Improving and Sustaining the Quality of Discharge Summaries.

High quality discharge information communication has been linked to a reduction in the incidence of adverse events, decreasing the risk of prescription errors and lost follow up. In this paper we describe how our trust-wide quality improvement project, led by acute physicians, successfully improved discharge documentation. We demonstrate how we identified obstacles to continued success, and the interventions we implemented. We recommend how discharge summary quality can be optimised through training of junior doctors, recruitment of local champions, and use of novel methods to preserve engagement, such as gamification.

Computed tomography-derived fractional flow reserve (FFRCT) has no additional clinical impact over the anatomical Coronary Artery Disease - Reporting and Data System (CAD-RADS) in real-world elective healthcare of coronary artery disease.

AIM: To evaluate the impact of computed tomography-derived fractional flow reserve (FFRCT) compared to the anatomical Coronary Artery Disease - Reporting and Data System (CAD-RADS) in the elective assessment of coronary artery disease in real-world cardiology practise. MATERIALS AND METHODS: A retrospective review was undertaken of 1,239 coronary CT examinations from August 2018 to December 2019 with a minimum follow-up period of 1 year. Coronary disease was classified according to the CAD-RADS system. A non-occlusive ≥30% maximum diameter stenosis was considered eligible for FFRCT. Lesion-specific FFRCT and FFR were considered positive if ≤ 0.80. The patients were followed up using the hospital radiology information system and the electronic patient record. A positive outcome was defined by a subsequent invasive angiogram (ICA) showing disease requiring revascularisation or FFR ≤0.80 or a positive stress test or medical therapy for angina in CAD-RADS 4. RESULTS: Of the 1,145 analysable studies (mean follow up 618 ± 153 days) the incidence of a positive result was 7% with a 5.4% elective revascularisation rate. Two hundred and forty-five patients (CAD-RADS 2-4) had FFRCT. FFRCT reduced the accuracy of the CAD-RADS grade from 91% to 78.4% (p<0.001). In CAD-RADS 2, the accuracy is reduced from 99% to 90.7% (p=0.005), and in CAD-RADS 3 from 93.9% to 67.7% (p<0.001). In CAD-RADS 4, FFRCT increases accuracy from 69.4% to 75.5% (p=0.025), but 89.8% of FFRCT are positive and specificity is low (26.7%). CONCLUSION: In the present "real-world" practise, FFRCT does not improve standard radiological assessment of coronary disease graded by the CAD-RADS alone.

Field-Level Exposure of Bumble Bees to Fungicides Applied to a Commercial Cherry Orchard.

Bumble bees, Bombus spp. (Apidae), are important native pollinators; however, populations of some species are declining in North America and agricultural chemicals are a potential cause. Fungicides are generally not highly toxic to bees, but little is known about sublethal or synergistic effects. This study evaluates bumble bee exposure to fungicides by quantifying concentrations of boscalid and pyraclostrobin in nectar and pollen collected by colonies of Bombus huntii Greene, 1860 (Hunt bumble bee) deployed in a commercial cherry Prunus avium L. orchard in the spring of 2016. Seven colonies were placed adjacent to an orchard block that was sprayed with a fungicide mixture of boscalid and pyraclostrobin and a control group of seven colonies was placed next to an unsprayed block of orchard 400 m away from the treated block. Nectar and pollen were collected daily, beginning 1 d before spray application and continuing for a total of 12 d, and analyzed for both fungicides. Fungicide concentrations varied spatially by colony and temporally by day. The highest concentrations in nectar occurred 1 and 3 d after spraying: up to 440 ng/g boscalid and 240 ng/g pyraclostrobin. Six days after application, pollen from cherry flowers contained the highest concentrations of the fungicides: up to 60,500 ng/g boscalid and 32,000 ng/g pyraclostrobin. These data can help to determine field-level fungicide concentrations in nectar and pollen and direct future work on understanding the effects of these compounds, including their interactions with important bumble bee pathogenic and beneficial symbionts.

Out of hospital cardiac arrest survivors with inconclusive coronary angiogram: Impact of cardiovascular magnetic resonance on clinical management and decision-making.

