Changing Strategies for the Detection of Bacteria in Platelet Components in Ireland: From Primary and Secondary Culture (2010-2020) to Large Volume Delayed Sampling (2020-2023).

Bacterial contamination of platelet components (PC) poses the greatest microbial risk to recipients, as bacteria can multiply over the course of PC storage at room temperature. Between 2010 and 2020, the Irish Blood Transfusion Service (IBTS) screened over 170,000 buffy coat-derived pooled (BCDP) and single-donor apheresis platelets (SDAPs) with the BACT/ALERT 3D microbial detection system (Biomerieux, L'Etoile, France), using a two-step screening protocol which incorporated primary and secondary cultures. Although the protocol was successful in averting septic transfusion reactions (STRs), testing large sample volumes at later time points was reported to improve detection of bacterial contamination. A modified large-volume delayed sampling (LVDS)-type protocol was adopted in 2020, which in the case of SDAP was applied to collections rather than individual splits (2020-2023, 44,642 PC screened). Rates of bacterial contamination for BCDP were 0.125% on Day-2, 0.043% on Day-4 vs. 0.191% in the post-LVDS period. SDAP contamination rates in the pre-LVDS period were 0.065% on Day-1, 0.017% on Day-4 vs. 0.072% in the post-LVDS period. Confirmed STRs were absent, and the interdiction rate for possibly contaminated SDAP was over 70%. In the post-LVDS period, BCDPs had a higher total positivity rate than SDAPs, 0.191% (1:525) versus 0.072% (1:1385), respectively, (chi-squared 12.124, 1 df, p = 0.0005). The majority of organisms detected were skin-flora-type, low pathogenicity organisms, including coagulase-negative staphylococci and Cutibacterium acnes, with little change in the frequency of clinically significant organisms identified over time. Both protocols prevented the issue of potentially harmful components contaminated (rarely) with a range of pathogenic bacteria, including Escherichia coli, Serratia marcesens, Staphylococcus aureus, and streptococci. Culture positivity of outdates post-LVDS whereby 100% of expired platelets are retested provides a residual risk estimate of 0.06% (95% CI 0.016-0.150). However, bacterial contamination rates in expired platelets did not demonstrate a statistically significant difference between the pre-LVDS 0.100% (CI 0.033-0.234) and post-LVDS 0.059% (0.016-0.150) periods (chi-squared = 0.651, 1 df, p = 0.42).

The influence of match exposure on injury risk in elite men's rugby union.

OBJECTIVES: To investigate the influence of previous season match exposure on injury incidence and burden in elite men's rugby union. DESIGN: A three-season (2016-17 to 2018-19) retrospective cohort design was used to collect and analyse injury and exposure data across English Premiership rugby union teams. METHODS: Generalised linear mixed-effects models were used to model the influence of match exposure (all match involvements, match involvements of ≥20 mins, and full-game equivalents) upon match and training injury incidence and burden in the following season. RESULTS: Involvement in ≥31 matches within a season was associated with substantially increased match and training injury burden in the following season. Match exposure was not clearly associated with injury incidence in the following season. The increased match injury burden associated with higher match involvements appeared to be driven by an increased risk for older (>26 y) Forwards, whilst the increased training injury burden associated with higher match involvements appeared to be driven by an increased risk for older (>26 y) Backs. CONCLUSIONS: The present study demonstrates that all match involvements, regardless of duration, should be considered when exploring associations between match exposure and injury risk. High match involvements (≥ 31 matches) are associated with elevated injury burden, in both matches and training, in the following season. The physical and psychological load of players with high previous-season match exposure should be carefully managed.

Patient experiences of the urgent cancer referral pathway-Can the NHS do better? Semi-structured interviews with patients with upper gastrointestinal cancer.

