bluuebunny/crossref_metadata_2025 huggingface dataset:
Environmental Survey of Drinking Water Sources in Kampala, Uganda, during a Typhoid Fever Outbreak
Authors: Murphy J. L. , Kahler A. M. , Nansubuga I. , Nanyunja E. M. , Kaplan B. , Jothikumar N. , Routh J. , Gómez G. A. , Mintz E. D. , Hill V. R.
Published: October 2017

In 2015, a typhoid fever outbreak began in downtown Kampala, Uganda, and spread into adjacent districts. In response, an environmental survey of drinking water source types was conducted in areas of the city with high case numbers. A total of 122 samples was collected from 12 source types and tested for
Escherichia coli
, free chlorine, and conductivity. An additional 37 grab samples from seven source types and 16 paired large volume (20 liter) samples from wells and springs were also collected and tested for the presence of
Salmonella enterica
serovar Typhi.
Escherichia coli
was detected in 60% of kaveras (drinking water sold in plastic bags) and 80% of refilled water bottles; free chlorine was not detected in either source type. Most jerry cans (68%) contained
E. coli
and had free chlorine residuals below the WHO-recommended level of 0.5 mg/liter during outbreaks. Elevated conductivity readings for kaveras, refilled water bottles, and jerry cans (compared to treated surface water supplied by the water utility) suggested that they likely contained untreated groundwater. All unprotected springs and wells and more than 60% of protected springs contained
E. coli
. Water samples collected from the water utility were found to have acceptable free chlorine levels and no detectable
E. coli
. While
S
. Typhi was not detected in water samples,
Salmonella
spp. were detected in samples from two unprotected springs, one protected spring, and one refilled water bottle. These data provided clear evidence that unregulated vended water and groundwater represented a risk for typhoid transmission.

IMPORTANCE
Despite the high incidence of typhoid fever globally, relatively few outbreak investigations incorporate drinking water testing. During waterborne disease outbreaks, measurement of physical-chemical parameters, such as free chlorine residual and electrical conductivity, and of microbiological parameters, such as the presence of
E. coli
or the implicated etiologic agent, in drinking water samples can identify contaminated sources. This investigation indicated that unregulated vended water and groundwater sources were contaminated and were therefore a risk to consumers during the 2015 typhoid fever outbreak in Kampala. Identification of contaminated drinking water sources and sources that do not contain adequate disinfectant levels can lead to rapid targeted interventions.
Potentiating Effect of Mandelate and Lactate on Chemically Induced Germination in Members of
Bacillus cereus Sensu Lato
Authors: Bishop Alistair H.
Published: October 2017

Endospores of the genus
Bacillus
can be triggered to germinate by a limited number of chemicals. Mandelate had powerful additive effects on the levels and rates of germination produced in non-heat-shocked spores of
Bacillus anthracis
strain Sterne,
Bacillus cereus
, and
Bacillus thuringiensis
when combined with
l
-alanine and inosine. Mandelate had no germinant effect on its own but was active with these germinants in a dose-dependent manner at concentrations higher than 0.5 mM. The maximum rate and extent of germination were produced in
B. anthracis
by 100 mM
l
-alanine with 10 mM inosine; this was equaled by just 25% of these germinants when supplemented with 10 mM mandelate. Half the maximal germination rate was produced by 40% of the optimum germinant concentrations or 15% of them when supplemented with 0.8 mM mandelate. Germination rates in
B. thuringiensis
were highest around neutrality, but the potentiating effect of mandelate was maintained over a wider pH range than was germination with
l
-alanine and inosine alone. For all species, lactate also promoted germination in the presence of
l
-alanine and inosine; this was further increased by mandelate. Ammonium ions also enhanced
l
-alanine- and inosine-induced germination but only when mandelate was present. In spite of the structural similarities, mandelate did not compete with phenylalanine as a germinant. Mandelate appeared to bind to spores while enhancing germination. There was no effect when mandelate was used in conjunction with nonnutrient germinants. No effect was produced with spores of
Bacillus subtilis
,
Clostridium sporogenes
, or
C. difficile
.

IMPORTANCE
The number of chemicals that can induce germination in the species related to
Bacillus cereus
has been defined for many years, and they conform to specific chemical types. Although not a germinant itself, mandelate has a structure that is different from these germination-active compounds, and its addition to this list represents a significant discovery in the fundamental biology of spore germination. This novel activity may also have important applied relevance given the impact of spores of
B. cereus
in foodborne disease and
B. anthracis
as a threat agent. The destruction of spores of
B. anthracis
, for example, particularly over large outdoor areas, poses significant scientific and logistical problems. The addition of mandelate and lactate to the established mixtures of
l
-alanine and inosine would decrease the amount of the established germinants required and increase the speed and level of germination achieved. The large-scale application of “germinate to decontaminate” strategy may thus become more practicable.
Genetic Dissection of DivIVA Functions in Listeria monocytogenes
Authors: Kaval Karan Gautam , Hauf Samuel , Rismondo Jeanine , Hahn Birgitt , Halbedel Sven
Published: October 2017

