Respiratory Syncytial Virus Disease Burden in Community-Dwelling and Long-Term Care Facility Older Adults in Europe and the United States: A Prospective Study.

Background: Data on respiratory syncytial virus (RSV) disease burden in adults remain scarce. We assessed the burden of confirmed RSV-acute respiratory infections (cRSV-ARIs) in community-dwelling (CD) adults and those in long-term care facilities (LTCFs). Methods: In this prospective cohort study covering 2 RSV seasons (October 2019-March 2020 and October 2020-June 2021), RSV-ARIs were identified through active surveillance, in medically stable CD-adults ≥50 years (Europe) or adults ≥65 years in LTCFs (Europe and the United States). RSV infection was confirmed by polymerase chain reaction from combined nasal and throat swabs. Results: Of 1981 adults enrolled, 1251 adults in CD and 664 LTCFs (season 1) and 1223 adults in CD and 494 LTCFs (season 2) were included in the analyses. During season 1, overall incidence rates ([IRs] cases/1000 person-years) and attack rates (ARs) for cRSV-ARIs were 37.25 (95% confidence interval [CI], 22.62-61.35) and 1.84% in adults in CD and 47.85 (CI, 22.58-101.4) and 2.26% in adults in LTCFs. Complications occurred for 17.4% (CD) and 13.3% (LTCFs) of cRSV-ARIs. One cRSV-ARI occurred in season 2 (IR = 2.91 [CI, 0.40-20.97]; AR = 0.20%), without complications. No cRSV-ARIs led to hospitalization or death. Viral pathogens were codetected in ≤17.4% of cRSV-ARIs. Conclusions: RSV is an important cause of disease burden in adults in CD and LTCFs. Despite the observed low severity of cRSV-ARI, our results support the need for RSV prevention strategies among adults ≥50 years old.

Pre-analytical error for three point of care venous blood testing platforms in acute ambulatory settings: A mixed methods service evaluation.

INTRODUCTION: Point of care blood testing to aid diagnosis is becoming increasingly common in acute ambulatory settings and enables timely investigation of a range of diagnostic markers. However, this testing allows scope for errors in the pre-analytical phase, which depends on the operator handling and transferring specimens correctly. The extent and nature of these pre-analytical errors in clinical settings has not been widely reported. METHODS: We carried out a convergent parallel mixed-methods service evaluation to investigate pre-analytical errors leading to a machine error reports in a large acute hospital trust in the UK. The quantitative component comprised a retrospective analysis of all recorded error codes from Abbott Point of Care i-STAT 1, i-STAT Alinity and Abbott Rapid Diagnostics Afinion devices to summarise the error frequencies and reasons for error, focusing on those attributable to the operator. The qualitative component included a prospective ethnographic study and a secondary analysis of an existing ethnographic dataset, based in hospital-based ambulatory care and community ambulatory care respectively. RESULTS: The i-STAT had the highest usage (113,266 tests, January 2016-December 2018). As a percentage of all tests attempted, its device-recorded overall error rate was 6.8% (95% confidence interval 6.6% to 6.9%), and in the period when reliable data could be obtained, the operator-attributable error rate was 2.3% (2.2% to 2.4%). Staff identified that the most difficult step was the filling of cartridges, but that this could be improved through practice, with a perception that cartridge wastage through errors was rare. CONCLUSIONS: In the observed settings, the rate of errors attributable to operators of the primary point of care device was less than 1 in 40. In some cases, errors may lead to a small increase in resource use or time required so adequate staff training is necessary to prevent adverse impact on patient care.

Sepsis recognition tools in acute ambulatory care: associations with process of care and clinical outcomes in a service evaluation of an Emergency Multidisciplinary Unit in Oxfordshire.