BACKGROUND: Timeliness is viewed as a key feature of health-care quality. Internationally, this is challenging. In England, cancer waiting time targets are currently not being met. For example, between 2015 and 2018 only 71% of patients with upper gastrointestinal (UGI) cancer started treatment within the recommended 62 days of referral. OBJECTIVE: We explored patients' experiences to identify areas for service improvement. DESIGN: Semi-structured interviews were conducted. SETTING AND PARTICIPANTS: Twenty patients who were referred through the urgent (two-week) GP referral route and were within six months of receiving first treatment were recruited. DATA ANALYSIS: Data from the interviews were analysed thematically. RESULTS: Four themes were developed: organization of care; diagnosis; support; and views and expectations of the NHS. Patients described cross-cutting issues such as complex and varied pathways and uncertainty about what would happen next. They felt daunted by the intensity and speed of investigations. They were presented with a recommended course of action rather than options and had little involvement in decision making. They were grateful for care, reluctant to complain and resigned to the status quo. DISCUSSION AND CONCLUSIONS: In order to meet patient needs, the NHS needs to improve communication and streamline pathways. Future cancer pathways also need to be designed to support shared decision making, be truly person-centred and informed by patient experience.

Interventions to reduce inequalities in avoidable hospital admissions: explanatory framework and systematic review protocol.

INTRODUCTION: Internationally there is pressure to contain costs due to rising numbers of hospital admissions. Alongside age, socioeconomic disadvantage is the strongest risk factor for avoidable hospital admission. This equity-focussed systematic review is required for policymakers to understand what has been shown to work to reduce inequalities in hospital admissions, what does not work and where the current gaps in the evidence-base are. METHODS AND ANALYSIS: An initial framework shows how interventions are hypothesised to reduce socioeconomic inequalities in avoidable hospital admissions. Studies will be included if the intervention focusses exclusively on socioeconomically disadvantaged populations or if the study reports differential effects by socioeconomic status (education, income, occupation, social class, deprivation, poverty or an area-based proxy for deprivation derived from place of residence) with respect to hospital admission or readmission (overall or condition-specific for those classified as ambulatory care sensitive). Studies involving individuals of any age, undertaken in OECD (Organisation for Economic Co-operation and Development) countries, published from 2000 to 29th February 2020 in any language will be included. Electronic searches will include MEDLINE, Embase, CINAHL, Cochrane CENTRAL and the Web of Knowledge platform. Electronic searches will be supplemented with full citation searches of included studies, website searches and retrieval of relevant unpublished information. Study inclusion, data extraction and quality appraisal will be conducted by two reviewers. Narrative synthesis will be conducted and also meta-analysis where possible. The main analysis will examine the effectiveness of interventions at reducing socioeconomic inequalities in hospital admissions. Interventions will be characterised by their domain of action and approach to addressing inequalities. For included studies, contextual information on where, for whom and how these interventions are organised, implemented and delivered will be examined where possible. ETHICS AND DISSEMINATION: Ethical approval was not required for this protocol. The research will be disseminated via peer-reviewed publication, conferences and an open-access policy-orientated paper. PROSPERO REGISTRATION NUMBER: CRD42019153666.

Shared decision-making for ICDs: a regional collaborative initiative.

The National Institute for Health and Care Excellence (NICE) and NHS England have shown a commitment to embedding shared decision-making (SDM) in clinical practice and developing decision aids based on clinical guidelines. Healthcare policy makers are keen to enhance the engagement of patients in SDM in the belief that it improves the benefits accrued from healthcare interventions. This may be important for interventions such as implantable cardioverter-defibrillator (ICD) implantation, where cost-effectiveness is under scrutiny. NHS England invited the ICD implanters in the north of England to participate in a regional commissioning quality incentive (CQUIN) project to improve decision- making around a primary prevention ICD implant. A collaborative project included the development of a specific SDM tool, the first of its kind in the UK, followed by training and education of the clinical teams. The project illustrates that this approach is practical and deliverable and could be applied and used in other regions, and considered in additional clinical areas.

Toxics source reduction and sewage upgrades eliminated winter flounder liver neoplasia (1984-2017) from Boston Harbor, MA, USA.

