Feasibility of a virtual reality course on adult tracheostomy safety skills.

The National Tracheostomy Safety Project has run high-quality, face-to-face skills courses since 2009. The aim of this project was to produce a virtual reality version of the established course and evaluate its impact on participant learning, and participant and faculty satisfaction. Healthcare staff and students were recruited and randomised to attend one of (1) a face-to-face traditional course (control); (2) a virtual reality course at a conference centre with on-site technical support; (3) a fully remote virtual reality course; the virtual reality groups were combined for the analysis of learning outcomes and satisfaction. The primary outcome was the difference in pre/post-course knowledge scores on a 30-item questionnaire; secondary outcomes included knowledge retention, usability, comfort/side effects and participant performance in a simulated tracheostomy emergency. Thirty-seven participants and 15 faculty participated in this study. There was no significant difference between mean pre/post-course scores from the face-to-face (from 21.1 to 23.1; +2) and combined virtual reality (from 17.1 to 21.1; +4) groups, with both showing improvement (p = 0.21). The mean System Usability Scale score for virtual reality was 76.8 (SD 12.6), which is above average; the median Simulator Sickness Questionnaire score was 7.5 (IQR 3.7-22.4), indicating minimal symptoms. All participants resolved the primary clinical problem in the simulated emergency, but the virtual reality (VR) group was slower overall (mean difference 61.8 s, p = 0.003). This technical feasibility study demonstrated that there was no difference in participant knowledge immediately after and 4 weeks following face-to-face and virtual reality courses. Virtual reality offers an immersive experience that can be delivered remotely and offers potential benefits of reducing travel and venue costs for attendees, therefore increasing the flexibility of training opportunities.

Doors to the Homes: Signal Potential of Red Coloration of Claws in Social Hermit Crabs.

Red coloration on a signaler's body may be an informative signal in many animals. For species that inhabit architecture (e.g., burrows, nests, or other structures), certain parts of the body are more exposed than others, potentially serving as superior platforms for signaling via coloration. Yet whether animals differentially advertise red coloration on body parts that are more versus less exposed from their architecture remains to be tested. Here, we systematically quantified red coloration in social hermit crabs (Coenobita compressus). These crabs inhabit architecturally remodeled shells and have claws that visibly block the shell entrance, like doors to their homes. We hypothesized that red coloration of claws may be a signal of resource-holding potential (RHP). Consistent with this RHP signaling hypothesis, we found that within the same individuals' bodies, exposed claws showed significantly greater red coloration than unexposed carapaces. Furthermore, larger body size predicted greater red coloration of claws. Competing hypotheses (e.g., interspecific signaling, camouflage, and UV protection), while not explicitly tested, nevertheless appear unlikely based on natural history. Red claw coloration may therefore function as a signal to conspecifics, and experiments are now needed to test recipient responses. Broadly, relative to surrounding architecture, exposed body surfaces offer rich potential as signaling platforms for coloration.

Outpatient secondary care pathways for head and neck cancer referral result in patient delays for cancer treatment.

INTRODUCTION: The majority of head and neck cancer referrals are received through primary care. A proportion of cancer referrals are received through secondary care specialties. Local delivery plan (LDP) targets in Scotland for cancer investigation are set at 31 days for diagnosis and 62 days to start treatment. The aim was to audit referrals made through non-primary care pathways compared with the standard primary care pathways against LDP targets. METHODS: New head and neck cancer patients between 1 January 2014 and 1 January 2019 were included. Pathway points were recorded between referral to outpatient clinic, time to multidisciplinary team discussion (MDT) and finally MDT to treatment. RESULTS: 1,276 new patient referrals were received over a 5-year period. Of these, 136 (10%) were referred via non-primary care pathways. The mean time for urgent suspicion of cancer (USoC) referrals to start treatment was 77 days (15 days over target) and for outpatient secondary care referrals was 102 days (40 days over target) (p<0.05). When treatment intent was considered, 841/1,131 (75%) of patients referred via primary care were treated curatively compared with 49/99 (49%) (p<0.05) of patients referred through the secondary outpatient pathway. CONCLUSION: Patients with head and neck cancer referred from other outpatient specialties face delays commencing cancer treatment and are also associated with a greater likelihood of being treated with palliative intent.

