Paediatric meningitis in the conjugate vaccine era and a novel clinical decision model to predict bacterial aetiology.

OBJECTIVES: The aims of this study were to assess aetiology and clinical characteristics in childhood meningitis, and develop clinical decision rules to distinguish bacterial meningitis from other similar clinical syndromes. METHODS: Children aged <16 years hospitalised with suspected meningitis/encephalitis were included, and prospectively recruited at 31 UK hospitals. Meningitis was defined as identification of bacteria/viruses from cerebrospinal fluid (CSF) and/or a raised CSF white blood cell count. New clinical decision rules were developed to distinguish bacterial from viral meningitis and those of alternative aetiology. RESULTS: The cohort included 3002 children (median age 2·4 months); 1101/3002 (36·7%) had meningitis, including 180 bacterial, 423 viral and 280 with no pathogen identified. Enterovirus was the most common pathogen in those aged <6 months and 10-16 years, with Neisseria meningitidis and/or Streptococcus pneumoniae commonest at age 6 months to 9 years. The Bacterial Meningitis Score had a negative predictive value of 95·3%. We developed two clinical decision rules, that could be used either before (sensitivity 82%, specificity 71%) or after lumbar puncture (sensitivity 84%, specificity 93%), to determine risk of bacterial meningitis. CONCLUSIONS: Bacterial meningitis comprised 6% of children with suspected meningitis/encephalitis. Our clinical decision rules provide potential novel approaches to assist with identifying children with bacterial meningitis. FUNDING: This study was funded by the Meningitis Research Foundation, Pfizer and the NIHR Programme Grants for Applied Research.

Gambling advertising during live televised male sporting events in Ireland: A descriptive study.

OBJECTIVES: There are no data relating to gambling advertisements shown during live sporting events in Ireland. The aim of the present study was to analyze gambling advertisements shown during live sporting events broadcast in Ireland and to assess these advertisements for responsible gambling (RG) practices. METHODS: Sixty-five live televised sporting events comprising Association Football (soccer), Rugby Union, and Gaelic Athletic Association (GAA) matches broadcast in Ireland were analyzed. Pre-match (up to 30 minutes before kick-off), half-time, and post-match (up to 30 minutes after the match has ended) advertisement breaks were analyzed for gambling advertisements, including in-game fixed (static advertising) and dynamic (electronic advertisements changing at regular intervals) pitch-side advertising. Gambling advertisements were studied for evidence of RG practices. RESULTS: A total of 3602 television advertisements, 618 dynamic advertisements, and 394 static advertisements were analyzed. Gambling advertisements were shown in 75.4% (n = 49) games and were the seventh most commonly televised advertisement shown overall. Gambling advertising was more common in football (fourth most common advertisement) compared to rugby (12th most common) and GAA (13th most common). Static and dynamic gambling advertising were common during football matches (second and first most common advertisements, respectively). The majority of advertisements contained RG messaging, an age limit, and an RG organization. No advertisements showing responsible gambling tools were observed. CONCLUSIONS: Gambling advertisements are commonly shown during live televised sporting broadcasts in Ireland, especially during live football matches and typically before the adult television watershed. Gambling legislation is required to minimize harm to vulnerable groups including children.

Age-related injury patterns resulting from knife violence in an urban population.

Interpersonal violence involving knives is a major public health problem. The majority of patients are young people in urban areas, but little is known about age-specific patterns of injury and recent trends in injury characteristics. We performed a retrospective cohort study of all patients presenting to an urban major trauma centre with stab injuries resulting from assault between 2012 and 2018. A total of 3583 patients were included. Young people (age under 25) were more likely to have sustained multiple stab wounds compared to older people (43% vs 35%, p < 0.001) and had significantly higher rates of stab injuries involving the lower limbs, groin and buttocks. The annual number of injuries increased steadily during the study period in patients aged under 25 (r2 = 0.82, p = 0.005) and those over 25 (r2 = 0.95, p < 0.001). Over time, limb and junctional injuries accounted for an increasing proportion of stab wounds in young people, overtaking torso injuries as most common pattern of injury by the end of the study period. These findings illustrate the influence of age on injury patterns resulting from knife violence, and support the expansion of outreach initiatives promoting bystander-delivered haemorrhage control of extremity wounds.

