiles 1 and 3 (OR 1.75, CI 0.99-3.08, p = 0.053 and OR 2.17, CI 1.22-3.86, p = 0.009, respectively), but this association was not upheld in our multivariable model containing age, sex, Performance Status and clinical parameters of severity at admission. Of the 12 pre-selected indicators of deprivation, two were associated with greater mortality in our multivariable analysis: income deprivation rate categorised by quartile (Q4 (most deprived): 2.11 (1.20-3.77) p = 0.011)) and greater than expected hospitalisations due to alcohol per SIMD data zone (1.96 (1.28-3.00) p = 0.002)). CONCLUSIONS: SIMD as an aggregate measure of deprivation was not predictive of mortality in our cohort when other exposure measures were accounted for. However, we identified a two-fold increased risk of mortality in patients residing in areas with greater income-deprivation and/or number of hospitalisations due to alcohol. In areas where aggregate measures fail to capture pockets of deprivation, exploring the impact of specific SIMD indicators may be helpful in targeting resources to residents at risk of poorer outcomes from Covid-19.

Evaluation of oral and perioral irritation and sensitization potential of a whitening gel and a whitening toothpaste containing potassium monopersulfate.

PURPOSE: Two clinical trials were conducted to investigate the oral and perioral irritation and sensitization potential of a tooth whitening leave-on-gel alone and in combination with a whitening toothpaste, each containing 1.0% of the active ingredient potassium monopersulfate (MPS). METHODS: Both clinical trials were Institutional Review Board (IRB) approved, double-blind, randomized, and parallel group designed studies. For the MPS leave-on gel study, 200 qualifying and consented subjects were randomly assigned to two groups: (1) 0.1% hydrogen peroxide (H2O2) gel pen (34 subjects); and (2) 0.1% H2O2 + 1.0% MPS gel pen (166 subjects). Subjects used the assigned products according to instructions provided and returned on Days 22 and 36 for oral and perioral tissue examination (pre-challenge). At the Day 36 visit, the subject applied the assigned gel on site (challenge) and received oral and perioral tissue examinations 1 and 24 hours following the application to detect any post-challenge tissue reactions. For the MPS toothpaste/MPS gel pen study, 200 qualifying and consented subjects were randomly assigned to three groups: (1) Placebo toothpaste + placebo gel pen (66 subjects); (2) 1.0% MPS toothpaste + 1.0% MPS gel pen (67 subjects); and (3) 1.0% MPS toothpaste + placebo gel pen (67 subjects). The study design and procedures were the same as those for the MPS gel pen study described above. RESULTS: For the MPS gel pen study, 192 subjects completed the study. None of the eight dropouts was related to the product use. The demographic data were comparable between the two groups. No evidence of tissue irritation and sensitization was detected in any subjects at any visit, and the findings were comparable between the groups. The detected and self-reported tissue issues were minimal and minor, and they were comparable between the two groups. For the MPS toothpaste/MPS gel pen study, 200 subjects were enrolled with 12 dropped from the study, resulting in an overall dropout rate of 6%. Of the 12 that did not complete the study, none were due to product-related use. The demographic data were comparable among the three groups. The detected and self-reported tissue issues were minimal and minor, and they were comparable among the three groups. CLINICAL SIGNIFICANCE: Potassium monopersulfate (MPS) at the active concentration of 1.0% in the tooth whitening leave-on-gel and the toothpaste plus the gel did not cause oral/perioral irritation nor sensitization.

Diagnostic performance of the combined nasal and throat swab in patients admitted to hospital with suspected COVID-19.

BACKGROUND: Accurate diagnosis in patients with suspected coronavirus disease 2019 (COVID-19) is essential to guide treatment and limit spread of the virus. The combined nasal and throat swab is used widely, but its diagnostic performance is uncertain. METHODS: In a prospective, multi-centre, cohort study conducted in secondary and tertiary care hospitals in Scotland, we evaluated the combined nasal and throat swab with reverse transcriptase-polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in consecutive patients admitted to hospital with suspected COVID-19. Diagnostic performance of the index and serial tests was evaluated for a primary outcome of confirmed or probable COVID-19, and a secondary outcome of confirmed COVID-19 on serial testing. The diagnosis was adjudicated by a panel, who recorded clinical, laboratory and radiological features blinded to the test results. RESULTS: We enrolled 1368 consecutive patients (median age 68 [interquartile range, IQR 53-80] years, 47% women) who underwent a total of 3822 tests (median 2 [IQR 1-3] tests per patient). The primary outcome occurred in 36% (496/1368), of whom 65% (323/496) and 35% (173/496) had confirmed and probable COVID-19, respectively. The index test was positive in 255/496 (51%) patients with the primary outcome, giving a sensitivity and specificity of 51.4% (95% confidence interval [CI] 48.8 to 54.1%) and 99.5% (95% CI 99.0 to 99.8%). Sensitivity increased in those undergoing 2, 3 or 4 tests to 60.1% (95% CI 56.7 to 63.4%), 68.3% (95% CI 64.0 to 72.3%) and 77.6% (95% CI 72.7 to 81.9%), respectively. The sensitivity of the index test was 78.9% (95% CI 74.4 to 83.2%) for the secondary outcome of confirmed COVID-19 on serial testing. CONCLUSIONS: In patients admitted to hospital, a single combined nasal and throat swab with RT-PCR for SARS-CoV-2 has excellent specificity, but limited diagnostic sensitivity for COVID-19. Diagnostic performance is significantly improved by repeated testing.