Tuberous Sclerosis: A Rare Disease with an Orphan Complex.

Introduction In the Republic of Ireland, there are no tuberous sclerosis complex (TSC) specialist clinics. Methods A clinical audit was carried out to assess the care received by patients attending two specialist adult epilepsy specialist centres, measuring their care against the UK guidelines. Results Although many baseline investigations are carried out, only one-third of patients had diagnostic genetic testing results available. Neuropsychiatry is largely neglected, and the completion of neuropsychiatric assessments checklists is inadequate. Discussions concerning SUDEP are not happening and access to treatment is limited. Reporting of radiological findings in TSC is inconsistent and the number of adults with TSC accessing specialist epilepsy services appear to be low. Discussion TSC care in the Republic of Ireland is fragmented, difficult to navigate and wasteful of resources due to the complex nature of the disease and no formal clinical setting to manage it. The service gaps echo the demand for an improved care system including consistent radiological reporting of TSC pathology. The absence of a specialist TSC clinic compounds the complexity of navigating care for individuals with TSC, families and healthcare professionals. Extending this audit nationally will give a more complete picture and highlight the resources required to bring care of these patients in line with recommended guidelines.

Maternal, placental, and fetal distribution of titanium after repeated titanium dioxide nanoparticle inhalation through pregnancy.

Epidemiological studies have associated ambient engineered nanomaterials or ultrafine particulate matter (PM0.1), collectively referred to as nanoparticles (NPs), with adverse pregnancy outcomes including miscarriage, preterm labor, and fetal growth restriction. Evidence from non-pregnant models demonstrate that NPs can cross the lung air-blood barrier and circulate systemically. Therefore, inhalation of NPs during pregnancy leading to fetoplacental exposure has garnered attention. The purpose of this study was to evaluate the distribution of inhaled titanium dioxide nanoparticles (nano-TiO2) from the maternal lung to maternal and fetal systemic tissues. Pregnant Sprague Dawley rats were administered whole-body exposure to filtered air or of nano-TiO2 aerosols (9.96 ± 0.06 mg/m3) between gestational day (GD) 4 and 19. On GD 20 maternal, placental, and fetal tissues were harvested then digested for ICP-MS analysis to measure concentrations of titanium (Ti). TEM was used to visualize particle internalization by the placental syncytium. The results demonstrate the extrapulmonary distribution of Ti to various maternal organs during pregnancy. Our study found Ti accumulation in the decidua/junctional and labyrinth zones of placentas embedded in all sections of uterine horns. Further, NPs deposited in the placenta, identified by TEM, were found intracellularly within nuclear, endoplasmic reticulum, and vesicle organelles. This study identified the systemic distribution and placental accumulation of Ti after nano-TiO2 aerosol inhalation in a pregnancy model. These findings arouse concerns for poor air quality for pregnant women and possible contributions to adverse pregnancy outcomes.

A quest for cytocompatible metal organic frameworks in non-viral gene therapy: Relevance of zeolitic imidazolate framework-8.

Metal-organic frameworks (MOFs) are an emerging group of nanomaterials for successful biomedical applications in gene therapy. The most commonly biocompatible MOFs are zinc-based ZIFs, zirconium-based UiOs, and iron-based MILs. However, despite increasing applications, a comparative study to underscore the critical factors for determining effective gene delivery by such MOFs is lacking. Herein, we evaluate the potential of UiO-66 and MIL-88B and ZIF-8 for gene therapeutics delivery; revealing the comparative importance of ZIF-8. Cytotoxicity assays proved insufficient for selecting the ideal gene delivery MOF vehicle. Synthesis conditions such as ability of the MOF scaffold to envelop the gene during in-situ synthesis, post-treatment such as washing, and gene loading efficiency proved to be the critical factors in determining the favourable MOF from the material selection perspective. Rapid in-situ synthesis under physiological conditions, successful gene loading, and low concentration requirements favour ZIF MOFs as gene delivery vehicles. Impact on cellular physiology, metabolism, and architecture revealed neutrality of the delivery system; and relative effects on pro-inflammatory and anti-inflammatory cytokines suggest immunomodulatory impact.

