Underdiagnosis of internal anal sphincter trauma following vaginal delivery.

OBJECTIVE: Damage to the anal sphincter during childbirth remains the leading cause of fecal incontinence in women. Defects in the internal (IAS) or external anal sphincter, alongside symptoms and sphincter tone, will generally dictate the suggested mode of delivery in any successive pregnancy. This study aimed to examine using endoanal ultrasonography the prevalence of IAS damage in women referred with Grade-3a or -3b obstetric anal sphincter injury (OASI) in a tertiary-referral perineal clinic. METHODS: This was a retrospective observational study of all women referred to a tertiary-referral perineal clinic after primary repair of OASI (Grade 3a-c, 4) diagnosed for the first time following vaginal delivery between January 2016 and December 2019, inclusive. Women were assessed using the Wexner bowel continence questionnaire, digital examination of sphincter tone and endoanal ultrasound. Injuries in each sphincter were classified as a scar (≤ 30°) or defect (> 30-90° or > 90°) on endoanal imaging in the axial plane. RESULTS: In total, 615 women were referred following primary repair of OASI. Sonographic evidence of damage to the IAS was seen in 9.1% (46/506) of women diagnosed with a Grade-3a/3b injury. In women referred with a Grade-3a/3b tear, symptom scores were statistically higher (P = 0.025) in those with an IAS defect > 30° compared to those with an intact or scarred IAS, although the median score was zero in both groups. The proportion of women in each group with severe symptoms (score > 9) was similar (2.6% vs 6.5%; P = 0.148). Among women referred with a Grade-3a/3b tear, sphincter tone was reduced more frequently in those with a defect of the IAS than in those with an intact or scarred IAS (52.2% vs 11.7%; odds ratio, 8.14 (95% CI, 4.26-15.67); P < 0.001). Regardless of the reason for referral, women with reduced sphincter tone on rectal examination were four times as likely to have had an IAS defect > 30° than were those with normal resting tone (risk ratio, 4.58 (95% CI, 3.25-6.45); P < 0.001). CONCLUSIONS: One in 11 women diagnosed with a Grade-3a or -3b tear have evidence of damage to their IAS on endoanal ultrasound. Damage to this muscle is linked to fecal incontinence in women and can have a significant impact on the planning of any future deliveries. This study highlights the importance of established perineal clinics with access to ultrasound. Nonetheless, if reduced sphincter tone is felt on rectal examination, a clinician should have a high index of suspicion for an occult IAS injury. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Non-Pediatric Nurses' Willingness to Provide Care to Pediatric Patients during a Disaster: An Assessment of Pediatric Surge Capacity in Four Midwestern Hospitals.

OBJECTIVE: To assess non-pediatric nurses' willingness to provide care to pediatric patients during a mass casualty event (MCE). METHODS: Nurses from 4 non-pediatric hospitals in a major metropolitan Midwestern region were surveyed in the fall of 2018. Participants were asked about their willingness to provide MCE pediatric care. Hierarchical logistical regression was used to describe factors associated with nurses' willingness to provide MCE pediatric care. RESULTS: In total, 313 nurses were approached and 289 completed a survey (response rate = 92%). A quarter (25.3%, n = 73) would be willing to provide MCE care to a child of any age; 12% (n = 35) would provide care only to newborns in the labor and delivery area, and 16.6% (n = 48) would only provide care to adults. Predictors of willingness to provide care to a patient of any age during an MCE included providing care to the youngest-age children during routine duties, reporting confidence in calculating doses and administering pediatric medications, working in the emergency department, being currently or previously certified in PALS, and having access to pediatric-sized equipment in the unit or hospital. CONCLUSION: Pediatric surge capacity is lacking among nurses. Increasing nurses' pediatric care self-efficacy could improve pediatric surge capacity and minimize morbidity and mortality during MCEs.

Hospital outbreak of linezolid-resistant and vancomycin-resistant ST80 Enterococcus faecium harbouring an optrA-encoding conjugative plasmid investigated by whole-genome sequencing.

