Real-world clinical effectiveness and sustainability of universal bloodborne virus testing in an urban emergency department in the UK.

Innovative testing approaches and care pathways are required to meet HIV, hepatitis B (HBV) and hepatitis C (HCV) elimination goals. Routine testing for blood-borne viruses (BBVs) within emergency departments (EDs) is suggested by the European Centre for Disease Prevention and Control but there is a paucity of supporting evidence. We evaluated the introduction of routine BBV testing in EDs at a large teaching hospital in northern England. In October 2018, we modified the electronic laboratory ordering system to reflex opt-out HIV, HBV and HCV testing for all ED attendees aged 16-65 years who had a routine blood test for urea and electrolytes (U&Es). Linkage to care (LTC) was attempted for newly diagnosed patients, those never referred and those who had previously disengaged from care. The project operated for 18 months, here we present evaluation of the initial nine months (2 October 2018-1 July 2019). We analysed testing uptake, BBV seropositivity, LTC and treatment initiation within six months post-diagnosis. Over 9 months, 17,026/28,178 (60.4%) ED attendees who had U&Es performed were tested for ≥ 1 BBV. 299 active BBV infections were identified: 70 HIV Ab/Ag-positive (0.4% seroprevalence), 73 HBsAg-positive (0.4%) and 156 HCV RNA-positive (1.0%). Only 24.3% (17/70) HIV Ab/Ag-positive individuals required LTC, compared to 94.9% (148/156) HCV RNA-positive and 53.4% (39/73) HBsAg-positive individuals. LTC was successful in 94.1% (16/17) HIV Ab/Ag-positive and 69.3% (27/39) HBsAg-positive individuals. However, at 6 months LTC was just 39.2% (58/148) for HCV RNA-positive individuals, with 64% (37/58) of these commencing treatment. Universal opt-out ED BBV testing proved feasible and effective in identifying active BBV infections, especially among marginalised populations with reduced healthcare access. Our integrated approach achieved good LTC rates although further service development is necessary, particularly for HCV RNA-positive people who inject drugs.

In silico characterisation of the complete Ly6 protein family in Fasciola gigantica supported through transcriptomics of the newly-excysted juveniles.

Fasciola gigantica is one of the aetiological trematodes associated with fascioliasis, which heavily impacts food-production systems and human and animal welfare on a global scale. In the absence of a vaccine, fascioliasis control and treatment is restricted to pasture management, such as clean grazing, and a limited array of chemotherapies, to which signs of resistance are beginning to appear. Research into novel control strategies is therefore urgently required and the advent of 'omics technologies presents considerable opportunity for novel drug and vaccine target discovery. Here, interrogation of the first available F. gigantica newly excysted juvenile (NEJ) transcriptome revealed several protein families of current interest to parasitic flatworm vaccine research, including orthologues of mammalian complement regulator CD59 of the Ly6 family. Ly6 proteins have previously been identified on the tegument of Schistosoma mansoni and induced protective immunity in vaccination trials. Incorporating the recently available F. gigantica genome, the current work revealed 20 novel Ly6 family members in F. gigantica and, in parallel, significantly extended the F. hepatica complement from 3 to 18 members. Phylogenetic analysis revealed several distinct clades within the family, some of which are unique to Fasciola spp. trematodes. Analysis of available proteomic databases also revealed three of the newly discovered FhLy6s were present in extracellular vesicles, which have previously been prioritised in studying the host-parasite interface. The presentation of this new transcriptomic resource, in addition to the Ly6 family proteins here identified, represents a wealth of opportunity for future vaccine research.

Evidence of Immune Modulators in the Secretome of the Equine Tapeworm Anoplocephala perfoliata.

Anoplocephala perfoliata is a neglected gastro-intestinal tapeworm, commonly infecting horses worldwide. Molecular investigation of A. perfoliata is hampered by a lack of tools to better understand the host-parasite interface. This interface is likely influenced by parasite derived immune modulators released in the secretome as free proteins or components of extracellular vesicles (EVs). Therefore, adult RNA was sequenced and de novo assembled to generate the first A. perfoliata transcriptome. In addition, excretory secretory products (ESP) from adult A. perfoliata were collected and EVs isolated using size exclusion chromatography, prior to proteomic analysis of the EVs, the EV surface and EV depleted ESP. Transcriptome analysis revealed 454 sequences homologous to known helminth immune modulators including two novel Sigma class GSTs, five α-HSP90s, and three α-enolases with isoforms of all three observed within the proteomic analysis of the secretome. Furthermore, secretome proteomics identified common helminth proteins across each sample with known EV markers, such as annexins and tetraspanins, observed in EV fractions. Importantly, 49 of the 454 putative immune modulators were identified across the secretome proteomics contained within and on the surface of EVs in addition to those identified in free ESP. This work provides the molecular tools for A. perfoliata to reveal key players in the host-parasite interaction within the horse host.

