Process mining to discover patterns in patient outcomes in a Psychological Therapies Service.

In the mental health sector, Psychological Therapies face numerous challenges including ambiguities over the client and service factors that are linked to unfavourable outcomes. Better understanding of these factors can contribute to effective and efficient use of resources within the Service. In this study, process mining was applied to data from the Northern Health and Social Care Trust Psychological Therapies Service (NHSCT PTS). The aim was to explore how psychological distress severity pre-therapy and attendance factors relate to outcomes and how clinicians can use that information to improve the service. Data included therapy episodes (N = 2,933) from the NHSCT PTS for adults with a range of mental health difficulties. Data were analysed using Define-Measure-Analyse model with process mining. Results found that around 11% of clients had pre-therapy psychological distress scores below the clinical cut-off and thus these individuals were unlikely to significantly improve. Clients with fewer cancelled or missed appointments were more likely to significantly improve post-therapy. Pre-therapy psychological distress scores could be a useful factor to consider at assessment for estimating therapy duration, as those with higher scores typically require more sessions. This study concludes that process mining is useful in health services such as NHSCT PTS to provide information to inform caseload planning, service management and resource allocation, with the potential to improve client's health outcomes.

Adaptive Proton Therapy for Pediatric Parameningeal Rhabdomyosarcoma: On-Treatment Anatomic Changes and Timing to Replanning.

PURPOSE: To characterize on-treatment changes in GTV morphology in children with parameningeal rhabdomyosarcoma receiving upfront proton therapy with concurrent chemotherapy and thereby provide guidance on the timing of on-treatment imaging and adaptive replanning. METHODS AND MATERIALS: GTV was delineated on 86 simulation and weekly MR images of 15 prospectively enrolled patients (aged 1-21 years). Temporal changes from baseline in volume and surface (95% Hausdorff distance) were analyzed in relation to the need for plan verification and the resultant doses with hypothetical no treatment adaptation. RESULTS: The median time was 6 days from the initiation of chemotherapy to CT+MR simulation and 15 days from the simulation to the start of radiotherapy. All but 1 patient showed a continuous decrease in GTV (0.16-1.52%/day) after simulation. At 3 weeks from simulation, 10 of 15 patients exhibited a significant reduction in volume (median, 20%; range, 6-29%). Without replanning, these changes could lead to a reduction in CTV V95 by 7-14% (n = 2) and/or an increase in D0.01 cc/Dmean of adjacent organs at risk by 6-21% of the prescribed target dose (n = 7). Significant dosimetric consequences occurred in cases with (1) a considerable weight gain, (2) shrinkage of the skin surface, or (3) tumor regression in the oral or nasal cavity and sinus that altered air-tissue components in the beam path. The subsequent GTV and dosimetry after 3 weeks from simulation (4 weeks from chemotherapy initiation) demonstrated a relatively stable trend. CONCLUSIONS: On-treatment imaging at 3 weeks after simulation is recommended, if the simulation is performed at 1 week after the initiation of chemotherapy, to detect significant anatomic changes that could result in >5% deviation from planned target coverage and/or organ doses in pediatric patients with parameningeal rhabdomyosarcoma receiving early proton therapy.

Mathematical Modeling Finds Disparate Interferon Production Rates Drive Strain-Specific Immunodynamics during Deadly Influenza Infection.

The timing and magnitude of the immune response (i.e., the immunodynamics) associated with the early innate immune response to viral infection display distinct trends across influenza A virus subtypes in vivo. Evidence shows that the timing of the type-I interferon response and the overall magnitude of immune cell infiltration are both correlated with more severe outcomes. However, the mechanisms driving the distinct immunodynamics between infections of different virus strains (strain-specific immunodynamics) remain unclear. Here, computational modeling and strain-specific immunologic data are used to identify the immune interactions that differ in mice infected with low-pathogenic H1N1 or high-pathogenic H5N1 influenza viruses. Computational exploration of free parameters between strains suggests that the production rate of interferon is the major driver of strain-specific immune responses observed in vivo, and points towards the relationship between the viral load and lung epithelial interferon production as the main source of variance between infection outcomes. A greater understanding of the contributors to strain-specific immunodynamics can be utilized in future efforts aimed at treatment development to improve clinical outcomes of high-pathogenic viral strains.

Multicellular spatial model of RNA virus replication and interferon responses reveals factors controlling plaque growth dynamics.

