Assessing the stability and sporicidal efficacy of oxidizing disinfectants.

BACKGROUND: The role of the healthcare environment in the transmission of clinical pathogens is well established. EN 17126:2018 was developed to address the need for regulated sporicidal product testing and includes a realistic medical soil to enable validation of products that claim combined cleaning and disinfection efficacy. AIM: To investigate the chemical stability and sporicidal efficacy of oxidizing disinfectant products in the presence of simulated clean and medical dirty conditions. METHODS: Disinfectant stability and sporicidal efficacy were evaluated in like-for-like ratios of soil:product. Disinfectants were exposed to simulated test soils and free chlorine, chlorine dioxide or peracetic acid concentrations were measured using standard colorimetric methods. Efficacy of disinfectants against C. difficile R027 endospores was assessed as per EN 17126:2018. Comparisons of performance between clean and medical dirty conditions were performed using one-way analysis of variance. Correlation analysis was performed using Pearson product-moment correlation. FINDINGS: Performance of chlorine-releasing agents (sodium dichloroisocyanurate, chlorine dioxide and hypochlorous acid) was concentration dependent, with 1000 ppm chlorine showing reduced stability and efficacy in dirty conditions. By contrast, peracetic acid product demonstrated stability and consistently achieved efficacy in dirty conditions. CONCLUSION: These results have implications for clinical practice, as ineffective environmental decontamination may increase the risk of transmission of pathogens that can cause healthcare-associated infections.

What the COVID pandemic taught us about the management of pediatric minor trauma.

The COVID-19 pandemic necessitated a change in our practice in the management of pediatric soft-tissue injuries. Patients were managed conservatively whenever possible. Our aim in this study was to see whether this more conservative approach adversely affected clinical, and patient-reported outcomes, including scarring. A prospective record of children presenting to the plastic surgery "Early Bird" clinic for pediatric trauma between 01.04.2020 and 30.06.2020 was kept. Electronic patient records were reviewed. An outpatient telephone clinic was scheduled for all patients. Parents were asked about complications and what they thought about the scar and to rate it as either: "poor," "satisfactory," "good," or "excellent." There were 240 patients, including 136 (57%) males and 104 (43%) females. The most frequent type of injury was a facial laceration in 123 patients (51.3%), followed by hand lacerations in 43 (17.9%), fingertip injuries in 31 (12.9%), and others. Ninety out of 240 (37.5%) were offered surgery. Follow-up times ranged from 17 to 20 months. Most parents (86.2%) were happy with the scarring and reported it as "good" or "excellent." The proportion rating the scar "excellent" or "good" was similar in the non-operated cohort (i.e., 85.5%) versus the operated cohort (88.5%) (p-value 0.16). The overall complication rate of patients seen during this time was 5.9%; 7.4% in the conservatively managed and 4.9% of those who went to the theater. Despite managing more wounds, including some dog bites, conservatively, patients and parents reported low complication rates and high levels of satisfaction with the final scarring.

Ammonium fluoride's analogy to ice: Possibilities and limitations.

Ammonium fluoride, NH4F, is often seen as an analog to ice, with several of its solid phases closely resembling known ice phases. While its ionic and hydrogen-ordered nature puts topological constraints on the ice-like network structures it can form, it is not clear what consequences these constraints have for NH4F compound formation and evolution. Here, we explore computationally the reach and eventual limits of the ice analogy for ammonium fluoride. By combining data mining of known and hypothetical ice networks with crystal structure prediction and density functional calculations, we explore the high-pressure phase diagram of NH4F and host-guest compounds of its hydrides. Pure NH4F departs from ice-like behavior above 80 GPa with the emergence of close-packed ionic structures. The predicted stability of NH4F hydrides shows that NH4F can act as a host to small guest species, albeit in a topologically severely constraint configuration space. Finally, we explore the binary NH3-HF chemical space, where we find candidate structures for several unsolved polyfluoride phases; among them is the chemical analog to H2O2 dihydrate.

