The impact of social determinants on health outcomes in a region in the North of England: a structural equation modelling analysis.

OBJECTIVES: The aim of this study was to identify the impact of social determinants of health on physical and mental health outcomes in a UK population. STUDY DESIGN: Structural equation modelling was used to hypothesise a model of relationships between health determinants and outcomes within a region in the North of England using large-scale population survey data (6208 responses). METHODS: We analysed responses from a population survey to assess the influence of a deprivation-based index at the environmental level, education and income on a behaviour index (smoking, alcohol consumption, physical activity, and dietary habits) and the influence of all these factors on self-reported physical health and the influence of the behaviour index and income on mental wellbeing. RESULTS: The proposed model was well supported by the data. Goodness-of-fit statistics, most notably a low value of the root mean square error of approximation (RMSEA), supported the validity of the proposed relationships (RMSEA = 0.054). The model revealed all examined paths to be statistically significant. Income and education were influential in determining an individual's behaviour index score, which, with income was the most important predictor of both the correlated outcomes of physical health and mental wellbeing (P < 0.001 in all cases). CONCLUSIONS: Findings challenge the traditional view of singular causal pathways, emphasising that interventions should consider the underlying influencing socio-economic conditions, which would influence behaviour and therefore physical and mental wellbeing. The extent to which the model is supported by the data, and the statistical significance of individual relationships accentuates the imperative for comprehensive public health strategies that integrate multiple socio-economic factors.

Tocilizumab for treatment of SARS-CoV-2 infection at home: A case report.

SARS-CoV-2 virtual wards have successfully developed to monitor and escalate patients to hospital throughout the pandemic. Here we describe the case of an 84 year old man who received his complete care for severe SARS-CoV-2 pneumonitis at home, including the administration of oxygen, dexamethasone and tocilizumab.

Geographical information system and spatial-temporal statistics for monitoring infectious agents in hospital: a model using Klebsiella pneumoniae complex.

BACKGROUND: The emergence and spread of antimicrobial resistance and infectious agents have challenged hospitals in recent decades. Our aim was to investigate the circulation of target infectious agents using Geographic Information System (GIS) and spatial-temporal statistics to improve surveillance and control of healthcare-associated infection and of antimicrobial resistance (AMR), using Klebsiella pneumoniae complex as a model. METHODS: A retrospective study carried out in a 450-bed federal, tertiary hospital, located in Rio de Janeiro. All isolates of K. pneumoniae complex from clinical and surveillance cultures of hospitalized patients between 2014 and 2016, identified by the use of Vitek-2 system (BioMérieux), were extracted from the hospital's microbiology laboratory database. A basic scaled map of the hospital's physical structure was created in AutoCAD and converted to QGis software (version 2.18). Thereafter, bacteria according to resistance profiles and patients with carbapenem-resistant K. pneumoniae (CRKp) complex were georeferenced by intensive and nonintensive care wards. Space-time permutation probability scan tests were used for cluster signals detection. RESULTS: Of the total 759 studied isolates, a significant increase in the resistance profile of K. pneumoniae complex was detected during the studied years. We also identified two space-time clusters affecting adult and paediatric patients harbouring CRKp complex on different floors, unnoticed by regular antimicrobial resistance surveillance. CONCLUSIONS: In-hospital GIS with space-time statistical analysis can be applied in hospitals. This spatial methodology has the potential to expand and facilitate early detection of hospital outbreaks and may become a new tool in combating AMR or hospital-acquired infection.

Environmental Distractions during Unsupervised Remote Digital Cognitive Assessment.

The current demand for cognitive assessment cannot be met with traditional in-person methods, warranting the need for remote unsupervised options. However, lack of visibility into testing conditions and effort levels limit the utility of existing remote options. This retrospective study analyzed the frequency of and factors associated with environmental distractions during a brief digital assessment taken at home by 1,442 adults aged 23-84. Automated scoring algorithms flagged low data capture. Frequency of environmental distractions were manually counted on a per-frame and per-trial basis. A total of 7.4% of test administrations included distractions. Distractions were more frequent in men (41:350) than women (65:1,092) and the average age of distracted participants (51.7) was lower than undistracted participants (57.8). These results underscore the challenges associated with unsupervised cognitive assessment. Data collection methods that enable review of testing conditions are needed to confirm quality, usability, and actionability.