Respiratory viruses present major public health challenges, as evidenced by the 1918 Spanish Flu, the 1957 H2N2, 1968 H3N2, and 2009 H1N1 influenza pandemics, and the ongoing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Severe RNA virus respiratory infections often correlate with high viral load and excessive inflammation. Understanding the dynamics of the innate immune response and its manifestations at the cell and tissue levels is vital to understanding the mechanisms of immunopathology and to developing strain-independent treatments. Here, we present a novel spatialized multicellular computational model of RNA virus infection and the type-I interferon-mediated antiviral response that it induces within lung epithelial cells. The model is built using the CompuCell3D multicellular simulation environment and is parameterized using data from influenza virus-infected cell cultures. Consistent with experimental observations, it exhibits either linear radial growth of viral plaques or arrested plaque growth depending on the local concentration of type I interferons. The model suggests that modifying the activity of signaling molecules in the JAK/STAT pathway or altering the ratio of the diffusion lengths of interferon and virus in the cell culture could lead to plaque growth arrest. The dependence of plaque growth arrest on diffusion lengths highlights the importance of developing validated spatial models of cytokine signaling and the need for in vitro measurement of these diffusion coefficients. Sensitivity analyses under conditions leading to continuous or arrested plaque growth found that plaque growth is more sensitive to variations of most parameters and more likely to have identifiable model parameters when conditions lead to plaque arrest. This result suggests that cytokine assay measurements may be most informative under conditions leading to arrested plaque growth. The model is easy to extend to include SARS-CoV-2-specific mechanisms or to use as a component in models linking epithelial cell signaling to systemic immune models.

Iterative community-driven development of a SARS-CoV-2 tissue simulator.

The 2019 novel coronavirus, SARS-CoV-2, is a pathogen of critical significance to international public health. Knowledge of the interplay between molecular-scale virus-receptor interactions, single-cell viral replication, intracellular-scale viral transport, and emergent tissue-scale viral propagation is limited. Moreover, little is known about immune system-virus-tissue interactions and how these can result in low-level (asymptomatic) infections in some cases and acute respiratory distress syndrome (ARDS) in others, particularly with respect to presentation in different age groups or pre-existing inflammatory risk factors. Given the nonlinear interactions within and among each of these processes, multiscale simulation models can shed light on the emergent dynamics that lead to divergent outcomes, identify actionable "choke points" for pharmacologic interventions, screen potential therapies, and identify potential biomarkers that differentiate patient outcomes. Given the complexity of the problem and the acute need for an actionable model to guide therapy discovery and optimization, we introduce and iteratively refine a prototype of a multiscale model of SARS-CoV-2 dynamics in lung tissue. The first prototype model was built and shared internationally as open source code and an online interactive model in under 12 hours, and community domain expertise is driving regular refinements. In a sustained community effort, this consortium is integrating data and expertise across virology, immunology, mathematical biology, quantitative systems physiology, cloud and high performance computing, and other domains to accelerate our response to this critical threat to international health. More broadly, this effort is creating a reusable, modular framework for studying viral replication and immune response in tissues, which can also potentially be adapted to related problems in immunology and immunotherapy.

Rapid community-driven development of a SARS-CoV-2 tissue simulator

The 2019 novel coronavirus, SARS-CoV-2, is a pathogen of critical significance to international public health. Knowledge of the interplay between molecular-scale virus-receptor interactions, single-cell viral replication, intracellular-scale viral transport, and emergent tissue-scale viral propagation is limited. Moreover, little is known about immune system-virus-tissue interactions and how these can result in low-level (asymptomatic) infections in some cases and acute respiratory distress syndrome (ARDS) in others, particularly with respect to presentation in different age groups or pre-existing inflammatory risk factors. Given the nonlinear interactions within and among each of these processes, multiscale simulation models can shed light on the emergent dynamics that lead to divergent outcomes, identify actionable "choke points" for pharmacologic interventions, screen potential therapies, and identify potential biomarkers that differentiate patient outcomes. Given the complexity of the problem and the acute need for an actionable model to guide therapy discovery and optimization, we introduce and iteratively refine a prototype of a multiscale model of SARS-CoV-2 dynamics in lung tissue. The first prototype model was built and shared internationally as open source code and an online interactive model in under 12 hours, and community domain expertise is driving regular refinements. In a sustained community effort, this consortium is integrating data and expertise across virology, immunology, mathematical biology, quantitative systems physiology, cloud and high performance computing, and other domains to accelerate our response to this critical threat to international health. More broadly, this effort is creating a reusable, modular framework for studying viral replication and immune response in tissues, which can also potentially be adapted to related problems in immunology and immunotherapy.