DivIVA is a membrane binding protein that clusters at curved membrane regions, such as the cell poles and the membrane invaginations occurring during cell division. DivIVA proteins recruit many other proteins to these subcellular sites through direct protein-protein interactions. DivIVA-dependent functions are typically associated with cell growth and division, even though species-specific differences in the spectrum of DivIVA functions and their causative interaction partners exist. DivIVA from the Gram-positive human pathogen
Listeria monocytogenes
has at least three different functions. In this bacterium, DivIVA is required for precise positioning of the septum at midcell, it contributes to the secretion of autolysins required for the breakdown of peptidoglycan at the septum after the completion of cell division, and it is essential for flagellar motility. While the DivIVA interaction partners for control of division site selection are well established, the proteins connecting DivIVA with autolysin secretion or swarming motility are completely unknown. We set out to identify
divIVA
alleles in which these three DivIVA functions could be separated, since the question of the degree to which the three functions of
L. monocytogenes
DivIVA are interlinked could not be answered before. Here, we identify such alleles, and our results show that division site selection, autolysin secretion, and swarming represent three discrete pathways that are independently influenced by DivIVA. These findings provide the required basis for the identification of DivIVA interaction partners controlling autolysin secretion and swarming in the future.

IMPORTANCE
DivIVA of the pathogenic bacterium
Listeria monocytogenes
is a central scaffold protein that influences at least three different cellular processes, namely, cell division, protein secretion, and bacterial motility. How DivIVA coordinates these rather unrelated processes is not known. We here identify variants of
L. monocytogenes
DivIVA, in which these functions are separated from each other. These results have important implications for the models explaining how DivIVA interacts with other proteins.
Parental experience of interaction with healthcare professionals during their infant’s stay in the neonatal intensive care unit
Authors: Gallagher Katie , Shaw Chloe , Aladangady Narendra , Marlow Neil
Published: October 2017

Objective

To explore the experiences of parents of infants admitted to the neonatal intensive care unit towards interaction with healthcare professionals during their infants critical care.

Design

Semi-structured interviews were conducted with parents of critically ill infants admitted to neonatal intensive care and prospectively enrolled in a study of communication in critical care decision making. Interviews were transcribed verbatim and uploaded into NVivo V.10 to manage and facilitate data analysis. Thematic analysis identified themes representing the data.

Results

Nineteen interviews conducted with 14 families identified 4 themes: (1) initial impact of admission affecting transition into the neonatal unit; (2) impact of consistency of care, care givers and information giving; (3) impact of communication in facilitating or hindering parental autonomy, trust, parental expectations and interactions; (4) parental perception of respect and humane touches on the neonatal unit.

Conclusion

Factors including the context of infant admission, interprofessional consistency, humane touches of staff and the transition into the culture of the neonatal unit are important issues for parents. These issues warrant further investigation to facilitate individualised family needs, attachment between parents and their baby and the professional team.
Mode of delivery and outcomes of infants with gastroschisis: a meta-analysis of observational studies
Authors: Kirollos Dina W , Abdel-Latif Mohamed E
Published: October 2017

Background

There is controversy among the literature for electing caesarean section (CS) delivery for infants with gastroschisis in an attempt to reduce mortality and morbidity.

Objective

This meta-analysis investigates whether there is enough evidence to support CS delivery over vaginal delivery.

Data sources

We conducted our search in April 2017. We searched Cochrane, Medline, Premedline, Embase, CINAHL, GoogleScholar and Web of Science. We also searched conferences for abstracts online. Additional studies were retrieved by reviewing reference lists.

Study selection

Observational studies, excluding case series, were eligible if data compared relevant outcomes of infants with gastroschisis in relation to mode of delivery.

Data extraction

Relevant information were extracted and assessed the methodological quality of the retrieved records.

Results

Thirty-eight studies were included. Evidence suggested that mode of delivery is not significantly associated with overall mortality (OR 0.82, 95% CI 0.57 to 1.18), primary repair (OR 0.82, 95% CI 0.57 to 1.18), neonatal mortality (OR 1.08, 95% CI 0.54 to 2.15), necrotising enterocolitis, secondary repair, sepsis, short gut syndrome, duration until enteral feeding and duration of hospital stay. Furthermore, sensitivity analyses based on economic status and quality of study showed no significant difference between the impact of mode of delivery for all investigated outcomes.

Limitations

Due to uncontrolled variables between and within studies, particularly regarding characteristics of delivery and postdelivery care, it is difficult to extract meaningful results from the literature.

Conclusions

There is insufficient evidence to advocate the use of CS over vaginal delivery for infants with gastroschisis.
Respiratory adaptation in term infants following elective caesarean section
Authors: Finn Daragh , De Meulemeester Julie , Dann Lisa , Herlihy Ita , Livingstone Vicki , Boylan Geraldine B , Ryan C Anthony , Dempsey Eugene M
Published: October 2017

Objective

To determine respiratory rate (RR), tidal volume (TV) and end-tidal carbon dioxide (EtCO2) values in full-term infants immediately after caesarean section, and to assess whether infants that develop transient tachypnoea of the newborn (TTN) follow the same physiological patterns.

Design and patients

A Respironics NM3 Monitor (Philips, Netherlands) continuously measured RR, TV and EtCO2 for 7 min in infants >37 weeks’ gestation following elective caesarean section (ECS). Monitoring was repeated at 2 hours of age for 2 min. Gestation, birth weight, Apgar scores and admissions to neonatal unit were documented.

Setting

The operative delivery theatre of Cork University Maternity Hospital, Ireland.

