Post-mortem confirmation of fetal brain abnormalities: challenges highlighted by the MERIDIAN cohort study.

OBJECTIVES: To assess and analyse the concordance between post-mortem findings and in utero magnetic resonance imaging (iuMRI) in the MERIDIAN (MRI to enhance the diagnosis of fetal developmental brain abnormalities in utero) cohort. DESIGN: Prospective cohort study. SETTING: Fetal medicine units in the UK. POPULATION: Pregnant women with a diagnosis of fetal brain abnormality identified on ultrasound at 18 weeks of gestation or later. METHODS: All pregnancies from the MERIDIAN study that resulted in a abortion were included and the rate of uptake and success of post-mortem examinations were calculated. In the cases in which diagnostic information about the fetal brain was obtained by post-mortem, the results were compared with the diagnoses from iuMRI. MAIN OUTCOME MEASURE: Outcome reference diagnosis from post-mortem examination. RESULTS: A total of 155 from 823 pregnancies (19%) ended in a termination of pregnancy and 71 (46%) had post-mortem brain examinations, 62 of which were diagnostically adequate. Hence, the overall rate of successful post-mortem investigation was 40%, and for those cases there was a concordance rate of 84% between iuMRI and post-mortem examination. Detailed information is provided when the results of the post-mortem examination and the iuMRI study differed. CONCLUSIONS: We have shown tissue-validation of radiological diagnosis is hampered by a low rate of post-mortem studies in fetuses aborted with brain abnormalities, a situation further compounded by a 12% rate of autopsy being technically unsuccessful. The agreement between iuMRI and post-mortem findings is high, but our analysis of the discrepant cases provides valuable clues for improving how we provide information for parents. TWEETABLE ABSTRACT: iuMRI should be considered a reliable indicator of fetal brain abnormalities when post-mortem is not performed.

The rate of brain abnormalities on in utero MRI studies in fetuses with normal ultrasound examinations of the brain and calculation of indicators of diagnostic performance.

AIM: To estimate the rate of unexpected brain abnormalities detected by in utero magnetic resonance imaging (iuMRI) in fetuses without abnormalities at ultrasonography (USS). MATERIALS AND METHODS: A prospective cohort study of pregnant women whose fetus had no structural brain (or body) abnormalities recognised on antenatal ultrasonography. Women were recruited from 12 centres across the UK and underwent iuMRI at 18 gestational weeks or more in the [blinded for review]. The imaging studies were reviewed by an experienced neuroradiologist. The positive and negative predictive values of both USS and iuMRI have been calculated by combining the results of this study with the results from the main [blinded for review] study. RESULTS: One hundred and ninety-eight pregnant women were recruited and underwent iuMRI of 205 fetuses. Brain abnormalities were shown on iuMRI in two fetuses that were not recognised on USS (one case of a focal cortical abnormality and one case of mild ventriculomegaly). The negative predictive value for USS was 99.5% and 100% for iuMRI. CONCLUSIONS: To the authors' knowledge, this is the first study comparing USS and iuMRI in low-risk pregnancies. USS has a comparatively high rule-out for fetal brain abnormalities and should remain the screening tool of choice.

Should we perform in utero MRI on a fetus at increased risk of a brain abnormality if ultrasonography is normal or shows non-specific findings?

There are a number of reasons why a pregnant woman might be considered to have an increased risk of carrying a fetus with a brain abnormality, but they fall broadly into two groups. First, there may be a relevant family history usually, but not always, when a fetus/child from a previous pregnancy has a developmental brain abnormality and a clinical geneticist judges that there is a risk of recurrence. Second, there may be findings in their current pregnancy that increases the risk of the fetus either having a developmental brain abnormality or accruing acquired brain pathology. Antenatal ultrasonography remains the mainstay of fetal screening and anomaly scanning, but there is now persuasive evidence that in utero magnetic resonance imaging should have an important supporting role. This is important, as more accurate and more certain diagnoses are central to providing parents with accurate information about the likely clinical outcome. In pregnancies at increased risk of brain abnormalities, it is also important to provide the best quality information that the fetal brain is normal to provide reassurance to parents. In this paper, we review the proposition that in utero magnetic resonance imaging should be used in pregnancies at increased risk of brain abnormalities, even if the consultant-led ultrasound examination is normal or showed non-specific findings only.

