Behavioural plasticity and the anthropause: an urban bird becomes less aggressive

Urban areas often impose strong, novel selection pressures on wildlife. Phenotypic plasticity, including behavioural plasticity, is an important mechanism helping organisms establish populations in novel environments. Behavioural plasticity can be difficult to study in urban wildlife because many urban environmental variables are challenging to isolate and manipulate experimentally. We took advantage of the COVID-19 lockdowns to assess whether urban birds expressed territorial aggression differently when relieved from frequent encounters with humans. We used simulated territorial intrusions to measure the behavioural responses of resident dark-eyed juncos, Junco hyemalis, on an urban college campus in Los Angeles, U.S.A. We found that the population overall displayed significantly reduced movement and singing behaviour associated with territorial aggression in a pandemic year (2021) compared to a typical year (2019). Furthermore, individuals measured in both 2019 and 2021 had significantly reduced responses in 2021, demonstrating that individual birds maintained behavioural plasticity in these traits. Our results show that human disturbance likely has a significant effect on the expression of behaviours associated with territorial aggression in urban birds. © 2023 The Author(s)

Improving mycobacterial sputum culture collection in adult patients during the highly effective modulator therapy era

Background: Taking annual mycobacterial sputum cultures (MSCx) is a best practice standard for surveillance of nontuberculous mycobacterium (NTM) infection. MSCx collection among sputum-producing people with CF (PwCF) is essential for early identification and management of NTM. Initiation of highly effective modulator therapy (HEMT), elexacaftor/ tezacaftor/ivacaftor in 2019, resulted in a reduction in sputum production in PwCF. The concurrent emergence of the COVID-19 pandemic led to a shift from in-person to virtual clinic visits. These two events led to a dramatic decline in the rate of MSCx collection at our center-from 52.7% (2019) to 26.5% (2020) based on our CF Patient Registry report. We used a multidisciplinary approach to evaluate and implement continuous quality improvement (CQI) measures with the aim of increasing MSCx collection from 52.7% to 65% in 12 months. Eligibility was defined as producing 1 mL or more of sputum and no MSCx within the past 12 months. Method(s): The Minnesota CF Center care team consists of multidisciplinary specialties and approximately 450 PwCF. The CQI team generated the aim and developed a process map highlighting key stakeholders and barriers to MSCx collection. The team used a plan-do-study-act (PDSA) model to optimize key steps involved in MSCx collection. The first PDSA model included microbiology lab leadership identifying optimal (5-10 mL) and acceptable (>=1 mL) sputum volumes to avoid rejected specimens. Next, providers approved a new protocol to prioritize first sputum collection for MSCx and subsequent collection for CF bacterial cultures in eligible PwCF. Development of a certified medical assistant flowchart guided determination of eligibility for MSCx collection (Figure 1). Certified medical assistant then used a paper tool to document eligibility, specimen type, and lab orders placed for PwCF in clinic during the 4-week PDSA cycle. The paper tool was adapted using electronic health record (EHR) capabilities to generate date of last MSCx and allow electronic documentation of specimen collection type and orders placed. Result(s):With the use of HEMT, the percentage of sputum-producing PwCF declined from 74% to 40%. Use of process mapping and paper tool identified barriers to collecting MSCx in our clinic. Workflows were established through recurrent PDSA cycles to identify actionable interventions (education of lab personnel, paper tool, EHR documentation), which has led to collection of 53% of eligible samples-up from 26.5% in 2020 and on Figure 1 : Certified medical assistant (CMA) flowchart for mycobacterial sputum culture (MSCx) collection to determine patient eligibility and order placement(Figure Presented) track for 65% MSCx collection for the year. The paper tool revealed that the greatest barrier to obtaining MSCx was lab cancellation. By November, the team will complete another PDSA cycle after further lab education with the aim of decreasing the number of MSCx that the lab erroneously rejects. Conclusion(s): Despite the reduction in sputum production after use of HEMT, approximately 40% of PwCF still produce sufficient sputum for MSCx monitoring. Applying effective CQI tools including process mapping, PDSA cycles, pareto charts, and run charts to implement an improved, standardized workflow can increase the rate of MSCx, which will aid in detection and management of NTM infections and inform the epidemiology of NTM in the era of HEMT Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