BACKGROUND: Non-traumatic out of hospital cardiac arrest (OHCA) is the leading cause of death worldwide, mainly due to acute coronary syndromes. Urgent coronary angiography with view to revascularisation is recommended in patients with suspected acute coronary syndrome. Diagnosis and management of patients with inconclusive coronary angiogram (unobstructed coronaries or unidentified culprit lesion) is challenging. We sought to assess the role of Cardiovascular Magnetic Resonance (CMR) in the diagnosis and management of OHCA survivors with an inconclusive coronary angiogram. METHODS AND RESULTS: This is a retrospective multicentre CMR registry analysis of OHCA survivors with an inconclusive angiogram. Clinical, ECG and multi-modality imaging data were analysed. Clinical impact of CMR was defined as a change in diagnosis or management. Out of 174 OHCA survivors referred for CMR, 110 patients (63%, 84 male, median age 58) had an inconclusive angiogram. CMR identified a pathologic substrate in 76/110 patients (69%): ischemic heart disease was found in 45 (41%) and non-ischemic heart disease in 31 (28%). A structurally normal heart was found in 25 patients (23%) and non-specific findings in 9 (8%). As compared to trans-thoracic echocardiogram, CMR proved to be superior in identifying a pathologic substrate (69% vs 54%, p=0.018). The CMR study carried a clinical impact in 70% of patients, determining a change in diagnosis in 25%, in management in 29% and a change in both in 16%. CONCLUSIONS: CMR showed a promising role in the diagnostic work-up of OHCA survivors with inconclusive angiogram and its wider use should be considered.

One-year outcomes after successful chronic total occlusion percutaneous coronary intervention: The impact of dissection re-entry techniques.

We aimed to determine clinical outcomes 1 year after successful chronic total occlusion (CTO) PCI and, in particular, whether use of dissection and re-entry strategies affects clinical outcomes. Hybrid approaches have increased the procedural success of CTO percutaneous coronary intervention (PCI) but longer-term outcomes are unknown, particularly in relation to dissection and re-entry techniques. Data were collected for consecutive CTO PCIs performed by hybrid-trained operators from 7 United Kingdom (UK) centres between 2012 and 2014. The primary endpoint (death, myocardial infarction, unplanned target vessel revascularization) was measured at 12 months along with angina status. One-year follow up data were available for 96% of successful cases (n = 805). In total, 85% of patients had a CCS angina class of 2-4 prior to CTO PCI. Final successful procedural strategy was antegrade wire escalation 48%; antegrade dissection and re-entry (ADR) 21%; retrograde wire escalation 5%; retrograde dissection and re-entry (RDR) 26%. Overall, 47% of CTOs were recanalized using dissection and re-entry strategies. During a mean follow up of 11.5 ± 3.8 months, the primary endpoint occurred in 8.6% (n = 69) of patients (10.3% (n = 39/375) in DART group and 7.0% (n = 30/430) in wire-based cases). The majority of patients (88%) had no or minimal angina (CCS class 0 or 1). ADR and RDR were used more frequently in more complex cases with greater disease burden, however, the only independent predictor of the primary endpoint was lesion length. CTO PCI in complex lesions using the hybrid approach is safe, effective and has a low one-year adverse event rate. The method used to recanalize arteries was not associated with adverse outcomes. © 2017 Wiley Periodicals, Inc.

Hybrid approach improves success of chronic total occlusion angioplasty.