Muscle-sparing transverse rectus abdominis musculocutaneous free flap breast reconstruction following cryolipolysis.

Cryolipolysis refers to the sub-physiological cooling of regional body parts (typically the abdomen) in order to reduce the volume of adipose tissue. It provides a non-invasive alternative to procedures such as liposuction, which have traditionally been considered as relative contraindications for future abdominal free flap-based reconstructions. We describe the first case of a patient undergoing skin-sparing mastectomy and a muscle-sparing transverse rectus abdominis musculocutaneous (msTRAM) free flap breast reconstruction, following cryolipolysis therapy. Pre- and intraoperative radiological investigations and clinical examination showed no obvious adverse effect of cryolipolysis on the flap. The patient recovered well, with no vascular complications noted on follow up.

COVID-19 pandemic related excessive electronic media exposure and mental health in Saudi Arabia.

OBJECTIVE: Due to the continued spread of COVID-19 and the emergence of novel mutated viral variants, families all over the world are experiencing wide-ranging stressors that threaten not only their financial well-being but also their physical and mental health. The present study assessed the association between excessive electronic media exposure of pandemic-related news and mental health of the residents of Ha'il Province, Saudi Arabia. The present study also assessed the prevalence of perceived stress, fear of COVID-19, anxiety, depression, and loneliness due to COVID-19-related restrictions in the same population. MATERIALS AND METHODS: A total of 490 residents of Ha'il Province participated in a cross-sectional online survey during a two-month period (March to April 2021). A validated 38-item self-report survey was used to collect the data. RESULTS: Significant associations were reported between excessive electronic media exposure and the prevalence of perceived stress (χ2=140.56; p<.001), generalized anxiety (χ2=74.55; p<.001), depression (χ2=71.58; p<.001), COVID-19-related fear (χ2=24.54; p<.001), and loneliness (χ2=11.46; p<.001). It was also found that participants without depressive symptoms were 0.28 times less likely to have been exposed to excessive electronic media exposure (AOR: 0.28; C.I. 0.16-0.48; p<.001). Similarly, participants with no stress/mild stress were 0.32 times less likely to have been exposed to excessive electronic media exposure (AOR: 0.32; C.I. 0.19-0.52; p<.001). CONCLUSIONS: The findings of the present study suggest an urgent need for educational resilience programs (online and in-person) for susceptible individuals (females, unemployed, urban residents, etc.). Such programs would help them to develop skills to cope with the psychological impact of the COVID-19 pandemic.

A conceptual model of nitrogen dynamics for the Great Barrier Reef catchments.

Nitrogen (N) from anthropogenic sources has been identified as a major pollutant of the Great Barrier Reef (GBR), Australia. We developed a conceptual framework to synthesise and visualise the fate and transport of N from the catchments to the sea from a literature review. The framework was created to fit managers and policymakers' requirements to reduce N in the GBR catchments. We used this framework to determine the N stocks and transformations (input, sources, and outputs) for ecosystems commonly found in the GBR: rainforests, palustrine wetlands, lakes, rivers (in-stream), mangroves and seagrasses. We included transformations of N such as nitrogen fixation, nitrification, denitrification, mineralisation, anammox, sedimentation, plant uptake, and food web transfers. This model can be applied to other ecosystems to understand the transport and fate of N within and between catchments. Importantly, this approach can guide management actions that attenuate N at different scales and locations within the GBR ecosystems. Finally, when combined with local hydrological modelling, this framework can be used to predict outcomes of management activities.