Anatomical subgroup analysis of the MERIDIAN cohort: posterior fossa abnormalities.

OBJECTIVE: To assess the diagnostic and clinical contribution of fetal magnetic resonance imaging (MRI) in fetuses of the MERIDIAN cohort diagnosed with abnormalities of the posterior fossa as the only intracranial abnormality recognized on antenatal ultrasound. METHODS: This was a subgroup analysis of the MERIDIAN study of fetuses with abnormalities of the posterior fossa (with or without ventriculomegaly) diagnosed on antenatal ultrasound in women who had MRI within 2 weeks of ultrasound and for whom outcome reference data were available. The diagnostic accuracy of ultrasound and MRI is reported, as well as indicators of diagnostic confidence and effects on prognosis and clinical management. Appropriate diagnostic confidence was assessed by the score-based weighted average method, which combines diagnostic accuracy with diagnostic confidence data. RESULTS: Abnormalities confined to the posterior fossa according to ultrasound were found in 81 fetuses (67 with parenchymal and 14 with cerebrospinal fluid-containing lesions). The overall diagnostic accuracy for detecting an isolated posterior fossa abnormality was 65.4% for ultrasound and 87.7% for MRI (difference, 22.3% (95% CI, 14.0-30.5%); P < 0.0001). There was an improvement in 'appropriate' diagnostic confidence, as assessed by the score-based weighted average method (P < 0.0001), and a three-fold reduction in 'high confidence but incorrect diagnosis' was achieved using MRI. Prognostic information given to the women changed after MRI in 44% of cases, and the overall effect of MRI on clinical management was considered to be 'significant', 'major' or 'decisive' in 35% of cases. CONCLUSIONS: Our data suggest that any woman whose fetus has a posterior fossa abnormality as the only intracranial finding on ultrasound should have MRI for further evaluation. This is on the basis of improved diagnostic accuracy and confidence, which impacts substantially on the prognostic information given to women as well as their clinical management. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Anatomical subgroup analysis of the MERIDIAN cohort: ventriculomegaly.

OBJECTIVE: To assess the contribution of fetal magnetic resonance imaging (MRI) in fetuses of the MERIDIAN cohort diagnosed with ventriculomegaly (VM) as the only abnormal intracranial finding on antenatal ultrasound. METHODS: This was a subgroup analysis of the MERIDIAN study of fetuses with only VM diagnosed on ultrasound in women who had a subsequent MRI examination within 2 weeks and for whom outcome reference data were available. The diagnostic accuracy of ultrasound and MRI was reported in relation to the severity of VM. The difference in measurements of trigone size on the two imaging methods and the clinical impact of adding MRI to the diagnostic pathway were also studied. RESULTS: In 306 fetuses with VM, ultrasound failed to detect 31 additional brain abnormalities, having an overall diagnostic accuracy of 89.9% for ultrasound, whilst MRI correctly detected 27 of the additional brain abnormalities, having a diagnostic accuracy of 98.7% (P < 0.0001). There were other brain abnormalities in 14/244 fetuses with mild VM on ultrasound (diagnostic accuracy, 94.3%) and MRI correctly diagnosed 12 of these (diagnostic accuracy, 99.2%; P = 0.0005). There was a close agreement between the size of trigones measured on ultrasound and on MRI, with categorical differences in only 16% of cases, showing that MRI did not systematically overestimate or underestimate trigone size. Complete prognostic data were available in 295/306 fetuses and the prognosis category changed after MRI in 69/295 (23.4%) cases. The overall effect of MRI on clinical management was considered to be 'significant', 'major' or 'decisive' in 76/295 (25.8%) cases. CONCLUSION: Our data suggest that a woman carrying a fetus with VM as the only intracranial finding on ultrasound should be offered an adjuvant investigation by MRI for further evaluation. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Anatomical subgroup analysis of the MERIDIAN cohort: failed commissuration.