OBJECTIVES: Treatment options for coronary chronic total occlusions (CTO) are limited, with low historical success rates from percutaneous coronary intervention (PCI). We report procedural outcomes of CTO PCI from 7 centres with dedicated CTO operators trained in hybrid approaches comprising antegrade/retrograde wire escalation (AWE/RWE) and dissection re-entry (ADR/RDR) techniques. METHODS: Clinical and procedural data were collected from consecutive unselected patients with CTO between 2012 and 2014. Lesion complexity was graded by the Multicentre CTO Registry of Japan (J-CTO) score, with ≥2 defined as complex. Success was defined as thrombolysis in myocardial infarction 3 flow with <30% residual stenosis, subclassified as at first attempt or overall. Inhospital complications and 30-day major adverse cardiovascular events (MACEs, death/myocardial infarction/unplanned target vessel revascularisation) were recorded. RESULTS: 1156 patients were included. Despite high complexity (mean J-CTO score 2.5±1.3), success rates were 79% (first attempt) and 90% (overall) with 30-day MACE of 1.6%. AWE was highly effective in less complex lesions (J-CTO ≤1 94% success vs 79% in J-CTO score ≥2). ADR/RDR was used more commonly in complex lesions (J-CTO≤1 15% vs J-CTO ≥2 56%). Need for multiple approaches during each attempt increased with lesion complexity (17% J-CTO ≤1 vs 48% J-CTO ≥2). Lesion modification ('investment procedures') at the end of unsuccessful first attempts increased the chance of subsequent success (96% vs 71%). CONCLUSIONS: Hybrid-trained operators can achieve overall success rates of 90% in real world practice with acceptable MACE. Use of dissection re-entry and investment procedures maintains high success rates in complex lesions. The hybrid approach represents a significant advance in CTO treatment.

Impact of proctoring on success rates for percutaneous revascularisation of coronary chronic total occlusions.

OBJECTIVE: To assess the impact of proctoring for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in six UK centres. METHODS: We retrospectively analysed 587 CTO procedures from six UK centres and compared success rates of operators who had received proctorship with success rates of the same operators before proctorship (pre-proctored) and operators in the same institutions who had not been proctored (non-proctored). There were 232 patients in the pre-proctored/non-proctored group and 355 patients in the post-proctored group. Complexity was assessed by calculating the Japanese CTO (JCTO) score for each case. RESULTS: CTO PCI success was greater in the post-proctored compared with the pre-proctored/non-proctored group (77.5% vs 62.1%, p<0.0001). In more complex cases where JCTO≥2, the difference in success was greater (70.7% vs 49.5%, p=0.0003). After proctoring, there was an increase in CTO PCI activity in centres from 2.5% to 3.5%, p<0.0001 (as a proportion of total PCI), and the proportion of very difficult cases with JCTO score ≥3 increased from 15.3% (35/229) to 29.7% (105/354), p<0.0001. CONCLUSIONS: Proctoring resulted in an increase in procedural success for CTO PCI, an increase in complex CTO PCI and an increase in total CTO PCI activity. Proctoring may be a valuable way to improve access to CTO PCI and the likelihood of procedural success.

Bumble bee fauna of Palouse Prairie: survey of native bee pollinators in a fragmented ecosystem.

Bumble bees, Bombus Latreille (Hymenoptera: Apidae:), are dominant pollinators in the northern hemisphere, providing important pollination services for commercial crops and innumerable wild plants. Nationwide declines in several bumble bee species and habitat losses in multiple ecosystems have raised concerns about conservation of this important group. In many regions, such as the Palouse Prairie, relatively little is known about bumble bee communities, despite their critical ecosystem functions. Pitfall trap surveys for ground beetles in Palouse prairie remnants conducted in 2002-2003 contained considerable by-catch of bumble bees. The effects of landscape context, remnant features, year, and season on bumble bee community composition were examined. Additionally, bees captured in 2002-2003 were compared with historic records for the region to assess changes in the presence of individual species. Ten species of bumble bee were captured, representing the majority of the species historically known from the region. Few detectable differences in bumble bee abundances were found among remnants. Community composition differed appreciably, however, based on season, landscape context, and elevation, resulting in different bee assemblages between western, low-lying remnants and eastern, higherelevation remnants. The results suggest that conservation of the still species-rich bumble bee fauna should take into account variability among prairie remnants, and further work is required to adequately explain bumble bee habitat associations on the Palouse.

Binary liquid mixtures in porous solids.

The technique of nuclear magnetic resonance cryoporometry has been used to study the behavior of binary liquid mixtures of water and decane in porous sol-gel silicas. It was observed that the water preferentially adsorbed onto the silica surface and so was able to displace the decane from the pores.

Pore surface exploration by NMR.

