Crimean-Congo Hemorrhagic Fever Virus Seroprevalence in Human and Livestock Populations, Northern Tanzania.

We conducted a cross-sectional study of Crimean-Congo hemorrhagic fever virus (CCHFV) in northern Tanzania. CCHFV seroprevalence in humans and ruminant livestock was high, as were spatial heterogeneity levels. CCHFV could represent an unrecognized human health risk in this region and should be included as a differential diagnosis for febrile illness.

ACCORD (ACcurate COnsensus Reporting Document): A reporting guideline for consensus methods in biomedicine developed via a modified Delphi.

BACKGROUND: In biomedical research, it is often desirable to seek consensus among individuals who have differing perspectives and experience. This is important when evidence is emerging, inconsistent, limited, or absent. Even when research evidence is abundant, clinical recommendations, policy decisions, and priority-setting may still require agreement from multiple, sometimes ideologically opposed parties. Despite their prominence and influence on key decisions, consensus methods are often poorly reported. Our aim was to develop the first reporting guideline dedicated to and applicable to all consensus methods used in biomedical research regardless of the objective of the consensus process, called ACCORD (ACcurate COnsensus Reporting Document). METHODS AND FINDINGS: We followed methodology recommended by the EQUATOR Network for the development of reporting guidelines: a systematic review was followed by a Delphi process and meetings to finalize the ACCORD checklist. The preliminary checklist was drawn from the systematic review of existing literature on the quality of reporting of consensus methods and suggestions from the Steering Committee. A Delphi panel (n = 72) was recruited with representation from 6 continents and a broad range of experience, including clinical, research, policy, and patient perspectives. The 3 rounds of the Delphi process were completed by 58, 54, and 51 panelists. The preliminary checklist of 56 items was refined to a final checklist of 35 items relating to the article title (n = 1), introduction (n = 3), methods (n = 21), results (n = 5), discussion (n = 2), and other information (n = 3). CONCLUSIONS: The ACCORD checklist is the first reporting guideline applicable to all consensus-based studies. It will support authors in writing accurate, detailed manuscripts, thereby improving the completeness and transparency of reporting and providing readers with clarity regarding the methods used to reach agreement. Furthermore, the checklist will make the rigor of the consensus methods used to guide the recommendations clear for readers. Reporting consensus studies with greater clarity and transparency may enhance trust in the recommendations made by consensus panels.

Noninvasive diagnosis of secondary infections in COVID-19 by sequencing of plasma microbial cell-free DNA.

Secondary infection (SI) diagnosis in severe COVID-19 remains challenging. We correlated metagenomic sequencing of plasma microbial cell-free DNA (mcfDNA-Seq) with clinical SI assessment, immune response, and outcomes. We classified 42 COVID-19 inpatients as microbiologically confirmed-SI (Micro-SI, n = 8), clinically diagnosed-SI (Clinical-SI, n = 13, i.e., empiric antimicrobials), or no-clinical-suspicion-for-SI (No-Suspected-SI, n = 21). McfDNA-Seq was successful in 73% of samples. McfDNA detection was higher in Micro-SI (94%) compared to Clinical-SI (57%, p = 0.03), and unexpectedly high in No-Suspected-SI (83%), similar to Micro-SI. We detected culture-concordant mcfDNA species in 81% of Micro-SI samples. McfDNA correlated with LRT 16S rRNA bacterial burden (r = 0.74, p = 0.02), and biomarkers (white blood cell count, IL-6, IL-8, SPD, all p < 0.05). McfDNA levels were predictive of worse 90-day survival (hazard ratio 1.30 [1.02-1.64] for each log10 mcfDNA, p = 0.03). High mcfDNA levels in COVID-19 patients without clinical SI suspicion may suggest SI under-diagnosis. McfDNA-Seq offers a non-invasive diagnostic tool for pathogen identification, with prognostic value on clinical outcomes.

Development and Narrow Validation of Computer Vision Approach to Facilitate Assessment of Change in Pigmented Cutaneous Lesions.