Results

There were 95 term infants born by ECS included. Median (IQR) gestation was 39 weeks (38.2–39.1) and median (IQR) birth weight 3420 g (3155–3740). Median age at initiation of monitoring was 26.5 s (range: 20–39). Data were analysed for the first 7 min of life. Mean breaths per minute (bpm) increased over the first 7 min of life (44.31–61.62). TV and EtCO2 values were correlated and increased from 1 min until maximum mean values were recorded at 3 min after delivery (5.18 mL/kg–6.44 mL/kg, and 4.32 kPa–5.64 kPa, respectively). Infants admitted to the neonatal unit with TTN had significantly lower RRs from 2 min of age compared with infants not admitted for TTN.

Conclusions

TV and EtCO2 values are correlated and increase significantly over the first few minutes following ECS. RR increases gradually from birth, and rates were lower in infants that develop TTN.
Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review
Authors: Imbulana Dilini I , Manley Brett J , Dawson Jennifer A , Davis Peter G , Owen Louise S
Published: October 2017

Objective

Binasal prongs are the most commonly used interface for the delivery of nasal positive airway pressure (CPAP) to preterm infants. However, they are associated with pressure-related nasal injury, which causes pain and discomfort. Nasal injury may necessitate a change in interface and occasionally damage is severe enough to require surgical repair. We aim to determine the incidence and risk factors for nasal injury in preterm infants, and to provide clinicians with strategies to effectively prevent and treat it.

Design

We conducted a systematic search of databases including MEDLINE (PubMed including the Cochrane Library), EMBASE, CINAHL and Scopus. Included studies enrolled human preterm infants and were published prior to 20 February 2017.

Results

Forty-five studies were identified, including 14 ra ndomised controlled trials, 10 observational studies, two cohort studies, eight case reports and 11 reviews. The incidence of nasal injury in preterm infants ranged from 20–100%. Infants born <30 weeks’ gestation are at highest risk. Strategies shown to reduce nasal injury included: nasal barrier dressings (2 studies, n=244, risk ratio (RD) −0.12, 95%, CI − 0.20 to −0.04), nasal high flow therapy as an alternative to binasal prong CPAP (7 studies, n=1570, risk difference (RD) −0.14, 95% CI −0.17 to −0.10), and nasal masks rather than binasal prongs (5 studies, n=544, RR 0.80, 95% CI 0.64 to 1.00).

Conclusions and relevance

Nasal injury is common in preterm infants born <30 weeks’ gestational age receiving CPAP via binasal prongs. Larger randomised trials are required to fully evaluate strategies to reduce nasal injury.
Thinking outside the box in clinical practice
Authors: Williams Andrew N
Published: October 2017

During difficult times we forget that as healthcare practitioners we are immensely privileged. We have a job, with regular work and generally don’t have to worry about putting food on our families’ table. But from a humanities perspective, we also have front row seats on the drama of life and no two days can be the same. Yet as we struggle to master our profession, the day to day realities of the job itself struggles to master us. If we become ‘too hard’ we may be fully competent yet fail to discharge our duties properly; however, should we become ‘too soft’, we may find ourselves not being able to discharge those duties at all. Striking that ‘happy’ balance is a decision we each make for ourselves every day during our decades of practice. For me, it has been necessary from the outset to include medical humanities within the clinico-medical perspective of daily practice. My definition of Medical Humanities will not only include medical history but also, stories, films and plays. This article relates some practices which I have found useful.
Isolated ascites in a newborn with ‘apple peel’ jejunal atresia
Authors: Osmulikevici Otilia , Renji Elizabeth , Jaffray Bruce , Embleton Nicholas
Published: October 2017

Isolated fetal ascites was diagnosed at 20 weeks in a primiparous woman with no significant medical history. Progressive fetal ascites worsened after 28 weeks and resulted in fetal hydroceles. Delivery was by caesarian section at 33 weeks, preceded by reduction of fetal ascites under ultrasound guidance. Following delivery, the baby required further reduction of abdominal fluid and endotracheal intubation to provide respiratory support. An extensive set of investigations, including metabolic and genetic screening, was performed; all results were negative. On day two of life, the baby developed bilious aspirates and an abdominal radiograph suggested intestinal obstruction. At laparotomy, an ‘apple peel’ jejunal atresia, abnormal mesentery with precarious blood supply and a proximal perforation were identified and the perforation ‘sewn over’. The postoperative course was unremarkable, with Monogen feeds tolerated three weeks later. The baby continued to thrive at one year, tolerating increasing amount of long-chain fatty acids in diet.
Differences in clinical ocular outcomes between exogenous and endogenous endophthalmitis caused by Sporothrix: a systematic review of published literature
Authors: Ramírez Soto Max Carlos
Published: October 2017

Background

Sporotrichosis is an implantation mycosis caused by Sporothrix species prevalent worldwide, which occasionally can also result in intraocular infection presenting as an exogenous or endogenous infection (disseminated sporotrichosis). Knowledge in its clinical recognition and management is limited.

Aims

To systematically review and analyse data from published literature with a view to comparing clinical outcomes between exogenous and endogenous endophthalmitis caused by Sporothrix.

Methods

Case reports of intraocular sporotrichosis, published from 1960 to 2016, were retrieved from MEDLINE, Embase, Cochrane, LILACS and SciELO databases. The entire data set was divided into two patient groups: (1) exogenous endophthalmitis and (2) endogenous endophthalmitis. Primary outcomes were differences in ocular findings and clinical ocular outcomes between the two groups.