Autism awareness in children and young people: surveys of two populations.

BACKGROUND: Increasingly, pupils on the autism spectrum are educated in inclusive mainstream classrooms. However, they often experience social isolation and bullying, and raising the awareness of autism in peers has been suggested as a remedy. METHODS: In order to assess autism awareness in peers, autism-related questions were included in two large-scale surveys: the Kids Life and Times survey for 11-year olds and the Young Life and Times survey for 16-year olds; a total of n = 3353 children and young people completed the surveys. RESULTS: Autism awareness was higher for the teenagers (80%) than for the younger children (50%). Many of the children knew someone with autism (50%) and generally reported positive and supportive attitudes. Self-reported prevalence of autism was 3.1% for teenagers and 2.7% for the younger children. Peers recognised bullying as a problem and were willing to help. CONCLUSIONS: Children and young people have good levels of awareness and knowledge about autism and reported positive attitudes towards peers with autism and are willing to help those who are bullied. A higher than expected number of children and young people self-reported being on the autism spectrum. These findings bode well for peer-mediated support strategies for inclusive education.

Multi-site clinical evaluation of the Xpert(®) HIV-1 viral load assay.

BACKGROUND: The most important reason for measuring HIV-1 viral load (VL) is to monitor the effectiveness of antiretroviral therapy (ART), both for the initial therapeutic response and sustained responses. Maintaining low or undetectable HIV-1 VL levels can reduce both the risks of progression to AIDS and transmission of infection to others. OBJECTIVES: To evaluate the diagnostic accuracy of Xpert(®) HIV-1 Viral Load (VL) assay compared to the Abbott RealTime HIV-1 assay, including assessing specificity by testing plasma specimens from confirmed HIV-1 negative blood donors. STUDY DESIGN: Subjects were enrolled from 4 participating sites, 2 in Europe and 2 in the USA. Fresh plasma samples were tested prospectively, while frozen plasma samples were collected prospectively, and tested retrospectively after selection of specimens to cover the assay's quantification range (40cp/mL-10,000,000 cp/mL). Eligibility criteria included a clinician ordered HIV-1 VL test from a confirmed HIV-1 positive adult (≥18 years) with a known antiviral treatment status. Exclusion criteria included previous enrollment in this study or improper specimen collection. Human blood donor specimens determined to be HIV-1 negative by standard blood bank antibody and nucleic acid amplification methods were used to assess specificity. RESULTS: Of the 764 specimens collected, 752 were eligible for inclusion but 5 were not tested by the Xpert, leaving 747 specimens tested (28.2% from females and 71.8% from males). Valid results were obtained for 724/747 (96.9%) specimens tested using the Xpert HIV-1 VL assay. The Xpert HIV-1 VL assay detected or quantified 568/724 (78.5%) specimens, while the RealTime HIV-1 assay detected or quantified 559/724 (77.2%). Of the 724 specimens tested by both assays, 390 were quantified by both assays and showed strong correlation: r=0.9847, with an R(2)=0.9696. Bland-Altman analysis showed good agreement between the two assays (381/390; 97.7%) with a distribution within 0.5 log10 cp/mL centered around zero. Xpert yielded VLs for 393 (80%) of the 494 quantifiable samples by Abbott. VLs of those specimens quantified by one of the assays, and either detected but not quantified or not detected by the other assay were all <170cp/mL. Specificity of the Xpert assay was found to be 100% (109/109), 95% CI: 96.7-100.0. CONCLUSION: Very good correlation was seen between the Xpert HIV-1 VL and Abbott RealTime HIV-1 assays, with added benefits for Xpert HIV-1 VL of: (1) lot-to-lot consistency traceable to WHO International Standard, (2) requiring both high and low level internal controls to be in range to have a valid result, (3) use of a single HIV-1 target for PCR and (4) faster turn-around-time for results, no need to wait to do batch testing of specimens. In summary, Xpert HIV-1 VL generated accurate VL results that if implemented could allow for actionable and timely treatment decisions during the same clinic visit. This scenario could reduce the loss to follow up often seen when these test results take days to weeks to become available to the clinician and patient.