Two cases of imported respiratory diphtheria in Edinburgh, Scotland, October 2019.

We report two cases of respiratory toxigenic Corynebacterium diphtheriae infection in fully vaccinated UK born adults following travel to Tunisia in October 2019. Both patients were successfully treated with antibiotics and neither received diphtheria antitoxin. Contact tracing was performed following a risk assessment but no additional cases were identified. This report highlights the importance of maintaining a high index of suspicion for re-emerging infections in patients with a history of travel to high-risk areas outside Europe.

Hypothesis-driven weight-of-evidence analysis of endocrine disruption potential: a case study with triclosan.

Triclosan is an antimicrobial agent used in a range of consumer products, such as deodorants, oral care, clothing, and household items. As with many consumer products, triclosan can be rinsed down the drain and transported to wastewater treatment plants. While most is eliminated during activated sludge sewage treatment by biodegradation and adsorption, some triclosan enters the aquatic environment and may expose wildlife. Given the potential for exposure to both humans and wildlife, resolving whether triclosan is endocrine active is important due to growing concerns about potential adverse public health and environmental effects of endocrine-disrupting substances. A weight of evidence (WoE) analysis focusing on specific hypotheses related to interaction with estrogen, androgen, and thyroid hormone pathways, and steroidogenesis was applied to triclosan. This WoE procedure involved systematic consideration of each endpoint, focused on screening level studies in the US Endocrine Disruptor Screening Program, as well as those in levels 1 through 5 of the OECD Conceptual Framework. This was followed by a semiquantitative relevance weighting of each endpoint to a given hypothesis to reach scientifically justified conclusions. Use of all relevant and reliable information and consistent observations in multiple studies strengthen support for or against each mode of action hypothesis. Using data from multiple animal species and in vitro systems, this systematic and transparent WoE assessment indicated that triclosan is not acting as an agonist or antagonist within the estrogen, androgen, thyroid, or steroidogenic pathways and is not impacting endocrine pathways as a lead or primary mode of toxicity.

Performance status: A key factor in predicting mortality in the first wave of COVID-19 in South-East Scotland.

BACKGROUND: COVID-19 mortality risk factors have been established in large cohort studies; long-term mortality outcomes are less documented. METHODS: We performed multivariable logistic regression to identify factors associated with in-patient mortality and intensive care unit (ICU) admission in symptomatic COVID-19 patients admitted to hospitals in South-East Scotland from 1st March to 30th June 2020. One-year mortality was reviewed. RESULTS: Of 726 patients (median age 72; interquartile range: 58-83 years, 55% male), 104 (14%) required ICU admission and 199 (27%) died in hospital. A further 64 died between discharge and 30th June 2021 (36% overall 1-year mortality). Stepwise logistic regression identified age >79 (odds ratio (OR), 4.77 (95% confidence interval (CI), 1.96-12.75)), male sex (OR, 1.83 (95% CI, 1.21-2.80)) and higher European Cooperative Oncology Group/World Health Organization performance status as associated with higher mortality risk. DISCUSSION: Poor functional baseline was the predominant independent risk factor for mortality in COVID-19. More than one-third of individuals had died by 1 year following admission.

Influence of age on behavioral, immune and endocrine responses to the T-cell superantigen staphylococcal enterotoxin A.

Aged subjects are more vulnerable to administration of the endotoxin lipopolysaccharide, but research on age-associated sensitivity to other immune stimulants has been limited. The current study examined the effects of administering the superantigen, staphylococcal enterotoxin A (SEA), to young (4-month-old) and aged (20-month-old) male C57BL/6J mice on consumption of a novel liquid, cytokine production, corticosterone levels, and expression of central mRNA levels of cytokines and corticotropin-releasing hormone. SEA produced exaggerated hypophagia in aged mice, as they showed decreased consumption that persisted for 24 h. SEA increased hypothalamic mRNA levels of interleukin-1beta in the aged, but not the young, mice 2 h after administration. No differences in cytokine expression were observed 24 h after SEA. Both age groups showed increased plasma corticosterone levels 2 h after SEA administration. However, 24 h after SEA exposure the aged, but not the young, mice showed an augmented corticosterone response to the consumption test. Collectively, these data show that aging may exacerbate the behavioral and neuroinflammatory response to superantigen exposure. Further, the present study suggests that immune activation may result in delayed alterations in stress-induced corticosterone production in aged subjects.