Splenectomy in Jamaican children with sickle cell disease: Outcome of selective blood transfusion.

We reviewed the post-operative morbidity and mortality of open splenectomy undertaken in conjunction with selective blood transfusion in Jamaican children with sickle cell disease. Data were collected on 150 splenectomies performed between November 1994 and October 2017. Selective blood transfusion involved raising haemoglobin levels to approximately 100 g/L in patients with admission haemoglobin ≥10 g/L below steady state. There was no mortality. Mean post-operative stay was 3.2 days with a median of three days. Total morbidity was 19/150 cases (12.7%), with acute chest syndrome accounting for 11/19 (57.9%). Among the non-transfused, acute chest syndrome occurred in 10/117 cases (8.5%), while among transfused, acute chest syndrome occurred in 1/33 cases (2.9%). We recommend this selective blood transfusion protocol for patients with sickle cell disease to surgeons who undertake splenectomies in settings where blood bank reserves are perennially low.

Predictive factors for sepsis by carbapenem resistant Gram-negative bacilli in adult critical patients in Rio de Janeiro: a case-case-control design in a prospective cohort study.

BACKGROUND: Studies have investigated risk factors for infections by specific species of carbapenem-resistant Gram-negative bacilli (CR-GNB), but few considered the group of GNB species and most of them were performed in the setting of bacteremia or hospital infection. This study was implemented to identify risk factors for sepsis by CR- and carbapenem-susceptible (CS) GNB in intensive care unit (ICU) patients to improve management strategies for CR-GNB sepsis. METHODS: We developed a case-case-control study from a prospective cohort of patients with systemic inflammatory response syndrome (SIRS), sepsis-2 or sepsis-3 criteria in which blood and other sample cultures were collected and antimicrobial therapy was instituted, in an adult clinical-surgical ICU, at tertiary public hospital in Rio de Janeiro, from August 2015 through March 2017. RESULTS: Among the total of 629 ICU admissions followed by 7797 patient-days, after applying inclusion and exclusion criteria we identified 184 patients who developed recurrent or single hospital-acquired sepsis. More than 90% of all evaluable cases of sepsis and 87% of control group fulfilled the modified sepsis-3 definition. Non-fermenting bacilli and ventilator-associated pneumonia predominated as etiology and source of CR-GNB sepsis. While Enterobacteriaceae and intra-abdominal surgical site plus urinary-tract infections prevailed in CS-GNB than CR-GNB sepsis. Carbapenemase production was estimated in 76% of CR-GNB isolates. Multivariate logistic regression analysis revealed previous infection (mostly hospital-acquired bacterial infection or sepsis) (OR = 4.28; 95% CI 1.77-10.35), mechanical ventilation (OR = 4.21; 95% CI 1.17-15.18), carbapenem use (OR = 3.42; 95% CI 1.37-8.52) and length of hospital stay (OR = 1.03; 95% CI 1.01-1.05) as independent risk factors for sepsis by CR-GNB. While ICU readmission (OR = 6.92; 95% CI 1.72-27.78) and nosocomial diarrhea (OR = 5.32; 95% CI 1.07-26.45) were factors associated with CS-GNB sepsis. CONCLUSIONS: The investigation of recurrent and not only bacteremic episodes of sepsis was the differential of this study. The results are in agreement with the basic information in the literature. This may help improve management strategies and future studies on sepsis by CR-GNB.

Hierarchical distance sampling to estimate population sizes of common lizards across a desert ecoregion.

Multispecies wildlife monitoring across large geographical regions is important for effective conservation planning in response to expected impacts from climate change and land use. Unlike many species of birds, mammals, and amphibians which can be efficiently sampled using automated sensors including cameras and sound recorders, reptiles are often much more challenging to detect, in part because of their typically cryptic behavior and generally small body sizes. Although many lizard species are more active during the day which makes them easier to detect using visual encounter surveys, they may be unavailable for sampling during certain periods of the day or year due to their sensitivity to temperature. In recognition of these sampling challenges, we demonstrate application of a recent innovation in distance sampling that adjusts for temporary emigration between repeat survey visits. We used transect surveys to survey lizards at 229 sites throughout the Mojave Desert in California, USA, 2016. We estimated a total population size of 82 million (90% CI: 65-99 million) for the three most common species of lizards across this 66,830 km2 ecoregion. We mapped how density at the 1-km2 scale was predicted to vary with vegetation cover and human development. We validated these results against independent surveys from the southern portion of our study area. Our methods and results demonstrate how multispecies monitoring programs spanning arid ecoregions can better incorporate information about reptiles.