Direct Screening of Blood by PCR and Pyrosequencing for a 16S rRNA Gene Target from Emergency Department and Intensive Care Unit Patients Being Evaluated for Bloodstream Infection.

Here we compared the results of PCR/pyrosequencing to those of culture for detecting bacteria directly from blood. DNA was extracted from 1,130 blood samples from 913 patients suspected of bacteremia (enrollment criteria were physician-ordered blood culture and complete blood count [CBC]), and 102 controls (healthy blood donors). Real-time PCR assays for beta-globin and Universal 16S rRNA gene targets were performed on all 1,232 extracts. Specimens identified by Universal 16S rRNA gene PCR/pyrosequencing as containing staphylococci, streptococci, or enteric Gram-negative rods had target-specific PCR/pyrosequencing performed. Amplifiable beta-globin (melting temperature [Tm], 87.2°C ± 0.2°C) occurred in 99.1% (1,120/1,130) of patient extracts and 100% (102/102) of controls. Concordance between PCR/pyrosequencing and culture was 96.9% (1,085/1,120) for Universal 16S rRNA gene targets, with positivity rates of 9.4% (105/1,120) and 11.3% (126/1,120), respectively. Bacteria cultured included staphylococci (59/126, 46.8%), Gram-negative rods (34/126, 27%), streptococci (32/126, 25.4%), and a Gram-positive rod (1/126, 0.8%). All controls screened negative by PCR/pyrosequencing. Clinical performance characteristics (95% confidence interval [CI]) for Universal 16S rRNA gene PCR/pyrosequencing included sensitivity of 77.8% (69.5 to 84.7), specificity of 99.3% (98.6 to 99.7), positive predictive value (PPV) of 93.3% (86.8 to 97.3), and negative predictive value (NPV) of 97.2% (96.0 to 98.2). Bacteria were accurately identified in 77.8% (98/126) of culture-confirmed sepsis samples with Universal 16S PCR/pyrosequencing and in 76.4% (96/126) with follow-up target-specific PCR/pyrosequencing. The initial PCR/pyrosequencing took ∼5.5 h to complete or ∼7.5 h when including target-specific PCR/pyrosequencing compared to 27.9 ± 13.6 h for Gram stain or 81.6 ± 24.0 h for phenotypic identification. In summary, this molecular approach detected the causative bacteria in over three-quarters of all culture-confirmed cases of bacteremia directly from blood in significantly less time than standard culture but cannot be used to rule out infection.

Prevalence and genotype distribution of human papillomavirus in cytology specimens containing atypical glandular cells: a case-control study.

BACKGROUND: Incidence of glandular cell cancers has risen. While atypical glandular cell (AGC) grade cytology results represent only a small percentage of all Pap test results reported annually in the US, a significant percentage represents a corresponding high-grade lesion on follow-up biopsy. The 2006 ASCCP consensus guidelines for AGC-grade cytology results include colposcopy, endocervical sampling, and high-risk (HR) HPV testing for patient management. OBJECTIVE: Determine HPV prevalence and genotype distribution in AGC-grade cytology specimens (n=53) compared to cytology specimens negative for intraepithelial lesion or malignancy (n=338). STUDY DESIGN: DNA extracted from residual, de-identified liquid-based cytology specimens, using QIAamp MinElute Media Kit was analyzed by PCR using Roche Linear Array HPV Genotyping and Detection Test Kits. Multivariate logistic regression compared HPV prevalence and genotype distribution between cases and controls to generate age-adjusted odds ratios (ORadj) and 95% confidence intervals (CI). RESULTS: HR-HPV DNA was found in 34.0% of cases and 7.4% of controls (ORadj=9.11; 95% CI: 4.08-20.33, p-value<0.001). Limiting analysis to HPV-16 and/or -18 resulted in finding HPV DNA in 20.8% of cases and 1.2% of controls (ORadj=40.10; 95% CI: 10.73-149.88, p-value<0.001). In contrast, prevalence of low-risk HPV DNA was similar between groups: 13.2% of cases and 17.2% of controls (ORadj=0.91; 95% CI: 0.35-2.31, p-value=0.834). CONCLUSIONS: AGC-grade cases contained a significantly higher rate of HR-HPV compared to controls, supporting earlier recommendations for HPV testing of AGC-grade cytology specimens. Our findings also suggest that follow-up genotyping of HR-HPV containing AGC cases for HPV-16 and/or -18 specifically would be useful in patient management.