Results

From 16 publications retrieved, a total of 8 eyes of 8 patients with exogenous endophthalmitis and 13 eyes of 10 patients with endogenous endophthalmitis were identified. Compared with exogenous endophthalmitis, endogenous endophthalmitis was more common in patients infected with HIV (p=0.001) and those from hyperendemic areas (p=0.036). Anterior uveitis (p=0.015) and posterior uveitis (p=0.04) were more common in the exogenous and endogenous endophthalmitis groups, respectively. The majority of patients with endogenous endophthalmitis had partial or full clinical resolution of ocular lesions with systemic amphotericin B alone or in combination with an oral antifungal, whereas patients with exogenous endophthalmitis had poor outcomes with irreversible vision loss, enucleation and evisceration.

Conclusions

Anterior uveitis is more common in exogenous endophthalmitis with worse overall outcomes and complications, compared with endogenous endophthalmitis where posterior uveitis is the most common clinical manifestation, especially in patients infected with HIV and those from hyperendemic areas. Sporothrix infection should be included in the differential diagnosis for ocular inflammation, regardless of the presence or absence of autoimmune comorbidities and whether the patient resides in an endemic area or not. Ophthalmologists should consider intravitreal and systemic antifungal therapy for exogenous and endogenous endophthalmitis caused by Sporothrix.
Risk factors for extraophthalmic involvement and treatment outcomes in patients with IgG4-related ophthalmic disease
Authors: Park Jinku , Lee Min Joung , Kim Namju , Kim Ji Eun , Park Sun-Won , Choung Ho-Kyung , Khwarg Sang In
Published: October 2017

Background/aim

To analyse the clinical risk factors for extraophthalmic involvement and treatment outcomes in patients with IgG4-related ophthalmic disease (IgG4-ROD) in Korea.

Methods

We retrospectively reviewed medical records of 42 patients diagnosed with IgG4-ROD confirmed by a surgical biopsy during the 7-year period, between January 2009 and March 2015, at three tertiary referral centres in Korea. Data regarding patients’ demographics, clinical characteristics and radiological findings were obtained. The relapse rate was compared between systemic steroids only and combined immunosuppressant therapy.

Results

The mean patient age was 55.2 years (male:female ratio, 1:1). Based on the primary orbital structure affected, the IgG4-RODs were classified as dacryoadenitis (52.4%), orbital soft tissue inflammation (21.4%), trigeminal nerve involvement (11.9%) and myositis (9.5%). Extraophthalmic involvement (n=21) was associated with bilateral involvement (p=0.004), longer symptom duration (p=0.033) and a higher serum IgG4 level (p=0.034). Initial treatment regimens included attentive observation (n=7), prednisolone alone (n=22) and prednisolone plus immunosuppressive agent (n=13). During follow-up (mean, 24 months), 13 patients (37.1%) experienced relapse. In the extraophthalmic involvement group, steroid therapy alone resulted in a significantly higher relapse rate than combined immunosuppressant treatment (p=0.028).

Conclusion

Bilateral involvement, longer symptom duration and higher IgG4 levels were significant risk factors for extraophthalmic involvement in Korean patients with IgG4-ROD. In patients with an extraophthalmic involvement, prednisolone combined with an immunosuppressive agent was more effective for preventing recurrence than prednisolone alone.
Tolerable rates of visual field progression in a population-based sample of patients with glaucoma
Authors: Salonikiou Angeliki , Founti Panayiota , Kilintzis Vassilis , Antoniadis Antonis , Anastasopoulos Eleftherios , Pappas Theofanis , Raptou Anastasia , Topouzis Fotis
Published: October 2017

Aims

To provide population-based data on the maximum tolerable rate of progression to avoid visual impairment (maxTRoP_VI) and blindness (maxTRoP_BL) from open-angle glaucoma (OAG).

Methods

Participants with OAG in the Thessaloniki Eye Study (cross-sectional, population-based study in a European population) were included in the analysis. Visual impairment was defined as mean deviation (MD) equal to or worse than −12dB and blindness as MD equal to or worse than −24dB. Additional thresholds for visual impairment were tested. For each participant maxTRoP_VI was defined as the rate of progression which would not lead to visual impairment during expected lifetime. MaxTRoP_BL was defined accordingly. Both parameters were calculated for each OAG subject using age, sex, MD and life expectancy data. The eye with the better MD per subject was included in the analysis.

Results

Among 135 subjects with OAG, 123 had reliable visual fields and were included in the analysis. The mean age was 73±6 years and the median MD was −3.65±5.28dB. Among those, 69.1% would have a maxTRoP_VI slower than −1dB/year and 18.7% would have a maxTRoP_VI between −1 and −2dB/year. Also, 72.4% would have a maxTRoP_BL slower than −2dB/year. For all tested thresholds for visual impairment, approximately 86% of the OAG study participants would not be able to tolerate a rate of progression equal to or faster than −2dB/year.