Medaka (Oryzias latipes) Multigeneration Test with Triclosan.

The medaka extended one-generation reproduction test (MEOGRT) is a tier-2 study in the US Environmental Protection Agency's Endocrine Disruptor Screening Program and a level-5 study in the Organisation for Economic Co-operation and Development's conceptual framework. Integrating nonspecific apical and endocrine-specific mechanistic endpoints, results of a MEOGRT can be used, with other data, in a weight-of-evidence evaluation to establish a dose-response relationship for risk assessment and identify potential causal relationships between an endocrine mode of action and adverse effects. The MEOGRT test design was used to evaluate the multigenerational effects of the antimicrobial agent triclosan. Japanese medaka were exposed to nominal concentrations of 1.4, 2.8, 5.6, 11, and 23 µg/L triclosan and a dilution water control starting with adult medaka (F0) through hatch in the second generation (F2). No consistent or concentration-related responses occurred in the 182-d test that suggested an endocrine-mediated effect. There were no impacts on hepatic vitellogenin, secondary sex characteristics, or sex ratio that were linked to an adverse reproductive outcome. Histopathological responses were consistent with a toxic or stress effect, particularly when considered in context with observed reductions in growth. The overall population-relevant no-observed-effect concentration was 11 µg/L based on effects on growth. The results of the present study support a previously conducted weight-of-evidence evaluation concluding that triclosan does not act as an agonist or antagonist within estrogen, androgen, thyroid, or steroidogenic pathways. Environ Toxicol Chem 2019;38:1770-1783. © 2019 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals, Inc. on behalf of SETAC.

Relationship of varying patterns of cytokine production to the anorexic and neuroendocrine effects of repeated Staphylococcal enterotoxin A exposure.

Staphylococcal enterotoxin A (SEA) is a superantigen that stimulates T cells and induces the production of multiple cytokines. Previous studies have shown that SEA augments gustatory neophobia and activates the hypothalamic-pituitary-adrenal (HPA) axis. This study aimed to determine if the cytokine response, behavioral effects, and HPA axis activation persisted after repeated SEA treatment. Male C57BL/6J mice were given 1-4 intraperitoneal injections of 5 microg SEA, after which food intake, corticosterone, or peripheral cytokines were measured. In a series of experiments, it was found that secondary exposure to SEA two or three days after priming increased corticosterone, but attenuated splenic TNFalpha, while augmenting IL-1beta, IL-2, and IFNgamma. The anorexic response was intact after secondary exposure, but absent after a third injection, which was still able to elevate corticosterone. It is unlikely that IL-1 mediated the persistent effects on corticosterone, since this was increased in groups lacking corticosterone elevations. Similarly, TNFalpha was only modestly elevated under repeated SEA conditions that elevated plasma corticosterone. This attenuation appeared to be inversely related to the levels of IL-10, the production of which incrementally rose with each successive injection. In conclusion, repeated exposure to SEA activates the HPA axis and alters behavior. However, there may be dissociation between the behavioral and endocrine effects of SEA with increased SEA exposure. Furthermore, it is possible that while TNFalpha was previously shown to be important in response to acute SEA-induced HPA axis activation, further exposure to SEA elicits other cytokines that may exert neuromodulatory effects through sensitization and/or synergistic mechanisms.

Improving the communication between teams managing boarded patients on a surgical specialty ward.

Transferring patients from the ward of their specialty or consultant is described as boarding. 1 Boarding patients is becoming increasingly prevalent due to greater pressure on hospital capacity. This practice compromises patient safety through delayed investigations, prolonged hospital stays, and increased risk of hospital-acquired infections. 1 2 We evaluated how regularly boarded patients were reviewed, and how effectively information regarding their management was communicated from their primary specialty to ward staff. We aimed to improve the frequency of patient reviews by ensuring that each patient was reviewed every weekday and increase communication between primary specialty, and medical and nursing teams by 20% from baseline during the data collection period. The project was based in the Otolaryngology ward in Ninewells Hospital, Dundee, where there was a high prevalence of boarded patients. Baseline data showed a clear deficit in communication between the primary specialty and ward staff with only 31% of patient reviews being communicated to ward doctors. We designed and implemented a communication tool, in the form of a sticker, to be inserted into patients' medical notes for use by the primary specialty. Implementation of the sticker improved communication between teams as stickers were completed in 93% of instances. In 88% of patient reviews, the junior doctor was informed of the management plan, showing a large increase from baseline. Through PDSA cycles, we aimed to increase the sustainability and reliability of the sticker; however, we faced challenges with sustainability of sticker insertion. We aim to engage more stakeholders to raise awareness of the problem, brainstorm solutions together, and review the production and implementation of stickers with senior hospital management to discuss the potential use of this tool within practice. There is potentially a large scope for utilisation of this communication tool on a local level, which we hope will significantly improve patient safety.

