Implementation and evaluation of a SARI surveillance system in a tertiary hospital in Scotland in 2021/2022.

OBJECTIVE: To set up and evaluate a new surveillance system for severe acute respiratory infection (SARI) in Scotland. STUDY DESIGN: Cross-sectional study and evaluation of surveillance system. METHODS: The SARI case definition comprised patients aged 16 years or over with an acute respiratory illness presentation requiring testing for influenza and SARS-CoV-2 and hospital admission. Data were collected from SARI cases by research nurses in one tertiary teaching hospital using a bespoke data collection tool from November 2021 to May 2022. Descriptive analyses of SARI cases were carried out. The following attributes of the surveillance system were evaluated according to Centers for Disease Control and Prevention (CDC) guidelines: stability, data quality, timeliness, positive predictive value, representativeness, simplicity, acceptability and flexibility. RESULTS: The final surveillance dataset comprised 1163 records, with cases peaking in ISO week 50 (week ending 19/12/2021). The system produced a stable stream of surveillance data, with the proportion of SARI records with sufficient information for effective surveillance increasing from 65.4% during the first month to 87.0% over time. Similarly, the proportion where data collection was completed promptly was low initially, but increased to 50%-65% during later periods. CONCLUSION: SARI surveillance was successfully established in one hospital, but for a national system, additional sentinel hospital sites across Scotland, with flexibility to ensure consistently high data completeness and timeliness are needed. Data collection should be automated where possible, and demands on clinicians minimised. SARI surveillance should be embedded and resourced as part of a national respiratory surveillance strategy.

British Society for Immunology and United Kingdom Primary Immunodeficiency Network (UKPIN) consensus guideline for the management of immunoglobulin replacement therapy.

Currently, there is no guideline to support the use of immunoglobulin replacement therapy (IgRT) in primary and secondary immunodeficiency disorders in UK. The UK Primary Immunodeficiency Network (UK-PIN) and the British Society of Immunology (BSI) joined forces to address this need. Given the paucity of evidence, a modified Delphi approach was used covering statements for the initiation, monitoring, discontinuation of IgRT as well as home therapy programme. A group of six consultant immunologists and three nurse specialists created the statements, reviewed responses and feedback and agreed on final recommendations. This guideline includes 22 statements for initiation, 22 statements for monitoring, 11 statement for home therapy, and 19 statements for discontinuation of IgRT. Further areas of research are proposed to improve future delivery of care.

Invasive dermatophyte infection with Trichophyton interdigitale is associated with prurigo-induced pseudoperforation and a signal transducer and activator of transcription 3 mutation.

Invasive dermatophyte infection, with extension beyond the dermis, in immunocompetent hosts is exceptionally rare. Dermatophytes are keratinophilic and are usually confined to the stratum corneum, hair and nails. Susceptibility to dermatophyte infections is incompletely understood, but inherited mutations in key signalling pathways of the innate immune system have been identified. We report the first case of an invasive dermatophyte infection associated with abrupt onset of a prurigo-induced pseudoperforation and a loss-of-function mutation in signal transducer and activator of transcription 3 (STAT3).

The Jamaican Haemophilia Registry: Describing the burden of disease.

INTRODUCTION: Jamaica has an estimated 200 persons with haemophilia (PWH), who face significant constraints in access to specialized haemophilia care, including access to clotting factor concentrates. AIM: The aim of this paper is to establish the current burden of disease in PWH in Jamaica. METHODS: PWH were enrolled through the University Hospital of the West Indies, Jamaica. The impact of haemophilia was assessed using a comprehensive battery of heath outcome measures that included the following: laboratory, clinical information and validated outcome measures of joint structure and function, activity, and health-related quality of life (HRQoL) to provide a health profile of the Jamaican haemophilia population. RESULTS: In all, 45 PWH were registered (mean age: 29, range: 0.17-69 years), including 13 children (<18 years of age) and 32 adults. In this sample, 41 had haemophilia A (30 severe) and 4 had haemophilia B (3 severe); 10 patients with haemophilia A were inhibitor positive. The results indicate that adults with haemophilia in Jamaica have significant joint damage: mean Haemophilia Joint Health Score (HJHS) = 42.1 (SD = 17.3); moderate activity levels - mean Haemophilia Activities List (HAL) score = 64.8 (SD = 17.8); and low HRQoL scores - mean Haemo-QoL-A score = 62.3 (SD = 19.4). Results for children are also reported but should be interpreted with caution due to the small sample size. CONCLUSIONS: There is a very high burden of disease in PWH in Jamaica. The health profiles reported in this paper are an essential first step in advocating for a multidisciplinary Comprehensive Care Program for assessment and care of PWH in Jamaica.