The documentation of the change in the number and appearance of pigmented cutaneous lesions over time is critical to the early detection of skin cancers and may provide preliminary signals of efficacy in early-phase therapeutic prevention trials for melanoma. Despite substantial progress in computer-aided diagnosis of melanoma, automated methods to assess the evolution of lesions are relatively undeveloped. This report describes the development and narrow validation of mathematical algorithms to register nevi between sequential digital photographs of large areas of skin and to align images for improved detection and quantification of changes. Serial posterior truncal photographs from a pre-existing database were processed and analyzed by the software, and the results were evaluated by a panel of clinicians using a separate Extensible Markup Language‒based application. The software had a high sensitivity for the detection of cutaneous lesions as small as 2 mm. The software registered lesions accurately, with occasional errors at the edges of the images. In one pilot study with 17 patients, the use of the software enabled clinicians to identify new and/or enlarged lesions in 3‒11 additional patients versus the unregistered images. Automated quantification of size change performed similarly to that of human raters. These results support the further development and broader validation of this technique.

Inter-rater reliability and prognostic value of baseline Radiographic Assessment of Lung Edema (RALE) scores in observational cohort studies of inpatients with COVID-19.

OBJECTIVES: To reliably quantify the radiographic severity of COVID-19 pneumonia with the Radiographic Assessment of Lung Edema (RALE) score on clinical chest X-rays among inpatients and examine the prognostic value of baseline RALE scores on COVID-19 clinical outcomes. SETTING: Hospitalised patients with COVID-19 in dedicated wards and intensive care units from two different hospital systems. PARTICIPANTS: 425 patients with COVID-19 in a discovery data set and 415 patients in a validation data set. PRIMARY AND SECONDARY OUTCOMES: We measured inter-rater reliability for RALE score annotations by different reviewers and examined for associations of consensus RALE scores with the level of respiratory support, demographics, physiologic variables, applied therapies, plasma host-response biomarkers, SARS-CoV-2 RNA load and clinical outcomes. RESULTS: Inter-rater agreement for RALE scores improved from fair to excellent following reviewer training and feedback (intraclass correlation coefficient of 0.85 vs 0.93, respectively). In the discovery cohort, the required level of respiratory support at the time of CXR acquisition (supplemental oxygen or non-invasive ventilation (n=178); invasive-mechanical ventilation (n=234), extracorporeal membrane oxygenation (n=13)) was significantly associated with RALE scores (median (IQR): 20.0 (14.1-26.7), 26.0 (20.5-34.0) and 44.5 (34.5-48.0), respectively, p<0.0001). Among invasively ventilated patients, RALE scores were significantly associated with worse respiratory mechanics (plateau and driving pressure) and gas exchange metrics (PaO2/FiO2 and ventilatory ratio), as well as higher plasma levels of IL-6, soluble receptor of advanced glycation end-products and soluble tumour necrosis factor receptor 1 (p<0.05). RALE scores were independently associated with 90-day survival in a multivariate Cox proportional hazards model (adjusted HR 1.04 (1.02-1.07), p=0.002). We replicated the significant associations of RALE scores with baseline disease severity and mortality in the independent validation data set. CONCLUSIONS: With a reproducible method to measure radiographic severity in COVID-19, we found significant associations with clinical and physiologic severity, host inflammation and clinical outcomes. The incorporation of radiographic severity assessments in clinical decision-making may provide important guidance for prognostication and treatment allocation in COVID-19.

Characterizing the evolving SARS-CoV-2 seroprevalence in urban and rural Malawi between February 2021 and April 2022: A population-based cohort study.