A carefully chosen set of experimental techniques applied to porous media characterization provides results that can be much greater than the sum of the individual parts. The inter-relation and complementarity of a number of techniques will be considered. NMR cryoporometry provides a valuable method of pore size measurement. An NMR method that is more widely used to assess pore dimensions relies on relaxation time analysis of a liquid that fills the pores and the enhanced relaxation that occurs in a liquid at the solid/liquid interface. Thermoporometry, a method based on the application of Differential Scanning Calorimetry (DSC), is closely related to cryoporometry, but employs a different set of assumptions to evaluate pore size distributions. Comparison of the results obtained on the same samples using all these methods together with gas adsorption serves to validate the methods and provide significantly more information about surface-fluid interaction and the behavior of nano-scale material within pores than each method employed in isolation. Technique developments will be discussed and applications of these methods to ideal silicas will be used to illustrate their power, particularly in combination.

The assault on ignorance: teaching menstrual etiquette in England, c. 1920s to 1960s.

At the end of the nineteenth century, medical paradigms of menstruation were located in a language of pathology and disability. Women were, therefore, perceived as incapable of competing with men in the world of education, work, and economics on account of their erratic and debilitating biology. This essay examines the challenge posed to this vision of menstrual disability by female medical practitioners in the early decades of the twentieth century. The new narratives of menstruation authored by these women not only re-cast normative menstrual experience as non-disabling, but were also formulated on the basis of canvassing the opinions of healthy schoolgirls rather than developing theories based on clinical contact with a minority of women defined as 'ill'. Yet female practitioners remained tied to a culture of 'menstrual discretion', thus perpetuating the secrecy and taboo associated with menstruation in the nineteenth century. This essay explores the tensions inherent in striving to overturn an oppressive medical model of menstruation whilst promoting menstrual discretion, and aims to place such apparent contradictions within the context of cultural notions of gendered identity and feminine sexuality.

An evaluation of NMR cryoporometry, density measurement and neutron scattering methods of pore characterisation.

Sol-gel silicas with nominal pore diameters ranging from 25A to 500A were studied by NMR cryoporometry, and by neutron diffraction and small angle scattering from dry silicas over the Q range 8. 10(-4)A(-1) < or = Q < or = 17A(-1). Density and imbibation experiments were also performed. Geometric models of porous systems were constructed and were studied by both analytic techniques and Monte-Carlo integration. These models, combined with the information from the above measurements, enabled the calculation of the fully density corrected solid-solid density correlation functions G(r) for the sol-gel silicas, deduction of the (voidless) silica matrix density, measurement of the silica fraction in the grain and of the packing fraction of the silica grains and an estimation of the water equivalent residual hydrogen on the dried silica surface. In addition, the pore diameter D, pore diameter to lattice spacing ratio D/a, and pore and lattice variance sigma could also be measured. While the NMR cryoporometry pore diameter measurements for the sol-gel silicas show excellent co-linearity with the nominal pore diameters as measured by gas adsorption, and the calculated pore diameters from the measured neutron scattering show surprisingly good agreement with these measurements at large pore diameters, there is a divergence between the calibrations for pore diameters below about 100A.

Combined MR-relaxation and MR-cryoporometry in the study of bone microstructure.

MR-Relaxation (MRR) of 1H nuclei and MR-Cryoporometry (MRC) are combined to assess their feasibility and their potential in the study of bone microstructure. In principle, both techniques are able to give information on the structure of the pore space confining the fluids. Cow femur samples were carefully cored and cleaned in order to remove the natural fluids inside. For MRR analysis quasi-continuous distributions of T(1) and T(2) were obtained on samples fully saturated with water. Cyclohexane was used as a saturating fluid for MRC analysis. All T(1) and T(2) quasi-continuous distributions of water confined in bone samples are more than three decades wide, showing sufficient details to differentiate the samples. Pore size distributions obtained by MRC also differentiate the samples showing different characteristics of the pore space structure in the range of the highest sensitivity of the method (typically 3 to 100 nm, mesopore range). In particular, in samples where MRR shows a large fraction of signal with relaxation times below 10(2) ms, MRC indicates a large fraction of pore volume with pore sizes in the mesopore range.