Acute isolated sphenoid sinusitis in children: A case series and systematic review of the literature.

OBJECTIVE: This study aims to present a case series and systematic review of acute isolated sphenoid sinusitis (AISS) in children in order to better characterize clinical presentation, diagnosis, treatment, and outcomes of this condition. DATA SOURCES: Ovid MEDLINE, Pubmed, Embase, Cochrane Library, and Google Scholar. STUDY SELECTION: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text, peer-reviewed journal publications from 1994 to 2020 in English; focus on acute sphenoid sinusitis; pediatric patients (<18 years of age); series with two or more children. Studies were assessed for data including demographics, presenting symptoms and signs, radiological investigations, treatment, outcomes and complications. RESULTS: Ten studies identifying 71 patients were included. Average age at presentation was 12.0 years (range 5-17 years). M:F ratio 1:1. The most common presenting symptoms were headache (98.6%), fever (50.7%), nasal symptoms (22.5%) ocular symptoms (19.7%) and decreased level of consciousness (12.7%). Twenty patients (28.1%) had neurological signs. Twenty-three patients (32.4%) presented with headache in isolation. Unsuspected diagnosis at presentation was noted in 54.0%. Average time to initial presentation was 14.0 days (median = 5.5 days, range 1-90 days). The majority of children were treated with antibiotics (98.6%) with 31.0%, 2.8% and 2.8% also undergoing sinus surgery, revision sinus surgery and neurosurgery, respectively. Intracranial complications occurred in 16.9% of patients. Significant long term sequelae occurred in 2 children (2.8%) and one death (1.4%) was also reported. LIMITATIONS: All studies were retrospective case note reviews. CONCLUSIONS: Acute sphenoid sinusitis is a rare and difficult condition to diagnose in children. The majority of patients make a full recovery with appropriate treatment. If treatment is delayed however consequences can be life-threatening.

Rate of replenishment and microenvironment contribute to the sexually dimorphic phenotype and function of peritoneal macrophages.

Macrophages reside in the body cavities where they maintain serosal homeostasis and provide immune surveillance. Peritoneal macrophages are implicated in the etiology of pathologies including peritonitis, endometriosis, and metastatic cancer; thus, understanding the factors that govern their behavior is vital. Using a combination of fate mapping techniques, we have investigated the impact of sex and age on murine peritoneal macrophage differentiation, turnover, and function. We demonstrate that the sexually dimorphic replenishment of peritoneal macrophages from the bone marrow, which is high in males and very low in females, is driven by changes in the local microenvironment that arise upon sexual maturation. Population and single-cell RNA sequencing revealed marked dimorphisms in gene expression between male and female peritoneal macrophages that was, in part, explained by differences in composition of these populations. By estimating the time of residency of different subsets within the cavity and assessing development of dimorphisms with age and in monocytopenic Ccr2 -/- mice, we demonstrate that key sex-dependent features of peritoneal macrophages are a function of the differential rate of replenishment from the bone marrow, whereas others are reliant on local microenvironment signals. We demonstrate that the dimorphic turnover of peritoneal macrophages contributes to differences in the ability to protect against pneumococcal peritonitis between the sexes. These data highlight the importance of considering both sex and age in susceptibility to inflammatory and infectious diseases.

Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP).