OBJECTIVES: This study aimed to investigate the changing SARS-CoV-2 seroprevalence and associated health and sociodemographic factors in Malawi between February 2021 and April 2022. METHODS: In total, four 3-monthly serosurveys were conducted within a longitudinal population-based cohort in rural Karonga District and urban Lilongwe, testing for SARS-CoV-2 S1 immunoglobulin (Ig)G antibodies using an enzyme-linked immunosorbent assay. Population seroprevalence was estimated in all and unvaccinated participants. Bayesian mixed-effects logistic models estimated the odds of seropositivity in the first survey, and of seroconversion between surveys, adjusting for age, sex, occupation, location, and assay sensitivity/specificity. RESULTS: Of the 2005 participants (Karonga, n = 1005; Lilongwe, n = 1000), 55.8% were female and median age was 22.7 years. Between Surveys (SVY) 1 and 4, population-weighted SARS-CoV-2 seroprevalence increased from 26.3% to 89.2% and 46.4% to 93.9% in Karonga and Lilongwe, respectively. At SVY4, seroprevalence did not differ by COVID-19 vaccination status in adults, except for those aged 30+ years in Karonga (unvaccinated: 87.4%, 95% credible interval 79.3-93.0%; two doses: 98.1%, 94.8-99.5%). Location and age were associated with seroconversion risk. Individuals with hybrid immunity had higher SARS-CoV-2 seropositivity and antibody titers, than those infected. CONCLUSION: High SARS-CoV-2 seroprevalence combined with low morbidity and mortality indicate that universal vaccination is unnecessary at this stage of the pandemic, supporting change in national policy to target at-risk groups.

Existing guidance on reporting of consensus methodology: a systematic review to inform ACCORD guideline development.

OBJECTIVE: To identify evidence on the reporting quality of consensus methodology and to select potential checklist items for the ACcurate COnsensus Reporting Document (ACCORD) project to develop a consensus reporting guideline. DESIGN: Systematic review. DATA SOURCES: Embase, MEDLINE, Web of Science, PubMed, Cochrane Library, Emcare, Academic Search Premier and PsycINFO from inception until 7 January 2022. ELIGIBILITY CRITERIA: Studies, reviews and published guidance addressing the reporting quality of consensus methodology for improvement of health outcomes in biomedicine or clinical practice. Reports of studies using or describing consensus methods but not commenting on their reporting quality were excluded. No language restrictions were applied. DATA EXTRACTION AND SYNTHESIS: Screening and data extraction of eligible studies were carried out independently by two authors. Reporting quality items addressed by the studies were synthesised narratively. RESULTS: Eighteen studies were included: five systematic reviews, four narrative reviews, three research papers, three conference abstracts, two research guidance papers and one protocol. The majority of studies indicated that the quality of reporting of consensus methodology could be improved. Commonly addressed items were: consensus panel composition; definition of consensus and the threshold for achieving consensus. Items least addressed were: public patient involvement (PPI); the role of the steering committee, chair, cochair; conflict of interest of panellists and funding. Data extracted from included studies revealed additional items that were not captured in the data extraction form such as justification of deviation from the protocol or incentives to encourage panellist response. CONCLUSION: The results of this systematic review confirmed the need for a reporting checklist for consensus methodology and provided a range of potential checklist items to report. The next step in the ACCORD project builds on this systematic review and focuses on reaching consensus on these items to develop the reporting guideline. PROTOCOL REGISTRATION: https://osf.io/2rzm9.

Development of anti-Crimean-Congo hemorrhagic fever virus Gc and NP-specific ELISA for detection of antibodies in domestic animal sera.

Crimean-Congo hemorrhagic fever (CCHF) is a priority emerging disease. CCHF, caused by the CCHF virus (CCHFV), can lead to hemorrhagic fever in humans with severe cases often having fatal outcomes. CCHFV is maintained within a tick-vertebrate-tick cycle, which includes domestic animals. Domestic animals infected with CCHFV do not show clinical signs of the disease and the presence of antibodies in the serum can provide evidence of their exposure to the virus. Current serological tests are specific to either one CCHFV antigen or the whole virus antigen. Here, we present the development of two in-house ELISAs for the detection of serum IgG that is specific for two different CCHFV antigens: glycoprotein Gc (CCHFV Gc) and nucleoprotein (CCHFV NP). We demonstrate that these two assays were able to detect anti-CCHFV Gc-specific and anti-CCHFV NP-specific IgG in sheep from endemic CCHFV areas with high specificity, providing new insight into the heterogeneity of the immune response induced by natural infection with CCHFV in domestic animals.