OBJECTIVE: To assess the contribution of fetal magnetic resonance imaging (MRI) in fetuses of the MERIDIAN cohort diagnosed with either agenesis or hypogenesis of the corpus callosum (referred to collectively as failed commissuration) on antenatal ultrasound. METHODS: This was a subgroup analysis of the MERIDIAN study of fetuses with failed commissuration (with or without ventriculomegaly) diagnosed on ultrasound in women who had MRI assessment within 2 weeks of ultrasound and for whom outcome reference data were available. The diagnostic accuracy of ultrasound and MRI was studied, as well as indicators of diagnostic confidence and effects on prognosis/clinical management. Appropriate diagnostic confidence was assessed by the score-based weighted average method, which combines diagnostic accuracy with diagnostic confidence data. RESULTS: In the MERIDIAN cohort, 79 fetuses were diagnosed with failed commissuration on ultrasound (55 with agenesis and 24 with hypogenesis of the corpus callosum). The diagnostic accuracy for detecting failed commissuration was 34.2% for ultrasound and 94.9% for MRI (difference, 60.7% (95% CI, 47.6-73.9%), P < 0.0001). The diagnostic accuracy for detecting hypogenesis of the corpus callosum as a discrete entity was 8.3% for ultrasound and 87.5% for MRI, and for detecting agenesis of the corpus callosum as a distinct entity was 40.0% for ultrasound and 92.7% for MRI. There was a statistically significant improvement in 'appropriate' diagnostic confidence when using MRI as assessed by the score-based weighted average method (P < 0.0001). Prognostic information given to the women changed in 36/79 (45.6%) cases after MRI and its overall effect on clinical management was 'significant', 'major' or 'decisive' in 35/79 cases (44.3%). CONCLUSIONS: Our data suggest that any woman whose fetus has failed commissuration as the only intracranial finding detected on ultrasound should have MRI examination for further evaluation. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Change in diagnostic confidence brought about by using in utero MRI for fetal structural brain pathology: analysis of the MERIDIAN cohort.

AIM: To measure possible change in diagnostic confidence by performing in utero magnetic resonance imaging (iuMRI) studies on fetuses with brain abnormalities recognised on ultrasonography (US). MATERIALS AND METHODS: The analyses are based on the primary cohort from the prospective MERIDIAN study, which consisted of 570 fetuses with brain abnormalities detected on US, with iuMRI performed within 2 weeks of US and complete outcome reference data. The cohort was recruited between July 2011 and August 2014, and written informed consent was obtained for all participants. They all had indicators of diagnostic confidence measured on US by fetal medicine experts and iuMRI by the reporting radiologists. Three assessments were carried out using the conventional uncorrected (C2-C1%) method, the conventional (C2-C1%) with the Omary correction, and the score-based weighted average method. RESULTS: All three assessments showed statistically significant (p<0·0001) positive effects indicating that iuMRI was potentially beneficial when included in the diagnostic pathway for prenatal structural brain anomalies (in terms of diagnostic confidence). CONCLUSION: These results strongly support the routine clinical use of iuMRI as an adjunct to US when assessing fetuses with structural brain abnormalities.

Major histocompatibility complex class II alleles and haplotypes associated with non-suppurative meningoencephalitis in greyhounds.

Non-suppurative meningoencephalitis is a breed-restricted canine neuroinflammatory disorder affecting young greyhounds in Ireland. A genetic risk factor is suspected because of the development of disease in multiple siblings and an inability to identify a causative infectious agent. The aim of this study was to examine potential associations between dog leucocyte antigen (DLA) class II haplotype and the presence of the disease. DLA three locus haplotypes were determined in 31 dogs with non-suppurative meningoencephalitis and in 115 healthy control dogs using sequence-based typing (SBT) methods. All dogs were unrelated at the parental level. Two haplotypes (DRB1*01802/DQA1*00101/DQB1*00802 and DRB1*01501/DQA1*00601/DQB1*02201) were significantly (P = 0.0099 and 0.037) associated with the presence of meningoencephalitis, with odds ratios (95% confidence interval) of 5.531 (1.168-26.19) and 3.736 (1.446-9.652), respectively. These results confirm that there is an association between DLA class II haplotype and greyhound meningoencephalitis, suggesting an immunogenetic risk factor for the development of the disease. Greyhound meningoencephalitis may be a suitable model for human neuroinflammatory diseases with an immunogenetic component.