OBJECTIVE: To assess the performance of currently available sepsis recognition tools in patients referred to a community-based acute ambulatory care unit. DESIGN: Service evaluation of consecutive patients over a 4-month period. SETTING: Community-based acute ambulatory care unit. DATA COLLECTION AND OUTCOME MEASURES: Observations, blood results and outcome data were analysed from patients with a suspected infection. Clinical features at first assessment were used to populate sepsis recognition tools including: systemic inflammatory response syndrome (SIRS) criteria, National Early Warning Score (NEWS), quick Sequential Organ Failure Assessment (qSOFA) and National Institute for Health and Care Excellence (NICE) criteria. Scores were assessed against the clinical need for escalated care (use of intravenous antibiotics, fluids, ongoing ambulatory care or hospital treatment) and poor clinical outcome (all-cause mortality and readmission at 30 days after index assessment). RESULTS: Of 533 patients (median age 81 years), 316 had suspected infection with 120 patients requiring care escalated beyond simple community care. SIRS had the highest positive predictive value (50.9%, 95% CI 41.6% to 60.3%) and negative predictive value (68.9%, 95% CI 62.6% to 75.3%) for the need for escalated care. Both NEWS and SIRS were better at predicting the need for escalated care than qSOFA and NICE criteria in patients with suspected infection (all P<0.001). While new-onset confusion predicted the need for escalated care for infection in patients ≥85 years old (n=114), 23.7% of patients ≥85 years had new-onset confusion without evidence for infection. CONCLUSIONS: Acute ambulatory care clinicians should use caution in applying the new NICE endorsed criteria for determining the need for intravenous therapy and hospital-based location of care. NICE criteria have poorer performance when compared against NEWS and SIRS and new-onset confusion was prevalent in patients aged ≥85 years without infection.

All contraindications to thrombolysis for life-threatening pulmonary embolus should be considered relative.

Acute massive pulmonary embolism (PE) can be fatal; however, timely thrombolytic therapy can be life saving. Guidelines advocate the use of thrombolysis for massive PE in patients with an acceptable bleeding-risk profile. Nonetheless, estimating what constitutes an acceptable bleeding risk in those with life-threatening PE is a clinical challenge, and even contraindications considered 'absolute' may present lesser risk than leaving PE untreated. We discuss the case of a 77-year-old man who received thrombolysis for a massive PE 4 weeks following admission with a significant intracerebral bleed. There was rapid resolution of hypotension and hypoxia and he survived to be discharged home. This case is used to illustrate that no potential therapy should be discounted in patients faced with acute life-threatening PE. Decisions to thrombolyse patients with traditional contraindications-even those considered absolute-must be taken by clinicians able to weigh relative risks.

Telemedicine for peer-to-peer psychiatry learning between U.K. and Somaliland medical students.

OBJECTIVE: The proportion of U.K. medical students applying for psychiatry training continues to decline, whereas, in Somaliland, there are no public-sector psychiatrists. This pilot study assessed the usefulness and feasibility of online, instant messenger, peer-to-peer exchange for psychiatry education between cultures. METHOD: Twenty medical students from King's College, London, and Hargeisa University (Somaliland) met online in pairs every 2 weeks to discuss prearranged psychiatric topics, clinical cases, and treatment options, completing online evaluations throughout. RESULTS: Average ratings of the enjoyment, academic helpfulness, and interest of sessions were 4.31, 3.56, and 4.54 (of a maximum of 5), respectively; 83% would recommend the partnership to a friend. CONCLUSION: This partnership enabled students on both sides to exploit psychiatry-learning resources at the other's disposal, outside the standard medical education context, illustrating the benefits to medical students in dramatically different locations of partnership through telemedicine. This pilot study presents an innovative, cost-effective, under-used approach to international medical education.

Letter: Real-time, intercontinental dermatology teaching of trainee physicians in Somaliland using a dedicated social networking portal.

We describe the use of MedicineAfrica.com, an innovative social networking portal, to deliver real-time, intercontinental, case-based dermatology teaching to geographically scattered trainee physicians in Somaliland by tutors based in the United Kingdom.

Management of adrenal incidentaloma: size still matters.