SARS-CoV-2 Evolution and Patient Immunological History Shape the Breadth and Potency of Antibody-Mediated Immunity.

Since the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), humans have been exposed to distinct SARS-CoV-2 antigens, either by infection with different variants, and/or vaccination. Population immunity is thus highly heterogeneous, but the impact of such heterogeneity on the effectiveness and breadth of the antibody-mediated response is unclear. We measured antibody-mediated neutralization responses against SARS-CoV-2Wuhan, SARS-CoV-2α, SARS-CoV-2δ, and SARS-CoV-2ο pseudoviruses using sera from patients with distinct immunological histories, including naive, vaccinated, infected with SARS-CoV-2Wuhan, SARS-CoV-2α, or SARS-CoV-2δ, and vaccinated/infected individuals. We show that the breadth and potency of the antibody-mediated response is influenced by the number, the variant, and the nature (infection or vaccination) of exposures, and that individuals with mixed immunity acquired by vaccination and natural exposure exhibit the broadest and most potent responses. Our results suggest that the interplay between host immunity and SARS-CoV-2 evolution will shape the antigenicity and subsequent transmission dynamics of SARS-CoV-2, with important implications for future vaccine design.

Neutralizing antibodies provide protection against viruses and are generated because of vaccination or prior infections. The main target of anti-SARS-CoV-2 neutralizing antibodies is a protein called spike, which decorates the viral particle and mediates viral entry into cells. As SARS-CoV-2 evolves, mutations accumulate in the spike protein, allowing the virus to escape antibody-mediated immunity and decreasing vaccine effectiveness. Multiple SARS-CoV-2 variants have appeared since the start of the COVID-19 pandemic, causing various waves of infection through the population and infecting­in some cases­people that had been previously infected or vaccinated. Because the antibody response is highly specific, individuals infected with different variants are likely to have different repertoires of neutralizing antibodies. We studied the breadth and potency of the antibody-mediated response against different SARS-CoV-2 variants using sera from vaccinated people as well as from people infected with different variants. We show that potency of the antibody response against different SARS-CoV-2 variants depends on the particular variant that infected each person, the exposure type (infection or vaccination) and the number and order of exposures. Our study provides insight into the interplay between virus evolution and immunity, as well as important information for the development of better vaccination strategies.

Improved 30-Day Heart Failure Readmissions Following Implementation of an Advanced Cardiovascular Education (ACE) Academy.

BACKGROUND: Heart failure readmissions are common, though some are preventable through evidence-based management. LOCAL PROBLEM: Despite outperforming national benchmarks for 30-day readmissions, compliance with an evidence-based institutional heart failure management pathway was inconsistent. The purpose of this project was to reduce 30-day heart failure readmission rates through an educational intervention and an electronic health record (EHR) redesign. METHODS: The cardiac services nursing leadership team conducted an education and documentation needs assessment to identify knowledge gaps and practical barriers to effective utilization of evidence-based interventions for heart failure management. INTERVENTIONS: This intervention included an Advanced Cardiovascular Education (ACE) Academy and an EHR workflow redesign for clinical and supportive nursing staff. RESULTS: The 30-day heart failure readmission rates reduced immediately following the intervention, and rates continued to decrease over a 3-year follow-up. CONCLUSIONS: Even among hospitals outperforming national benchmarks, 30-day heart failure readmissions can be reduced and sustained with enhanced education and EHR redesign.

ACCORD guideline for reporting consensus-based methods in biomedical research and clinical practice: a study protocol.