Performance evaluation of a pilot-scale anaerobic membrane bioreactor (AnMBR) treating ethanol thin stillage.

The ethanol industry has grown rapidly during the past ten years, mainly due to increasing oil prices. However, efficient and cost-effective solutions for treating thin stillage wastewater have still to be developed. The anaerobic membrane bioreactor (AnMBR) technology combines classical anaerobic treatment in a completely-stirred tank reactor (CSTR) with membrane separation. The combination of these two technologies can achieve a superior effluent quality and also increase biogas production compared to conventional anaerobic solutions. A pilot-scale AnMBR treating thin stillage achieved very high treatment efficiencies in terms of chemical oxygen demand (COD) and total suspended solids (TSS) removal (>98%). An average permeate flux of 4.3 L/m2 x h was achieved at relatively low transmembrane pressure (TMP) values (0.1-0.2 bars) with flat-sheet membranes. Experience gained during the pilot-scale studies provides valuable information for scaling up of AnMBRs treating complex and high-strength wastewaters.

Viral pathogens.

SUMMARY: Despite continuous improvement in safety and purity of blood products for individuals with haemophilia, transmissible agents continue to affect individuals with haemophilia. This chapter addresses three viral pathogens with significant clinical impact: HIV, hepatitis C and parvovirus B19. Hepatitis C is the leading cause of chronic hepatitis and the major co-morbid complication of haemophilia treatment. Clinically, asymptomatic intermittent alanine aminotransferase elevation is typical, with biopsy evidence of advanced fibrosis currently in 25%. Current treatment is effective in up to 70%, and many new agents are in development. For those progressing to end-stage liver disease, liver transplantation outcomes are similar to those in non-haemophilia subjects, although pretransplant mortality is higher. HIV infection, the second leading co-morbid condition in haemophilia, is managed as a chronic infection with highly active antiretroviral therapy (HAART). HAART also slows hepatitis C virus (HCV) progression in those with HIV/HCV co-infection. Viral inactivation and recombinant technologies have effectively prevented transfusion-transmitted viral pathogens in haemophilia. Human parvovirus B19 infection, typically associated with anaemia or, rarely severe aplastic crisis, is a non-lipid enveloped virus, for which standard inactivation techniques are ineffective. Thus, nucleic acid testing (NAT) to screen the blood supply for B19 DNA is currently under consideration by the Food and Drug Administration. To the extent, viral inactivation, recombinant, and NAT technologies are available worldwide, and the lifespan for those with haemophilia is approaching that of the normal population. The purpose of this chapter is to provide an update on three clinically significant transfusion-transmitted viral pathogens.

Utility of pyrosequencing in identifying bacteria directly from positive blood culture bottles.

Growth in liquid media is the gold standard for detecting microorganisms associated with bloodstream infections. The Gram stain provides the first clue as to the etiology of infection, with phenotypic identification completed 1 or 2 days later. Providing more detailed information than the Gram stain can impart, and in less time than subculturing, would allow the use of more directed empirical therapy and, thus, reduce the patient's exposure to unnecessary or ineffective antibiotics sooner. The study had two objectives, as follows: (i) to identify new targets to improve our ability to differentiate among certain enteric gram-negative rods or among certain Streptococcus species and (ii) to determine whether real-time PCR and pyrosequencing could as accurately identify organisms directly from positive blood culture bottles as culture-based methods. Two hundred and fifty-five consecutive positive blood culture bottles were included. The results showed a high level of agreement between the two approaches; of the 270 bacteria isolated from the 255 blood culture bottles, results for pyrosequencing and culture-based identifications were concordant for 264/270 (97.8%) bacteria with three failed sequences, and three sequences without match. Additionally, compared to the universal 16S rRNA gene target, the new 23S rRNA gene targets greatly improved our ability to differentiate among certain enteric gram-negative rods or among certain Streptococcus species. In conclusion, combining real-time PCR and pyrosequencing provided valuable information beyond that derived from the initial Gram stain and in less time than phenotypic culture-based identification. This strategy, if implemented, could result in a more directed empirical therapy in patients and would promote responsible antibiotic stewardship.

Use of polymerase chain reaction as a diagnostic tool for neonatal sepsis can result in a decrease in use of antibiotics and total neonatal intensive care unit length of stay.