The COVID-19 pandemic is causing a significant increase in the number of patients requiring relatively prolonged invasive mechanical ventilation and an associated surge in patients who need a tracheostomy to facilitate weaning from respiratory support. In parallel, there has been a global increase in guidance from professional bodies representing staff who care for patients with tracheostomies at different points in their acute hospital journey, rehabilitation and recovery. Of concern are the risks to healthcare staff of infection arising from tracheostomy insertion and caring for patients with a tracheostomy. Hospitals are also facing extraordinary demands on critical care services such that many patients who require a tracheostomy will be managed outside established intensive care or head and neck units and cared for by staff with little tracheostomy experience. These concerns led NHS England and NHS Improvement to expedite the National Patient Safety Improvement Programme's 'Safe Tracheostomy Care' workstream as part of the NHS COVID-19 response. Supporting this workstream, UK stakeholder organisations involved in tracheostomy care were invited to develop consensus guidance based on: expert opinion; the best available published literature; and existing multidisciplinary guidelines. Topics with direct relevance for frontline staff were identified. This consensus guidance includes: infectivity of patients with respect to tracheostomy indications and timing; aerosol-generating procedures and risks to staff; insertion procedures; and management following tracheostomy.

Establishing a baseline for a national paediatric antimicrobial stewardship programme.

BACKGROUND: The majority of antimicrobial stewardship programmes focus on prescribing in adult populations; however, there is a recognized need for targeted paediatric antimicrobial stewardship to improve the quality and safety of prescribing amongst this patient group. OBJECTIVES: To describe the current epidemiology of antimicrobial prescribing in paediatric inpatient populations in Scotland to establish a baseline of evidence and identify priority areas for quality improvement to support a national paediatric antimicrobial stewardship programme. METHODS: A total of 559 paediatric inpatients were surveyed during the Scottish national point prevalence survey of healthcare-associated infections and antimicrobial prescribing, 2016. The prevalence of antimicrobial prescribing was calculated and characteristics of antimicrobial prescribing were described as proportions and compared between specialist hospitals and paediatric wards in acute hospitals. RESULTS: Prevalence of antimicrobial use in paediatric inpatients was 35.4% (95% CI = 31.6%-39.4%). Treatment of community- and hospital-acquired infections accounted for 47.1% and 20.7% of antimicrobial use, respectively, with clinical sepsis being the most common diagnosis and gentamicin the most frequently prescribed antimicrobial for the treatment of infection. The reason for prescribing was documented in the notes for 86.5% of all prescriptions and, of those assessed for compliance against local policy, 92.9% were considered compliant. CONCLUSIONS: Data from national prevalence surveys are advantageous when developing antimicrobial stewardship programmes. Results have highlighted differences in the prescribing landscape between paediatric inpatient populations in specialist hospitals and acute hospitals, and have informed priorities for the national antimicrobial stewardship programme, which reinforces the need for a targeted paediatric antimicrobial stewardship programme.

Position statement on defining and standardizing an oncoplastic approach to breast-conserving surgery in Canada.

Although mastectomy is an effective procedure, it can have a negative effect on body image, sense of attractiveness, and sexuality. As opposed to the combination of breast oncologic surgery and plastic surgery, whose primary focus is on replacing lost volume, breast-conserving oncoplastic surgery (ops) redistributes remaining breast tissue in a manner that requires vision, anatomic knowledge, and an appreciation of esthetics, symmetry, and breast function. Modern surgical treatment of breast cancer can be realized only with breast and plastic surgeons working together using oncoplastic techniques to deliver superior cosmetic and cancer outcomes alike. Using this collaborative approach, oncologic and plastic surgeons in Canada have a significant opportunity to improve the care of their breast cancer patients. We propose a tri-level classification for volume displacement procedures to act as a rubric for the training of general surgeons and oncologic breast surgeons in oncoplastic breast-conserving therapy techniques. It is our position that ops enhances outcomes for many women with breast cancer and should become part of the standard repertoire of procedures used by Canadian oncologic surgeons treating breast cancer.

Identification and quantification of gold engineered nanomaterials and impaired fluid transfer across the rat placenta via ex vivo perfusion.