Conclusions

The majority of patients with glaucoma in our study would have a maximum tolerable rate of progression slower than −1dB/year in their better eye. Patient-tailored strategies to monitor the visual field are important, but raise the issue of feasibility with regard to the number of visual field tests needed.
Green emission fluorophores in eyes with atrophic age-related macular degeneration: a colour fundus autofluorescence pilot study
Authors: Borrelli Enrico , Lei Jianqin , Balasubramanian Siva , Uji Akihito , Cozzi Mariano , Sarao Valentina , Lanzetta Paolo , Staurenghi Giovanni , Sadda SriniVas R
Published: October 2017

Background/Aims

To investigate the presence of short-wave fluorophores within regions of age-related macular degeneration (AMD)-associated macular atrophy (MA) area.

Methods

This is a prospective, observational, cross-sectional case series. 25 eyes (18 patients) with late AMD and clinically identified MA were enrolled. Eyes were imaged using a confocal light-emitting diode blue-light fundus autofluorescence (FAF) device (EIDON, CenterVue, Padua, Italy) with 450 nm excitation wavelength and the capability for ‘colour’ FAF imaging, including both the individual red and green components of the emission spectrum. To produce images with a high contrast for isolating the green component, the red component was subtracted from the total FAF image. The main outcome measure was the presence of green emission fluorescence component (GEFC) within the MA area. Volume spectral domain optical coherence tomography (SD-OCT) scans were obtained through the macula and the OCT was correlated with the MA lesions identified on the FAF images, including regions of increased GEFC.

Results

Of the investigated eyes, 11 out of 25 (44.0 %) showed the absence of GEFC in the MA area, whereas 14 eyes (56.0%) were characterised by GEFC within the MA area. The presence and distribution of GEFC in the MA area correlated with the presence of hyper-reflective material over Bruch’s membrane on the corresponding SD-OCT scans.

Conclusion

Short-wave fluorophores, which contribute to the GEFC, are present in the MA area and appear to correspond to residual debris or drusenoid material. Short-wavelength fluorophores revealed by colour FAF imaging may warrant further study.
Are there researcher allegiance effects in diagnostic validation studies of the PHQ-9? A systematic review and meta-analysis
Authors: Manea Laura , Boehnke Jan Rasmus , Gilbody Simon , Moriarty Andrew S , McMillan Dean
Published: October 2017

Objectives

To investigate whether an authorship effect is found that leads to better performance in studies conducted by the original developers of the Patient Health Questionnaire (PHQ-9) (allegiant studies).

Design

Systematic review with random effects bivariate diagnostic meta-analysis. Search strategies included electronic databases, examination of reference lists and forward citation searches.

Inclusion criteria

Included studies provided sufficient data to calculate the diagnostic accuracy of the PHQ-9 against a gold standard diagnosis of major depression using the algorithm or the summed item scoring method at cut-off point 10.

Data extraction

Descriptive information, methodological quality criteria and 2×2 contingency tables.

Results

Seven allegiant and 20 independent studies reported the diagnostic performance of the PHQ-9 using the algorithm scoring method. Pooled diagnostic OR (DOR) for the allegiant group was 64.40, and 15.05 for non-allegiant studies group. The allegiance status was a significant predictor of DOR variation (p<0.0001).

Five allegiant studies and 26 non-allegiant studies reported the performance of the PHQ-9 at recommended cut-off point of 10. Pooled DOR for the allegiant group was 49.31, and 24.96 for the non-allegiant studies. The allegiance status was a significant predictor of DOR variation (p=0.015).

Some potential alternative explanations for the observed authorship effect including differences in study characteristics and quality were found, although it is not clear how some of them account for the observed differences.

Conclusions

Allegiant studies reported better performance of the PHQ-9. Allegiance status was predictive of variation in the DOR. Based on the observed differences between independent and non-independent studies, we were unable to conclude or exclude that allegiance effects are present in studies examining the diagnostic performance of the PHQ-9. This study highlights the need for future meta-analyses of diagnostic validation studies of psychological measures to evaluate the impact of researcher allegiance in the primary studies.
Attitudes and perceptions of GPs and community pharmacists towards their role in the prevention of bisphosphonate-related osteonecrosis of the jaw: a qualitative study in the North East of England
Authors: Sturrock Andrew , Preshaw Philip , Hayes Catherine , Wilkes Scott
Published: October 2017

Background

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a rare, yet significant, adverse effect of bisphosphonate therapy. A multidisciplinary approach to the prevention of BRONJ is recommended due to the significant morbidity and difficulty treating the condition. Current evidence suggests that both general practitioners (GPs) and community pharmacists have limited knowledge relating to BRONJ and that preventative strategies are rarely implemented.

Objective

To explore the attitudes and perceptions of GPs and community pharmacists on the risks and preventative strategies for the development of BRONJ.

Design

Interpretivist methodological approach using qualitative semistructured interviews.

Participants

9 community pharmacists and 8 GPs.

Setting

Primary Care in North East England and Cumbria, UK.

Methods

Using a Grounded Theory methodology and integrating a process of constant comparison in the iterative enrichment of data sets, semistructured interviews were undertaken, transcribed and analysed using framework analysis. Salient themes were identified and related back to extant literature in the field.