National Comparative Audit of Blood Transfusion: report on the 2014 audit of patient information and consent.

OBJECTIVES: The aim of this study was to assess current practices around obtaining consent for blood transfusion and provision of patient information in hospitals across the UK and identify areas for improvement. BACKGROUND: Recommendations from the Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO) (2011) state that valid consent should be obtained for blood transfusion and documented in clinical records. A standardised source of information should be available to patients. Practices in relation to this have historically been inconsistent. METHODS: The consent process was studied in hospitals across the UK over a 3-month period in 2014 by means of an audit of case notes and simultaneous surveys of patients and staff. RESULTS: In total, 2784 transfusion episodes were reviewed across 164 hospital sites. 85% of sites had a policy on consent for transfusion. Consent was documented in 43% of case notes. 68% of patients recalled being given information on benefits of transfusion, 38% on risks and 8% on alternatives and 28% reported receiving an information leaflet. In total, 85% of staff stated they had explained the reason for transfusion, but only 65% had documented this. 41% of staff had received training specifically on transfusion consent in the last 2 years. CONCLUSIONS: There is a need to improve clinical practice in obtaining valid consent for transfusion in line with existing national guidelines and local Trust policies, with emphasis on documentation within clinical records. Provision of patient information is an area particularly highlighted for action, and transfusion training for clinicians should be strengthened.

Activating PI3Kδ mutations in a cohort of 669 patients with primary immunodeficiency.

The gene PIK3CD codes for the catalytic subunit of phosphoinositide 3-kinase δ (PI3Kδ), and is expressed solely in leucocytes. Activating mutations of PIK3CD have been described to cause an autosomal dominant immunodeficiency that shares clinical features with common variable immunodeficiency (CVID). We screened a cohort of 669 molecularly undefined primary immunodeficiency patients for five reported mutations (four gain-of-function mutations in PIK3CD and a loss of function mutation in PIK3R1) using pyrosequencing. PIK3CD mutations were identified in three siblings diagnosed with CVID and two sporadic cases with a combined immunodeficiency (CID). The PIK3R1 mutation was not identified in the cohort. Our patients with activated PI3Kδ syndrome (APDS) showed a range of clinical and immunological findings, even within a single family, but shared a reduction in naive T cells. PIK3CD gain of function mutations are more likely to occur in patients with defective B and T cell responses and should be screened for in CVID and CID, but are less likely in patients with a pure B cell/hypogammaglobulinaemia phenotype.

A national benchmark for the initial assessment of men with LUTS: data from the 2010 Royal College of Physicians National Audit of Continence Care.

OBJECTIVE: To assess the degree of adherence to the current National Institute for Health and Clinical Excellence (NICE) guidelines on the management of urinary incontinence (UI) in men. DESIGN: Retrospective survey of male patients with UI in primary and acute hospital (AH) care as part of a national audit. SETTING: NHS AH and primary care (PC) trusts. SAMPLE: Twenty-five men <65 years old and 25 men ≥65 years old from each participating site. METHODS: All NHS trusts in England, Wales Northern Ireland and Channel Islands were eligible to participate. A web-based data collection form aligned to the NICE guidelines was constructed for the study. All data submitted to the audit were anonymous, and access to the web tool was password protected for confidentiality. RESULTS: Data were returned by 80 % (128/161) of acute trusts and 52 % (75/144) of PC trusts in England, and 71 % (10/14) of combined trusts from Northern Ireland, Wales and the Channel Islands including data on 559 men <65 and 1271 65+ from 141 sites within acute hospitals and 445 men <65 and 826 men 65+ in PC, a total of 3101 participants. CONCLUSION: The majority of men seen within the NHS with LUTS do not receive management according to evidence-informed NICE guidelines; in general, older men are less likely to receive care that meets guideline standards than younger men.

Dissemination of thermodynamic temperature above the freezing point of silver.