Efficacy of a Novel Surgical Manikin for Simulating Emergency Surgical Procedures.

The practical component of the Advanced Trauma Life Support (ATLS®) course typically includes a TraumaMan® manikin. This manikin is expensive; hence, a low-cost alternative (SurgeMan®) was developed in Brazil. Our primary objective was to compare user satisfaction among SurgeMan, TraumaMan, and porcine models during the course. Our secondary objective was to determine the user satisfaction scores for SurgeMan. This study included 36 ATLS students and nine instructors (4:1 ratio). Tube thoracostomy, cricothyroidotomy, pericardiocentesis, and diagnostic peritoneal lavage were performed on all the three models. The participants then rated their satisfaction both after each activity and after the course. The porcine and TraumaMan models fared better than SurgeMan for all skills except pericardiocentesis. In the absence of ethical or financial constraints, 58 per cent of the students and 66 per cent of the instructors indicated preference for the porcine model. When ethical and financial factors were considered, no preference was evident among the students, whereas 66 per cent of instructors preferred SurgeMan over the others. The students gave all three models an overall adequacy rating of >80 per cent; the instructors gave only the animal models an adequacy rating of <80 per cent. Although the users were more satisfied with TraumaMan than with SurgeMan, both were considered acceptable for the ATLS course.

Quantification of anti-nutritional factors and their correlations with protein and oil in soybeans.

Soybeans contain about 30% carbohydrate, mainly consisting of non-starch polysaccharides (NSP) and oligosaccharides. NSP are not hydrolyzed in the gastrointestinal tract of monogastric animals. These NSP negatively affect the development of these animals, especially the soluble fraction. This work aimed to establish a method to quantify NSP in soybeans, using high performance liquid chromatography (HPLC), and to estimate correlations between NSP, oligosaccharides, protein and oil. Sucrose, raffinose + stachyose, soluble and insoluble NSP contents were determined by HPLC. Oil and protein contents were determined by near-infrared spectroscopy (NIRS). The soluble PNAs content showed no significant correlation with protein, oil, sucrose and raffinose + stachyose contents, but oligosaccharides showed a negative correlation with protein content. These findings open up the possibility of developing cultivars with low soluble NSP content, aiming to develop feed for monogastric animals.

Quantification of anti-nutritional factors and their correlations with protein and oil in soybeans

ABSTRACT Soybeans contain about 30% carbohydrate, mainly consisting of non-starch polysaccharides (NSP) and oligosaccharides. NSP are not hydrolyzed in the gastrointestinal tract of monogastric animals. These NSP negatively affect the development of these animals, especially the soluble fraction. This work aimed to establish a method to quantify NSP in soybeans, using high performance liquid chromatography (HPLC), and to estimate correlations between NSP, oligosaccharides, protein and oil. Sucrose, raffinose + stachyose, soluble and insoluble NSP contents were determined by HPLC. Oil and protein contents were determined by near-infrared spectroscopy (NIRS). The soluble PNAs content showed no significant correlation with protein, oil, sucrose and raffinose + stachyose contents, but oligosaccharides showed a negative correlation with protein content. These findings open up the possibility of developing cultivars with low soluble NSP content, aiming to develop feed for monogastric animals.

Trends in antimicrobial resistance among Bacteroides species and Parabacteroides species in the United States from 2010-2012 with comparison to 2008-2009.