A broken heart? Unexplained cardiac ischaemia after intrauterine fetal death

Introduction: Cardiac disease is the leading cause of maternal death in the UK [1].We present the case of awoman with late intrauterine fetal death (IUFD) and intrapartum cardiac ischaemia. A family history of limb girdle muscular dystrophy (LGMD) may be relevant. Case Report: A 23-year-old nulliparous woman at 39 weeks of gestation presented with reduced fetal movements and IUFD was confirmed. She had no medical history, and despite two first degree relatives with LGMD, she was asymptomatic and had not been tested. Uterine contractions started and epidural analgesia was initiated. Shortly thereafter, the woman was found to be bradycardic at 35– 40 beats/min. All other observations were normal and she was asymptomatic with no detectable sensory or motor block. A 12 -lead ECG showed inferior T-wave inversion and serial troponins were markedly elevated. Caesarean section (CS) under general anaesthesia was performed at maternal request and was uneventful. Postpartum echocardiogram demonstrated a dilated left atrium, left ventricular akinesis and an ejection fraction of 45–50%. The next day the woman developed chest pain and desaturated. CTPA and CT coronary angiogram were normal. Oxygenation improved and other than sporadic chest heaviness she remained well and was discharged 4 days post CS. Cardiology follow-up did not occur due to a communication breakdown. Post-mortem of the fetus found no cause for the IUFD and no features of LGMD. Thewoman suffered a miscarriage four months after this but delivered a healthy baby at elective CS two years later. During the latter pregnancy cardiology input from a tertiary centrewas requested but did not occur due to the COVID-19 pandemic. An echocardiogram in the third trimester was normal and the woman has been well since. Discussion: Troponin rise is abnormal in pregnancy and requires investigation. IUFD in itself can lead to sequelae requiring a low threshold for investigation. The family history in this case is autosomal dominant type 1B LGMD, associated with cardiomyopathy and arrhythmias [2]. The woman has declined testing and the cause for the peripartum cardiac disease remains unknown. The recovery and recent uneventful pregnancy suggest Takotsubo’s cardiomyopathy or coronary vasospasm as additional possible diagnoses. This case also underlines the importance in sensitive communication in cases of IUFD to ensure women are investigated and not lost to follow-up.

P.155 When the patient would rather run for the hills than encounter the anaesthetist