On a new nitrogen sX hydrate from ice XVII.

Recently, a new gas hydrate structure has been discovered. This structure, sX, is unique in a sense that it is so far the only gas hydrate with chiral channels. It is formed by hydrogen-water or carbon dioxide-water mixtures at pressures above 0.300 GPa, and it has been shown that it is the only clathrate hydrate that is refillable with hydrogen. This property makes it a possible storage material for gases. By analyzing neutron diffraction data and calculations based on density-functional theory, we show that sX is also refillable with nitrogen; the guest:host ratio will be shown to be 2.6(3). Furthermore, we report sX's decomposition behavior and give evidence that it undergoes several transitions into the exotic hydrates sH and sIII that have not been observed at these pressure and temperature conditions-before forming the stable nitrogen hydrate sII.

Increased recurrence in Scarf osteotomy for mild & moderate hallux valgus with Meary's line disruption.

BACKGROUND: Scarf osteotomy for hallux valgus is a successful procedure. Neverthless recurrence of deformity is reported as 5-8%. First ray instability is a recognised risk factor for recurrence. We investigate whether a radiographic marker such as Meary's line can be used to predict recurrence. This paper aims to test the null hypothesis that there is no difference in recurrence for mild and moderate hallux valgus treated with Scarf osteotomy in the presence of a disrupted Meary's line compared to an intact line. METHODS: At a minimum of 3 months follow up we retrospectively analysed radiographs, theatre and clinic notes of 74 (n=74) consecutive patients treated with Scarf osteotomy for mild and moderate hallux valgus at a single centre. The patients were divided into Group A (n=30) - patients who on pre-operative weight bearing radiographs had a disrupted Meary's line, and Group B (n=44) - those with a normal Meary's line on pre-operative weight bearing radiographs. RESULTS: Our results demonstrate statistically significant five times higher odds of recurrence in Group A compared to Group B with an odds ratio of 5.2 p=0.006 [95% CI 1.6-17]. On this basis we reject the Null hypothesis. CONCLUSION: In this paper, we link a disrupted Meary's line with risk of recurrence of deformity. We demonstrate that, when Scarf osteotomy is used to correct mild and moderate hallux valgus in the presence of a broken Meary's line, the odds of recurrence as compared to the same procedure being performed with an intact line are 5.2 times higher. Alternative corrective techniques such as the Lapidus procedure warrant further investigation for the treatment of mild and moderate hallux valgus in the presence of Meary's line disruption.

The role of joint engagement in the development of language in a community-derived sample of slow-to-talk children.

We explored whether supported (SJE) or coordinated joint engagement (CJE) between mothers recruited from the community and their 24-month-old children who were slow-to-talk at 18 months old were associated with child language scores at ages 24, 36, and 48 months (n = 197). We further explored whether SJE or CJE modified the concurrent positive associations between maternal responsive behaviours and language scores. Previous research has shown that SJE, maternal expansions, imitations, and responsive questions were associated with better language scores. Our main finding was that SJE but not CJE was consistently positively associated with 24- and 36-month-old expressive and receptive language scores, but not with 48-month-old language scores. SJE modified how expansions and imitations, but not responsive questions, were associated with language scores; the associations were evident in all but the highest levels of SJE. Further research is necessary to test these findings in other samples before clinical recommendations can be made.

Control of carbapenemase-producing Enterobacteriaceae outbreaks in acute settings: an evidence review.