The susceptibility trends for Bacteroides fragilis and related species against various antibiotics were determined using data from 3 years of surveillance (2010-2012) on 779 isolates referred by 7 medical centers. The antibiotic test panel included imipenem, ertapenem, meropenem, ampicillin-sulbactam, piperacillin-tazobactam, cefoxitin, clindamycin, moxifloxacin, tigecycline, linezolid, chloramphenicol and . MICs were determined using the agar dilution CLSI reference method. Carbapenem resistance remained low (range 1.1%-2.5%) and unchanged from 2008 to 9 through 2010-2012. Resistance also remained low to the beta-lactam/beta-lactamase inhibitor combinations (1.1%-4.4%). While resistance to clindamycin and moxifloxacin remained high; rates were lower for B. fragilis in 2010-12 (24% and 19% respectively) compared to the earlier time frame of 2008-9 (29% and 35% respectively for the earlier time frame). There were notable species and resistance associations which have been demonstrated previously. No resistance to metronidazole or chloramphenicol resistance was seen. These data demonstrate the continued variability in resistance among Bacteroides and Parabacteroides species, but do demonstrate that carbapenems and beta-lactam/beta-lactamase inhibitor combinations remain very active throughout the United States.

Intended and unintended consequences of abortion law reform: perspectives of abortion experts in Victoria, Australia.

INTRODUCTION: In Victoria, Australia, abortion was decriminalised in October 2008, bringing the law in line with clinical practice and community attitudes. We describe how experts in abortion service provision perceived the intent and subsequent impact of the 2008 Victorian abortion law reform. METHODS: Experts in abortion provision in Victoria were recruited for a qualitative semi-structured interview about the 2008 law reform and its perceived impact, until saturation was reached. Nineteen experts from a range of health care settings and geographic locations were interviewed in 2014/2015. Thematic analysis was conducted to summarise participants' views. RESULTS: Abortion law reform, while a positive event, was perceived to have changed little about the provision of abortion. The views of participants can be categorised into: (1) goals that law reform was intended to address and that have been achieved; (2) intent or hopes of law reform that have not been achieved; (3) unintended consequences; (4) coincidences; and (5) unfinished business. All agreed that law reform had repositioned abortion as a health rather than legal issue, had shifted the power in decision making from doctors to women, and had increased clarity and safety for doctors. However, all described outstanding concerns; limited public provision of surgical abortion; reduced access to abortion after 20 weeks; ongoing stigma; lack of a state-wide strategy for equitable abortion provision; and an unsustainable workforce. CONCLUSION: Law reform, while positive, has failed to address a number of significant issues in abortion service provision, and may have even resulted in a 'lull' in action.

Elevated triglycerides are associated with decreased executive function among adolescents with bipolar disorder.

OBJECTIVE: Cardiovascular risk factors that comprise metabolic syndrome (MetS) have been linked with cognition in adults with bipolar disorder (BD). This study examines the association between MetS components and executive function in adolescents with BD. METHODS: A total of 34 adolescents with BD and 35 healthy control (HC) adolescents were enrolled. MetS components included triglycerides, high-density lipoprotein, glucose, waist circumference, and systolic and diastolic blood pressure. Executive functioning was measured using the intra-extra-dimensional (IED) set-shifting task from the Cambridge Neuropsychological Tests Automated Battery. RESULTS: Adolescents with BD were more likely to have ≥1 MetS components (64.7%) as compared to HC participants (22.9%, χ(2) = 12.29, P = <0.001). Adolescents with BD also had poorer IED task performance compared to HC adolescents (composite Z-score: 0.21 ± 0.52 vs. 0.49 ± 0.51, P = 0.011). Within the BD group, IED composite Z-scores were correlated with diastolic blood pressure and triglyceride levels (ρ = -0.358, P = 0.041 and ρ = -0.396, P = 0.020 respectively). The association of triglycerides with executive function remained significant after controlling for age, IQ, and current use of second-generation antipsychotics. CONCLUSION: Elevated triglycerides are associated with poorer executive function among adolescents with BD. Studies of behavioural and pharmacological interventions targeting MetS components for the purpose of improving executive function among adolescents with BD are warranted.

An ultra-deep sequencing strategy to detect sub-clonal TP53 mutations in presentation chronic lymphocytic leukaemia cases using multiple polymerases.

