Healthcare staff perceptions towards influenza and potential COVID-19 vaccination in the 2020 pandemic context.

The COVID-19 pandemic generated renewed focus on infectious disease transmission in healthcare settings. This study aimed to evaluate staff perceptions towards influenza vaccination in the COVID-19 context. All healthcare workers within a major UK tertiary referral hospital were invited to answer a survey conducted from September 2nd to 13th, 2020. In all, 593 responses were received across a spectrum of roles; 44% reported they were more likely to get an influenza vaccine this year due to COVID-19; however, 10% felt that an influenza vaccine was less important due to social distancing. Additional questions evaluated intention to receive COVID-19 vaccination. There were substantial differences of opinion between staff groups.

Sediment metal enrichment and ecological risk assessment of ten ports and estuaries in the World Harbours Project.

Ten global harbours were assessed for sediment quality by quantifying the magnitude of anthropogenic change and ecological risk. Anthropogenic change (enrichment) was high for Derwent River and Sydney estuary, moderate for Santander Harbour, Rio de Janeiro and Dublin Port, slight for Hong Kong, minimal for Darwin. All 10 enrichment indices used showed similar results. Derwent River sediment was rated at high ecological risk, followed by Sydney and Santander estuaries with moderate risk. Auckland and Darwin sediments exhibited minimal ecological risk and sediment in the remaining harbours (Dublin, Hong Kong, Ravenna, Ria de Vigo and Rio de Janeiro) were assessed at slight ecological risk. The extraordinary variety of environments and types/quantities/qualities of data investigated resulted in as much a critique and development of methodology, as an assessment of human impact, including unique techniques for elemental normalisation and contaminant classification. Recommendations for an improved technical framework for sediment quality assessment are provided.

Nosocomial outbreak of measles amongst a highly vaccinated population in an English hospital setting.

In May 2017 a patient attended the emergency department at a hospital in England, with a presumed allergic reaction. He was subsequently diagnosed with measles. There were seven further confirmed cases, five of whom had received two doses of MMR vaccine. This outbreak highlights the importance of not relying on vaccination status to rule out the diagnosis of measles. Epidemiological investigations of this outbreak were particularly challenging due to the highly infectious nature of the measles virus, and prevented full elucidation of either the source of this outbreak or the transmission pathways.

The art of human anatomy: Renaissance to 21st century.

This session examines the relationship between the art and science of anatomy from the time of Vesalius to the present with particular emphasis on the role of the medical artist and the changing nature of anatomical illustration over the last five centuries. Pivotal changes in the art of anatomy will be examined including the evolution of media and brain imaging from Golgi to Geschwind.

'It is life threatening but I don't mind'. A qualitative study using photo elicitation interviews to explore adolescents' experiences of renal replacement therapies.

BACKGROUND: Renal replacement therapy (RRT) transforms the life prospects of young people with established renal failure. However, these treatments can have significant physiological and psychological implications for adolescents as they prepare to transition into adulthood. Health policies increasingly emphasize children and youth's active participation and consultation as users of health services, yet studies infrequently seek their experiences directly. METHODS: Adolescents receiving RRT in a large UK teaching hospital took photographs illustrating the impact of their condition and treatment on their lives. Qualitative photo elicitation interviews were conducted to explore the significance of the images and the young person's experiences. Interviews were analysed using descriptive thematic analysis. RESULTS: Ten young people aged 13-17 years participated. Themes identified were: (1) understanding and acceptance of treatment; (2) living in a non-functioning body; (3) impact upon daily life; (4) sources of support. Young people found treatments challenging and experienced significant impact on relationships and daily routines. Yet, health was prioritized over body image and participants demonstrated great emotional resilience. Young people valued support from family and friends, although were wary of disclosing their condition in case it resulted in being highlighted as different. Young people reported hospital staff as being caring and professional, but their biggest virtue appeared to be their willingness to treat the young people as 'normal'. CONCLUSIONS: Young people engaged readily with the research, and frankly described the impact of RRT on their everyday lives. Service providers must ensure that adolescents' developmental needs are met as traditional tasks of adolescence may lose priority. However, it is also clear that young people's ability to cope with treatments should not be underestimated.