OBJECTIVE: To retrospectively determine if a negative 16S ribosomal RNA (rRNA) polymerase chain reaction (PCR) (PCR(-)) could lead to a decrease in the number of antibiotic doses and neonatal intensive care unit (NICU) length of stay (LOS) for infants admitted to the NICU for presumed early-onset sepsis (EOS) with negative blood culture results (BC(-)). STUDY DESIGN: Analysis included 419 infants, greater than 35 weeks gestational age, with PCR(-), BC(-) and LOS > 48 h. Both the investigators and clinical care team were unaware of the PCR results. The actual number of antibiotic doses (AAD) administered was compared to an estimated number of antibiotics doses (EAD) that would have been given until PCR(-) results were available by 18 h. The number of antibiotic doses saved was calculated as (AAD-EAD). The actual NICU LOS in hours (aLOS) for a subset of infants who remained in the hospital primarily for antibiotic therapy was compared to an estimated LOS (eLOS) if infants with PCR(-) were discharged from the NICU when clinically stable. The number of hours saved was calculated as (aLOS-eLOS). RESULTS: Approximately eight antibiotic doses and 85 NICU hours per infant could be saved using PCR(-) results available at 18 h. CONCLUSIONS: Use of 16S rRNA PCR could decrease the number of antibiotics doses and NICU LOS for infants admitted for EOS. This may facilitate: (1) earlier NICU discharge; (2) parental satisfaction; and (3) decreased health care costs.

Factors affecting measurement of specific methanogenic activity.

Specific methane production (SMP) tests have been used to determine the potential loading rate capacity of anaerobic reactors, to characterize biomass prior to its use as an inoculum for new anaerobic reactors, to detect changes in biomass activity during operation, or to assess the occurrence of toxic conditions. SMP tests also provide a basis for estimating specific methanogenic activity in mixed anaerobic cultures. SMP protocols used to date have varied widely in both procedure and objective. Tests conducted by the present authors indicated that biomass concentration, substrate type and concentration, and mixing intensity are factors that can affect the results of SMP tests.

Real-time PCR improves detection of Trichomonas vaginalis infection compared with culture using self-collected vaginal swabs.

OBJECTIVE: To compare a real-time polymerase chain reaction (PCR) assay with broth culture for the detection of Trichomonas vaginalis using self-collected vaginal swabs. METHODS: Self-collected vaginal swabs were obtained from adolescent and young adult African-American women participating in HIV-1 prevention programs. T. vaginalis culture was performed using the InPouch TV System. Samples for the real-time PCR assay were collected using the BDProbeTec ET Culturette Direct Dry Swab system and tested in a laboratory-developed assay which targeted a repeated sequence of the genome. Discrepant samples that were culture negative and positive in the real-time PCR assay were tested in a confirmatory PCR which targeted a different region of the T. vaginalis genome, the18S ribosomal DNA gene. RESULTS: Of the 524 specimens tested by both culture and real-time PCR, 36 were culture positive and 54 were positive in the real-time PCR assay; 16 of the 18 discrepant specimens were also positive in the confirmatory PCR assay. Using a modified gold standard of positive by culture or positive in both PCR assays, the sensitivity of the real-time PCR assay was 100% and the specificity was 99.6%, whereas culture had a sensitivity of 69.2% and a specificity of 100%. CONCLUSIONS: The real-time PCR assay was sensitive and specific for the detection of T. vaginalis DNA from self-collected vaginal swab specimens. The ability to use the BDProbeTec dry swab system for the real-time PCR testing allowed for the detection of Chlamydia trachomatis, Neisseria gonorrhoeae, and T. vaginalis from a single specimen.

Development of the European Colposcopy Core Curriculum: use of the Delphi technique.

The objective of this study was to develop a European competence-based colposcopy core curriculum using the Delphi technique. Thirty expert colposcopists from 21 countries participated. A four-round iterative questionnaire was used. Competencies were rated using a five-point Likert scale. Competences rated as 4 or more by at least 90% of the respondents were regarded as necessary for the core curriculum. Eighteen participants took part in all four rounds, and 27 were active in each of the last three rounds. Fifty-one core competences were selected from a list of 76 competences collated by the group as a whole. The majority (n = 44) of the selected core competences received a score of 4 or greater in each round. Overall, there was some evidence of increasing consensus but the individual shift in opinion was slight. The Delphi technique was an effective tool for obtaining an expert consensus and enabled group "ownership" of the identified core curriculum.