A 56-year-old man was found to have an adrenal incidentaloma on a CT scan of the abdomen. Clinically and biochemically, the mass was not functional. MRI scan revealed a heterogeneously enhancing, T2-hyperintense, right-sided adrenal mass (4.5×6.5 cm). Meta-iodo-benzylguanidine scan was normal, making a diagnosis of pheochromocytoma unlikely. As the mass was larger that 4 cm, it was excised and histopathological examination revealed a rare, composite tumour: benign adrenal adenoma with haemangiomatous and myelolipomatous components. This case highlights the difficulties encountered by a clinician faced with investigating a potentially malignant adrenal mass (based on size) and correlates radiological findings with a rare histopathological specimen.

Incorporation of radioactivity from labeled Di-(2-ethylhexyl)phthalate into DNA of rat liver in vivo.

Di-(2-ethylhexyl)phthalate (DEHP), when fed at high levels in the diet for two years, is reportedly an hepatocarcinogen to rats and mice. Radioactivity from ethylhexyl-labeled, but not from phthalate-labeled, [14C]-DEHP is associated with highly purified DNA from the livers of treated rats and this radioactivity is not accounted for by assumptions of adsorption, intercalation, attachment to RNA or histones, an impurity in the labeled DEHP, or artifactual binding during sample workup. Spontaneous binding of radioactivity to DNA from either ethylhexyl-labeled DEHP or its total urinary metabolites could not be detected. Although rat liver slices generated all of the known metabolites of DEHP in vitro, no binding to DNA occurred. Administration of dual 3H/14C-labeled DEHP to rats yielded liver DNA whose 3H/14C ratio was inconsistent with the attachment of any reasonable multi-carbon fragment from the ethylhexyl portion to the DNA. The observation that roughly 100 times as high a percentage of the 14C administered was found in urea as in total DNA suggests that the 14C entered DNA through carbamyl phosphate, a precursor of both urea and pyrimidine bases. If this is the case, the association of C-1 from the ethylhexyl portion of DEHP with DNA may not involve alteration of the DNA or genetic damage.

Chromatographic separation and quantitative determination of the metabolites of di-(2-ethylhexyl) phthalate from urine of laboratory animals.

Free, glycine-conjugated, and glucuronide-conjugated metabolites of di-(2-ethylhexyl) phthalate may be stripped from urine with XAD-2 resin, derivatized, and quantitatively analyzed by liquid chromatography on a nitrile column with UV and/or radioactivity monitors. One class of metabolites requires reversed-phase chromatography or gas-liquid chromatography for its resolution. Relative molar responses of the hydrogen flame-ionization detector to these metabolites have been determined. Packed gas chromatography columns (OV-3, OV-210, cyclohexanedimethanol succinate) and fused-silica capillary columns (SP2100 and FFAP) are useful for quantitative analysis under appropriate conditions. The simplest gas chromatographic procedure permitting complete quantitative analysis requires hydrolysis of conjugates, formation of methyl esters of carboxyl groups, butyration of hydroxyl groups and chromatography on OV-3. Typical distributions of di-(2-ethylhexyl) phthalate metabolites in urine from mice, hamsters, and guinea pigs are presented.

Applications of isotope differentiation for metabolic studies with di-(2-ethylhexyl) phthalate.

The pervasiveness of the plasticizer di-(2-ethylhexyl) phthalate (DEHP) in the environment and especially in the laboratory results in a background that may cause severe interference with analytical studies. Animal-to-animal variability in the distribution of DEHP metabolites in excreta normally makes it necessary to use large groups of animals when different treatments are compared. Finally, radioactive tracers are usually considered undesirable for metabolic studies involving human subjects. All of these problems can be overcome through the use of multiple isotopic labels, especially 12C/13C/14C. Examples are given involving rats and monkeys, and applicability to humans is discussed. The principles involved are not limited to any particular class of test compounds. In rats, the competing pathways for metabolism of phthalate esters produce a different distribution of metabolites from a small intravenous dose of DEHP than from a large oral dose.