Evaluation of lower-starch diets for lactating Holstein dairy cows.

The objective of this experiment was to measure ruminal and lactational responses of Holstein dairy cows fed diets containing 3 different starch levels: 17.7 (low; LS), 21.0 (medium; MS), or 24.6% (high; HS). Twelve multiparous cows (118 ± 5 d in milk) were assigned randomly to dietary treatment sequence in a replicated 3 × 3 Latin square design with 3-wk periods. All diets were fed as total mixed rations and contained approximately 30.2% corn silage, 18.5% grass silage, and 5.0% chopped alfalfa hay. Dietary starch content was manipulated by increasing dry ground corn inclusion (% of dry matter) from 3.4 (LS) to 10.1 (MS) and 16.9 (HS) and decreasing inclusion of beet pulp and wheat middlings from 6.7 and 13.4 (LS) to 3.4 and 10.1 (MS) or 0 and 6.8 (HS). In vitro 6-h starch digestibility of the diet increased as nonforage sources of fiber replaced corn grain (% of dry matter; 73.6, HS; 77.3, MS; 82.5, LS) resulting in rumen-fermentable starch content by 14.6, 16.2, and 18.1% for the LS, MS, and HS diets, respectively. Diets had similar neutral detergent fiber from forage and particle size distributions. Dry matter intake, solids-corrected milk yield, and efficiency of solids-corrected milk production were unaffected by diet, averaging 26.5 ± 0.8, 40.8 ± 1.6, and 1.54 ± 0.05 kg/d, respectively. Reducing dietary starch did not affect chewing time (815 ± 23 min/d), mean ruminal pH over 24h (6.06 ± 0.12), acetate-to-propionate ratio (2.4 ± 0.3), or microbial N synthesized in the rumen (585 ± 24 g/d). Total tract organic matter digestibility was higher for HS compared with MS and LS diets (69.2, 67.3, and 67.0%, respectively), but crude protein, neutral detergent fiber, and starch digestibilities were unaffected. As dietary starch content decreased, in vitro ruminal starch fermentability increased and, consequently, the range between HS and LS in rumen-fermentable starch (3.5 percentage units) was less than the range in starch content (6.9 percentage units). Under these conditions, dietary starch content had no measurable effect on ruminal fermentation or short-term lactational performance of high-producing Holstein dairy cows.

Effect of reducing dietary forage in lower starch diets on performance, ruminal characteristics, and nutrient digestibility in lactating Holstein cows.

This experiment evaluated the effect of feeding a lower starch diet (21% of dry matter) with different amounts of forage (52, 47, 43, and 39% of dry matter) on lactational performance, chewing activity, ruminal fermentation and turnover, microbial N yield, and total-tract nutrient digestibility. Dietary forage consisted of a mixture of corn and haycrop silages, and as dietary forage content was reduced, chopped wheat straw (0-10% of dry matter) was added in an effort to maintain chewing activity. Dietary concentrate was adjusted (corn meal, nonforage fiber sources, and protein sources) to maintain similar amounts of starch and other carbohydrate and protein fractions among the diets. Sixteen lactating Holstein cows were used in replicated 4×4 Latin squares with 21-d periods. Dry matter intake increased while physically effective neutral detergent fiber (peNDF1.18) intake was reduced as forage content decreased from 52 to 39%. However, reducing dietary forage did not influence milk yield or composition, although we observed changes in dry matter intake. Time spent chewing, eating, and ruminating (expressed as minutes per day or as minutes per kilogram of NDF intake) were not affected by reducing dietary forage. However, addition of chopped wheat straw to the diets resulted in greater time spent chewing and eating per kilogram of peNDF1.18 consumed. Reducing dietary forage from 52 to 39% did not affect ruminal pH, ruminal digesta volume and mass, ruminal pool size of NDF or starch, ruminal digesta mat consistency, or microbial N yield. Ruminal acetate-to-propionate ratio was reduced, ruminal turnover rates of NDF and starch were greater, and total-tract digestibility of fiber diminished as dietary forage content decreased. Reducing the dietary forage content from 52 to 39% of dry matter, while increasing wheat straw inclusion to maintain chewing and rumen function, resulted in similar milk yield and composition although feed intake increased. With the lower starch diets in this short-term study, the minimal forage content to maintain lactational performance was between 39 and 43%.