Development and implementation of products incorporating nanoparticles are occurring at a rapid pace. These particles are widely utilized in domestic, occupational, and biomedical applications. Currently, it is unclear if pregnant women will be able to take advantage of the potential biomedical nanoproducts out of concerns associated with placental transfer and fetal interactions. We recently developed an ex vivo rat placental perfusion technique to allow for the evaluation of xenobiotic transfer and placental physiological perturbations. In this study, a segment of the uterine horn and associated placenta was isolated from pregnant (gestational day 20) Sprague-Dawley rats and placed into a modified pressure myography vessel chamber. The proximal and distal ends of the maternal uterine artery and the vessels of the umbilical cord were cannulated, secured, and perfused with physiological salt solution (PSS). The proximal uterine artery and umbilical artery were pressurized at 80 mmHg and 50 mmHg, respectively, to allow countercurrent flow through the placenta. After equilibration, a single 900 µL bolus dose of 20 nm gold engineered nanoparticles (Au-ENM) was introduced into the proximal maternal artery. Distal uterine and umbilical vein effluents were collected every 10 min for 180 min to measure placental fluid dynamics. The quantification of Au-ENM transfer was conducted via inductively coupled plasma mass spectrometry (ICP-MS). Overall, we were able to measure Au-ENM within uterine and umbilical effluent with 20 min of material infusion. This novel methodology may be widely incorporated into studies of pharmacology, toxicology, and placental physiology.

A potential key role for alpha-haemolysin of Staphylococcus aureus in mediating chondrocyte death in septic arthritis.

OBJECTIVES: Staphylococcus aureus (S. aureus) is the most commonly implicated organism in septic arthritis, a condition that may be highly destructive to articular cartilage. Previous studies investigating laboratory and clinical strains of S. aureus have demonstrated that potent toxins induced significant chondrocyte death, although the precise toxin or toxins that were involved was unknown. In this study, we used isogenic S. aureus mutants to assess the influence of alpha (Hla)-, beta (Hlb)-, and gamma (Hlg)-haemolysins, toxins considered important for the destruction of host tissue, on in situ bovine chondrocyte viability. METHODS: Bovine cartilage explants were cultured with isogenic S. aureus mutants and/or their culture supernatants. Chondrocyte viability was then assessed within defined regions of interest in the axial and coronal plane following live- and dead-cell imaging using the fluorescent probes 5-chloromethylfluorescein diacetate and propidium iodide, respectively, and confocal laser-scanning microscopy. RESULTS: Hla-producing mutants caused substantial chondrocyte death compared with the toxin-deficient control (Hla-Hlb-Hlg-), whilst mutants producing Hlb and Hlg in the absence of Hla induced minimal chondrocyte death. Coronal studies established that Hla-induced chondrocyte death started in the superficial zone of cartilage and spread to deeper layers, whereas Hlb and Hlg toxins were without significant effect. CONCLUSION: This study identified Hla as a highly potent S. aureus toxin that caused rapid chondrocyte death in bovine cartilage, with other toxins or metabolic products produced by the bacteria playing a minor role. The identification of Hla in mediating chondrocyte death may assist in the development of therapeutic strategies aimed at reducing the extent of cartilage damage during and after an episode of septic arthritis.Cite this article: I. D. M. Smith, K. M. Milto, C. J. Doherty, S. G. B. Amyes, A. H. R. W. Simpson, A. C. Hall. A potential key role for alpha-haemolysin of Staphylococcus aureus in mediating chondrocyte death in septic arthritis. Bone Joint Res 2018;7:457-467. DOI: 10.1302/2046-3758.77.BJR-2017-0165.R1.

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies.

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

Patient safety ward round checklist via an electronic app: implications for harm prevention.

