Advance care planning documentation strategies; goals-of-care as an alternative to not-for-resuscitation in medical and oncology patients. A pre-post controlled study on quantifiable outcomes

Background: Health services in Tasmania, Victoria and now Western Australia are changing to goals-of-care (GOC) advance care planning (ACP) documentation strategies. Aim: To compare the clinical impact of two different health department-sanctioned ACP documentation strategies. Methods: A non-blinded, pre–post, controlled study over two corresponding 6-month periods in 2016 and 2017 comparing the current discretional not-for-resuscitation (NFR) with a new, inclusive GOC strategy in two medical/oncology wards at a large private hospital. Main outcomes were the uptake of ACP forms per hospitalisation and the timing between hospital admission, ACP form completion and in-patient death. Secondary outcomes included utilisation of the rapid response team (RRT), palliative and critical care services. Results: In total, 650 NFR and 653 GOC patients underwent 1885 admissions (mean Charlson Comorbidity Index = 3.7). GOC patients had a higher uptake of ACP documentation (346 vs 150 ACP forms per 1000 admissions, P \u3c 0.0001) and a higher proportion of ACP forms completed within the first 48 h of admission (58 vs 39%, P = 0.0002) but a higher incidence of altering the initial ACP level of care (P = 0.003). All other measures, including ACP documentation within 48 h of death (P = 0.50), activation of RRT (P = 0.73) and admission to critical (P = 0.62) or palliative (P = 0.81) care services, remained similar. GOC documentation was often incomplete, with most sub-sections left blank between 74 and 87% of occasions. Conclusion: Despite an increased uptake of the GOC form, overall use remained low, written completion was poor, and most quantitative outcomes remained statistically unchanged. Further research is required before a wider GOC implementation can be supported in Australia’s healthcare systems

Visualisation of BioPAX Networks using BioLayout Express (3D).

BioLayout Express (3D) is a network analysis tool designed for the visualisation and analysis of graphs derived from biological data. It has proved to be powerful in the analysis of gene expression data, biological pathways and in a range of other applications. In version 3.2 of the tool we have introduced the ability to import, merge and display pathways and protein interaction networks available in the BioPAX Level 3 standard exchange format. A graphical interface allows users to search for pathways or interaction data stored in the Pathway Commons database. Queries using either gene/protein or pathway names are made via the cPath2 client and users can also define the source and/or species of information that they wish to examine. Data matching a query are listed and individual records may be viewed in isolation or merged using an 'Advanced' query tab. A visualisation scheme has been defined by mapping BioPAX entity types to a range of glyphs. Graphs of these data can be viewed and explored within BioLayout as 2D or 3D graph layouts, where they can be edited and/or exported for visualisation and editing within other tools

Cognitive behavioural therapy for tinnitus (Protocol)

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects and safety of CBT for tinnitus in adults

Distributed N-body Simulation on the Grid Using Dedicated Hardware

We present performance measurements of direct gravitational N -body simulation on the grid, with and without specialized (GRAPE-6) hardware. Our inter-continental virtual organization consists of three sites, one in Tokyo, one in Philadelphia and one in Amsterdam. We run simulations with up to 196608 particles for a variety of topologies. In many cases, high performance simulations over the entire planet are dominated by network bandwidth rather than latency. With this global grid of GRAPEs our calculation time remains dominated by communication over the entire range of N, which was limited due to the use of three sites. Increasing the number of particles will result in a more efficient execution. Based on these timings we construct and calibrate a model to predict the performance of our simulation on any grid infrastructure with or without GRAPE. We apply this model to predict the simulation performance on the Netherlands DAS-3 wide area computer. Equipping the DAS-3 with GRAPE-6Af hardware would achieve break-even between calculation and communication at a few million particles, resulting in a compute time of just over ten hours for 1 N -body time unit. Key words: high-performance computing, grid, N-body simulation, performance modellingComment: (in press) New Astronomy, 24 pages, 5 figure

Non-random escape pathways from a broadly neutralizing human monoclonal antibody map to a highly conserved region on the hepatitis C virus E2 glycoprotein encompassing amino acids 412-423

A challenge for hepatitis C virus (HCV) vaccine development is to define epitopes that are able to elicit protective antibodies against this highly diverse virus. The E2 glycoprotein region located at residues 412-423 is conserved and antibodies to 412-423 have broadly neutralizing activities. However, an adaptive mutation, N417S, is associated with a glycan shift in a variant that cannot be neutralized by a murine but by human monoclonal antibodies (HMAbs) against 412-423. To determine whether HCV escapes from these antibodies, we analyzed variants that emerged when cell culture infectious HCV virions (HCVcc) were passaged under increasing concentrations of a specific HMAb, HC33.1. Multiple nonrandom escape pathways were identified. Two pathways occurred in the context of an N-glycan shift mutation at N417T. At low antibody concentrations, substitutions of two residues outside of the epitope, N434D and K610R, led to variants having improved in vitro viral fitness and reduced sensitivity to HC33.1 binding and neutralization. At moderate concentrations, a S419N mutation occurred within 412-423 in escape variants that have greatly reduced sensitivity to HC33.1 but compromised viral fitness. Importantly, the variants generated from these pathways differed in their stability. N434D and K610R-associated variants were stable and became dominant as the virions were passaged. The S419N mutation reverted back to N419S when immune pressure was reduced by removing HC33.1. At high antibody concentrations, a mutation at L413I was observed in variants that were resistant to HC33.1 neutralization. Collectively, the combination of multiple escape pathways enabled the virus to persist under a wide range of antibody concentrations. Moreover, these findings pose a different challenge to vaccine development beyond the identification of highly conserved epitopes. It will be necessary for a vaccine to induce high potency antibodies that prevent the formation of escape variants, which can co-exist with lower potency or levels of neutralizing activities

The puzzle of long-term morbidity after critical illness

Data continue to emerge demonstrating the poor quality of life of ICU survivors in the months and years following critical illness. In this issue of Critical Care, Cuthbertson and colleagues present new data on quality of life from a cohort of ICU survivors who were followed for 5 years. They found that survivors had poor physical quality of life and low quality adjusted life-years in comparison to age-adjusted norms, describing the long-term impact of critical illness as similar to a co-morbidity. Studies are now needed that seek to identify potentially modifiable factors both during and following an ICU admission to allow for eventual improvement in long-term morbidity. Such studies will likely need to incorporate extensive planning for data collection, as well as coordinated linkage with other available datasets that include substantial amounts of patient information from outside of the ICU