BACKGROUND: Linezolid is an antibiotic used to treat infections caused by multi-drug-resistant Gram-positive bacteria. Linezolid resistance in enterococci has been reported with increasing frequency, with a recent rise in resistance encoded by optrA, poxtA or cfr. AIM: To investigate a hospital outbreak of linezolid- and vancomycin-resistant Enterococcus faecium (LVREfm) using whole-genome sequencing (WGS). METHODS: Thirty-nine VREfm from patient screening (19 isolates, 17 patients) and environmental sites (20 isolates) recovered in October 2019 were investigated. Isolates were screened using polymerase chain reaction for optrA, poxtA and cfr, and underwent Illumina MiSeq WGS. Isolate relatedness was assessed using E. faecium core genome multi-locus sequence typing (cgMLST). One LVREfm underwent MinION long-read WGS (Oxford Nanopore Technologies) and hybrid assembly with MiSeq short-read sequences to resolve an optrA-encoding plasmid. FINDINGS: Twenty isolates (51.3%) were LVREfm and optrA-positive, including the LVREfm from the index patient. A closely related cluster of 28 sequence type (ST) 80 isolates was identified by cgMLST, including all 20 LVREfm and eight linezolid-susceptible VREfm, with an average allelic difference of two (range 0-10), indicating an outbreak. Nineteen (95%) LVREfm harboured a 56,684-bp conjugative plasmid (pEfmO_03). The remaining LVREfm exhibited 44.1% sequence coverage to pEfmO_03. The presence of pEfmO_03 in LVREfm and the close relatedness of the outbreak cluster isolates indicated the spread of a single strain. The outbreak was terminated by enhanced infection prevention and control (IPC) and environmental cleaning measures, ceasing ward admissions and ward-dedicated staff. CONCLUSION: WGS was central in investigating an outbreak of ST80 LVREfm. The rapid implementation of enhanced IPC measures terminated the outbreak.

Creating new guidelines on how best to treat foot symptoms in people with EB.

Epidermolysis bullosa (EB) is a complex rare condition that affects the skin and many parts of the body. Those born with EB have skin so fragile they are called 'butterfly children', their skin is quite simply as fragile as the wing of a butterfly. In the UK it is estimated that there are more than 5,000 people living with EB and 500,000 worldwide. Little clinical guidance for care existed until DEBRA International started a programme to develop clinical practice guidelines (CPGs). There were no previous guidelines and few published studies on foot care in EB so treatment decisions were largely based on individual opinion and experience. The panel - made up of clinical experts and people living with EB representing Australia, the UK, and the USA - aimed to describe foot problems in people of all ages with EB, and summarise current evidence and management. The authors used a logical podiatric (foot) care literature review focussed on patients with EB. The authors found that the evidence in this area was limited but several interventions (treatments) currently practised by podiatrists show positive outcomes. The study allowed the group to make recommendations on how to treat foot and nail disorders in patients with EB. Furthermore, the authors concluded that further research is needed. This is a summary of the study: Foot care in epidermolysis bullosa: evidence-based guideline.

Foot care in epidermolysis bullosa: evidence-based guideline.

This guideline was designed to provide service providers and users with an evidence-based set of current best practice guidelines for people and their families and carers, living with epidermolysis bullosa (EB). A systematic literature review relating to the podiatric care of patients with EB was undertaken. Search terms were used, for which the most recent articles relating to podiatric treatment were identified from as early as 1979 to the present day, across seven electronic search engines: MEDLINE, Wiley Online Library, Google Scholar, Athens, ResearchGate, Net and PubFacts.com. The Scottish Intercollegiate Guidelines Network (SIGN) methodology was used. The first guideline draft was analysed and discussed by clinical experts, methodologists and patients and their representatives at four panel meetings. The resulting document went through an external review process by a panel of experts, other healthcare professionals, patient representatives and lay reviewers. The final document will be piloted in three different centres in the U.K. and Australia. Following an EB community international survey the outcomes indicated six main areas that the community indicated as a priority to foot management. These include blistering and wound management, exploring the most suitable footwear and hosiery for EB, management of dystrophic nails, hyperkeratosis (callus), maintaining mobility and fusion of toes (pseudosyndactyly). The evidence here is limited but several interventions currently practised by podiatrists show positive outcomes.