INTRODUCTION: Patient safety is a value at the core of modern healthcare. Though awareness in the medical community is growing, implementing systematic approaches similar to those used in other high reliability industries is proving difficult. The aim of this research was twofold, to establish a baseline for patient safety practices on routine ward rounds and to test the feasibility of implementing an electronic patient safety checklist application. METHODS: Two research teams were formed; one auditing a medical team to establish a procedural baseline of "usual care" practice and an intervention team concurrently was enforcing the implementation of the checklist. The checklist was comprised of eight standard clinical practice items. The program was conducted over a 2-week period and 1 month later, a retrospective analysis of patient charts was conducted using a global trigger tool to determine variance between the experimental groups. Finally, feedback from the physician participants was considered. RESULTS: The results demonstrated a statistically significant difference on five variables of a total of 16. The auditing team observed low adherence to patient identification (0.0%), hand decontamination (5.5%), and presence of nurse on ward rounds (6.8%). Physician feedback was generally positive. CONCLUSIONS: The baseline audit demonstrated significant practice bias on daily ward rounds which tended to omit several key-proven patient safety practices such as prompting hand decontamination and obtaining up to date reports from nursing staff. Results of the intervention arm demonstrate the feasibility of using the Checklist App on daily ward rounds.

Non-attendance of vulnerable populations within epilepsy outpatient services in Ireland.

BACKGROUND: Outpatient non-attendance is a prevalent issue that contributes to significant wasted clinical resources and can be influenced by a number of complex factors. AIMS: The aim of this study is to characterize "did not attend" (DNA) rates in three identified subpopulations of epilepsy patients to determine if current care provision models suffice. METHODS: In this study, we identified all patients residing in social housing, in residential care, and those incarcerated who have been offered appointments by our service. We calculated the total number of appointments issued to each group over their entire interaction with our service and their subsequent non-attendance rate as a group. Additionally, we calculated the baseline DNA rate for our epilepsy clinic as a whole for comparison. RESULTS: We found that the baseline DNA rate for the clinic as a whole was 18.9%. Those in social housing, in residential care, and incarcerated had significantly higher DNA rates of 24, 20.2, and 54.3%, respectively. CONCLUSIONS: This study provided evidence that in certain groups of patients, clinicians may need to explore other care delivery models due to high DNA rates.

Hypoxia determines survival outcomes of bacterial infection through HIF-1alpha dependent re-programming of leukocyte metabolism.

Hypoxia and bacterial infection frequently co-exist, in both acute and chronic clinical settings, and typically result in adverse clinical outcomes. To ameliorate this morbidity, we investigated the interaction between hypoxia and the host response. In the context of acute hypoxia, both S. aureus and S. pneumoniae infections rapidly induced progressive neutrophil mediated morbidity and mortality, with associated hypothermia and cardiovascular compromise. Preconditioning animals through longer exposures to hypoxia, prior to infection, prevented these pathophysiological responses and profoundly dampened the transcriptome of circulating leukocytes. Specifically, perturbation of HIF pathway and glycolysis genes by hypoxic preconditioning was associated with reduced leukocyte glucose utilisation, resulting in systemic rescue from a global negative energy state and myocardial protection. Thus we demonstrate that hypoxia preconditions the innate immune response and determines survival outcomes following bacterial infection through suppression of HIF-1α and neutrophil metabolism. The therapeutic implications of this work are that in the context of systemic or tissue hypoxia therapies that target the host response could improve infection associated morbidity and mortality.

Two-dimensional knee valgus displacement as a predictor of patellofemoral pain in adolescent females.

Patellofemoral pain (PFP) is a prevalent lower limb musculo-skeletal injury in adolescent females. Female athletes with PFP display increased frontal plane knee joint motion in comparison to control subjects. The current investigation aimed to determine prospectively whether two-dimensional knee valgus displacement during landing could predict the risk of developing PFP. Seventy-six injury-free adolescent female athletes (age = 12.9 ±0.35 years) participated. At baseline participants performed three drop vertical jump trials from a 31-cm box. A standard video camera was used to record frontal plane knee joint kinematics. Over the 24-month follow-up, eight participants developed PFP, as diagnosed by a Chartered Physiotherapist. Knee valgus displacement was significantly increased in those who developed PFP compared to those who did not (mean difference = 7.79°; P = 0.002; partial eta squared = 0.07). Knee valgus displacement ≥10.6° predicted PFP with a sensitivity of 0.75 and specificity of 0.85. The associated positive likelihood ratio was 5. These results have clinical utility suggesting that two-dimensional analysis could be implemented to screen for increased risk of PFP in adolescent female athletes.