BACKGROUND: In recent years, infections with carbapenemase-producing Enterobacteriaceae (CPE) have been increasing globally and present a major public health challenge. AIM: To review the international literature: (i) to describe CPE outbreaks in acute hospital settings globally; and (ii) to identify the control measures used during these outbreaks and report on their effectiveness. METHODS: A systematic search of MEDLINE and EMBASE databases, abstract lists for key conferences and reference lists of key reviews was undertaken, and information on unpublished outbreaks was sought for 2000-2015. Where relevant, risk of bias was assessed using the Newcastle-Ottawa scale. A narrative synthesis of the evidence was conducted. FINDINGS: Ninety-eight outbreaks were eligible. These occurred worldwide, with 53 reports from Europe. The number of cases (CPE infection or colonization) involved in outbreaks varied widely, from two to 803. In the vast majority of outbreaks, multi-component infection control measures were used, commonly including: patient screening; contact precautions (e.g. gowns, gloves); handwashing interventions; staff education or monitoring; enhanced environmental cleaning/decontamination; cohorting of patients and/or staff; and patient isolation. Seven studies were identified as providing the best-available evidence on the effectiveness of control measures. These demonstrated that CPE outbreaks can be controlled successfully using a range of appropriate, commonly used, infection control measures. However, risk of bias was considered relatively high for these studies. CONCLUSION: The findings indicate that CPE outbreaks can be controlled using combinations of existing measures. However, the quality of the evidence base is weak and further high-quality research is needed, particularly on the effectiveness of individual infection control measures.

Profiles of language development in pre-school children: a longitudinal latent class analysis of data from the Early Language in Victoria Study.

BACKGROUND: Pre-school language impairment is common and greatly reduces educational performance. Population attempts to identify children who would benefit from appropriately timed intervention might be improved by greater knowledge about the typical profiles of language development. Specifically, this could be used to help with the early identification of children who will be impaired on school entry. METHODS: This study applied longitudinal latent class analysis to assessments at 8, 12, 24, 36 and 48 months on 1113 children from a population-based study, in order to identify classes exhibiting distinct communicative developmental profiles. RESULTS: Five substantive classes were identified: Typical, i.e. development in the typical range at each age; Precocious (late), i.e. typical development in infancy followed by high probabilities of precocity from 24 months onwards; Impaired (early), i.e. high probabilities of impairment up to 12 months followed by typical language development thereafter; Impaired (late), i.e. typical development in infancy but impairment from 24 months onwards; Precocious (early), i.e. high probabilities of precocity in early life followed by typical language by 48 months. The entropy statistic (0.84) suggested classes were fairly well defined, although there was a non-trivial degree of uncertainty in classification of children. That half of the Impaired (late) class was expected to have typical language at 4 years and 6% of the numerically large Typical class was expected to be impaired at 4 years illustrates this. Characteristics indicative of social advantage were more commonly found in the classes with improving profiles. CONCLUSIONS: Developmental profiles show that some pre-schoolers' language is characterized by periods of accelerated development, slow development and catch-up growth. Given the uncertainty in classifying children into these profiles, use of this knowledge for identifying children who will be impaired on school entry is not straightforward. The findings do, however, indicate greater need for language enrichment programmes among disadvantaged children.

Epinephrine induced leucocytosis in a non-infective exacerbation of asthma.

In life-threatening cases of Acute Asthma the administration of epinephrine may be given as part of the initial management by paramedics. Concurrent infection is a frequent precipitant of an asthma exacerbation and consequently a leucocytosis is often found in such a situation. This case illustrates that marked leucocytosis can occur without an underlying infective process following epinphrine use.

Effect of fat supplementation and wheat pasture maturity on forage intake and digestion characteristics of steers grazing wheat pasture.