312 MAX Phases: Elastic Properties and Lithiation.

Interest in the Mn+1AXn phases (M = early transition metal; A = group 13-16 elements, and X = C or N) is driven by their ceramic and metallic properties, which make them attractive candidates for numerous applications. In the present study, we use the density functional theory to calculate the elastic properties and the incorporation of lithium atoms in the 312 MAX phases. It is shown that the energy to incorporate one Li atom in Mo3SiC2, Hf3AlC2, Zr3AlC2, and Zr3SiC2 is particularly low, and thus, theoretically, these materials should be considered for battery applications.

Randomized controlled trial of plain English and visual abstracts for disseminating surgical research via social media.

BACKGROUND: Patients are increasingly taking an active role in the design and delivery of surgical research. Public communication of results should also be encouraged, but this is often limited to non-expert commentary. This study assessed the role of plain English abstracts disseminated via social media in engaging patients and clinicians in the communication of surgical research. METHODS: A three-arm randomized controlled trial with crossover of two intervention arms was performed. Manuscripts accepted for publication in BJS were allocated to one of three arms and disseminated via Twitter: plain English abstracts, visual abstracts and standard tweets. The primary outcome was online engagement (a composite of tweets, replies and likes) by members of the public within 14 days. The secondary outcome was online engagement by healthcare professionals. RESULTS: Forty-one manuscripts were randomized to plain English abstracts (14), visual abstracts (14) and standard tweets (13). The number of public engagements was low, with a mean of 1·8 (range 0-8), 2·5 (0-11), and 1·2 (0-4) for plain English abstracts, visual abstracts and standard tweets respectively. The mean number of engagements by healthcare professionals was 29·4 (6-66), 45·3 (6-161) and 28·8 (10-52) respectively. Overall, visual abstracts attracted a significantly greater number of engagements than plain English ones (P < 0·001). CONCLUSION: Online, public engagement with surgical research was low. Overall engagement (predominantly from healthcare professionals) was enhanced by the use of visual abstracts.

ANTECEDENTES: Los pacientes están tomando cada vez más un papel activo en el diseño y en la difusión de la investigación quirúrgica. También se debe fomentar la comunicación pública de los resultados, pero a menudo ésta se limita a comentarios de personas no expertas. Este estudio evaluó el papel de los resúmenes redactados en un inglés sencillo difundidos a través de las redes sociales para involucrar a pacientes y médicos en la comunicación de la investigación quirúrgica. MÉTODOS: Se realizó un ensayo aleatorizado y controlado de tres brazos con un diseño cruzado de los dos brazos de intervención. Los manuscritos aceptados para publicación en BJS se asignaron a tres brazos y se difundieron vía twitter: resúmenes redactados en un inglés sencillo, resúmenes visuales, y tweets estándar. El criterio de valoración principal fue la interacción online (variable compuesta de tweets, respuestas y me gusta) por parte del público durante los primeros 14 días. El criterio de valoración secundario fue la interacción online de los profesionales de la salud. RESULTADOS: Un total de 41 manuscritos se asignaron al azar a resúmenes redactados en un inglés sencillo (n = 14), resúmenes visuales (n = 14) y tweets estándar (n = 13). El número de interacciones por parte del público fue bajo, con una media de 1,8 (rango 0-8), 2,5 (rango 0-11) y 1,2 (rango 0-4) para resúmenes en inglés sencillo, resúmenes visuales y tweets estándar, respectivamente. El número medio de interacciones por profesionales de la salud fue de 29,4 (rango 6-66), 45,3 (6-161) y 28,8 (10-52). En general, los resúmenes visuales atrajeron un número significativamente mayor de interacciones que los de inglés sencillo (P = 0,001). CONCLUSIÓN: La interacción online del público con la investigación quirúrgica fue baja. La participación general (predominantemente de profesionales de la salud) mejoró mediante el uso de resúmenes visuales. Los próximos trabajos podrían considerar si el público desea interaccionar y de qué modo con resúmenes redactados en un inglés sencillo.

A Dedicated Perineal Clinic ­ An Audit in Support

Aims To assess the quality of care in both the initial management of obstetric anal sphincter injury (OASI) and subsequent follow up postnatally in a tertiary maternity hospital without direct access to a perineal clinic. Methods Medical records were reviewed over a one-year period in University Maternity Hospital Limerick (UMHL) to determine the characteristics of patients sustaining OASI, how and where the repair was undertaken, the complications recorded and their follow up in the postpartum period. This pathway of care was compared with care currently available in three dedicated perineal clinics nationally. Results There were 44 patients with OASI recorded over a one-year period in UMHL. The majority were diagnosed in primiparous women having an operative vaginal delivery (OVD). Only 23 of 44 women had a documented review postnatally. Conclusion Audit of OASI is paramount to providing the best standard of care for affected women. It also aids clinician training and will be important in the establishment of a dedicated perineal clinic in UMHL.