Clearance of hepatitis C in chimpanzees is associated with intrahepatic T-cell perforin expression during the late acute phase.

The liver is the primary site of hepatitis C virus (HCV) replication. Therefore, we undertook detailed intrahepatic studies of T-cell dynamics, apoptosis, and gene expression during the acute phase of infection using liver biopsies from chimpanzees that developed persistent infection or spontaneously cleared the virus. We examined more than 40 liver biopsies histologically and quantitatively for T-cell infiltration, hepatocyte apoptosis and perforin expression. These data were correlated with outcome and viral kinetics. We observed intrahepatic T-cell infiltration in both groups of animals with CD8(+) T cells representing the major population. The appearance of T cells was always associated with apoptosis and mild alanine aminotransferase (ALT) elevations. Apoptosis (5-20% of hepatocytes) always occurred prior to serum ALT peak. Quantification of intrahepatic ALT mRNA revealed no upregulation of gene expression confirming that serum ALT increases were due to release of this enzyme from cells. During the late acute phase, cleared animals showed an increased frequency of hepatocyte apoptosis relative to persistently infected animals (P < 0.05). This correlated with a higher intrahepatic CD8(+) T-cell frequency in the cleared group (P < 0.01) with a greater proportion of lymphocytes expressing perforin compared with the persistent group (P < 0.001). All infected animals mounted intrahepatic immune responses during the acute phase, but these were not maintained in frequency or efficacy in persistent infections. There is a reduction in the numbers of intrahepatic T cells during the late acute phase in infections that become persistent with significantly fewer of these cells functional in clearing the virus by killing infected hepatocytes.

Standards for research ethics committees: purpose, problems and the possibilities of other approaches.

Criticism of ethical review of research continues and research ethics committees (RECs) need to demonstrate that they are "fit for purpose" by meeting acknowledged standards of process, debate and outcome. This paper reports a workshop in Warsaw in April 2008, organised by the European Forum for Good Clinical Practice, on the problems of setting standards for RECs in the European Union. Representatives from 27 countries were invited; 16 were represented. Problems identified were the limited and variable resources, difficulties of setting standards for ethical debate and its outcomes and that REC members, as volunteers, may resent the imposition of standards. Other ways to set standards were discussed, including analysis of current multicentre review, collecting REC member reports for review, learning from appeals and feedback from applicants, and use of other regional and national meetings. The place of a central, national board or ethics committee was debated as was the need for collaborating with partners in other fields.

T-cell vaccines that elicit effective immune responses against HCV in chimpanzees may create greater immune pressure for viral mutation.

A prime/boost vaccine strategy that transfects antigen-presenting cells using ligand-modified immunoliposomes to efficiently deliver plasmid DNA, followed by boosting with non-replicating recombinant adenovirus was used in chimpanzees to generate HCV-specific memory T-cells. Three chimpanzees (two vaccines, one control) were immunized with immunoliposomes complexed with DNA expressing NS3-NS5B or complexed with empty vector. Animals were boosted with adenovirus expressing NS3-NS5B, or non-recombinant adenovirus (control). Using liposome delivery we were able to obtain specific HCV responses following DNA priming in the chimpanzees. This data and mouse immunization studies confirm this as a more efficient delivery system than direct intramuscular inoculations with naked DNA. Subsequent to the adenovirus boost significant increases in peripheral HCV-specific T-cell responses and intrahepatic IFN-gamma and CD3varepsilon mRNA were also observed in the two vaccinated animals. Following challenge (100 CID(50)) both vaccinated animals showed immediate and significant control of viral replication (peak titers 3.7x10(4) and 9x10(3)IU/mL at weeks 1 and 2), which coincided with increases in HCV-specific T-cell responses. Viral kinetics in the control animal were comparable to historical controls with exponential increases in titer during the first several weeks. One vaccinated animal developed a low-level persistent infection (2x10(3)IU/mL) which correlated with a decrease in HCV-specific T-cell responses. Circulating virus isolated from both vaccinated animals showed approximately 2-fold greater nonsynonymous mutation rates compared to controls and the nonsynonymous/synonymous mutation rate ratio was indicative of positive selection. These data suggest that although T-cell vaccines can induce immune responses capable of controlling HCV, they also induce high levels of immune pressure for the potential selection of escape mutants.