BACKGROUND: Structured, systematic methods to formulate consensus recommendations, such as the Delphi process or nominal group technique, among others, provide the opportunity to harness the knowledge of experts to support clinical decision making in areas of uncertainty. They are widely used in biomedical research, in particular where disease characteristics or resource limitations mean that high-quality evidence generation is difficult. However, poor reporting of methods used to reach a consensus - for example, not clearly explaining the definition of consensus, or not stating how consensus group panellists were selected - can potentially undermine confidence in this type of research and hinder reproducibility. Our objective is therefore to systematically develop a reporting guideline to help the biomedical research and clinical practice community describe the methods or techniques used to reach consensus in a complete, transparent, and consistent manner. METHODS: The ACCORD (ACcurate COnsensus Reporting Document) project will take place in five stages and follow the EQUATOR Network guidance for the development of reporting guidelines. In Stage 1, a multidisciplinary Steering Committee has been established to lead and coordinate the guideline development process. In Stage 2, a systematic literature review will identify evidence on the quality of the reporting of consensus methodology, to obtain potential items for a reporting checklist. In Stage 3, Delphi methodology will be used to reach consensus regarding the checklist items, first among the Steering Committee, and then among a broader Delphi panel comprising participants with a range of expertise, including patient representatives. In Stage 4, the reporting guideline will be finalised in a consensus meeting, along with the production of an Explanation and Elaboration (E&E) document. In Stage 5, we plan to publish the reporting guideline and E&E document in open-access journals, supported by presentations at appropriate events. Dissemination of the reporting guideline, including a website linked to social media channels, is crucial for the document to be implemented in practice. DISCUSSION: The ACCORD reporting guideline will provide a set of minimum items that should be reported about methods used to achieve consensus, including approaches ranging from simple unstructured opinion gatherings to highly structured processes.

Radiographic Assessment of Lung Edema (RALE) Scores are Highly Reproducible and Prognostic of Clinical Outcomes for Inpatients with COVID-19.

INTRODUCTION: Chest imaging is necessary for diagnosis of COVID-19 pneumonia, but current risk stratification tools do not consider radiographic severity. We quantified radiographic heterogeneity among inpatients with COVID-19 with the Radiographic Assessment of Lung Edema (RALE) score on Chest X-rays (CXRs). METHODS: We performed independent RALE scoring by ≥2 reviewers on baseline CXRs from 425 inpatients with COVID-19 (discovery dataset), we recorded clinical variables and outcomes, and measured plasma host-response biomarkers and SARS-CoV-2 RNA load from subjects with available biospecimens. RESULTS: We found excellent inter-rater agreement for RALE scores (intraclass correlation co-efficient=0.93). The required level of respiratory support at the time of baseline CXRs (supplemental oxygen or non-invasive ventilation [n=178]; invasive-mechanical ventilation [n=234], extracorporeal membrane oxygenation [n=13]) was significantly associated with RALE scores (median [interquartile range]: 20.0[14.1-26.7], 26.0[20.5-34.0] and 44.5[34.5-48.0], respectively, p<0.0001). Among invasively-ventilated patients, RALE scores were significantly associated with worse respiratory mechanics (plateau and driving pressure) and gas exchange metrics (PaO2/FiO2 and ventilatory ratio), as well as higher plasma levels of IL-6, sRAGE and TNFR1 levels (p<0.05). RALE scores were independently associated with 90-day survival in a multivariate Cox proportional hazards model (adjusted hazard ratio 1.04[1.02-1.07], p=0.002). We validated significant associations of RALE scores with baseline severity and mortality in an independent dataset of 415 COVID-19 inpatients. CONCLUSION: Reproducible assessment of radiographic severity revealed significant associations with clinical and physiologic severity, host-response biomarkers and clinical outcome in COVID-19 pneumonia. Incorporation of radiographic severity assessments may provide prognostic and treatment allocation guidance in patients hospitalized with COVID-19.

Prone Team: A Large-Scale Prone Position Initiative During COVID-19 Pandemic.