The mise-en-pratique for the definition of the kelvin at high temperatures will formally allow dissemination of thermodynamic temperature either directly or mediated through high-temperature fixed points (HTFPs). In this paper, these two distinct dissemination methods are evaluated, namely source-based and detector-based. This was achieved by performing two distinct dissemination trials: one based on HTFPs, the other based on absolutely calibrated radiation thermometers or filter radiometers. These trials involved six national metrology institutes in Europe in the frame of the European Metrology Research Programme joint project 'Implementing the new kelvin' (InK). The results have shown that both dissemination routes are possible, with similar standard uncertainties of 1-2 K, over the range 1273-2773 K, showing that, depending on the facilities available in the laboratory, it will soon be possible to disseminate thermodynamic temperatures above 1273 K to users by either of the two methods with uncertainties comparable to the current temperature scale.

Thermodynamic temperature assignment to the point of inflection of the melting curve of high-temperature fixed points.

The thermodynamic temperature of the point of inflection of the melting transition of Re-C, Pt-C and Co-C eutectics has been determined to be 2747.84 ± 0.35 K, 2011.43 ± 0.18 K and 1597.39 ± 0.13 K, respectively, and the thermodynamic temperature of the freezing transition of Cu has been determined to be 1357.80 ± 0.08 K, where the ± symbol represents 95% coverage. These results are the best consensus estimates obtained from measurements made using various spectroradiometric primary thermometry techniques by nine different national metrology institutes. The good agreement between the institutes suggests that spectroradiometric thermometry techniques are sufficiently mature (at least in those institutes) to allow the direct realization of thermodynamic temperature above 1234 K (rather than the use of a temperature scale) and that metal-carbon eutectics can be used as high-temperature fixed points for thermodynamic temperature dissemination. The results directly support the developing mise en pratique for the definition of the kelvin to include direct measurement of thermodynamic temperature.

Development of training for medicines-oriented policymakers to apply evidence.

BACKGROUND: Health systems globally promote appropriate prescribing by healthcare providers and safe and effective medicine use by consumers. Rx for Change, a publicly available database, provides access to systematic reviews regarding best practices for prescribing and using medicines. Despite the value of the database for improving prescribing and medicine use, its use remains suboptimal. This study aimed to develop a training program for five medicine-focused organisations in Canada and Australia to facilitate the use and understanding of the Rx for Change database. METHODS: Four steps were undertaken: 1) key informant interviews were completed across all organisations to understand the knowledge user perspective; 2) a directed content analysis was completed of the interview transcripts and proposed training was developed; 3) a second round of feedback on the proposed training by knowledge users was gathered; and 4) feedback was integrated to develop the final training. RESULTS: Sixteen key informant interviews with knowledge users were conducted. Themes for training content included the scope of, navigation and strategies for using Rx for Change (generic content) and practical examples on incorporating evidence within their workplace context (tailored content). The final training consisted of an informational video, a 60-minute face-to-face workshop and two post-training reminders. CONCLUSIONS: A method of engaging knowledge users in the development of a training program to improve the use of an on-line database of systematic reviews was established and used to design training. Next steps include the delivery and evaluation of the training.

Health related quality of life following the treatment of oropharyngeal cancer by transoral laser.

In 2006, our Institution changed the treatment strategy for small volume primary oropharyngeal tumours to transoral laser microsurgery (TOLM). The main aim of this cohort study was to report the health related quality of life (HRQOL) at around 2 years following TOLM in consecutive patients treated from July 2006 through April 2013. The University of Washington Quality of Life (UW-QOL) questionnaire was administered annually up to Spring 2014 and adjusting for mortality the overall response rate was 71 % (108/153). Tonsil primary site characterised 60 % (98) of patients, base of tongue 25 % (40), soft palate 13 % (21) and others 2 %, (3). Most patients had TOLM, neck dissection and adjuvant radiotherapy, with 21 % (34) of tumours at stage 1 or 2, 25 % (40) at stage 3 and 54 % (88) at stage 4. Kaplan-Meier estimates of overall survival were 94 % at 1 year, 88 % at 2 years and 68 % at 5 years after TOLM. Three-quarters (76 %) reported their overall QOL as being good, very good or outstanding, and by domain a clear majority of patients (range 57-94 %, median 79 %) reported none or only minor problems, most notably for swallowing, chewing and speech. The main dysfunction was in saliva (39 %). In conclusion, the outcomes in TOLM for oropharyngeal squamous cell carcinoma are very encouraging. The data supports the current treatment strategy in the Unit. Further outcomes research is required to help refine patient selection to help optimise the survival and HRQOL benefit of TOLM.