Effect of alternative models for increasing stocking density on the short-term behavior and hygiene of Holstein dairy cows.

The primary objective of this study was to evaluate short-term responses in lying behavior and hygiene of Holstein dairy cows housed at a stocking density of 100 (1 cow per stall and headlock) or 142% imposed by 1) the denial of access to freestalls and headlocks, 2) the denial of access to freestalls, headlocks, and 26.6 m(2) of alley space, or 3) the addition of a rotating group of 14 cows to the resident group of 34 cows. The secondary objective was to determine the bioequivalence of the 3 methods of experimentally increasing stocking density. Cows (n=136) were assigned to 1 of 4 pens in a 4-row freestall barn and treatments were allocated using a 4×4 Latin square with 14-d periods. Lying time (h/d) and number of bouts/d for 12 focal cows per pen were determined using dataloggers recording at 1-min intervals during the final 5 d of each period. Dry matter intake (DMI) was established from the pen mean over the final 4 d of each period. Feeding and rumination activities on focal cows were determined by direct observation at 10-min intervals for 24h on d 11. Hygiene of focal cows was assessed from the difference in the scores after the legs and udder were cleaned on d 2 of each period and those on d 14. Lying time was greater for 100% stocking density (13.0 h/d) than the 142% stocking density treatments (11.8 h/d), which did not differ. Lying bouts (12.3/d) and bout duration (64.8 min/bout) did not differ among treatments. Short-term responses in DMI (24.6 kg/d) did not differ in response to the treatments. The 3 stocking density treatments decreased, or tended to decrease, the time spent feeding compared with 100% (4.4 versus 4.2 h/d). The stocking density treatments decreased the percentage of rumination occurring within a stall (92.3 versus 85.3%). A treatment effect on udder and leg hygiene scores was not evident on d 14 of each period or in the change from d 2 to 14 of each period. With the exception of rumination time (h/d), the 3 methods for experimentally imposing stocking density were bioequivalent for responses in behaviors, DMI, and hygiene. Future stocking density experiments in 4-row barns should simply deny resting and feeding space to simulate overcrowded housing conditions for lactating dairy cows because it is bioequivalent to more complicated, and potentially confounding, research models.

Short-term increases in stocking density affect the lying and social behavior, but not the productivity, of lactating Holstein dairy cows.

Reduced access to resources because of increased stocking density may have a detrimental effect on the behavior of the lactating dairy cow. The objective of this study was to determine the short-term responses in behavior, productivity, fecal cortisol metabolites, and udder and leg hygiene of lactating Holstein dairy cows housed at stocking densities of 100 (1 cow per freestall and headlock), 113, 131, and 142%. Multiparous cows (n=92) and primiparous cows (n=44) were assigned to 1 of 4 pens (34 cows per pen) in a 4-row freestall barn. Pens were balanced for parity, milk production, and days in milk. Stocking densities were imposed for 14 d using a 4 × 4 Latin square design. Time spent feeding and time spent ruminating were quantified by 24 h of direct observation of focal cows (n=12 per pen) beginning at 0800 h on d 11 of each period. Data loggers recorded lying behavior (time and bouts) from the same focal cows per pen at 1-min intervals during the final 5 d of each period. Fecal cortisol metabolites were quantified from samples collected on d 13 and 14 of each period from the same focal cows. Displacements from the feed barrier were recorded on a pen basis after 9 milkings over the last 4 d of each period. Productivity was assessed on a pen basis from milk yield (recorded from d 10 to 14 of each period) and milk components (quantified from composite samples collected on d 12 of each period). Milk composition was further analyzed for milk fatty acid profiles, which were determined from a subset (n=6 per pen) of the focal cows. Data were analyzed using the MIXED procedure of SAS, with the pen (n=4 per treatment, except displacements where n=3 per treatment) as the experimental unit. Feeding and ruminating (h/d) did not differ among treatments. Lying time was reduced at stocking densities of 131 and 142%, relative to 100 or 113%. Lying bouts were not affected by treatment. Stocking densities of 131 and 142% reduced the percentage of time cows spent ruminating within a freestall relative to 100%. Displacements from the feed bunk increased linearly across treatments. Fecal cortisol metabolites, udder hygiene score, milk yields, milk composition, and milk fatty acids did not differ among treatments. Decreased lying time and increased aggression at the feed bunk suggest that an alteration of the time budgets of lactating dairy cows may occur at higher stocking densities, but it is unclear at what point these changes might have further biological consequences.