Introduction of a junior doctors' handbook: an essential guide for new doctors.

The transition period for new junior doctors is a daunting and challenging time, as vast amounts of information specific to each hospital, ward, and job must be learnt while maintaining patient care standards.[1] In NHS Tayside, Scotland, tips and guidance for each job are informally handed over from previous junior doctors to the next, resulting in an unreliable and unsustainable handover of information. Time must then be spent by new doctors learning the intricacies and practicalities of their new job, rather than spending time focusing on patient care. Our aim was to improve this transition period for new junior doctors to NHS Tayside through the creation and implementation of a junior doctors' handbook, which would provide information and practical advice on day to day life as a junior doctor. We hoped to implement this project by August 2015 to coincide with the arrival of these new doctors to NHS Tayside. Through repeat PDSA cycles we created a sustainable and reliable junior doctors' handbook, containing a centralised hub of information for doctors that was accessible through our health board's website. The junior doctors' handbook has been a highly beneficial resource that has been praised for its detailed information on all aspects of day to day life for doctors in NHS Tayside. Feedback also demonstrated that doctors felt the junior doctors' handbook had improved their efficiency. Our hope is that this project can continue to be developed within our hospital, but also to be used as an idea outside our health board to improve the transition period for new doctors on a wider scale.

Impact of superantigenic molecules on central nervous system function.

Superantigens (SAgs) activate the immune system by stimulating massive proliferation of T cells in a major histocompatibility complex (MHC)-dependent manner. This excessive increase in T cells results in the release of cytokines such as interleukin-2 (IL-2), interferon-gamma (IFNgamma), and tumor necrosis factor-alpha (TNFa). As an adaptive feedback mechanism, SAgs can also activate the hypothalamic pituitary adrenal (HPA) axis by stimulating the release of corticotropin releasing hormone (CRH) from the hypothalamus, adrenocorticotropic hormone (ACTH) from the anterior pituitary, and ultimately corticosterone (CORT) from the adrenal gland. Additionally, SAg exposure modifies behavior, although it has not been shown to induce malaise or decrease mobility. Some behavioral consequences include increased gustatory neophobia, neophobia to inanimate non-gustatory objects, and heightened anxiety. Cytokines such as TNFa have been shown to mediate some of these behavioral consequences as well as the endocrine and neurobiological effects of SAg exposure. The particular behavioral repertoire and cytokine profiles observed are in some cases unique to SAgs, as compared to other immune challenges such as lipopolysaccharide (LPS). Therefore, SAgs serve as a useful model to understand the behavioral, endocrine, and neurobiological effects of a T cell driven immune response.

Effects of acute and repeated exposure to lipopolysaccharide on cytokine and corticosterone production during remyelination.

Chronic exposure to the copper-chelating agent, cuprizone (CPZ), is an increasingly popular model for producing demyelination. More importantly, cessation of cuprizone exposure allows for full remyelination, which represents a window of opportunity for determining the influence of environmental factors on regenerative processes. In the present study, CPZ-treated animals were assessed for functional status of systemic and central cytokine responsiveness to LPS, as well as assessment for signs of body weight changes. Exposure of male C57BL/6J mice to 5 weeks of 0.2% CPZ in the diet was optimal in producing demyelination and microglial activation, as measured by myelin basic protein, CD11b, and CD45 immunohistochemistry. Acute challenge with LPS at the end of 5 weeks CPZ treatment did not alter IL-1beta, IL-6, nor TNFalpha responses in the spleen and corpus callosum. Similarly, repeated exposure to LPS during the remyelination phase (CPZ removal) did not influence these measures to LPS. Plasma corticosterone was unaffected following acute challenge of CPZ-pretreated animals, but after repeated LPS treatment, there was a significant augmentation of the corticosterone response in CPZ-pretreated mice. Interestingly, the basal concentration of IL-1beta in the corpus callosum of CPZ treated animals was significantly increased, which was in keeping with the increase in activated microglial cells. In conclusion, the cuprizone model of demyelination and remyelination does not appear to influence the systemic nor central IL-1, IL-6, and TNF responses to acute nor repeated LPS. This opens up the possibility for studying the contribution of systemic inflammatory processes on remyelination after cessation of CPZ treatment.