The physiological strain index does not reliably identify individuals at risk of reaching a thermal tolerance limit.

PURPOSE: The physiological strain index (PSI) was developed to assess individuals' heat strain, yet evidence supporting its use to identify individuals at potential risk of reaching a thermal tolerance limit (TTL) is limited. The aim of this study was to assess whether PSI can identify individuals at risk of reaching a TTL. METHODS: Fifteen females and 21 males undertook a total of 136 trials, each consisting of two 40-60 minute periods of treadmill walking separated by ~ 15 minutes rest, wearing permeable or impermeable clothing, in a range of climatic conditions. Heart rate (HR), skin temperature (Tsk), rectal temperature (Tre), temperature sensation (TS) and thermal comfort (TC) were measured throughout. Various forms of the PSI-index were assessed including the original PSI, PSIfixed, adaptive-PSI (aPSI) and a version comprised of a measure of heat storage (PSIHS). Final physiological and PSI values and their rate of change (ROC) over a trial and in the last 10 minutes of a trial were compared between trials completed (C, 101 trials) and those terminated prematurely (TTL, 35 trials). RESULTS: Final PSIoriginal, PSIfixed, aPSI, PSIHS did not differ between TTL and C (p > 0.05). However, differences between TTL and C occurred in final Tsk, Tre-Tsk, TS, TC and ROC in PSIfixed, Tre, Tsk and HR (p < 0.05). CONCLUSION: These results suggest the PSI, in the various forms, does not reliably identify individuals at imminent risk of reaching their TTL and its validity as a physiological safety index is therefore questionable. However, a physiological-perceptual strain index may provide a more valid measure.

Optimizing the Use of Phase Change Material Vests Worn During Explosives Ordnance Disposal Operations in Hot Conditions.

Phase change material (PCM) cooling garments' efficacy is limited by the duration of cooling provided. The purpose of this study was to evaluate the effect of replacing a PCM vest during a rest period on physiological and perceptual responses during explosive ordnance disposal (EOD) related activity. Six non-heat acclimated males undertook three trials (consisting of 2 × 3 × 16.5 min activity cycles interspersed with one 10 min rest period) in 40°C, 12% relative humidity whilst wearing a ≈38 kg EOD suit. Participants did not wear a PCM cooling vest (NoPCM); wore one PCM vest throughout (PCM1) or changed the PCM vest in the 10 min rest period (PCM2). Rectal temperature (T re ), mean skin temperature (T skin ), heart rate (HR), Physiological Strain Index (PSI), ratings of perceived exertion, temperature sensation and thermal comfort were compared at the end of each activity cycle and at the end of the trial. Data displayed as mean [95% CI]. After the rest period, a rise in T re was attenuated in PCM2 compared to NoPCM and PCM1 (-0.57 [-0.95, -0.20]°C and -0.46 [-0.81, -0.11]°C, respectively). A rise in HR and T skin was also attenuated in PCM2 compared to NoPCM and PCM1 (-23 [-29, -16] beats⋅min-1 and -17 [-28, -6.0] beats⋅min-1; -0.61 [-1.21, -0.10]°C and -0.89 [-1.37, -0.42]°C, respectively). Resulting in PSI being lower in PCM2 compared to NoPCM and PCM1 (-2.2 [-3.1, -1.4] and -0.8 [-1.3,-0.4], respectively). More favorable perceptions were also observed in PCM2 vs. both NoPCM and PCM1 (p < 0.01). Thermal perceptual measures were similar between NoPCM and PCM1 and the rise in T re after the rest period tended to be greater in PCM1 than NoPCM. These findings suggest that replacing a PCM vest better attenuates rises in both physiological and perceptual strain compared to when a PCM vest is not replaced. Furthermore, not replacing a PCM vest that has exhausted its cooling capacity, can increase the level of heat strain experienced by the wearer.

Prediction of Core Body Temperature from Multiple Variables.