Assessing whether COVID-19 patients will benefit from critical care, and an objective approach to capacity challenges during a pandemic: An Intensive Care Society clinical guideline.

This national professional society guidance lays out operational and ethical principles for decision-making during a pandemic, in the immediate context of COVID-19 in the early 2020 surge iteration but with potential ongoing relevance. It identifies the different phases of a pandemic and the implications for capacity and mutual aid within a national healthcare system, and introduces a revised CRITCON-PANDEMIC framework for shared operational responsibilities and clinical decision-making. Usual legal and ethical frameworks should continue to apply while capacity and mutual aid are available (CRITCON-PANDEMIC levels 0-3); clinicians should focus on current clinical needs and should not treat patients differently because of anticipated future pressures. In conditions of resource limitation (CRITCON-PANDEMIC 4), a structured and equitable approach is necessary and an objective Decision Support Aid is proposed. In producing this guidance, we emphasise that all patients must be treated with respect and without discrimination, because everyone is of equal value. The guidance has been put together with input from patient and public groups and aims to provide standards that are fair to everyone. We acknowledge that COVID-19 is a new disease with a partial and evolving knowledge base, and aim to provide an objective clinical decision-making framework based on the best available information. It is recognised that a factual assessment of likely benefit may take into account age, frailty and comorbidities, but the guidance emphasises that every assessment must be individualised on a balanced, case by case, basis and may inform clinical judgement but not replace it. The effects of a comorbidity on someone's ability to benefit from critical care should be individually assessed. Measures of frailty should be used with care, and should not disadvantage those with stable disability.

Nitrogen processing by treatment wetlands in a tropical catchment dominated by agricultural landuse.

Agriculture is a major contributor to marine nitrogen pollution, and treatment wetlands can be a strategy to reduce it. However, few studies have assessed the potential of treatment wetlands to mitigate nitrogen pollution in tropical regions. We quantify the nitrogen removal rates of four recently constructed treatment wetlands in tropical Australia. We measured denitrification potential (Dt), the inflow-outflow of nutrients, and tested whether the environment in these tropical catchments is favourable for nitrogen removal. Dt was detected in three of the four systems with rates between 2.0 and 12.0 mg m-2 h-1; the highest rates were measured in anoxic soils (ORP -100 to 300 mV) that were rich in carbon and nitrogen (>2% and >0.2%, respectively). The highest nitrogen removal rates were measured when NO3--N concentrations were >0.4 mg L-1 and when water flows were slow. Treatment wetlands in tropical regions can deliver high removal rates of nitrogen and other pollutants when adequately managed. This strategy can reduce nutrient loads and their impacts on sensitive coastal zones such as the Great Barrier Reef.

Imaging in traumatic injury to the inferior vena cava.

Inferior vena cava (IVC) injury is a rare but serious consequence of trauma. It presents with high scores on trauma assessment scales and is often life threatening. Factors that contribute to poor survival include delay and difficulty in diagnosis due to non-specific clinical features. As it is a relatively rare entity, imaging in IVC injury is not well described in the literature. As radiologists, it is vital that features of potential IVC injury are recognised promptly and findings relayed to the treating clinician in a timely manner to improve survival and reduce the risk of possible complications. Imaging features that should alert radiologists to IVC injury include contour abnormalities, active extravasation, pseudoaneurysm, and pericaval haematoma. Trauma to the IVC is associated with significant complications. These include exsanguination and refractory shock in the acute period while in the longer term, thrombosis can develop with potential for subsequent pulmonary embolism. Additionally, there are complications that may develop post-surgically including further haemorrhage, IVC stenosis, and infection. We review the spectrum of imaging findings in traumatic IVC injury, which are exemplified with cases from our practice. Furthermore, we discuss important factors to consider during interpretation and the challenges that a radiologist may encounter when making the diagnosis.