Nine ruminally cannulated mixed-breed steers were used in a split-plot design to evaluate effects of fat supplementation and forage maturity on intake, digestibility, and ruminal fermentation. Treatment was the main plot, and stage of forage maturity was the subplot. Treatments were supplements containing mineral pack (M) offered at 114 g/d; M plus fiber as soybean hulls-wheat middlings (MF) offered at 0.50% BW; and MF plus tallow (MFT) offered at 0.625% BW. Stages of wheat maturity were mid-March (MAR) and early April (APR). Steers grazed in a single wheat pasture with supplements offered individually at 0700 h daily. There were supplement type x forage maturity interactions (P < 0.05) for forage OM, CP, and NDF intakes. During MAR, forage OM, CP, and NDF intakes were not affected (P > 0.05) by supplementation. During APR, forage OM, CP, and NDF intakes differed (MF = M > MFT, P < 0.05). There was also supplement type x forage maturity interaction (P = 0.04) for forage OM digestibility. The OM digestibility differed during MAR (M = MF > MFT, P < 0.05) and during APR (MF > M > MFT, P < 0.05). Crude protein digestibility was affected by supplement type (M > MF > MFT, P < 0.05) and stage of forage maturity (MAR > APR, P < 0.01). Rates of DM and NDF ruminal disappearance were not affected (P > 0.05) by supplement or forage maturity. Supplementation increased (P < 0.05) ruminal propionate concentration (19.7, 21.4, and 25.1 +/- 0.49 mol/100 mol for M, MF, and MFT, respectively). Tallow can be used in supplements for cattle grazing wheat pasture to increase energy intake without negatively affecting forage intake or ruminal fermentation, particularly if used in the early stage of wheat maturity.

Transport policy and health inequalities: a health impact assessment of Edinburgh's transport policy.

Health impact assessment (HIA) can be used to examine the relationships between inequalities and health. This HIA of Edinburgh's transport policy demonstrates how HIA can examine how different transport policies can affect different population groupings to varying degrees. In this case, Edinburgh's economy is based on tourism, financial services and Government bodies. These need a good transport infrastructure, which maintains a vibrant city centre. A transport policy that promotes walking, cycling and public transport supports this and is also good for health. The HIA suggested that greater spend on public transport and supporting sustainable modes of transport was beneficial to health, and offered scope to reduce inequalities. This message was understood by the City Council and influenced the development of the city's transport and land-use strategies. The paper discusses how HIA can influence public policy.

Developing principles for health impact assessment.

BACKGROUND: Policies and practice in many sectors affect health. Health impact assessment (HIA) is a way to predict these health impacts, in order to recommend improvements in policies to improve health. There has been debate about appropriate methods for this work. The Scottish Executive funded the Scottish Needs Assessment Programme to conduct two pilot HIAs and from these to develop guidance on HIA. METHODS: Case study 1 compared three possible future scenarios for developing transport in Edinburgh, based on funding levels. It used a literature review, analysis of local data and the knowledge and opinions of key informants. Impacts borne by different population groups.were compared using grids. Case study 2 assessed the health impacts of housing investment in a disadvantaged part of Edinburgh, using published literature, focus groups with community groups and interviews with professionals. RESULTS: Disadvantaged communities bore more detrimental effects from the low transport investment scenario, in the areas of: accidents; pollution; access to amenities, jobs and social contacts; physical activity; and impacts on community networks. The housing investment had greatest impact on residents' mental health, by reducing overcrowding, noise pollution, stigma and fear of crime. CONCLUSION: Although there is no single 'blueprint' for HIA that will be appropriate for all circumstances, key principles to inform future HIA were defined. HIA should be systematic; involve decision-makers and affected communities; take into account local factors; use evidence and methods appropriate to the impacts identified and the importance and scope of the policy; and make practical recommendations.

Achieving better health through health impact assessment.

OBJECTIVE: Health Impact Assessment (HIA) provides a method of predicting the health impacts of policies and activities, in order to recommend changes that would improve health. We piloted approaches to health impact assessment and made recommendations for its use as part of the planning and policy making processes in Scotland. DESIGN: Two Health Impact Assessments were done as case studies. One assessed the City of Edinburgh Council's Local Transport Strategy. The other assessed North Edinburgh Area Renewal Housing Strategy. Both were done in partnership with the professionals responsible for developing the strategies. RESULTS: The main health impacts of transport strategy were in the areas of: accidents, pollution, access to amenities, jobs and social contacts, opportunities for physical activity in walking and cycling and impacts on community networks. Overall, housing strategy impacted most on mental health, especially stress and depression. The recommendations of both HIAs are being used in developing the strategies further. CONCLUSIONS: Health impact assessment can make explicit the health consequences of decisions in different sectors, including impacts on health inequalities. Health Impact Assessment should be done as part of community planning and other partnership activities. Consideration of health impacts should become part of routine decision making.