AIM: To identify strategies to improve time to prone in ICUs during the coronavirus disease 2019 (COVID-19) pandemic for patients meeting the criteria for prone position ventilation. BACKGROUND: Healthcare systems worldwide experienced an influx of COVID-19 patients, especially in critical care. COVID-19 patients are at risk of acute respiratory distress syndrome (ARDS). Prone position ventilation is the standard of care for mechanically ventilated patients with moderate to severe ARDS. Prone maneuvers in and of itself are time-consuming and labor-intensive, posing additional risks to patients. APPROACH: Our academic medical center developed a travel proning team to address the rapid increase in COVID-19 patients with ARDS necessitating prone positioning. EVALUATION: Over a period of 30 days, 420 ICU patients were intubated, 131 had moderate to severe ARDS and underwent prone positioning. Patients were placed in prone position or returned to supine position more than 834 times over 38 days. At the highest point, 37 procedures were done in 24 hours. CONCLUSION: This quality initiative demonstrated that utilization of a traveling proning team provides efficiency in time to prone. Developing a travel prone team allowed for efficiency in time to prone, supported the ICU clinical teams, and enhanced interdisciplinary collaboration, which is essential during times of crisis.

Tiered Model of Nurse Staffing for Critical Care and Emergency Departments in the Wake of a Pandemic.

AIM: To identify strategies that increase hospital bed capacity, material resources, and available nurse staffing during a national pandemic. BACKGROUND: The COVID-19 outbreak resulted in an influx of acutely ill patients requiring critical care. The volume and acuity of this patient population increased the demand for care and stretched hospitals beyond their capacity. While increasing hospital bed capacity and material resources are crucial, healthcare systems have noted one of the greatest limitations to rapid expansion has been the number of available medical personnel, particularly those trained in emergency and critical care nursing. EVALUATION: Program evaluation occurred on a daily basis with hospital throughput, focusing on logistics including our ability to expand bed volume, resource utilization, and the ability to meet staffing needs. CONCLUSION: This article describes how a quaternary care hospital in New York City prepared for the COVID-19 surge in patients by maximizing and shifting nursing resources to its most impacted services, the emergency department (ED) and the intensive care units (ICUs). A tier-based staffing model and rapid training were operationalized to address nurse-staffing shortages in the ICU and ED, identifying key factors for swift deployment. IMPLICATIONS FOR NURSING MANAGERS: Frequent communication between staff and leaders improves teamwork and builds trust and buy-in during normal operations and particularly in times of crisis.

Severe Acute Respiratory Syndrome Coronavirus 2 Serosurveillance in a Patient Population Reveals Differences in Virus Exposure and Antibody-Mediated Immunity According to Host Demography and Healthcare Setting.

Identifying drivers of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure and quantifying population immunity is crucial to prepare for future epidemics. We performed a serial cross-sectional serosurvey throughout the first pandemic wave among patients from the largest health board in Scotland. Screening of 7480 patient serum samples showed a weekly seroprevalence ranging from 0.10% to 8.23% in primary and 0.21% to 17.44% in secondary care, respectively. Neutralization assays showed that highly neutralizing antibodies developed in about half of individuals who tested positive with enzyme-linked immunosorbent assay, mainly among secondary care patients. We estimated the individual probability of SARS-CoV-2 exposure and quantified associated risk factors. We show that secondary care patients, male patients, and 45-64-year-olds exhibit a higher probability of being seropositive. The identification of risk factors and the differences in virus neutralization activity between patient populations provided insights into the patterns of virus exposure during the first pandemic wave and shed light on what to expect in future waves.

Zoonotic Pathogens of Dromedary Camels in Kenya: A Systematised Review.