Meeting report: 3rd international transplant conference: how much risk can you take?

The 3rd International Transplant Conference took place on 31st October and 1st November 2014 at the University of Warwick, Coventry, UK. Key focal points of the meeting were the exploration of the molecular basis of antibody-antigen interactions and their relation to clinical practice and to share experiences and knowledge regarding strategies to transplant the 'high-risk' patient. In addition, lively debate sessions were hosted where controversial clinical and immunological themes were discussed by leading experts in the field.

Do the elderly raise different issues when using the Patient Concerns Inventory in routine head and neck cancer follow-up clinics?

Head and Neck (H&N) cancer treatment can have a major detrimental impact on patient lives, and these issues can go unrecognised and be inadequately addressed. The aim of this paper is to compare the Patient Concerns Inventory (PCI) responses across age groups attending routine H&N cancer follow-up clinics with particular focus on the elderly (75 years or older). The PCI-HN data were obtained from patients attending follow-up clinics between August 2007 and January 2013. The groups for comparison were: <55 (n = 105), 55-64 (n = 170), 65-69 (n = 64), 70-74 (n = 68), and ≥75 (n = 76), the median in this last group of 79.1 years. Regarding quality of life (QoL) on first completing the PCI the elderly reported better anxiety and mood, higher social-emotional subscale scores and better overall QoL. On the PCI, being elderly did not seem to affect the total numbers of items selected, though fewer items were selected from the psychological, emotional and spiritual well-being domain, and in particular the item about fear of recurrence. Dentist and surgeon were the two health professionals most often selected that patients wished to see or be referred on to. It is possible to recognise concerns in routine clinical care, thus allowing the opportunity for intervention and support to improve the outcome for the elderly.

How often do head and neck cancer patients raise concerns related to intimacy and sexuality in routine follow-up clinics?

Intimacy and sexuality problems are underreported in head and neck cancer patients. The aim of this study was to collate the various prompts available in a routine follow-up clinic through the use of an intimacy screening question and Patient's Concerns Inventory (PCI), and to identify how often these problems were raised by patients and what possible actions took place as a consequence. 177 patients completed the intimacy screening question, PCI and UW-QOLv.4 at follow-up clinics, from October 2008 to January 2011. Case note review identified if intimacy was mentioned in clinic letters and if referral for support was made. On the intimacy screening question, 15 % (26) reported problems of considerable/some concern (24) or selected intimacy/sexuality on the PCI (2). The PCI identified that 9 of the 24 reporting the worst problems wanted the topic discussed in clinic, and clinic letters suggested that 5 of these discussed the issue in clinic with 4 being referred on, 3 to a clinical psychologist and 1 to a clinical nurse specialist. Intimacy problems are underreported in clinic reviews. It is a difficult subject to discuss. It will remain a potential unmet need unless attempts are made to advance the opportunities for patient screening, information leaflets, staff training on how to talk about such sensitive issues and referral for counselling.

'What will I be like' after my diagnosis of head and neck cancer?

Consequences of treating head and neck cancer are reflected in health-related quality of life (HRQOL) patient-reported outcomes. HRQOL is an important outcome alongside survival and recurrence. However, relatively little HRQOL information is in a format that patients and oncology teams can easily interpret as a guide to likely outcomes following curative treatment. The study aim was to collate University of Washington Quality of Life (UW-QOL) questionnaires collected 1995-2012 at the Regional Head and Neck Surgical Unit with a view of summarizing key clinical-demographic influences on HRQOL outcomes at 2 years following diagnosis. Patients completing UW-QOL questionnaires at 9-60 months had their record closest to 2 years selected for cross-sectional analyses, while all questionnaires were analyzed to assess temporal trends. 65 % (1,134) of survivors to 9 months had a UW-QOL record in the cross-sectional analysis (median 23 months). Overall 1,349 completed 5,573 UW-QOL questionnaires. Various associations were seen, notably late overall clinical staging and treatment adversely associated with UW-QOL physical functioning domains. Logistic regression was used to better understand the predictive factors of UW-QOL outcome and determined the final formatting of tables for results. These tables provide important reference data about UW-QOL outcome at 2 years relevant to patients at the outset of their cancer journey. The increasing amount of HRQOL data allows for quite detailed subgroup analysis, which can help give patients and the clinical team a better understanding of likely long-term HRQOL outcomes. How this is best utilized in clinical care needs further evaluation.