Retrospective study evaluation of DGGR lipase for diagnosis, agreement with pancreatic lipase and prognosis in dogs with suspected acute pancreatitis.

OBJECTIVES: Activity of 1,2-o-dilauryl-rac-glycero-3-glutaric acid-(6'-methylresorufin) ester (DGGR) lipase is considered to be more pancreas specific than traditional lipase assays. The aim of this study was to evaluate the diagnostic performance of DGGR lipase activity for suspected acute pancreatitis in dogs and to assess its prognostic usefulness. METHODS: Retrospective study of case records for suspected acute pancreatitis based on clinician-stated diagnosis, point-of-care and quantitative canine pancreas-specific lipase (cPL) results and consistent ultrasonographic features. Diagnostic performance of DGGR lipase was assessed by receiver-operating characteristic curve analysis, agreement by Cohen's kappa (κ) and prognostic value by multiple regression analysis. RESULTS: Median DGGR lipase activity was significantly (P < 0.001) higher in dogs with suspected acute pancreatitis [93.7 (range, 11.0-2853.0) U/L (n = 158)] compared to those with no evidence of pancreatitis [range, 20.9 (6.7-89.0) U/L (n = 356)]. A DGGR lipase activity >42.15 U/L had the best combined diagnostic sensitivity (81.0%) and specificity (92.1%). Previously established cut-offs (>130 and >80 U/L) had sensitivities of 40.5 and 43.0%, and specificities of 100 and 99.7%, respectively. There was near perfect (κ = 0.821) and substantial (κ = 0.751) agreement between DGGR lipase activity >42.15 U/L and quantitative cPL concentrations ≥200 and ≥400 µg/L, respectively. DGGR lipase activity but not quantitative cPL concentration was statistically (P = 0.043, odds ratio = 0.999) predictive of discharge but clinical utility is questionable. CLINICAL SIGNIFICANCE: Using DGGR lipase at the lower cut-off could provide an additional test for supporting a diagnosis of acute pancreatitis in dogs particularly if cPL results are not available. Larger studies are required to more fully assess its value in prognostication.

Qualitative and semiquantitative assessment of thyroid hormone binding proteins in greyhounds and other dog breeds.

Total thyroxine (T4) concentrations are lower in healthy greyhounds compared to most other non-sighthound breeds. In humans, variations in the structure or concentration of the major thyroid hormone binding proteins are responsible for most reported differences between total T4 concentrations in healthy individuals from different ethnic groups or other subpopulations. The aim of this study was to determine if such variations are also responsible for the lower total T4 concentrations in greyhounds. The predicted protein sequences of thyroxine-binding globulin (TBG), transthyretin and albumin were determined in liver tissue from a euthyroid greyhound with decreased T4 concentration and a Jack Russell terrier using reverse-transcriptase PCR. Sequences were compared to each other and online reference sequences. Serum proteins from 21 greyhounds and 21 non-sighthound dogs were separated by denaturing electrophoresis and immunoblots probed with polyclonal antibodies to human TBG and transthyretin. Reactive bands were quantified by densitrometry, expressed relative to the mean of reference samples included in each gel. Serum albumin concentrations were measured using a commercially-available assay. Several SNPs were identified but none was thought likely to explain the lower total T4 concentrations in greyhounds. There was no significant difference between the quantity of any of the binding proteins in serum from greyhounds and non-sighthound dogs. However, total T4 and transthyretin concentrations were highly correlated in the greyhound group (r = 0.73, P = 0.0002). Variation in the sequence of thyroid hormone binding proteins is not responsible for low greyhound total T4 concentrations. Further evaluation of the role of transthyretin is warranted.

Development and internal validation of a diagnostic prediction model for COVID-19 at time of admission to hospital.