Introduction: It is estimated that needle phobia is present in up to 10% of the population.1 We present the antenatal anaesthetic management of a pregnant woman initially refusing any blood tests or cannulation but ultimately requiring emergency caesarean delivery. Case Report: The high risk antenatal anaesthetic clinic became aware of a 26-year-old woman (G1P0) of 30 weeks’ gestation with extreme needle phobia. She had no medical history, the pregnancy was low risk and a midwifery-led delivery was planned. The woman declined blood tests in pregnancy. We met the woman with her community midwife. She stated she would run for the hills rather than have a cannula or would lock herself in the bathroom if the need arose. She was indifferent on hearing that a cannula is required for anaesthesia or that refusing one may be life-threatening. Her phobia possibly stemmed from a childhood experience but she had no recall of this. Although sceptical, the woman worked with us on a multifaceted plan. We emphasised the importance of her engagement. A referral for cognitive behavioural therapy failed due to the Covid-19 pandemic. Instead we suggested hypno-birthing techniques and mindfulness apps to manage anxiety. We taught applied tension although doubtful of its use as the woman did not suffer vasovagal symptoms with her phobia. We described graded exposure and gave resources, however she did not manage any of these. We devised distractions involving her partner and media, for example FaceTiming her mother and using headphones to listen to music or watch videos. We asked her to work on positive visualisation, focusing on gains, empowerment and rewards. Medical strategies were planned, specifically topical anaesthesia before cannulation and Entonox. In the event of an emergency caesarean we ruled out inhalational induction before cannulation. In turn, we agreed to be empathetic to her phobia and respect her choices. We agreed to minimise interventions but would not be influenced into deviating from safe protocol. Following initial consultation we remained in telephone contact. She remained unsure if she would consent. Hospital legal services were contacted for advice and a discussion with a QC was arranged. We were advised to create advance consent documents to avoid applying to the courts. After a few hesitant weeks the woman turned a corner and the community midwife reported improvement in mindset. We discussed the legal paperwork but the woman decided it was not necessary. An action plan was attached to her notes. Ultimately she required a cannula for antibiotics, induction of labour, epidural and caesarean delivery under epidural top-up. She was compliant and coped by using varying degrees of the above outlined strategies. On follow-up in the community the midwifery team reported a happy mother looking forward to future pregnancies and being able to keep her phobia under check. Discussion: This case demonstrates the importance of developing a management plan for the extreme needle phobic parturient. A pregnant woman’s greatest fear was controlled in order to facilitate safe delivery.

Viva la VOSCE?

BACKGROUND: The COVID-19 pandemic lockdown precluded face-to-face final Objective Structured Clinical Examinations (OSCE) in the UK. RESULTS: In response, we rapidly developed and then successfully implemented a novel Virtual Objective Structured Clinical Examination (VOSCE). CONCLUSIONS: In this article we both describe and reflect on our experience as well as discuss the implications for future undergraduate assessment as the situation evolves.

The COVID-19 Army Rapid Assessment Tool (CARAT) for Management of COVID-19 in the Deployed Setting

The COVID-19 pandemic poses unique challenges within the austere clinical setting, and the time between patient presentation and deterioration is a critical opportunity for intervention. In some cases, this may be a life-saving transfer to a higher level of care. US Central Command (CENTCOM) has provided valuable guidance for COVID-19 management in the operational environment,1 and has proposed the National Early Warning System 2 (NEWS2) scoring tool as a useful adjunct to gauging illness severity. NEWS2, however, does not consider co-morbidities, such as diabetes or chronic cardiac disease, which could worsen the clinical course of SARS-CoV-2 patients. Thus, NEWS2 fails to address such factors during the risk stratification of patients to a higher level of care. To address this concern, June 2020, 3rd Medical Brigade, Operation Spartan Shield (OSS) developed the COVID-19 Army Rapid Assessment Tool (CARAT) with inputs from clinicians and researchers (The Team). The CARAT is a clinical scoring system, modified from the NEWS2, which combines the effects of co-morbid disease with the current physiological condition of a COVID-19 patient. The Team obtained clinical data for 105 patients from the CENTCOM area of responsibility (AOR), who presented to a military treatment facility (MTF) symptomatic for, and testing positive for SARS-CoV-2, during the time period of June to mid-August 2020. Each patient was retrospectively assigned a CARAT score based on his or her initial presentation. Preliminary review of data suggested a CARAT value of 4 or greater was an indicator for risk of further deterioration. Patients were then grouped into two categories: patients who received transfer to a higher level of care, versus "stay-in-place" supportive care. Results showed that 100% of patients with a score >=4 had been transferred to a higher echelon of care, compared to 2% of patients with scores less than 4. A Fisher's exact test demonstrated a statistically significant difference between these two groups (p is less than 0.001). Interestingly, when compared with the NEWS2 score, the CARAT identified 9 individuals for transfer to a higher level of care, of whom only one patient was identified by the NEWS2, clearly underscoring the significance of CARAT despite small sample size. We therefore recommend that CARAT be further validated in predicting disease severity and need for emergent evacuation in larger patient settings.