This paper aims to improve the prediction of rectal temperature (T re) from insulated skin temperature (T is) and micro-climate temperature (T mc) previously reported (Richmond et al., Insulated skin temperature as a measure of core body temperature for individuals wearing CBRN protective clothing. Physiol Meas 2013; 34:1531-43.) using additional physiological and/or environmental variables, under several clothing and climatic conditions. Twelve male (25.8±5.1 years; 73.6±11.5kg; 178±6cm) and nine female (24.2±5.1 years; 62.4±11.5kg; 169±3cm) volunteers completed six trials, each consisting of two 40-min periods of treadmill walking separated by a 20-min rest, wearing permeable or impermeable clothing, under neutral (25°C, 50%), moderate (35°C, 35%), and hot (40°C, 25%) conditions, with and without solar radiation (600W m(-2)). Participants were measured for heart rate (HR) (Polar, Finland), skin temperature (T s) at 11 sites, T is (Grant, Cambridge, UK), and breathing rate (f) (Hidalgo, Cambridge, UK). T mc and relative humidity were measured within the clothing. T re was monitored as the 'gold standard' measure of T c for industrial or military applications using a 10cm flexible probe (Grant, Cambridge, UK). A stepwise multiple regression analysis was run to determine which of 30 variables (T is, T s at 11 sites, HR, f, T mc, temperature, and humidity inside the clothing front and back, body mass, age, body fat, sex, clothing, Thermal comfort, sensation and perception, and sweat rate) were the strongest on which to base the model. Using a bootstrap methodology to develop the equation, the best model in terms of practicality and validity included T is, T mc, HR, and 'work' (0 = rest; 1 = exercise), predicting T re with a standard error of the estimate of 0.27°C and adjusted r (2) of 0.86. The sensitivity and specificity for predicting individuals who reached 39°C was 97 and 85%, respectively. Insulated skin temperature was the most important individual parameter for the prediction of T re. This paper provides novel information about the viability of predicting T c under a wide range of conditions, using predictors which can practically be measured in a field environment.

Blood glucose monitoring.

I found the CPD article on blood glucose monitoring and management in acute stroke care interesting and informative. As I am a mental health nursing student, my knowledge of chronic physical conditions is limited, so I learned a lot.

Prediction of human core body temperature using non-invasive measurement methods.

The measurement of core body temperature is an efficient method for monitoring heat stress amongst workers in hot conditions. However, invasive measurement of core body temperature (e.g. rectal, intestinal, oesophageal temperature) is impractical for such applications. Therefore, the aim of this study was to define relevant non-invasive measures to predict core body temperature under various conditions. We conducted two human subject studies with different experimental protocols, different environmental temperatures (10 °C, 30 °C) and different subjects. In both studies the same non-invasive measurement methods (skin temperature, skin heat flux, heart rate) were applied. A principle component analysis was conducted to extract independent factors, which were then used in a linear regression model. We identified six parameters (three skin temperatures, two skin heat fluxes and heart rate), which were included for the calculation of two factors. The predictive value of these factors for core body temperature was evaluated by a multiple regression analysis. The calculated root mean square deviation (rmsd) was in the range from 0.28 °C to 0.34 °C for all environmental conditions. These errors are similar to previous models using non-invasive measures to predict core body temperature. The results from this study illustrate that multiple physiological parameters (e.g. skin temperature and skin heat fluxes) are needed to predict core body temperature. In addition, the physiological measurements chosen in this study and the algorithm defined in this work are potentially applicable as real-time core body temperature monitoring to assess health risk in broad range of working conditions.

Thermal perceptions and skin temperatures during continuous and intermittent ventilation of the torso throughout and after exercise in the heat.

OBJECTIVE: This study tested the hypothesis that intermittent cooling in air-perfused vests (APV) will not only maintain thermal balance but, due to cyclical activations of cutaneous thermoreceptors, also enhance thermal perceptions. METHOD: Ten physically active males completed four conditions where they exercised (walking: 5 km h(-1), 2 % gradient) in a hot environment (~34.0 °C, 50 % RH) for 72 min, followed by a 33-min period of rest. They wore an APV throughout. The four conditions differed in respect to the profile of ambient air that was perfused through the APV: continuous perfusion (CP); intermittent perfusion of 6 min ON/OFF periods (IPonoff); a steady increase and decrease in flow rate in equal increments (IPramp); and an initial step-increase in the flow rate followed by an incremental decrease to zero flow rate (IPtriang). Whole body and torso thermal comfort (TC, TTC), whole body and torso temperature sensation (TS, TTS), whole body and torso skin temperature ([Formula: see text], [Formula: see text]), local relative humidity ([Formula: see text]) and rectal temperature (T re) were measured. RESULTS: There were no significant differences in T re, absolute whole body and local [Formula: see text], TC, TTC and TS between the cooling profiles. However, TTS was cooler in CP and IPramp than IPonoff and IPtriang. Even though intermittent cooling did not significantly enhance thermal perceptions in CP, a trend existed for TC (P = 0.063) to become less favourable over time. CONCLUSION: To reduce the power consumption and extend the battery life of an APV, it is recommended that an intermittent cooling profile should be adopted.