Comparison of PEAK PlasmaBlade™ to conventional diathermy in abdominal-based free-flap breast reconstruction surgery-A single-centre double-blinded randomised controlled trial.

BACKGROUND: Electrosurgery makes dissection with simultaneous haemostasis possible. The produced heat can cause injury to the surrounding tissue. The PEAK PlasmaBlade™(PPB) is a new electrosurgery device which may overcome this by having the ability to operate on a lower temperature, therefore reducing collateral thermal damage. METHOD: A single-centre, double-blinded, randomised controlled trial (RCT) was conducted which included 108 abdominal-based free-flap breast reconstruction patients who had their flap raise performed using either the PPB (n = 56) or the conventional diathermy (n = 52). Data were collected during their in-patient stay and out-patient appointments. The primary outcome value was the number of days the abdominal drains were required. RESULTS: Baseline characteristics were similar between the groups, except a significantly lower flap weight in the PPB group. The median number of days the drains were required did not differ significantly (p = 0.48; 6.0 days for the diathermy and 5.0 days for the PPB). The total drain output (p = 0.68), the inflammatory cytokine in the drain fluid (p>0.054) and complications (p>0.24) did not differ significantly between the two groups. At the 2-week follow-up appointment, there was a trend towards less abdominal seromas on abdominal ultrasound (p = 0.09) in the PPB group which were significantly smaller (p = 0.04). CONCLUSION: The use of the PPB did not result in a significant reduction of drain requirement, total drain output or inflammatory cytokines but did reduce the size of seroma collections at the 2-week follow-up appointment. Therefore, the use of the PPB device could reduce early seroma formation after drain removal.

Vascular bowel and mesenteric injury in blunt abdominal trauma: a single centre experience.

AIM: To establish common patterns of injury in vascular bowel and mesenteric injury (VBMI) and to identify any factors that may lead to delayed treatment. METHODS AND MATERIALS: Forty-one patients with blunt VBMI presented to the level 1 trauma centre of the The Royal London Hospital over 5 years. Computed tomography (CT) images were reviewed to identify the specific location of injury and additional features such as seatbelt bruising and lumbar hernias. Surgical reports were reviewed to record any pertinent surgical findings at laparotomy. RESULTS: The commonest mechanism of injury was a restrained car occupant involved in a road traffic collision (49%, n=20). The ileocaecal mesenteric vasculature was most frequently injured (41.5%, n=17), followed by the mid ileum (17.1%, n=7). Seatbelt bruising was identified in 80% of restrained car occupants and lumbar hernias in 22% of all patients with VBMI. CONCLUSION: Restrained car occupants involved in road traffic collisions are at increased risk of VBMI with particular susceptibility of the ileocaecal mesentery. This has implications for the reporting radiologist and trauma surgeon in deciding which patients require careful monitoring for the development of delayed bowel ischaemia.

Esophageal atresia and tracheoesophageal fistula associated with tetralogy of Fallot: a review of mortality.

INTRODUCTION: Oesophageal atresia ± tracheoesophageal fistula (EA/TEF) associated with congenital heart disease (CHD) carries a worse prognosis than EA/TEF alone. Though the Spitz classification takes major CHD into account, there are no data regarding survival with the specific combination of EA/TEF and Tetralogy of Fallot (TOF). With advances in postnatal care, we hypothesised that, survival is improving in these complex patients. This study reports morbidity and mortality outcomes of newborns with oesophageal atresia and TOF cardiac malformations METHODS: All patients with EA/TEF and TOF treated at Alder Hey Children's Hospital between the years 2000-2020, were identified. Data sets regarding gestation, birth weight, associated anomalies, operative intervention, morbidity, and mortality were analysed. RESULTS: Of a total of 350, EA/TEF patients 9 (2.6%) cases had EA/TEF associated with TOF (M:F 4:5). The median gestational age was 35/40 (range 28-41 weeks) with a median birth weight of 1790 g (range 1060-3350 g). Overall survival was 56% (5/9 cases) and all survivors remain under follow up (range 37-4458 days). Surgical strategies for managing EA/TEF with Fallot's tetralogy included 6/9 primary repairs and 3/9 cases with TEF ligation only (+ gastrostomy ± oesophagostomy). CONCLUSIONS: This study reports outcome data from one of the largest series of EA TEF patients with Fallot's tetralogy. Whilst outcomes may be challenging for this unique patient cohort, survival metrics provide important prognostic information that can be widely shared with health care teams and parents.