Mutations of Arabidopsis thaliana that transform leaves into cotyledons.

We describe mutations of three genes in Arabidopsis thaliana-extra cotyledon1 (xtc1), extra cotyledon2 (xtc2), and altered meristem programming1 (amp1)-that transform leaves into cotyledons. In all three of these mutations, this transformation is associated with a change in the timing of events in embryogenesis. xtc1 and xtc2 delay the morphogenesis of the embryo proper at the globular-to-heart transition but permit the shoot apex to develop to an unusually advanced stage late in embryogenesis. Both mutations have little or no effect on seed maturation and do not affect the viability of the shoot or the rate of leaf initiation after germination. amp1 perturbs the pattern of cell division at an early globular stage, dramatically increases the size of the shoot apex and, like xtc1 and xtc2, produces enlarged leaf primordia during seed development. These unusual phenotypes suggest that these genes play important regulatory roles in embryogenesis and demonstrate that the development of the shoot apical meristem and the development of the embryo proper are regulated by independent processes that must be temporally coordinated to ensure normal organ identity.

Energy metabolism during CAPD: a controlled study.

Abnormalities of energy metabolism may exacerbate the high prevalence of protein-calorie malnutrition and inadequate calorie intake in continuous ambulatory peritoneal dialysis (CAPD) patients, leading to further nutritional depletion. In a controlled study, using indirect calorimetry, we evaluated oxygen consumption (VO2), CO2 production, resting energy expenditure, and respiratory exchange ratio (RER) in 12 CAPD patients at rest and during a standard CAPD exchange and in 11 healthy nonuremic control patients. In addition, we investigated the influence of nutritional status and dialysis adequacy on energy metabolism in the CAPD group. There was no significant difference in resting energy parameters between the two groups. Unlike the control group, blood glucose and RER were maintained during prolonged fasting in the CAPD patients. This observation indicates that all the absorbed glucose was used as a metabolic fuel preventing fat oxidation. There was no significant relationship between energy expenditure and dialysis adequacy. There was no significant relationship between nutritional state (including energy intake) and energy expenditure despite evidence of malnutrition in 41% of the patients. If maintenance of "normal levels" of energy expenditure occurs in dialysis patients with suboptimal calorie intake (especially with evidence of protein-calorie malnutrition), this inability to conserve energy may act as an additional risk factor for ongoing malnutrition.

Diagnosis of polyhydramnios in early gestation: indication for prenatal diagnosis?

Previously published reports have indicated that idiopathic polyhydramnios may be associated with trisomies 18 and 21 and that chromosomal analysis is indicated. Furthermore, the natural history and fetal outcome of polyhydramnios diagnosed in early gestation have not been well delineated. We identified 138 pregnancies with polyhydramnios prior to 26 weeks' gestation. Of 131 complete cases, 21 were diagnosed as severe, 18 as moderate, and 92 as mild polyhydramnios. Congenital abnormalities were noted in 18 of 21 severe cases (86 per cent). Two of the remaining three cases were twin-to-twin transfusion. Thirteen of 18 cases with moderate polyhydramnios (72 per cent) were associated with anomalies; six of the remaining cases were twin-to-twin transfusion. Sixteen of 92 cases of mild polyhydramnios (17 per cent) were associated with congenital abnormalities. In 69 of 76 cases of mild hydramnios not associated with anomalies (91 per cent), the hydramnios resolved prior to delivery. Only 2 of 16 (13 per cent) associated with anomalies resolved. In 4 of 5 cases (80 per cent) with moderate hydramnios and no anomalies, the amniotic fluid volume was normal on subsequent ultrasound. No case of moderate polyhydramnios associated with anomalies or maternal conditions nor any case of severe polyhydramnios resolved. There were seven cases of chromosomal abnormalities in this series; all were associated with sonographic findings in addition to the presence of polyhydramnios. On the basis of these data, we doubt the benefit of amniocentesis following the early diagnosis of idiopathic polyhydramnios in the absence of other ultrasound findings.