Kenya is home to Africa's third largest population of dromedary camels, and production at commercial and local levels are increasingly important. In pastoral and nomadic communities in the arid and semi-arid lands (ASALs), camels play a vital role in food security, while commercial milk production and formalized export markets are rapidly emerging as camel populations expand into non-traditional areas. Until recently, little focus was placed on camels as hosts of zoonotic disease, but the emergence of Middle Eastern respiratory coronavirus (MERS-CoV) in 2012, and the discovery of exposure to the virus in Kenyan camels, highlighted the need for further understanding of this area. This systematised review utilised a robust search strategy to assess the occurrence of camel-associated zoonoses in Kenya and to evaluate the quality of the published literature. Seventy-four studies were identified, covering sixteen pathogens, with an increasing number of good quality studies in recent years. Despite this, the area remains under-researched and there is a lack of robust, high-quality research. Trypanosome spp., Echinococcus granulosus and Brucella spp. appeared most frequently in the literature. Pathogens with the highest reported prevalence were MERS-CoV (0-100%), Echinococcus granulosa (7-60%) and Rift Valley fever virus (7-57%). Exposure to Brucella spp., Coxiella burnetii and Crimean-Congo haemorrhagic fever virus showed higher levels in camel or camel-associated vectors than other livestock species, although brucellosis was the only disease for which there was robust evidence linking camel and human exposure. Zoonotic agents with less severe human health outcomes, such as Dermatophilosus congolensis and contagious ecthyma, were also represented in the literature. This review provides an important summary of the scope and quality of current knowledge. It demonstrates that further research, and improved adherence to robust study design and reporting are essential if the zoonotic risk from camels in Kenya, and elsewhere, is to be better understood.

Co-induction of anaesthesia with alfaxalone and midazolam in dogs: a randomized, blinded clinical trial.

OBJECTIVE: To qualitatively assess the co-induction of anaesthesia with midazolam and alfaxalone and to determine cardiovascular or respiratory alterations compared with alfaxalone alone. STUDY DESIGN: A randomized, blinded, clinical trial. ANIMALS: A total of 29 American Society of Anesthesiologists grade I or II, client-owned dogs undergoing elective orthopaedic or soft tissue surgery. METHODS: All dogs received 0.02 mg kg-1 acepromazine and 0.3 mg kg-1 methadone intramuscularly 30 minutes prior to anaesthesia. Measurements of heart rate (HR), respiratory frequency and blood pressure (BP) were assessed pre-induction and at 0, 2 and 5 minutes post-induction. Anaesthesia was induced with 0.5 mg kg-1 alfaxalone followed by either 0.4 mg kg-1 midazolam intravenously (group M) or an equal volume of saline (group S). Conditions were assessed for intubation and further boluses of 0.25 mg kg-1 alfaxalone were given as required. Response to co-induction, ease of intubation and quality of induction were scored, and total dose of alfaxalone required for intubation was recorded. Repeated measures one-way analysis of variance with post hoc Tukey's test was used to assess within group changes over time and Student t tests were used to compare between groups. Incidence of apnoea was assessed using a Fisher's exact test. Data are shown as mean ± standard deviation. RESULTS: Group M included 14 dogs and group S 15 dogs. There was a significant difference in the total dose of alfaxalone required for intubation, 0.65 ± 0.20 mg kg-1 group M and 0.94 ± 0.26 mg kg-1 group S (p = 0.002). Apnoea occurred significantly more frequently in group M (p = 0.007). There were no clinically significant differences in HR or BP at the measured time points between groups. CONCLUSIONS AND CLINICAL RELEVANCE: Co-induction with midazolam had significant alfaxalone-sparing effects with no clinically detectable cardiovascular changes. Apnoea is common after co-induction.

Evaluation of the Psychiatric Decisions Unit (PDU): effect on emergency department presentations and psychiatric inpatient admissions.