Apoptotic activity in villous trophoblast cells during B19 infection correlates with clinical outcome: assessment by the caspase-related M30 Cytodeath antibody.

Human parvovirus B19 (B19) infection during pregnancy can result in horizontal transmission of the virus and congenital infection. The main targets for B19 replication are the erythroid precursor cell of the colony and burst forming units. The cellular receptor necessary for B19 infectivity is globoside. Other non-erythroid cells can express this receptor, including megakaryocytes, endothelial cells, cardiac myocytes and placental trophoblast cells. B19 infection of globoside-containing erythroid cells results in cell death via apoptosis. We asked whether globoside-containing placental trophoblast cells, although not permissive for complete viral replication, would show evidence of apoptotic activity as a result of B19 infection. Placentas from 26 pregnancies with documented maternal and/or congenital B19 infection, 14 with poor outcomes and 12 with good outcomes were examined for evidence of apoptosis using the caspase-related M30 Cytodeath monoclonal antibody (Mab). M30 Mab recognizes a caspase 3 directed cleavage event within cytokeratin 18, a protein widely distributed in epithelial cells, of which trophoblast cells are classified. The results of the immunohistochemical analysis revealed a significant number of M30-staining placental villous trophoblast cells from B19-complicated pregnancies with poor outcomes compared to B19-complicated pregnancies with good outcomes or the 24 age-matched controls (P< 0.001). This is the first description of an association between B19-complicated pregnancies ending in foetal death and increased apoptosis within placental villous trophoblast cells. Damage due to premature death of the protective barrier of the placental trophoblast layer may compromise its integrity and play a role in pathogenesis.

Virtual reality training leads to faster adaptation to the novel psychomotor restrictions encountered by laparoscopic surgeons.

BACKGROUND: The fulcrum effect of the body wall on instrument handling poses a major obstacle to the mastery of instrument coordination for junior laparoscopic surgeons. This study evaluated three types of laparoscopic simulator training to assess their ability to promote the user's adaptation to the fulcrum effect. METHODS: Thirty-two participants with no previous experience in laparoscopic surgery were randomly assigned to one of four groups representing different training conditions. One group was assigned to use a virtual reality simulator (MIST VR); two others were given a laparoscopic Z or U maze-tracking task. The control group received no training. Subjects were asked to perform a 2-min laparoscopic cutting task under normal laparoscopic imaging conditions first before and then after training. RESULTS: In the test trial, subjects who trained on MIST VR made significantly more correct incisions (p < 0.0001) and fewer incorrect incisions (p < 0.0001). CONCLUSION: Training on a virtual reality simulator such as MIST VR helps laparoscopic novices adapt to the fulcrum effect faster.

In vitro phagocytosis of carrier mouse red blood cells is increased by Band 3 cross-linking or diamide treatment.

Chemical alteration of red blood cells (RBCs) can induce increased phagocytosis of modified cells by macrophages. In this study we have used different chemical treatments for the modification of the mouse red-blood-cell membrane surface, namely oxidant compounds, such as ascorbate/Fe(+2) and diamide [azodicarboxylic acid bis(dimethylamide)], or Band 3-cross-linking reagents. We monitored the phagocytosis of oxidized or Band 3-cross-linked mouse red blood cells by peritoneal macrophages. The extent of phagocytosis of RBCs is not affected by oxidation with ascorbate/Fe(3+), but it is increased (up to 10%) by oxidation with 2 mM diamide. Furthermore, phagocytosis is greatly increased (up to 40%) as a result of cross-linking with either of two Band 3 bifunctional reagents [bis(sulphosuccinimidyl) suberate (BS(3)) and 3,3'-dithiobis(sulphosuccinimidyl propionate) (DTSSP)]. To evaluate targeting towards macrophages of such modified RBCs for therapeutical purposes, we have determined the phagocytosis of Band 3 carrier RBCs loaded with carbonic anhydrase. In this case phagocytosis is high enough (25%) to deliver the enzyme into macrophages. We have also assayed the influence of serum components and IgG on the efficiency of phagocytosis and discuss the possible phagocytosis mechanisms. In the case of BS(3)-cross-linked carrier RBCs, phagocytosis is markedly enhanced (from 12% up to 25%) by serum components. This opens a way for therapeutic application of these carrier RBCs, with special relevance in short-term delivery to cells of the mononuclear phagocytic system.