Chemical carcinogen biomarkers can validate public investment in environmental remediation. A major factor driving the clean-up of Boston Harbor, MA, USA, induced by the federal Clean Water Act legislation of 1972, was the high prevalence of petroleum and halogenated aromatic hydrocarbon contaminant-associated liver neoplasia in winter flounder Pseudopleuronectes americanus in the harbor in the 1980s. In the present study, we examined the spatial and temporal relationships between the suspended solids and contaminants in the municipal sewage discharge, and liver neoplasia and histopathology in flounder, from 1987 to 2017. Toxics source reduction, sewage treatment, and sludge removal in the 1990s and outfall relocation offshore in 2000 enabled a decreasing prevalence of persistent toxic chemicals in flounder, effluent, and sediment, and consequent disappearance of liver neoplasia and reduction of neoplasm-associated, hydropically vacuolated biliary epithelial cells to background levels. This supports long-term investment in elimination and treatment of anthropogenic waste streams and the value of federal regulatory mandates to maintain and improve regional environmental quality.

Camera traps and activity signs to estimate wild boar density and derive abundance indices.

BACKGROUND: Populations of wild boar and feral pigs are increasing worldwide, in parallel with their significant environmental and economic impact. Reliable methods of monitoring trends and estimating abundance are needed to measure the effects of interventions on population size. The main aims of this study, carried out in five English woodlands were: (i) to compare wild boar abundance indices obtained from camera trap surveys and from activity signs; and (ii) to assess the precision of density estimates in relation to different densities of camera traps. For each woodland, we calculated a passive activity index (PAI) based on camera trap surveys, rooting activity and wild boar trails on transects, and estimated absolute densities based on camera trap surveys. RESULTS: PAIs obtained using different methods showed similar patterns. We found significant between-year differences in abundance of wild boar using PAIs based on camera trap surveys and on trails on transects, but not on signs of rooting on transects. The density of wild boar from camera trap surveys varied between 0.7 and 7 animals/km2 . Increasing the density of camera traps above nine per km2 did not increase the precision of the estimate of wild boar density. CONCLUSION: PAIs based on number of wild boar trails and on camera trap data appear to be more sensitive to changes in population size than PAIs based on signs of rooting. For wild boar densities similar to those recorded in this study, nine camera traps per km2 are sufficient to estimate the mean density of wild boar. © 2017 Crown copyright. Pest Management Science © 2017 Society of Chemical Industry.

Validating activity indices from camera traps for commensal rodents and other wildlife in and around farm buildings.

BACKGROUND: Indices of rodent activity are used as indicators of population change during field evaluation of rodenticides. We investigated the potential for using camera traps to determine activity indices for commensal rodents living in and around farm buildings, and sought to compare these indices against previously calibrated survey methods. RESULTS: We recorded 41 263 images of 23 species, including Norway rats (Rattus norvegicus Berk.) and house mice (Mus musculus L.). We found a positive correlation between activity indices from camera traps and activity indices from a method (footprint tracking) previously shown to have a linear relationship with population size for Norway rats. Filtering the camera trap data to simulate a 30-s delay between camera trigger events removed 59.9% of data and did not adversely affect the correlation between activity indices from camera traps and footprint tracking. The relationship between activity indices from footprint tracking and Norway rat population size is known from a previous study; from this, we determined the relationship between activity indices from camera traps and population size for Norway rats living in and around farm buildings. CONCLUSION: Systematic use of camera traps was used to determine activity indices for Norway rats living in and around farm buildings; the activity indices were positively correlated with those derived from a method previously calibrated against known population size for this species in this context. © 2017 Crown copyright. Pest Management Science © 2017 Society of Chemical Industry.

Evaluation of an enhanced cleaning and disinfection protocol in Salmonella contaminated pig holdings in the United Kingdom.