Spread of ESBL-producing Escherichia coli in nursing home residents in Ireland and the Netherlands may reflect infrastructural differences.

A prevalence study in two nursing homes (one each in the Netherlands and Ireland) found four (11%) Dutch and six (9%) Irish residents colonized with 11 extended-spectrum beta-lactamase-producing Escherichia coli, 10 of which contained CTX-M-15. Four Dutch isolates, from three residents of the same ward, belonged to E. coli O25:H4, sequence type (ST) 131 and were part of the same cluster type by whole-genome sequencing. Four Irish residents on three different wards were colonized with an identical E. coli O89:H9, ST131, complex type 1478. Cross-transmission between three Irish wards may reflect differences in nursing home infrastructure, specifically communal areas and multi-bedded resident rooms.

Development of consensus-based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education.

BACKGROUND: Healthcare professionals are involved in an array of patient- and medicine-related stewardship activities, for which an understanding and engagement with antimicrobial stewardship (AMS) is important. Undergraduate education provides an ideal opportunity to prepare healthcare professionals for these roles and activities. AIM: To provide UK national consensus on a common set of antimicrobial stewardship competencies appropriate for undergraduate healthcare professional education. METHODS: A modified Delphi approach comprising two online surveys delivered to a UK national panel of 21 individuals reflecting expertise in prescribing and medicines management with regards to the education and practice of nurses and midwives, pharmacists, physiotherapists, and podiatrists; and antimicrobial prescribing and stewardship. Data collection took place between October and December 2017. FINDINGS: A total of 21 participants agreed to become members of the expert panel, of whom 19 (90%) completed round 1 questionnaire, and 17 (89%) completed round 2. Panelists reached a consensus, with consistently high levels of agreement reached, on six overarching competency statements (subdivided into six domains), and 55 individual descriptors essential for antimicrobial stewardship by healthcare professionals. CONCLUSION: Due to the consistently high levels of agreement reached on competency statements and their associated descriptors, this competency framework should be used to direct education for undergraduate healthcare professionals, and those working in new clinical roles to support healthcare delivery where an understanding of, and engagement with, AMS is important. Although the competencies target basic education, they can also be used for continuing education.

Risk factors for community-associated multidrug-resistant Pseudomonas aeruginosa in veterans with spinal cord injury and disorder: a retrospective cohort study.

STUDY DESIGN: Retrospective cohort studyObjectives:To identify independent risk factors associated with community-associated multidrug-resistant Psedomonas aeruginosa (MDRPA) in a population of veterans with spinal cord injury and disorders (SCI/D). SETTING: A total of 127 Veterans Affairs healthcare facilities. METHODS: Laboratory results from 1 January 2012 to 31 December 2013 were collected, and MDRPA cultures were compared with non-MDRPA cultures. RESULTS: One thousand four hundred forty-one cultures were collected from Veterans with SCI/D, including 227 cultures with MDRPA isolates. Characteristics associated with an increased odds of MDRPA include age 50-64 (adjusted odds ratio (aOR)=1.80, 95% confidence interval (CI)=1.13-2.87), MDRPA culture in the past 365 days (aOR=9.12, 95% CI=5.88-14.15) and carbapenem exposure in the past 90 days (aOR=2.56, 95% CI=1.35-4.87). In contrast, paraplegia was associated with a 53% decreased odds of MDRPA compared with those with tetraplegia (aOR=0.47, 95% CI=0.32-0.69). CONCLUSIONS: Risk factors for community-associated MDRPA include prior history of MDRPA and exposure to carbapenems. Awareness of these factors is important for targeted prevention and treatment of MDRPA in patients with SCI/D.

Exposing Baccalaureate Nursing Students to Transitional Care.