BACKGROUND: Busy emergency departments (EDs) are not the optimum environment for assessment of patients in mental health crisis. The Psychiatric Decisions Unit (PDU) was developed by the Birmingham and Solihull Mental Health Foundation Trust as an enhanced assessment service to ensure patients in mental health crisis receive optimal care. AIMS: To evaluate the activities of the PDU and its impact on the frequency of ED presentations and inpatient admissions, and to explore patient satisfaction. METHODS: Data were collected over a 6-month period during 2015 regarding patient demographics, referral sources, length of stay, and frequency of mental health-related ED presentations and inpatient psychiatric admissions. Comparison group data were used to evaluate the impact of the PDU. Patient satisfaction was measured using the 'Friends and Family Test' and structured feedback forms. RESULTS: In total, 385 patients were referred to the PDU during the study period. Implementation of the PDU was associated with a 39% decrease in the number of patients taken to the ED by Street Triage and a 26% fall in inpatient psychiatric admissions via the Trusts' in-hospital liaison psychiatry team. Ninety-eight per cent of patients surveyed felt that they were treated with respect and understanding, and 94% reported that they were likely or extremely likely to recommend the service to friends and family. CONCLUSIONS: Implementation of the PDU was associated with a reduction in the frequency of ED presentations and inpatient psychiatric admissions. This study suggests that patients are satisfied with the care provided at the PDU.

Taenia multiceps coenurosis in Tanzania: a major and under-recognised livestock disease problem in pastoral communities.

AbstractA neurological syndrome of small ruminants, known locally as 'ormilo', has been reported among pastoralist livestock keepers in Tanzania. This study was carried out in four affected pastoral communities to determine the prevalence and associated risk factors, characterise the clinical signs and investigate the aetiology of the syndrome. Questionnaires were administered at all households (n=480) within four study villages. Overall, 94 per cent of households reported at least one case in the previous 12 months. By village, the individual-level 12-month period prevalence ranged from 11 per cent to 34 per cent, equivalent to about 10,000 small ruminants across the four villages. Thirty-eight households were randomly selected for further investigation. Proprioceptive deficits and weakness were the most commonly observed clinical signs in affected animals. Brain and spinal cord cysts consistent with Taenia multiceps infection were detected in 32 (82 per cent) of 39 affected animals selected for postmortem examination. Feeding small ruminant brains to dogs was identified as an important risk factor for the syndrome, even in households that did not own dogs. This study confirms cerebral coenurosis as a major cause of small ruminant neurological disease in northern Tanzania and highlights the urgent need for further investigation to quantify the disease burden and to identify and implement control measures.

Evaluation of Biodistribution of Sulforaphane after Administration of Oral Broccoli Sprout Extract in Melanoma Patients with Multiple Atypical Nevi.

Broccoli sprout extract containing sulforaphane (BSE-SFN) has been shown to inhibit ultraviolet radiation-induced damage and tumor progression in skin. This study evaluated the toxicity and potential effects of oral BSE-SFN at three dosages. Seventeen patients who each had at least 2 atypical nevi and a prior history of melanoma were randomly allocated to 50, 100, or 200 µmol oral BSE-SFN daily for 28 days. Atypical nevi were photographed on days 1 and 28, and plasma and nevus samples were taken on days 1, 2, and 28. Endpoints assessed were safety, plasma and skin sulforaphane levels, gross and histologic changes, IHC for phospho-STAT3(Y705), Ki-67, Bcl-2, HMOX1, and TUNEL, plasma cytokine levels, and tissue proteomics. All 17 patients completed 28 days with no dose-limiting toxicities. Plasma sulforaphane levels pooled for days 1, 2, and 28 showed median postadministration increases of 120 ng/mL for 50 µmol, 206 ng/mL for 100 µmol, and 655 ng/mL for 200 µmol. Median skin sulforaphane levels on day 28 were 0.0, 3.1, and 34.1 ng/g for 50, 100, and 200 µmol, respectively. Plasma levels of proinflammatory cytokines decreased from day 1 to 28. The tumor suppressor decorin was increased from day 1 to 28. Oral BSE-SFN is well tolerated at daily doses up to 200 µmol and achieves dose-dependent levels in plasma and skin. A larger efficacy evaluation of 200 µmol daily for longer intervals is now reasonable to better characterize clinical and biological effects of BSE-SFN as chemoprevention for melanoma. Cancer Prev Res; 11(7); 429-38. ©2018 AACR.