Results

Four salient and inter-related themes emerged: (1) uncertain knowledge, indicating limited exposure of respondents to BRONJ, and limited awareness of the implications of its diagnosis, risk factors and preventative strategies; (2) patient specific, referring to the complexity of patients, patient education and prioritising aspects of care; (3) wider context, indicating a lack of interdisciplinary communication and referral processes between professions, workload pressures, access and patient receptivity to dental services; and (4) professional, reflecting professional roles and responsibilities, authority and educational initiatives

Conclusions

Effective communication or collaborative care between GPs and community pharmacists for the prevention of BRONJ is not apparent. Interventions to mitigate against the risk of developing BRONJ and clarity of GP and community pharmacy roles are required.
Quantifying sociodemographic and income disparities in medical therapy and lifestyle among symptomatic patients with suspected coronary artery disease: a cross-sectional study in North America
Authors: Ladapo Joseph A , Coles Adrian , Dolor Rowena J , Mark Daniel B , Cooper Lawton , Lee Kerry L , Goldberg Jonathan , Shapiro Michael D , Hoffmann Udo , Douglas Pamela S
Published: October 2017

Objectives

To evaluate potential gaps in preventive medical therapy and healthy lifestyle practices among symptomatic patients with suspected coronary artery disease (CAD) seeing primary care physicians and cardiologists and how gaps vary by sociodemographic characteristics and baseline cardiovascular risk.

Design

Cross-sectional study assessing potential preventive gaps.

Participants

10 003 symptomatic outpatients evaluated by primary care physicians, cardiologists or other specialists for suspected CAD.

Setting

PROspective Multicenter Imaging Study for Evaluation of Chest Painfrom 2010 to 2014.

Measures

Primary measures were absence of an antihypertensive, statin or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker for renal protection in patients with hypertension, dyslipidaemia or diabetes, respectively, and being sedentary, smoking or being obese.

Results

Preventive treatment gaps affected 14% of patients with hypertension, 36% of patients with dyslipidaemia and 32% of patients with diabetes. Overall, 49% of patients were sedentary, 18% currently smoked and 48% were obese. Women were significantly more likely to not take a statin for dyslipidaemia and to be sedentary. Patients with lower socioeconomic status were also significantly more likely to not take a statin. Compared with Whites, Blacks were significantly more likely to be obese, while Asians were less likely to smoke or be obese. High-risk patients sometimes experienced larger preventive care gaps than low-risk patients. For patients with dyslipidaemia, the presence of a treatment gap was associated with a higher risk of an adverse event (HR 1.35, 95% CI 1.02 to 1.82).

Conclusions

Among contemporary, symptomatic patients with suspected CAD, significant gaps exist in preventive care and lifestyle practices, and high-risk patients sometimes had larger gaps. Differences by sex, age, race/ethnicity, socioeconomic status and geography are modest but contribute to disparities and have implications for improving opulation health. For patients with dyslipidaemia, the presence of a treatment gap was associated with a higher risk of an adverse event.

Clinical trial registration

Clinical Trials.gov identifierNCT01174550.
How health service delivery guides the allocation of major trauma patients in the intensive care units of the inclusive (hub and spoke) trauma system of the Emilia Romagna Region (Italy). A cross-sectional study
Authors: Chieregato Arturo , Volpi Annalisa , Gordini Giovanni , Ventura Chiara , Barozzi Marco , Caspani Maria Luisa Rita , Fabbri Andrea , Ferrari Anna Maria , Ferri Enrico , Giugni Aimone , Marino Massimiliano , Martino Costanza , Pizzamiglio Mario , Ravaldini Maurizio , Russo Emanuele , Trabucco Laura , Trombetti Susanna , De Palma Rossana
Published: October 2017

Objective

To evaluate cross-sectional patient distribution and standardised 30-day mortality in the intensive care units (ICU) of an inclusive hub and spoke trauma system.

Setting

ICUs of the Integrated System for Trauma Patient Care (SIAT) of Emilia-Romagna, an Italian region with a population of approximately 4.5 million.

Participants

5300 patients with an Injury Severity Score (ISS) >15 were admitted to the regional ICUs and recorded in the Regional Severe Trauma Registry between 2007 and 2012. Patients were classified by the Abbreviated Injury Score as follows: (1) traumatic brain injury (2) multiple injuriesand (3) extracranial lesions. The SIATs were divided into those with at least one neurosurgical level II trauma centre (TC) and those with a neurosurgical unit in the level I TC only.

Results

A higher proportion of patients (out of all SIAT patients) were admitted to the level I TC at the head of the SIAT with no additional neurosurgical facilities (1083/1472, 73.6%) compared with the level I TCs heading SIATs with neurosurgical level II TCs (1905/3815; 49.9%). A similar percentage of patients were admitted to level I TCs (1905/3815; 49.9%) and neurosurgical level II TCs (1702/3815, 44.6%) in the SIATs with neurosurgical level II TCs. Observed versus expected mortality (OE) was not statistically different among the three types of centre with a neurosurgical unit; however, the best mean OE values were observed in the level I TC in the SIAT with no neurosurgical unit.

Conclusion

The Hub and Spoke concept was fully applied in the SIAT in which neurosurgical facilities were available in the level I TC only. The performance of this system suggests that competition among level I and level II TCs in the same Trauma System reduces performance in both. The density of neurosurgical centres must be considered by public health system governors before implementing trauma systems.
Understanding patients’ experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography
Authors: Rodríguez-Prat Andrea , Balaguer Albert , Booth Andrew , Monforte-Royo Cristina
Published: October 2017

Objectives

Patients with advanced disease sometimes express a wish to hasten death (WTHD). In 2012, we published a systematic review and meta-ethnography of qualitative studies examining the experience and meaning of this phenomenon. Since then, new studies eligible for inclusion have been reported, including in Europe, a region not previously featured, and specifically in countries with different legal frameworks for euthanasia and assisted suicide. The aim of the present study was to update our previous review by including new research and to conduct a new analysis of available data on this topic.