Effects of L-arginine on the proliferation of T lymphocyte subpopulations.

BACKGROUND: Dietary supplementation of L-arginine as a mechanism to enhance cellular immune response (T lymphocytes), has slowly gained approval, and appears especially important during critical illness. Despite its clinical use, little is known as to the direct effects of L-arginine on the different T lymphocyte subpopulations. METHODS: Lymphocytes were harvested from spleens of C57 B1/6 mice, and proliferation was induced with anti-CD3 in the presence of different concentrations of L-arginine ranging from 0 to 1000 micromol/L. Flow cytometry was used to evaluate the effect of L-arginine on T lymphocyte subpopulations. Interleukin-2 production was measured by ELISA and gene expression by RT-PCR. RESULTS: L-Arginine at or greater than 100 micromol/L significantly enhanced anti-CD3 stimulated T lymphocyte proliferation (p = .01). L-Arginine was essential for adequate T lymphocyte (CD3+) cellular maturation (p = .01). Proliferation of Helper T cells (CD4+) was not dependent on L-arginine. In contrast, Cytotoxic T cells (CD8+) showed a dose dependent proliferation in response to L-arginine (p = .01). Of the CD8+ cells, an increase in the CD45RA negative CD8 positive (memory) T cell subpopulation was observed with the addition of L-arginine. In addition, the number of cell surface CD8 receptors (CD8R) and CD3 receptors (CD3R) increased in the presence of L-arginine (p = .01, p = .04). Interleukin-2 receptor (IL-2R) expression was not up-regulated by L-arginine. L-Arginine modestly increased IL-2 production and had pronounced effects on its disappearance from the culture media (p < .0001). Interleukin-2 mRNA expression was not dependent on L-arginine. CONCLUSIONS: The requirements for L-arginine for the proliferation of CD3 stimulated T lymphocytes vary widely, and have to be taken into account when studying the mechanism of how L-arginine enhances cellular proliferation. L-Arginine may increase cellular proliferation by increasing specific receptor expression and the utilization of interleukin-2.

Optimum timing of miticide applications for control of Varroa destructor (Acari: Varroidae) in Apis mellifera (Hymenoptera: Apidae) in Washington State, USA.

Seven treatments for the control of Varroa destructor (Anderson & Trueman) were tested to determine the optimum timing of miticide application. Threshold mite levels indicating miticide application were determined for three possible treatment dates: April, August, and October. The treatments were as follows: (1) fluvalinate in April, (2) fluvalinate in August, (3) fluvalinate in October, (4) fluvalinate in April and October, (5) fluvalinate applied continuously (except during honey flow) with replacement every 42 d, (6) control (no treatment), and (7) coumaphos in April. The number of miticide applications in a season had no effect on brood area or colony bee population a year after initiating the experiment. However, the absence of any treatment significantly reduced brood area and colony bee population and significantly increased colony mite population. Date of treatment had significant effects on colony mortality rates, mite levels, and brood area the following spring. When coupled with sampling and threshold recommendations, a single, late-season application of fluvalinate is as effective for the control of V. destructor as semiannual or continuous miticide applications. Treatment thresholds were recommended for ether roll and 48-h sticky board sampling methods in April (three and 24 mites, respectively) and August (14 and 46 mites, respectively) and for ether rolls in October (three mites) in cold climates.

Diffusion-weighted imaging of bacteria colonies in the STRAFI plane.

Imaging colonies of bacteria in water suspension using NMR requires that the water inside the bacteria can be differentiated from the surrounding water. This is commonly carried out by using diffusion-weighted pulsed field gradient techniques. However, it is also possible to use the diffusion sensitivity inherent in stray field imaging (STRAFI). In STRAFI, the subject to be imaged is normally moved along the axis of a superconducting magnet so that it passes through the sensitive slice. However, by moving the sample in the transverse direction and by using a long copper strip in place of a surface induction coil, a diffusion-weighted one-dimensional projection profile can be obtained across the sensitive slice. Profiles from a water phantom and from a bacteria suspension show convincing discrimination between intracellular and extracellular water.