Salmonella is the second most commonly reported zoonotic gastrointestinal pathogen in the European Union, and a significant proportion of the cases are linked to the consumption of contaminated pork. Reduction of Salmonella at the farm level helps to mininimise the contamination pressure at the slaughterhouse, and therefore the number of Salmonella bacteria entering the food chain. Cleaning and disinfection (C&D) between batches of pigs is an intervention measure that has potential to reduce the transmission of Salmonella contamination within farms. In this study, two pig finisher buildings in each of 10 Salmonella positive farms were sampled pre-C&D, post-C&D, post-restocking with the following batch of pigs, and shortly before these pigs were sent to slaughter. The incoming batch of pigs was also sampled before it reached the study building (pre-restocking). At each visit, pooled and individual faecal samples were collected and Salmonella isolation was carried out according to an ISO 6579:2002 Annex D-based method. One building on each farm (intervention) was cleaned and disinfected according to a rigorous protocol consisting of several steps and a Defra-approved disinfectant used at the General Orders concentration, whilst the other building (control) was cleaned and disinfected as per normal farm routine. At the post-C&D visit, Enterobacteriaceae and total bacterial counts were determined to evaluate residual faecal contamination and general hygiene levels. Rodent specialists visited the farms before and after C&D and rodent carcasses were collected for Salmonella testing. The intervention buildings were significantly less likely (p = 0.004) to be positive for Salmonella after C&D. The pre-restocking pigs had the highest likelihood (p<0.001) of being Salmonella positive (often with multiple serovars) and there was no significant difference between intervention and control buildings in Salmonella prevalence at the post-restocking visit (p = 0.199). However, the pigs housed in the intervention buildings were significantly less likely (p = 0.004) to be positive for Salmonella at slaughter age. Multivariable analysis suggested that cleaning all fixtures of buildings, leaving the pens empty for 2-3 days and using an effective disinfectant are factors significantly improving the likelihood of removing Salmonella contamination during C&D. Signs of rodents were recorded in all farms, but rodent activity and harbourage availability decreased between visits. All the rats tested were Salmonella negative. S. Typhimurium or its monophasic variants were isolated from 6 mouse carcasses in 3 farms where the same serovars were isolated from pigs. This study demonstrates that an appropriate C&D programme significantly reduces the likelihood of residual contamination in Salmonella positive pig buildings, and suggests a significant reduction in the prevalence of Salmonella in the pigs in appropriately cleaned and disinfected buildings when sampled before slaughter. Due to a high prevalence of infection in replacement pigs, control of Salmonella in pig farms is challenging. Rodents may also contribute to the carry-over of infection between batches. C&D is a useful measure to help reduce the number of infected pigs going to the slaughterhouse, but should be supplemented by other control measures along the pig breeding and production chain.

Does access to a demand-led evidence briefing service improve uptake and use of research evidence by health service commissioners? A controlled before and after study.

BACKGROUND: The Health and Social Care Act mandated research use as a core consideration of health service commissioning arrangements in England. We undertook a controlled before and after study to evaluate whether access to a demand-led evidence briefing service improved the use of research evidence by commissioners compared with less intensive and less targeted alternatives. METHODS: Nine Clinical Commissioning Groups (CCGs) in the North of England received one of three interventions: (A) access to an evidence briefing service; (B) contact plus an unsolicited push of non-tailored evidence; or (C) unsolicited push of non-tailored evidence. Data for the primary outcome measure were collected at baseline and 12 months using a survey instrument devised to assess an organisations' ability to acquire, assess, adapt and apply research evidence to support decision-making. Documentary and observational evidence of the use of the outputs of the service were sought. RESULTS: Over the course of the study, the service addressed 24 topics raised by participating CCGs. At 12 months, the evidence briefing service was not associated with increases in CCG capacity to acquire, assess, adapt and apply research evidence to support decision-making, individual intentions to use research findings or perceptions of CCG relationships with researchers. Regardless of intervention received, participating CCGs indicated that they remained inconsistent in their research-seeking behaviours and in their capacity to acquire research. The informal nature of decision-making processes meant that there was little traceability of the use of evidence. Low baseline and follow-up response rates and missing data limit the reliability of the findings. CONCLUSIONS: Access to a demand-led evidence briefing service did not improve the uptake and use of research evidence by NHS commissioners compared with less intensive and less targeted alternatives. Commissioners appear well intentioned but ad hoc users of research. Further research is required on the effects of interventions and strategies to build individual and organisational capacity to use research.

Assessing potential local routine monitoring indicators of reach for the NHS health checks programme.