Setting

Eligible studies originated from Australia, Canada, China, Germany, The Netherlands, Switzerland, Thailand and USA.

Participants

Studies of patients with life-threatening conditions that had expressed the WTHD.

Design

The search strategy combined subject terms with free-text searching of PubMed MEDLINE, Web of Science, CINAHL and PsycInfo. The qualitative synthesis followed the methodology described by Noblit and Hare, using the ‘adding to and revising the original’ model for updating a meta-ethnography, proposed by Franceet al. Quality assessment was done using the Critical Appraisal Skills Programme checklist.

Results

14 studies involving 255 participants with life-threatening illnesses were identified. Five themes emerged from the analysis: suffering (overarching theme), reasons for and meanings and functions of the WTHD and the experience of a timeline towards dying and death. In the context of advanced disease, the WTHD emerges as a reaction to physical, psychological, social and existential suffering, all of which impacts on the patient’s sense of self, of dignity and meaning in life.

Conclusions

The WTHD can hold different meanings for each individual—serving functions other than to communicate a genuine wish to die. Understanding the reasons for, and meanings and functions of, the WTHD is crucial for drawing up and implementing care plans to meet the needs of individual patients.
Study protocol for a longitudinal study evaluating the impact of rape on women’s health and their use of health services in South Africa
Authors: Abrahams Naeemah , Seedat Soraya , Lombard Carl , Kengne Andre P , Myers Bronwyn , Sewnath Alesha , Mhlongo Shibe , Ramjee Gita , Peer Nasheeta , Garcia-Moreno Claudia , Jewkes Rachel
Published: October 2017

Introduction

South Africa is a country known for its high levels of HIV infection and sexual violence. Although the interface between gender-based violence, HIV and mental health has been described, there are substantial gaps in knowledge of the medium-term and long-term health impact. The 2010 Global Burden of Disease study excluded many health outcomes associated with rape and other forms of gender-based violence because systematic reviews revealed huge gaps in data and poor evidence of health effects. This study aims to describe the incidence and attributable burden of physical and mental health problems (including HIV acquisition) in adult women over a 2-year postrape period, through comparison with a cohort of women who have not been raped. The study will substantially advance our understanding of the impact of rape and will generate robust data to assist in the development of postrape health services and the delivery of evidence-based care.

Methods and analysis

This longitudinal study seeks to recruit 1008 rape-exposed and 1008 rape non-exposed women. Women were recruited from health services, and assessments were carried out at baseline, 3, 6, 9, 12, 18 and 24 months. Outcome measures include exposure to risk factors; mental health status; cardio-metabolic risks; and biomarkers for HIV, sexually transmitted infections, pregnancy and stress. The primary analysis will be to compare HIV incidence in the two groups using log-rank tests. Appropriate models to predict health outcomes over time will also be applied.

Ethics and dissemination

The South African Medical Research Council’s Ethics Committee approved the study. As rape is a key element of the study, the safety and protection of participants guides the research process. We will adopt a research uptake strategy to ensure dissemination to policy makers, service providers and advocacy groups. Peer-reviewed journal articles will be published.
Association between eczema and major cardiovascular outcomes in population-based studies: a systematic review protocol
Authors: Ascott Anna , Yu Ashley M , Schmidt Morten , Abuabara Katrina , Smeeth Liam , Langan Sinéad M
Published: October 2017

Introduction

Chronic inflammatory diseases such as eczema (also known as atopic dermatitis) have been inconsistently linked to cardiovascular disease and stroke in both mechanistic and epidemiological studies. There is a need to review the existing epidemiological data examining the association between eczema and major cardiovascular outcomes, including angina, myocardial infarction, coronary revascularisation, heart failure, cardiac arrhythmias, stroke and cardiovascular death, in order to improve our understanding of the comorbidities of eczema.

Methods and analysis

We will systematically review population-based studies, including cohort, case–control and cross-sectional studies, reporting on the association between eczema and cardiovascular outcomes. We will search Medline, Embase and Global Health, from their date of inception to April 2017, using a comprehensive search strategy formulated with the help of a librarian. Two reviewers will independently screen titles and abstracts in duplicate, followed by independent data extraction and quality assessment. We will group studies by the cardiovascular outcome under study and synthesise them narratively. If sufficient numbers of homogeneous studies are returned, we will perform meta-analyses to obtain pooled effect estimates. Preferred Reporting Items for Systematic Review and Meta-Analysis will be used to inform the reporting of this study.

Trial registration number

CRD42017060359.
To GP or not to GP: a natural experiment in children triaged to see a GP in a tertiary paediatric emergency department (ED)
Authors: Smith Laurie , Narang Yajur , Ibarz Pavon Ana Belen , Edwardson Karl , Bowers Simon , Jones Katharine , Lane Steve , Ryan Mary , Taylor-Robinson David , Carrol Enitan
Published: October 2017

Objective

To evaluate the impact of integrating a general practitioner (GP) into a tertiary paediatric emergency department (ED) on admissions, waiting times and antibiotic prescriptions.

Design

Retrospective cohort study.