Chronic lymphocytic leukaemia (CLL) is the most common clonal B-cell disorder characterized by clonal diversity, a relapsing and remitting course, and in its aggressive forms remains largely incurable. Current front-line regimes include agents such as fludarabine, which act primarily via the DNA damage response pathway. Key to this is the transcription factor p53. Mutations in the TP53 gene, altering p53 functionality, are associated with genetic instability, and are present in aggressive CLL. Furthermore, the emergence of clonal TP53 mutations in relapsed CLL, refractory to DNA-damaging therapy, suggests that accurate detection of sub-clonal TP53 mutations prior to and during treatment may be indicative of early relapse. In this study, we describe a novel deep sequencing workflow using multiple polymerases to generate sequencing libraries (MuPol-Seq), facilitating accurate detection of TP53 mutations at a frequency as low as 0.3%, in presentation CLL cases tested. As these mutations were mostly clustered within the regions of TP53 encoding DNA-binding domains, essential for DNA contact and structural architecture, they are likely to be of prognostic relevance in disease progression. The workflow described here has the potential to be implemented routinely to identify rare mutations across a range of diseases.

Transposons to toxins: the provenance, architecture and diversification of a widespread class of eukaryotic effectors.

Enzymatic effectors targeting nucleic acids, proteins and other cellular components are the mainstay of conflicts across life forms. Using comparative genomics we identify a large class of eukaryotic proteins, which include effectors from oomycetes, fungi and other parasites. The majority of these proteins have a characteristic domain architecture with one of several N-terminal 'Header' domains, which are predicted to play a role in trafficking of these effectors, including a novel version of the Ubiquitin fold. The Headers are followed by one or more diverse C-terminal domains, such as restriction endonuclease (REase), protein kinase, HNH endonuclease, LK-nuclease (a RNase) and multiple distinct peptidase domains, which are predicted to carry their toxicity determinants. The most common types of these proteins appear to have originated from prokaryotic transposases (e.g. TN7 and Mu) and combine a CDC6/ORC1-STAND clade NTPase domain with a C-terminal REase domain. Other than the so-called Crinkler effectors of oomycetes and fungi, these effectors are encoded by other eukaryotic parasites such as trypanosomatids (the RHS proteins) and the rhizarian Plasmodiophora, and symbionts like Capsaspora Remarkably, we also find these proteins in free-living eukaryotes, including several viridiplantae, fungi, amoebozoans and animals. These versions might either still be transposons or function in other poorly understood eukaryote-specific inter-organismal and inter-genomic conflicts. These include the Medea1 selfish element of Tribolium that spreads via post-zygotic killing. We present a unified mechanism for the recombination-dependent diversification and action of this widespread class of molecular weaponry deployed across diverse conflicts ranging from parasitic to free-living forms.

Role of endothelium-derived hyperpolarising factor in acetylcholine-mediated vasodilatation in skin.

AIM: Acetylcholine (ACh) is an endothelium-dependent vasodilator used to investigate endothelial function in the microcirculation. The mediators of its vasodilatory effects are not clear, but endothelium-derived hyperpolarising factor (EDHF) is thought to contribute, and appears to have particular importance in smaller peripheral vessels. The aim of this study was to investigate the role of EDHF in ACh-mediated vasodilator responses in human forearm skin. METHODS: Laser Doppler imaging was used to measure forearm skin blood flow responses to iontophoretic administration of ACh in 7 healthy men. ACh in a 10-mg/mL solution was administered in accumulating doses using increasing delivery currents of 10, 15, 20, 50 and 100 µA. The measurements were repeated on subsequent visits when the effects of EDHF were blocked using intra-arterial sulphaphenazole at 2 mg/min (a cytochrome P-450 inhibitor), nitric oxide (NO) was blocked using intra-arterial administration of the NO synthetase inhibitor l-NG-monomethyl arginine (l-NMMA) at 4 µmol/min, and prostanoids were blocked with oral aspirin 1 g. RESULTS: The microvascular response to ACh was significantly attenuated by sulphaphenazole alone (P=0.018), l-NMMA alone (P<0.001) and the combination of sulphaphenazole plus l-NMMA (P<0.001), and aspirin had no additional effect. CONCLUSION: EDHF is a significant contributor to the vasodilatory effects of ACh in the human dermal microcirculation. Information about abnormalities in specific pathways of endothelial function in patient groups may help in the targeting of appropriate drug therapies.

Hepatitis C virus and other risk factors in hepatocellular carcinoma.