OBJECTIVES: Success in reaching target populations is an important factor in determining the impact of public health programmes. The NHS Health Check (NHSHC) Programme is directed towards reducing excess cardiovascular mortality in England. As the programme is locally commissioned, local monitoring of programme reach is essential. This study aimed to assess indicators of programme reach available to local service commissioners. STUDY DESIGN: Ecological. METHODS: The programme reach of NHSHC was assessed in three health districts in the North East of England. Local data returned from GP practices to commissioners on their NHSHC activities was collated for the period October 2010 to March 2013 together with related national published data. Three candidate indicators were chosen and the association between each of these and NHSHCs at GP practice level was examined by univariate logistic regression. RESULTS: Data were available from 101 GP practices, together undertaking almost 20,000 health checks a year. Number of NHSHCs by practices explained most (77-92%) of the variance the numbers identified at high risk of cardiovascular disease (two for every ten NHSHCs). NHSHCs were not associated with growth in GP practice disease registers for either diabetes or hypertension. NHSCHs predicted practices identification of new cases of hypertension (with one case identified for every ten checks), albeit the proportion of variation explained was much more variable (2-60%) less consistent effect. CONCLUSIONS: Data routinely available to NHSHC commissioners can support monitoring programme reach, with numbers of new cases of hypertension being the most promising indicator of reach.

Large-scale structure of brown rat (Rattus norvegicus) populations in England: effects on rodenticide resistance.

The brown rat (Rattus norvegicus) is a relatively recent (<300 years) addition to the British fauna, but by association with negative impacts on public health, animal health and agriculture, it is regarded as one of the most important vertebrate pest species. Anticoagulant rodenticides were introduced for brown rat control in the 1950s and are widely used for rat control in the UK, but long-standing resistance has been linked to control failures in some regions. One thus far ignored aspect of resistance biology is the population structure of the brown rat. This paper investigates the role population structure has on the development of anticoagulant resistance. Using mitochondrial and microsatellite DNA, we examined 186 individuals (from 15 counties in England and one location in Wales near the Wales-England border) to investigate the population structure of rural brown rat populations. We also examined individual rats for variations of the VKORC1 gene previously associated with resistance to anticoagulant rodenticides. We show that the populations were structured to some degree, but that this was only apparent in the microsatellite data and not the mtDNA data. We discuss various reasons why this is the case. We show that the population as a whole appears not to be at equilibrium. The relative lack of diversity in the mtDNA sequences examined can be explained by founder effects and a subsequent spatial expansion of a species introduced to the UK relatively recently. We found there was a geographical distribution of resistance mutations, and relatively low rate of gene flow between populations, which has implications for the development and management of anticoagulant resistance.

Effects of a demand-led evidence briefing service on the uptake and use of research evidence by commissioners of health services: protocol for a controlled before and after study.

BACKGROUND: Clinical Commissioning Groups (CCGs) are mandated to use research evidence effectively to ensure optimum use of resources by the National Health Service (NHS), both in accelerating innovation and in stopping the use of less effective practices and models of service delivery. We intend to evaluate whether access to a demand-led evidence service improves uptake and use of research evidence by NHS commissioners compared with less intensive and less targeted alternatives. METHODS/DESIGN: This is a controlled before and after study involving CCGs in the North of England. Participating CCGs will receive one of three interventions to support the use of research evidence in their decision-making: 1) consulting plus responsive push of tailored evidence; 2) consulting plus an unsolicited push of non-tailored evidence; or 3) standard service unsolicited push of non-tailored evidence. Our primary outcome will be changed at 12 months from baseline of a CCGs ability to acquire, assess, adapt and apply research evidence to support decision-making. Secondary outcomes will measure individual clinical leads and managers' intentions to use research evidence in decision making. Documentary evidence of the use of the outputs of the service will be sought. A process evaluation will evaluate the nature and success of the interactions both within the sites and between commissioners and researchers delivering the service. DISCUSSION: The proposed research will generate new knowledge of direct relevance and value to the NHS. The findings will help to clarify which elements of the service are of value in promoting the use of research evidence. Those involved in NHS commissioning will be able to use the results to inform how best to build the infrastructure they need to acquire, assess, adapt and apply research evidence to support decision-making and to fulfil their statutory duties under the Health and Social Care Act.

Recombinant blood group proteins facilitate the detection of alloantibodies to high-prevalence antigens and reveal underlying antibodies: results of an international study.