Setting

Alder Hey Children’s NHS Foundation Trust, a tertiary paediatric hospital in Liverpool, UK.

Participants

From October 2014, a GP was colocated within the ED, from 14:00 to 22:00 hours, 7 days a week. Children triaged green on the Manchester Triage System without any comorbidities were classed as ‘GP appropriate’. The natural experiment compared patients triaged as ‘GP appropriate’ and able to be seen by a GP between 14:00 and 22:00 hours (GP group) to patients triaged as ‘GP appropriate’ seen outside of the hours when a GP was available (ED group). Intention-to-treat (ITT) analysis was used to assess the main outcomes.

Results

5223 patients were designated as ‘GP appropriate’—18.2% of the total attendances to the ED over the study period. There were 2821 (54%) in the GP group and 2402 (46%) in the ED group. The median duration of stay in the ED was 94 min (IQR 63–141) for the GP group compared with 113 min (IQR 70–167) for the ED group (p<0.0005). Using the ITT analysis equivalent, we demonstrated that the GP group were less likely to: be admitted to hospital (2.2% vs 6.5%, OR 0.32, 95% CI 0.24 to 0.44), wait longer than 4 hours (2.3% vs 5.1%, OR 0.45, 95% CI 0.33 to 0.61) or leave before being seen (3.1% vs 5.7%, OR 0.53, 95% CI 0.41 to 0.70), but more likely to receive antibiotics (26.1% vs 20.5%, OR 1.37, 95% CI 1.10 to 1.56). Sensitivity analyses yielded similar results.

Conclusions

Introducing a GP to a paediatric ED service can significantly reduce waiting times and admissions, but may lead to more antibiotic prescribing. This study demonstrates a novel, potentially more efficient ED care pathway in the current context of rising demand for children’s emergency services.
Emergency consultants value medical scribes and most prefer to work with them, a few would rather not: a qualitative Australian study
Authors: Cowan Timothy Luke , Dunlop William A , Ben-Meir Michael , Staples Margaret , Treadwell Ainsley , Gardner-Brunton Eliza , Walker Katherine Justice
Published: October 2017

Objective

The utilisation of medical scribes in the USA has enabled productivity gains for emergency consultants, though their personal experiences have not been widely documented. We aimed to evaluate the consultant experience of working with scribes in an Australian ED.

Methods

Emergency consultants working with scribes and those who declined to work with scribes were invited to participate in individual interviews (structured and semistructured questions) about scribes, scribe work and the scribe program in October 2016.

Results

Of 16 consultants, 13 participated in interviews, that is, 11 worked with scribes and 2 did not and 3 left Cabrini prior to the interviews. Consultants working with scribes found them most useful for capturing initial patient encounters, for finding information and completing discharge tasks. Scribes captured more details than consultants usually did. Editing was required for omissions, misunderstandings and rearranging information order, but this improved with increasing scribe experience. Consultants described changing their style to give more information to the patient in the room. Consultants felt more productive and able to meet demands. They also described enjoyment, less stress, less cognitive loading, improved ability to multitask, see complex patients and less fatigue.

In interviews with the two consultants declining scribes, theme saturation was not achieved. Consultants declining scribes preferred to work independently. They did not like templated notes and felt that consultation nuances were lost. They valued their notes write-up time as time for cognitive processing of the presentation. They thought the scribe and computer impacted negatively on communication with the patient.

Conclusion

Medical scribes were seen to improve physician productivity, enjoyment at work, ability to multitask and to lower stress levels. Those who declined scribes were concerned about losing important nuances and cognitive processing time for the case.
Diagnostic accuracy of fungal PCR and β-d-glucan for detection of candidaemia: a preliminary evaluation
Authors: McKeating Cara , White P Lewis , Posso Raquel , Palmer Michael , Johnson Elizabeth , McMullan Ronan
Published: October 2017

Aims

Although treatment for candidaemia is time critical, culture-based tests prolong turnaround times and may promote underdiagnosis. Non-culture-based tests have the potential to overcome these difficulties but are in limited clinical use. The aim of this work was to undertake an initial evaluation of two non-culture-based tests for diagnosis of candidaemia.

Methods

Patients with candidaemia were identified prospectively over a 4-month period. Sera drawn from case (candidaemic) and control (non-candidaemic) patients on the same day as the positive blood culture were tested with both the Renishaw RenDx Fungiplex test and a commercial β-d-glucan (BDG) assay (Fungitell, Associates of Cape Cod). Sensitivity and specificity were calculated independently and in combination, using paired blood culture as the reference standard.

Results

There were 10 eligible case patients and 39 negative controls. PCR sensitivity and specificity were found to be 44.4% (95% CI 18.9% to 73.3%) and 87.2% (72.8% to 94.8%), respectively. BDG sensitivity and specificity were 80% (47.9% to 95.4%) and 89.7% (75.9% to 96.5%), respectively. When combining PCR and BDG, sensitivity was 90% (95% CI 57.4% to 100%) and specificity was 79.5% (64.2% to 89.5%). When two sequential specimens were tested, PCR sensitivity increased to 60% (95% CI 31.2% to 83.3%) and BDG sensitivity to 90% (54.7% to 100%).

Conclusion

A combination of tests, or a single test at multiple time points, may be preferable to relying on one test at a single time point. This should be accounted for in design of future diagnostic accuracy studies of tests for invasive candidosis.