Assessing clinical significance of apnea exceeding fifteen seconds with event recording.

Using event recording, we determined how often apnea exceeding 15 seconds in duration was associated with bradycardia and how often patients with apnea resumed breathing spontaneously. Of 1306 documented apnea events exceeding 15 seconds (54 patients), 926 lasted 16 to 20 seconds, 262 lasted 21 to 25 seconds, and 118 exceeded 25 seconds. Of these episodes, 75.3% were isolated and 14.9% were associated with pulse deceleration, 4.4% with irregular transthoracic impedance, and 5.4% with bradycardia. Event recording provided data supporting discontinuation of monitoring in 50 of 54 patients: 36 spontaneously resumed breathing before the auditory alarm and 14 had a decreased incidence of apnea with maturation. Follow-up of 51 patients (three not located) showed that none had subsequent apparent life-threatening events or sudden infant death syndrome. Our results in these older infants and children (median age 6.7 months) provide substantiation that such patients with apnea of less than 20 seconds without bradycardia do not require continued monitoring. Further, these data suggest that in selected older infants, longer isolated apnea may be well tolerated; however, hemoglobin saturation during sleep and the ability to resume breathing after the apnea alarm delay is prolonged should be verified. Our patient population had a wide age range and heterogeneity of diagnoses, and was typically free of symptoms, so these results should not be extrapolated uncritically to premature infants, infants with chronic lung disease, and patients with symptomatic apnea.

Comparison of transthoracic impedance/heart rate monitoring and pulse oximetry for patients using diaphragm pacemakers.

Patients using diaphragm pacemakers have several respiratory-related problems placing them at high risk for death during sleep, including central hypoventilation, abnormal arousal responses, upper airway and/or tracheostomy obstruction, and, in the case of high quadriplegia, lack of motor response to airway obstruction. The recent death from airway obstruction of a patient using diaphragm pacemakers prompted us to re-evaluate both the need for home monitoring and the type of monitor to prescribe. We compared the performance of a transthoracic impedance/heart rate (TI/HR) monitor with that of a pulse oximeter in six patients with central hypoventilation syndrome whose treatment included diaphragm pacing. Polygraphic recordings of airflow, ECG, SaO2, transthoracic impedance, heart rate, and breath detection were obtained during brief tracheostomy occlusion during patient sleep. Although none of 13 occlusions was detected by the TI/HR monitor, the pulse oximeter identified 13 of 13 occlusions. Three reasons for TI/HR monitor failure included 1) the breath detection circuit consistently registered a breath with each obstructed, paced diaphragmatic contraction; 2) bradycardia did not occur during any airway occlusion; and 3) pacemaker stimuli were misinterpreted as additional heart beats, increasing apparent heart rate. Thus, pulse oximetry, but not TI/HR monitoring, can detect life-threatening airway obstruction in children using diaphragm pacemakers.

Assessing validity of infant monitor alarms with event recording.

We evaluated the performance of an event recorder system in a large, consecutive series of referred monitored patients to determine the relative incidence of true apnea and true bradycardia, false alarms, and alarms for movement or a loose lead. In addition, we developed an event classification system based on the reason for the event being recorded. The recorder stored transthoracic impedance and electrocardiogram signals on a floppy disk before, during, and after each monitor alarm. These events on 302 disks from 83 patients were analyzed and classified as true, false, or movement-loose lead. Of 14,131 events, only 8% were caused by apnea or bradycardia (true events). Of true events, 70% were triggered by apnea and 30% by bradycardia. These true events occurred in 48% of the patients. False alarms constituted 23%, and movement-loose lead 69%, of all events. Even when movement-loose lead events were excluded, nearly three of four events were found to be false. Event recording proved helpful clinically, allowing discontinuation of the monitor in 49% of patients, modification of monitor alarm settings, or reassurance and counseling for parents.