BACKGROUND: Alloantibodies to high-prevalence red blood cell (RBC) antigens are not easily identified by routine serologic techniques. This multicenter study was conducted to test the effectiveness of recombinant blood group proteins (rBGPs) at regional and international RBC reference laboratories. STUDY DESIGN AND METHODS: Single or mixed soluble rBGPs (Lu, Yt, Kn, JMH, Sc, Rg, Ch, Do, and Cr) were assessed for their ability to inhibit the reactivity of antibodies to specific antigens. Initially, the effect of rBGPs was validated by testing panels of well-characterized patient serum samples containing antibodies to high-prevalence antigens in the hemagglutination inhibition assay. Subsequently, the rBGPs were prospectively used for routine antibody identification and the results were compared to those obtained with RBC-based diagnostics. RESULTS: Panels of predefined antibodies to high-prevalence antigens were completely and specifically neutralized by the corresponding rBGP specificities. For prospective identification, antibodies to high-prevalence antigens (n = 62) were specifically inhibited by the corresponding rBGP specificities except for some Complement Receptor 1-related antibodies, which may be directed to epitopes not expressed on the truncated recombinant Kn. In 14 cases, additional clinically relevant alloantibodies were identified. In cross-matching, the rBGPs were successfully used to inhibit the reactivity of clinically irrelevant antibodies to high-prevalence antigens to determine compatibility between donor and recipient. CONCLUSION: rBGPs enable the identification of antibodies to high-prevalence antigens without the need for rare RBC reagents, which are often unavailable. Underlying antibodies can be reliably detected and cross-matching results validated, resulting in a more efficient blood supply for immunized patients.

Feasibility of applying review criteria for depression and osteoporosis national guidance in primary care.

BACKGROUND: Data on the uptake of clinical guidelines into practice are essential to guide and evaluate quality improvement interventions. Organizations responsible for service specification, monitoring and improvement need to consider the practicality of and trade-offs made in different data collection methods. We examined the feasibility of deriving and applying review criteria for clinical guidelines in English primary care. METHODS: We selected two sets of guidance, on osteoporosis and depression, and used a consensus process to derive review criteria. We manually extracted data on adherence to review criteria from patient records in 20 general practices from three NHS primary care trusts in northern England. We compared the relative utility of extracted data with that of routinely available data, summarizing feasibility using what we termed a Resource Ratio. RESULTS: Of 53 proposed review criteria we assessed, 41 were judged clinically important, valid, relevant and measurable. Thirty-one could be assessed in 10% or more of sampled patients, whereas 15 could be readily extracted (resource ratio of 15 or less). Only eight met all desirable attributes for use as review criteria. Resource ratios correlated poorly with local stakeholders' prior views on feasibility of data collection. We observed wide variations in compliance with review criteria, with notably low levels among self-care standards. CONCLUSIONS: A minority of guideline recommendations were suitable for review criteria development, fewer still when using routinely available data. Local stakeholders tend to underestimate the actual resource requirements of data collection. Although improved design and use of clinical records may facilitate measurement of adherence to recommended practice, detailed assessments are still likely to rely upon some degree of manual data collection in the foreseeable future.

Pacific partnership 2010: Anesthesia support aboard the USNS Mercy humanitarian civic assistance.

INTRODUCTION: The USNS Mercy has been integral in providing humanitarian and civic assistance as part of the Department of Defense's ongoing Combatant Commander Theater Security Cooperation Plans. The purpose of this study was to critically assess patient demographics and procedures performed to provide guidance for future missions. METHODS: A retrospective review was performed on a cohort of 825 surgical patients who underwent surgery during a 4-month period during Pacific Partnership 2010. Patient demographics, anesthesia exam findings, comorbidities, and surgical data were compared among the mission sites. RESULTS: Of the 825 patients, the mean age ranged from 39.7 to 24.7 with a statistical difference between Vietnam (39.7, p < 0.0087 for all tests) and the remaining sites. Poorer health by American Society of Anesthesiologist grading was noted in Vietnam (1.61) as compared to patients in Cambodia (1.21, p < 0.001) and Timor-Leste (1.40, p = 0.001). No difference in complication rates was noted. DISCUSSION: The reason for apparent differences in age or health status by site weren't clearly explained, but these differences had no bearing on surgical outcome. CONCLUSION: Analysis of anesthesia data compiled during Pacific Partnership 2010 provided meaningful data for future humanitarian efforts at these sites.