You can love it so much. Heart shape.

Diagnostic imaging can sometimes reveal interesting shapes. In this case we describe a transoesophageal echocardiogram of a mitral valve prolapse in shape of a heart sign, which was successfully repaired.

How can we provide effective training for research ethics committee members? A European assessment.

Training for members of research ethics committees (RECs) varies from state to state in Europe. To follow this up, the European Forum for Good Clinical Practice organised a workshop in March 2007 to explore these issues and look for solutions. This article summarises the discussion, providing ways forward to develop REC training.

Octogenarians undergoing cardiac surgery outlive their peers: a case for early referral.

OBJECTIVE: To examine short and long term outcomes of octogenarians having heart operations and to analyse the interaction between patient and treatment factors. METHODS: Multivariate analysis of prospectively collected data and a survival comparison with an age and sex matched national population. The outcomes were base in-hospital mortality, risk stratified by logistic EuroSCORE (European system for cardiac operative risk evaluation), and long term survival. RESULTS: 12,461 consecutive patients (706 over 80 years) operated on between 1996 and 2003 in a regional UK unit were studied. Octogenarians more often had impaired ventricular function, pulmonary hypertension, and valve operations. They also included a higher proportion of women, had a higher serum creatinine concentration, and had a trend towards more unstable angina. Younger patients had a higher prevalence of previous cardiac operation, previous myocardial infarction, and diabetes. The in-hospital mortality rate was 3.9% for all patients (EuroSCORE predicted 6.1%, p < 0.001) and 9.8% for octogenarians (predicted 14.1%, p = 0.002). Long bypass time and non-elective surgery increased the risk of death above EuroSCORE prediction in both groups. A greater proportion of octogenarians stayed in intensive care more than 24 hours (37% v 23%, p < 0.001). Long term survival was significantly better in the study patients than in a general population with the same age-sex distribution (survival rate at five years 82.1% v 55.9%, p < 0.001). CONCLUSIONS: Cardiac surgery in a UK population of octogenarians produced excellent results. Elective referrals should be encouraged in all age groups.

Mitral repair best practice: proposed standards.

OBJECTIVES: To define best practice standards for mitral valve repair surgery. DESIGN: Development of standards for process and outcome by consensus. SETTING: Multidisciplinary panel of surgeons, anaesthetists, and cardiologists with interests and expertise in caring for patients with severe mitral regurgitation. MAIN OUTCOME MEASURES: Standards for best practice were defined including the full spectrum of multidisciplinary aspects of care. RESULTS: 19 criteria for best practice were defined including recommendations on surgical training, intraoperative transoesophageal echocardiography, surgery for atrial fibrillation, audit, and cardiology and imaging issues. CONCLUSIONS: Standards for best practice in mitral valve repair were defined by multidisciplinary consensus. This study gives centres undertaking mitral valve repair an opportunity to benchmark their care against agreed standards that are challenging but achievable. Working towards these standards should act as a stimulus towards improvements in care.

Relationship between pulmonary function and lung cancer surgical outcome.

The British Thoracic Society and American College of Chest Physician guidelines outline criteria for investigating patients for lung cancer surgery. However, the guidelines are based on relatively old studies. Therefore, the relationship between pulmonary function test results and surgical outcome were studied prospectively in a large cohort of lung cancer patients. From January 2001 to December 2003, 110 patients underwent surgery for lung cancer. All underwent full lung function testing in order to predict post-operative lung function. The hospital mortality rate was 3% and major complication rate 22%. There was poor overall outcome in 13%. Mean pre-operative lung function values were: forced expiratory volume in one second (FEV1) 2.0 L (79.4% of the predicted value), and carbon monoxide diffusing capacity of the lung (D(L,CO)) 73.6% pred. The mean post-operative lung function values were: FEV1 1.4 L (55.6% pred), and D(L,CO) 51.3% pred. All lung function values were better predictors of poor surgical outcome when expressed as a percentage of the predicted value. Using a threshold of pre-operative FEV1 of 47% pred resulted in the most useful positive and negative predictive probabilities, 0.90 and 0.67, respectively. Lung function values expressed as a percentage of the predicted value are more useful predictors of post-operative outcome than absolute values. The threshold of predicted forced expiratory volume in one second for surgical intervention could be lower (45-50% pred) than is currently accepted without increased mortality.