Use of oxygen at the end of life: on what basis are decisions made?

Discussing and conducting research on end-of-life issues is often difficult. However, it is important to initiate a dialogue about various topics surrounding death and dying. This paper looks at the available scientific literature relating to oxygen use at the end of life, describes associated attitudes and beliefs, and presents some brief examples of institutional practices. The aim is to stimulate thoughtful reflection and encourage research on this important topic. There is limited research regarding oxygen use at the end of life, and many questions remain. Despite the difficulty with research in this area, there is a need to expand the data and awareness in this field. Several authors have questioned the use of oxygen in end-of-life care, and the evidence that oxygen use may not always be indicated is growing.

Post-exercise cooling techniques in hot, humid conditions.

Major sporting events are often held in hot and humid environmental conditions. Cooling techniques have been used to reduce the risk of heat illness following exercise. This study compared the efficacy of five cooling techniques, hand immersion (HI), whole body fanning (WBF), an air cooled garment (ACG), a liquid cooled garment (LCG) and a phase change garment (PCG), against a natural cooling control condition (CON) over two periods between and following exercise bouts in 31 degrees C, 70%RH air. Nine males [age 22 (3) years; height 1.80 (0.04) m; mass 69.80 (7.10) kg] exercised on a treadmill at a maximal sustainable work intensity until rectal temperature (T (re)) reached 38.5 degrees C following which they underwent a resting recovery (0-15 min; COOL 1). They then recommenced exercise until T (re) again reached 38.5 degrees C and then undertook 30 min of cooling with (0-15 min; COOL 2A), and without face fanning (15-30 min; COOL 2B). Based on mean body temperature changes (COOL 1), WBF was most effective in extracting heat: CON 99 W; WBF: 235 W; PCG: 141 W; HI: 162 W; ACG: 101 W; LCG: 49 W) as a consequence of evaporating more sweat. Therefore, WBF represents a cheap and practical means of post-exercise cooling in hot, humid conditions in a sporting setting.

The effect of repeated endurance exercise on IL-6 and sIL-6R and their relationship with sensations of fatigue at rest.

Strenuous, prolonged exercise increases interleukin-6 (IL-6) release. The effect of IL-6 is dependent on the availability of IL-6 receptors. Few studies have addressed the impact of exercise on IL-6 receptor levels or procalcitonin (PCT), an indicator of systemic inflammation. Changes in these molecules may give insight into cytokine-related mechanisms underlying exercise-related fatigue. Thirteen trained male subjects partook in the study. They cycled a total distance of 468 km over 6 days. Blood samples were obtained prior to and immediately following Day 1 of the study and then each morning prior to exercise. Blood samples were analysed for plasma IL-6, soluble IL-6 receptor (sIL-6R), C-reactive protein (CRP), PCT, creatine kinase (CK) and cortisol concentrations. Subjects also completed mood state questionnaires each day prior to exercise. IL-6 was elevated immediately post-exercise on Day 1 but was unchanged at rest for the duration of the event. In contrast, sIL-6R, CRP, PCT and CK concentrations were unchanged immediately post-exercise on Day 1 but were significantly elevated at rest over the duration of the event compared with pre-event baseline. sIL-6R was highly correlated to CRP. Cortisol concentrations remained unchanged at all time points. In conclusion, strenuous, prolonged exercise stimulated an acute phase response which was maintained throughout the 6-day event. sIL-6R increase is associated with CRP and may affect subjective sensations of post-exercise fatigue at rest.

Men's voices: postnatal depression from the perspective of male partners.

Postnatal depression (PND) is a serious and debilitating condition that is recognized as being disruptive to women's lives at a time when they are already under stress adapting to the demands that a new baby creates. What has not always been fully acknowledged is that PND is linked with elevated levels of depression in male partners. In this article, the authors report on men's experiences of PND and of participation in a 6-week group treatment program specifically designed for male partners. The men experienced their partners' PND as overwhelming, isolating, stigmatizing, and frustrating. Coping with PND was assisted by participation in the men's group. Men reported lowered levels of depression and stress, and higher levels of social support, as a result of their participation. The men valued highly the opportunity to share experiences with peers, to hear strategies for engaging in their relationship, and to gain factual information.