Do head and neck cancer survivors attend a high street dentist on a regular basis?

Head and neck cancer (HNC) patients face complex oral health issues following treatment. The aims of this study were to determine the proportion of HNC patients attending their dentist regularly and investigate clinicodemographic characteristics associated with attendance. Two surveys asked about patient attendance patterns and dentition. Pre-treatment orthopantomographs were evaluated for those treated between 2007-2009. The response rate was 66% (444/672). 69% (305/444) saw a high street dentist regularly. 28% of edentulous patients attended regularly compared with 84% with natural teeth, p < 0.001. Associations at p < 0.001 with regular attendance were the leaving of formal education (> 16 years) and earlier clinical staging. HNC patients should be encouraged to see a dentist regularly for routine dental care and cancer surveillance in partnership with the cancer service.

Spot size measurement of a deuterium-tritium dense plasma focus using neutron radiography.

Neutron radiography is a technique uniquely suited to applications in nuclear diagnostics, non-destructive testing, and subcritical experiments. The spatial resolution of neutron radiographs is degraded by optical blur in the imaging system and the neutron source size, where the ideal source is point-like to optimize the point-spread function. A potential neutron source for radiography is the dense plasma focus (DPF), a coaxial Z-pinch that produces thermonuclear and beam-target neutrons. To assess if the source size is suitable for radiography, a neutron imaging system was used to measure the source size of the 4 MA Sodium DPF at the Nevada National Security Site operating with deuterium-tritium gas-fill. The source size was measured using the edge-spread function of tungsten objects, each having a rolled (convex) edge. The spot size was found to be 7-12 mm full-width at half-max (FWHM) assuming a Gaussian source, though comparison is presented for Lorentzian and Bennett distributions. The average FWHM was found to be 8.6 ± 1.2 mm vertically and 10.8 ± 1.2 mm horizontally with respect to the image plane, averaging over varied edges and alignments. The results were sensitive to source alignment and edge metrology, which introduced notable uncertainties. These results are consistent with separate experimental measurements as well as magnetohydrodynamics simulations of this DPF, which suggest that neutron production can originate from pinches ∼5-7 mm off-axis. These results suggest that the DPF should be used for radiography at low magnification (M < 1) where spot size does not dominate spatial blur.

Meeting report: 2nd international conference: antibody incompatible transplantation and transplant infectious disease.

The 2nd International Conference on Antibody Incompatible Transplantation and Transplant Infectious Disease took place at the University of Warwick on 23rd and 24th November 2012. The aims of the meeting were to discuss the pertinent clinical and laboratory issues surrounding antibody incompatible transplantation and to provide a contemporary analysis of transplant infectious disease. This report summarises the key points discussed at the meeting.

Vibration platform for mice to deliver precise, low intensity mechanical signals to the musculoskeleton.

OBJECTIVE: Low intensity vibration as a therapeutic and training modality has received increased attention despite the lack of clear mechanistic pathways. Thus, to determine mechanisms underpinning vibration-induced musculoskeletal adaptations, a vibration platform for mice was designed, constructed, and validated. METHODS: Critical aspects of the platform include use of off-the-shelf components to (1) tailor individual parameter selection (acceleration and frequency), (2) produce low error across the plate's surface and throughout the range of vibration parameters, and (3) utilize accelerometer feedback to ensure fidelity within and between bouts of vibration. The vibration device is controlled by a centrally-mounted linear actuator on the underside of the platform that is modulated by accelerometer feedback. RESULTS: Triaxial accelerometers confirmed that vibrations were purely vertical and acceleration responses were within 5% of target stimuli for all accelerations (0.2-1.0 g) and frequencies (25-90 Hz). The platform produced acceleration responses with ≤4% error between 25-90 Hz. Vibration modes were not detected indicating that the circular plate produced uniform stimuli across the platform (error ≤1.1%, P≥0.23) and mouse body mass did not affect the platform's performance (P≥0.43). CONCLUSIONS: Our vibration device for mice improves upon existing devices and enables precise, low intensity mechanical signals to be applied with confidence.