BACKGROUND: Early coronavirus disease 2019 (COVID-19) diagnosis prior to laboratory testing results is crucial for infection control in hospitals. Models exist predicting COVID-19 diagnosis, but significant concerns exist regarding methodology and generalizability. AIM: To generate the first COVID-19 diagnosis risk score for use at the time of hospital admission using the TRIPOD (transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) checklist. DESIGN: A multivariable diagnostic prediction model for COVID-19 using the TRIPOD checklist applied to a large single-centre retrospective observational study of patients with suspected COVID-19. METHODS: 581 individuals were admitted with suspected COVID-19; the majority had laboratory-confirmed COVID-19 (420/581, 72.2%). Retrospective collection was performed of electronic clinical records and pathology data. RESULTS: The final multivariable model demonstrated AUC 0.8535 (95% confidence interval 0.8121-0.8950). The final model used six clinical variables that are routinely available in most low and high-resource settings. Using a cut-off of 2, the derived risk score has a sensitivity of 78.1% and specificity of 86.8%. At COVID-19 prevalence of 10% the model has a negative predictive value (NPV) of 96.5%. CONCLUSIONS: Our risk score is intended for diagnosis of COVID-19 in individuals admitted to hospital with suspected COVID-19. The score is the first developed for COVID-19 diagnosis using the TRIPOD checklist. It may be effective as a tool to rule out COVID-19 and function at different pandemic phases of variable COVID-19 prevalence. The simple score could be used by any healthcare worker to support hospital infection control prior to laboratory testing results.

Early and discrete changes in permeability of Escherichia coli and certain other gram-negative bacteria during killing by granulocytes.

Rapid killing of Escherichia coli by intact or disrupted rabbit granulocytes or by granulocyte fractions was found to be accompanied by an equally rapid increase in permeability of the E.coli envelope. This increase in permeability was detected by determining entry of substances that normally do not cross E.coli's permeability barrier, namely actinomycin D and o-nitrophenyl-beta-D-galactopyranoside (ONPG), a substrate for cytoplasmic beta-galactosidase. Because E.coli continue to incorporate radioactively labeled precursors into bacterial RNA and protein for at least 1 h, despite rapid killing by granulocytes, entry of actinomycin D could be measured by its inhibitory effect on macromolecular synthesis. Entry was evident within minutes after exposure to granulocytes or granulocyte fractions and is independent of pH over a range of 6.5-9.0. The effect of disrupted granulocytes or partially purified fractions on susceptibility of E.coli to actinomycin D and entry of ONPG is dose dependent. That the entry of actinomycin D and ONPG was not caused by gross destruction of the envelope is indicated by two sets of observations: (a) net influx of (42)K was maintained for at least 15 min, even though efflux of potassium was immediately accelerated upon addition of bactericidal concentrations of granulocyte fractions; (b) beta-galactosidase did not leak out of E.coli under conditions that produce maximal inhibition by actinomycin D. Different species of gram-negative bacteria exhibited different susceptibilities to the bactericidal and permeability effects of granulocyte fractions. Thus, three strains of E.coli and one strain of Salmonella typhimurium were highly susceptible to both the bactericidal and the permeability enhancing effects of granulocyte fractions, whereas two strains of Serratia marcescens and one strain of Pseudomonas aeruginosa were resistant to both effects. Another strain of P. aeruginosa was rendered susceptible to actinomycin D without being killed and two strains of S. typhimurium remained insensitive to actinomycin D while being killed by granulocytes.

Assessment of the reliability and validity of a novel point-of-care fibrinogen (F-Point) device against an industry standard at fibrinogen levels >2 g/L in non-haemorrhage scenarios.