Downregulation of Salmonella Virulence Gene Expression During Invasion of Epithelial Cells Treated with Lactococcus lactis subsp. cremoris JFR1 Requires OppA.

Invasion of Salmonella into host intestinal epithelial cells requires the expression of virulence genes. In this study, cell culture models of human intestinal cells (mucus-producing HT29-MTX cells, absorptive Caco-2 cells, and combined cocultures of the two) were used to determine the effects of Lactococcus lactis subsp. cremoris treatments (exopolysaccharide producing and nonproducing strains) on the virulence gene expression of Salmonella Typhimurium and its mutant lacking the oligopeptide permease subunit A (ΔoppA). During the course of epithelial cell (HT29-MTX, Caco-2, and combined) infection by Salmonella Typhimurium DT104, improved barrier function was reflected by increased transepithelial electrical resistance in cells treated with both strains of L. lactis subsp. cremoris. In addition, virulence gene expression was downregulated, accompanied with lower numbers of invasive bacteria into epithelial cells in the presence of L. lactis subsp. cremoris treatments. Similarly, virulence gene expression of Salmonella was also suppressed when coincubated with overnight cultures of both L. lactis subsp. cremoris strains in the absence of epithelial cells. However, in medium or in the presence of cell cultures, Salmonella lacking the OppA permease function remained virulent. HT29-MTX cells and combined cultures stimulated by Salmonella Typhimurium DT104 showed significantly lower secretion levels of pro-inflammatory cytokine IL-8 after treatment with L. lactis subsp. cremoris cell suspensions. Contrarily, these responses were not observed during infection with S. Typhimurium ΔoppA. Both the exopolysaccharide producing and nonproducing strains of L. lactis subsp. cremoris JFR1 exhibited an antivirulence effect against S. Typhimurium DT104 although no significant difference between the two strains was observed. Our results show that an intact peptide transporter is essential for the suppression of Salmonella virulence genes which leads to the protection of the barrier function in the cell culture models studied.

Effect of fermented milk from Lactococcus lactis ssp. cremoris strain JFR1 on Salmonella invasion of intestinal epithelial cells.

The process of fermentation contributes to the organoleptic properties, preservation, and nutritional benefits of food. Fermented food may interfere with pathogen infections through a variety of mechanisms, including competitive exclusion or improving intestinal barrier integrity. In this study, the effect of milk fermented with Lactococcus lactis ssp. cremoris JFR1 on Salmonella invasion of intestinal epithelial cell cultures was investigated. Epithelial cells (HT29-MTX, Caco-2, and cocultures of the 2) were treated for 1 h with Lactococcus lactis ssp. cremoris JFR1 fermented milk before infection with Salmonella enterica ssp. enterica Typhimurium. Treatment with fermented milk resulted in increased transepithelial electrical resistance, which remained constant for the duration of infection (up to 3 h), illustrating a protective effect. After gentamicin treatment to remove adhered bacterial cells, enumeration revealed a reduction in numbers of intracellular Salmonella. Quantitative reverse-transcription PCR data indicated a downregulation of Salmonella virulence genes hilA, invA, and sopD after treatment with fermented milk. Fermented milk treatment of epithelial cells also exhibited an immunomodulatory effect reducing the production of proinflammatory IL-8. In contrast, chemically acidified milk (glucono delta-lactone) failed to show the same effect on monolayer integrity, Salmonella Typhimurium invasion, and gene expression as well as immune modulation. Furthermore, an oppA knockout mutant of Salmonella Typhimurium infecting treated epithelial cells did not show suppressed virulence gene expression. Collectively, these results suggest that milk fermented with Lactococcus lactis ssp. cremoris JFR1 is effective in vitro in the reduction of Salmonella invasion into intestinal epithelial cells. A functional OppA permease in Salmonella is required to obtain the antivirulence effect of fermented milk.