Vocal fold palsy due to plombage for tuberculosis.

A 67-year-old patient, who had previously undergone Lucite ball plombage for pulmonary tuberculosis, presented with a hoarse voice, intermittent stridor and breathlessness. Direct laryngoscopy confirmed a left vocal fold palsy. A left supraclavicular mass became apparent and a computerized tomograph (CT) scan showed that a Lucite ball had migrated into her supraclavicular fossa. Subsequently she developed left arm pain and weakness. The balls were removed surgically, following which her arm symptoms improved but her voice remained unchanged. Migration of implanted material should be considered when new symptoms appear in patients who have undergone plombage treatment.

Transiently elevated diastolic blood pressure is associated with a gender-dependent effect on cardiovascular risk.

We assessed the morbidity and mortality of subjects with transiently elevated diastolic pressure in the General Practice Hypertension Study Group (GPHSG) population. A total of 23 578 patients (aged 18-65 years) from seven UK general practices were screened in 1974 for a diastolic blood pressure (DBP4) of > or = 90 mmHg. Two further readings of DBP4 determined hypertensive (either DBP4 > or = 90 mmHg) or transient hypertensive (both DBP4 < 90 mmHg) status. Transients (n = 850) were matched with normotensive controls (n = 824) and risk ratios calculated over a mean follow-up of 18.7 years. Rescreening was conducted in six of the practices (n = 20 942) after 7.7 years. Male transients had a higher relative hazard for cardiovascular mortality than controls (11.8%, 8.6%, adjusted relative hazard 1.59, P = 0.056). Female transients had a lower relative hazard for cardiovascular mortality than controls (3.6%, 5.4%, adjusted relative hazard 0.39, P = 0.018). In all, 422 patients with transient hypertension were rescreened along with 367 matched controls. Significantly more transients were on antihypertensive treatment compared with their controls (odds ratio (OR) [95% CI]) for both male (4.2 [1.6-11.1]) and female patients (2.4 [1.0-5.56]) and more untreated female transients developed hypertension. Male transients had a higher rates of diabetes mellitus (adj OR = 5.1, P = 0.04) and stroke (adj OR 15.9, P = 0.03). This study has shown that transiently elevated DBP in GPHSG is associated with a significantly higher risk of later hypertension in men and women and of diabetes, stroke and cardiovascular mortality in men. Women with this condition have a significantly lower cardiovascular mortality.

Effect of lung cancer surgery on quality of life.

BACKGROUND: Health related quality of life (HRQOL) after surgery is important, although very limited data are available on the QOL after lung cancer surgery. METHODS: The effect of surgery on HRQOL was assessed in a prospective study of 110 patients undergoing potentially curative lung cancer surgery at Papworth Hospital, 30% of whom had borderline lung function as judged by forced expiratory volume in 1 second. All patients completed the EORTC QLQ-C30 and LC13 lung cancer module before surgery and again at 1, 3 and 6 months postoperatively. RESULTS: On average, patients had high levels of functioning and low levels of symptoms. Global QOL had deteriorated significantly 1 month after surgery (p = 0.001) but had returned to preoperative levels by 3 months (p = 0.93). Symptoms had worsened significantly at 1 month after surgery but had returned to baseline levels by 6 months. Low values on the preoperative HRQOL scales were not significantly associated with poor surgical outcome. However, patients with low preoperative HRQOL functioning scales and high preoperative symptom scores were more likely to have poor postoperative (6 months) QOL. The only lung function measurement to show a marginally statistically significant association with quality of life at 6 months after surgery was percentage predicted carbon monoxide transfer factor (Tlco). CONCLUSION: Although surgery had short term negative effects on quality of life, by 6 months HRQOL had returned to preoperative values. Patients with low HRQOL functioning scales, high preoperative symptom scores, and preoperative percentage predicted Tlco may be associated with worse postoperative HRQOL.