Management and facilitation of care transitions from hospital to alternative settings requires skill and attention to avoid adverse events. Several interprofessional organizations and nurse leaders have called for the expansion and redesign of undergraduate nursing curricula to include care transitions. Yet there is little evidence describing how undergraduate baccalaureate nursing students are educated on this critical topic or how successful they are in improving student knowledge about care transitions. To address this gap, an in-classroom and clinical experience was implemented to prepare students to manage and facilitate care transitions from the hospital to alternative settings-including the home. Perceptions of undergraduate nursing students and home healthcare nurse preceptors were assessed via an electronic survey that was emailed to participants. Forty-eight responses to the survey were received. Students agreed this experience contributed to their understanding of caring for adults and older adults who are experiencing a care transition and they had a good understanding of care transitions to apply to their future nursing courses. Home healthcare nurse preceptors agreed they were able to demonstrate transitional care and that students were engaged. Future work should include expanding transitional care immersion to other care settings as well as the inclusion of additional healthcare disciplines in care transition education.

Differential proteomics reveals the hallmarks of seed development in common bean (Phaseolus vulgaris L.).

UNLABELLED: Common bean (Phaseolus vulgaris L.) is one of the most consumed staple foods worldwide. Little is known about the molecular mechanisms controlling seed development. This study aims to comprehensively describe proteome dynamics during seed development of common bean. A high-throughput gel-free proteomics approach (LC-MS/MS) was conducted on seeds at 10, 20, 30 and 40days after anthesis, spanning from late embryogenesis until desiccation. Of the 418 differentially accumulated proteins identified, 255 were characterized, most belonging to protein metabolism. An accumulation of proteins belonging to the MapMan functional categories of "protein", "glycolysis", "TCA", "DNA", "RNA", "cell" and "stress" were found at early seed development stages, reflecting an extensive metabolic activity. In the mid stages, accumulation of storage, signaling, starch synthesis and cell wall-related proteins stood out. In the later stages, an increase in proteins related to redox, protein degradation/modification/folding and nucleic acid metabolisms reflect that seed desiccation-resistance mechanisms were activated. Our study unveils new clues to understand the regulation of seed development mediated by post-translational modifications and maintenance of genome integrity. This knowledge enhances the understanding on seed development molecular mechanisms that may be used in the design and selection of common bean seeds with desired quality traits. SIGNIFICANCE: Common bean (P. vulgaris) is an important source of proteins and carbohydrates worldwide. Despite the agronomic and economic importance of this pulse, knowledge on common bean seed development is limited. Herein, a gel-free high throughput methodology was used to describe the proteome changes during P. vulgaris seed development. Data obtained will enhance the knowledge on the molecular mechanisms controlling this grain legume seed development and may be used in the design and selection of common bean seeds with desired quality traits. Results may be extrapolated to other pulses.

Triage of LSIL/ASC-US with p16/Ki-67 dual staining and human papillomavirus testing: a 2-year prospective study.

OBJECTIVE: To investigate human papillomavirus (HPV) DNA testing and p16/Ki-67 staining for detecting cervical intraepithelial grade 2 or worse (CIN2+) and CIN3 in women referred to colposcopy with minor abnormal cervical cytology low-grade squamous intraepithelial lesions (LSIL) and atypical squamous cells of undermined significance (ASC-US). The clinical performance of both tests was evaluated as stand-alone tests and combined, for detection CIN2+ and CIN3 over 2 years. METHODS: ThinPrep(®) liquid-based cytology (LBC) specimens were collected from 1349 women with repeat LSIL or ASC-US. HPV DNA was performed using Hybrid Capture. Where adequate material remained (n = 471), p16/Ki-67 overexpression was assessed. Clinical performance for detection of histologically diagnosed CIN2+ and CIN3 was calculated. RESULTS: Approximately 62.2% of the population were positive for HPV DNA, and 30.4% were positive for p16/Ki-67. p16/Ki-67 showed no significant difference in positivity between LSIL and ASC-US referrals (34.3% versus 28.6%; P = 0.189). Women under 30 years had a higher rate of p16/Ki-67 compared to those over 30 years (36.0% versus 26.6%; P = 0.029). Overall HPV DNA testing produced a high sensitivity for detection of CIN3 of 95.8% compared to 79.2% for p16/Ki-67. In contrast, p16/Ki-67 expression offered a higher specificity, 75.2% versus 40.4% for detection of CIN3. Combining p16/Ki-67 with HPV DNA improved the accuracy in distinguishing between CIN3 and