Control of Salmonella Newport on cherry tomato using a cocktail of lytic bacteriophages.

Bacteriophages have been envisioned as tools to control a variety of foodborne pathogenic bacteria. Salmonella is a foodborne pathogen that is a threat to public health around the world. Contaminated tomatoes have been associated with several Salmonella outbreaks. Hence, the objective of this work was to identify and characterize different lytic bacteriophages against Salmonella Newport, as one of top ten Salmonella serovars associated with human salmonellosis in North America, and then apply these phages to enhance the safety of cherry tomatoes. Four lytic phages against Salmonella Newport were selected based on their ability to lyse a majority of the 26 screened Salmonella serovars. The selected phages belong to Myoviridae (vB_SnwM_CGG4-1, vB_SnwM_CGG4-2) and Siphoviridae (vB_SnwM_CGG3-1, vB_SnwM_CGG3-2) families. They were found to be stable at different temperatures and pH, have latent periods ranging from 53 to 65 min and burst sizes from 92 to 177. In addition, the two Myoviridae phages have a lower frequency of developing bacteriophage insensitive mutants when compared with the Siphoviridae phages. No significant change in virulence gene expression was observed in the developed bacteriophage insensitive mutants when compared to the parental phage sensitive strain. Furthermore, the vB_SnwM_CGG4-1 genome revealed no homology to virulence or lysogenic genes. A phage cocktail was used to control the growth of S. Newport in broth medium and on contaminated cherry tomato. Complete inhibition of bacterial growth in broth medium was observed at 25 °C for 24 h. In addition, a 4.5 log10 unit reduction in the bacterial count was observed when applying the phage cocktail onto contaminated tomatoes stored at 22 °C for 3 days. These findings suggest that the isolated phages can be used for biocontrol of S. Newport to improve the safety of ready-to-eat (RTE) produce.

Evaluation of protective effect of Lactobacillus acidophilus La-5 on toxicity and colonization of Clostridium difficile in human epithelial cells in vitro.

Clostridium difficile infection is a range of toxin - mediated intestinal diseases that is often acquired in hospitals and small communities in developed countries. The main virulence factors of C. difficile are two exotoxins, toxin A and toxin B, which damage epithelial cells and manifest as colonic inflammation and mild to severe diarrhea. Inhibiting C. difficile adherence, colonization, and reducing its toxin production could substantially minimize its pathogenicity and lead to faster recovery from the disease. This study investigated the efficacy of probiotic secreted bioactive molecules from Lactobacillus acidophilus La-5, in decreasing C. difficile attachment and cytotoxicity in human epithelial cells in vitro. L. acidophilus La-5 cell-free supernatant (La-5 CFS) was used to treat the hypervirulent C. difficile ribotype 027 culture with subsequent monitoring of cytotoxicity and adhesion. In addition, the effect of pretreating cell lines with La-5 CFS in protecting cells from the cytotoxicity of C. difficile culture filtrate or bacterial cell attachment was examined. La-5 CFS substantially reduced the cytotoxicity and cytopathic effect of C. difficile culture filtrate on HT-29 and Caco-2 cells. Furthermore, La-5 CFS significantly reduced attachment of the C. difficile bacterial cells on both cell lines. It was also found that pretreatment of cell lines with La-5 CFS effectively protected cell lines from cytotoxicity and adherence of C. difficile. Our study suggests that La-5 CFS could potentially be used to prevent and cure C. difficile infection and relapses.