UNLABELLED: Hepatocellular carcinoma (HCC) increased in Egypt in the past years, becoming the most common cancer among men. Hepatitis B virus (HBV) and hepatitis C virus (HCV) are the known primary risk factors for HCC. This study describes the viral profile of HCC in a predominantly rural area in Egypt. We included 148 HCC cases and 148 controls from the Tanta Cancer Center and the Gharbiah Cancer Society in the Nile delta region. Serological (ELISA) and molecular (PCR) analysis for HBV and HCV infection were performed on plasma samples from each subject. Epidemiologic, environmental, and medical histories were collected by interviewing of subjects. Around 90.5% of cases and controls were from rural areas. HCV infection was high in both cases and controls (89.2% and 49.3%, for cases and controls respectively by serology). HCV was the most important HCC risk factor [OR 9.7 (95% CI: 3.3-28.0, P <0.01)], and HBV infection showed marginal tendency of increased risk [OR 5.4 (95% CI: 0.9-31.8, P <0.06)]. Ever worked in farming [OR 2.8 (95% CI: 1.1-7.2, P <0.03)] and history of cirrhosis [OR 3.6 (95% CI: 1.6-8.1, P <0.01)] or blood transfusion [OR 4.2 (95% CI: 0.99-17.8, P <0.05)] were also associated with increased HCC risk. This study in a predominantly rural area in Egypt supports previous reports from other parts of Egypt that HCV infection is the primary HCC risk factor in Egypt. Further understanding of the relationship between infection and other risk factors in the development of HCC could lead to targeted interventions for at-risk individuals. KEYWORDS: hepatocellular carcinoma; hepatitis; rural; risk factors; Egypt.

Penetrating anorectal injuries in Jamaican children.

PURPOSE: To discuss the presentation, management and outcomes of penetrating anorectal injuries at the Bustamante Hospital for Children. METHODS: A retrospective review over an 11-year period (January 2001-December 2011) was undertaken. The data analysed were extracted from patients' case notes which were pulled based on the hospital's admission database. RESULTS: Over the study period a total of 14 children presented with penetrating anorectal injuries. The medical records for one child were missing. The mean age at presentation was 6 years. Impalement by a metal spike was the mechanism of injury in 12 children, with one case of sexual assault. Three of the children had associated urogenital injuries. Ten rectal injuries were extraperitoneal. Five of the 13 cases (38 %) were managed with a colostomy-average time to closure was 6 months. There was one case of perineal wound infection and dehiscence. There was no mortality. CONCLUSION: Selective fecal diversion in the form of a sigmoid loop colostomy is a safe and acceptable management option for children with penetrating anorectal injuries. The perineal wound itself can be closed primarily except in cases of delayed presentation.

Long-term retention of injected aluminium-26.

Data previously reported on the whole-body retention of aluminium-26 ((26)Al) in a male volunteer are extended to 8 years after intravenous administration as citrate, when only ~2% of the injected tracer remained. The extended data, combined with a report elsewhere of the late urinary and faecal excretion of (26)Al by this subject, reinforce indications that transdermal losses contribute to the clearance of systemic aluminium and mitigate its long-term accumulation from chronic exposure.

Detecting diabetes and impaired glucose tolerance in patients with atherosclerotic peripheral arterial disease.

AIM: In patients with peripheral arterial disease (PAD), diabetes mellitus is associated with increased mortality rates. The aim of this study was to estimate the prevalence of undiagnosed diabetes in PAD patients, and to assess whether a glucose tolerance test is more sensitive than a simple fasting glucose measurement for diagnosis in this group. METHODS: A standard glucose tolerance test and fasting glucose measurements were performed in 53 patients with PAD, who were then categorised into diagnostic groups according to each test result. RESULTS: Using the glucose tolerance test results, 11.5% of patients were diagnosed with diabetes mellitus and 28.8% had either impaired fasting glucose or impaired glucose tolerance. Using fasting glucose levels only, 7.7% received a diagnosis of diabetes mellitus and 17.3% had impaired fasting glucose. The glucose tolerance data and the fasting glucose data were in agreement in 82.7% of cases, but the glucose tolerance test identified an additional 3.8% of cases with diabetes and an additional 13.5% of cases with impaired glucose tolerance. CONCLUSION: Undiagnosed diabetes and impaired glucose homeostasis are common in patients with PAD. Routine screening using a simple glucose tolerance test should be considered in the clinical assessment of this group.