INTRODUCTION: A diagnostic accuracy study assessing the reliability and validity of a novel plasma fibrinogen point-of-care (F-Point) device compared with the von Clauss method of assay. METHODS: Forty-one women presenting for elective caesarean delivery and 43 non-pregnant female patients presenting for elective gynaecological surgery were recruited to assess agreement at normal fibrinogen levels (elective gynaecological cohort) and high fibrinogen levels (elective caesarean section cohort). Validity was assessed by comparing the F-Point results with the gold standard of von Clauss fibrinogen assay performed on the ACL Top 500. Reliability (test-retest) and validity were assessed using the intraclass correlation to control for operator variance (two-way random absolute agreement method), presented as intra class correlation coefficients (ICCs) and 95% confidence interval, and Bland-Altman analysis, presented as mean bias and 95% limits of agreement and coefficient of variation (COV). RESULTS: The results demonstrated a high test-retest reliability demonstrated in the paired F-Point measurements with an intraclass correlation coefficient (ICC) of 0.95, a bias of 0 (-00.69 to 0.69) and a COV of 9%. Similarly, there was acceptable agreement demonstrated between F-Point and von Clauss assay with an ICC of 0.91, a bias of -0.1 (-0.96 to 0.75) and a COV of 11%. CONCLUSIONS: Our novel plasma fibrinogen point-of-care device has been shown to be reliable and valid when testing fibrinogen levels as low as 2 g/L. Future studies investigating the correlation at lower fibrinogen levels, for example during haemorrhage and in patients with coagulopathies, are required.

Plasma microRNA levels in male and female children with cystic fibrosis.

A gender gap exists in cystic fibrosis (CF). Here we investigate whether plasma microRNA expression profiles differ between the sexes in CF children. MicroRNA expression was quantified in paediatric CF plasma (n = 12; six females; Age range:1-6; Median Age: 3; 9 p.Phe508del homo- or heterozygotes) using TaqMan OpenArray Human miRNA Panels. Principal component analysis indicated differences in male versus female miRNA profiles. The miRNA array analysis revealed two miRNAs which were significantly increased in the female samples (miR-885-5p; fold change (FC):5.07, adjusted p value: 0.026 and miR-193a-5p; FC:2.6, adjusted p value: 0.031), although only miR-885-5p was validated as increased in females using specific qPCR assay (p < 0.0001). Gene ontology analysis of miR-885-5p validated targets identified cell migration, motility and fibrosis as processes potentially affected, with RAC1-mediated signalling featuring significantly. There is a significant increase in miR-885-5p in plasma of females versus males with CF under six years of age.

The development and implementation of the pathway for improving the care of the dying in general medical wards.

The majority of deaths in Australia occur in general hospital wards and most are neither sudden nor unexpected. The Pathway for Improving the Care of the Dying (PICD) is an adaptation of the Liverpool Care Pathway to the Australian healthcare setting (or 'to Australian conditions') and is designed to help ensure a 'good death' for patients dying outside the palliative care system. PICD consists of a series of prompts, guidelines, revised medical and nursing care plans and a number of medication algorithms.

Clinical evaluation of a novel liquid formulation of L-thyroxine for once daily treatment of dogs with hypothyroidism.

BACKGROUND: A liquid solution of levothyroxine (L-T4) is available for treatment of canine hypothyroidism. HYPOTHESIS: Once daily oral administration of a liquid L-T4 solution is effective and safe for controlling hypothyroidism in dogs. ANIMALS: Thirty-five dogs with naturally occurring hypothyroidism. METHODS: Dogs received L-T4 solution PO once daily at a starting dosage of 20 microg/kg body weight (BW). The dose was adjusted every 4 weeks, based on clinical signs and peak serum total T4 (tT4) concentrations. Target peak serum tT4 and thyroid stimulating hormone (TSH) concentrations, 4-6 hours posttreatment, were 35-95 nmol/L and < 0.68 ng/mL, respectively. Dogs were followed for up to 22 weeks after establishment of the maintenance dose. RESULTS: Clinical signs of hypothyroidism improved or resolved in 91% of dogs after 4 weeks of L-T4 treatment at 20 microg/kg once daily. The maintenance dose was established in 76, 94, and 100% of dogs after 4, 8, and 12 weeks of treatment, respectively. This was 20 microg L-T4/kg BW for 79% of the dogs, 30 microg/kg BW for 15%, and 10-15 microg/kg BW in the remaining 6%, once daily. Thereafter, median peak tT4 and TSH concentrations were 51 nmol/L and 0.18 ng/mL, respectively, and remained stable during the 22-week follow-up; clinical signs did not recur. CONCLUSIONS AND CLINICAL IMPORTANCE: All of the hypothyroid dogs had rapid clinical and hormonal responses to supplementation with the PO-administered L-T4 solution. The starting dosage of 20 microg L-T4/kg BW once daily was suitable for 79% of dogs.