A large pericardial effusion and bilateral pleural effusions as the initial manifestations of Familial Mediterranean Fever

Familial Mediterranean Fever (FMF) is a condition characterized by recurrent febrile poly-serositis. Typical presentations of the disease include episodes of fever, abdominal pain and joint pains. Chest pain is a less common presentation. We report a case of FMF which presented with a large pericardial effusion and bilateral pleural effusions in a lady who had no positive family history and negative genetic testing.peer-reviewe

Evaluating Mobility as a Service for sustainable travel among young adults

Young adults delay obtaining their driver’s licence, make fewer trips and are more open to using different transport modes. The continuation of this trend as young adults transition from university education into the workforce is less certain. This thesis explores the potential of Mobility as a Service (MaaS) to shift university graduates away from cars and towards public transport and shared mobility services, using the metropolitan city of Birmingham, UK as a case study. MaaS is an app-based scheduling, booking and payment platform for multiple transport modes on a per trip or subscription basis. First, questionnaire survey data was analysed using Ajzen’s Theory of Planned Behaviour to understand multimodal travel behaviour. Second, a discrete choice experiment was used to test the attractiveness of a MaaS subscription relative to conventional transport modes. Third, semi-structured interviews explored the underlying factors influencing graduates’ travel choices as they transition from university education to the workforce using Michie’s Capability, Opportunity and Motivation Behaviour model. The results of the quantitative studies found cost, time, accessibility, and the opinions and behaviour of significant others influence participants’ choice of transport mode. The interviews revealed how students’ negative experiences of using public transport had motivated them to learn to drive, and the transition into the workforce provided the financial means to buy a car. Information and communication technologies were found to play a role in influencing young adults’ travel choices as shown by the reliance on smartphone travel apps. The uptake of MaaS in the current market is optimistic given the relative appeal of its cost, time, and flexibility. The adoption of MaaS among young adults depends on institutional incentives, location, and ease of use. Overall, the flexible multimodal characteristics of MaaS needs strengthening if it is to reduce car-based commuting among new graduate employee

Are low carbon innovations appealing? A typology of functional, symbolic, private and public attributes

Attributes are central to understanding the consumer appeal of low carbon innovations. In this paper we provide a comprehensive understanding of the wide ranging attributes of low carbon innovations. We use a two-by-two dimensional typology which identifies four discrete domains of attribute: private functional, public functional, private symbolic, and public symbolic. Using structured elicitation with over 65 people we examine perceived attributes of 12 consumer innovations in mobility, food, homes and energy. We find that low carbon innovations are relatively unappealing against the private functional and symbolic attributes valued by potential mainstream consumers. This includes features such as money saving, time saving, ease of access, ease of use, trust, and private identity. They are, however, highly appealing against many public functional and symbolic attributes including a range of social and environmental benefits. Food innovations in particular have high social appeal where they support local businesses, protect and build communities around food and build community spirit. Home innovations such as smart appliances and smart lighting are highly appealing because they are novel yet also fit within current social norms. Low carbon innovations based on the sharing economy model offer unique sources of added value related to the creation of social institutions and localised networks. It is important that low carbon innovations are positioned within the marketplace so as to emphasise unique sources of added value within the public domain rather than compete directly with established incumbents whose business models are largely built on volume, scale and costs

The potential contribution of disruptive low-carbon innovations to 1.5 °C climate mitigation

This paper investigates the potential for consumer-facing innovations to contribute emission reductions for limiting warming to 1.5 °C. First, we show that global integrated assessment models which characterise transformation pathways consistent with 1.5 °C mitigation are limited in their ability to analyse the emergence of novelty in energy end-use. Second, we introduce concepts of disruptive innovation which can be usefully applied to the challenge of 1.5 °C mitigation. Disruptive low-carbon innovations offer novel value propositions to consumers and can transform markets for energy-related goods and services while reducing emissions. Third, we identify 99 potentially disruptive low-carbon innovations relating to mobility, food, buildings and cities, and energy supply and distribution. Examples at the fringes of current markets include car clubs, mobility-as-a-service, prefabricated high-efficiency retrofits, internet of things, and urban farming. Each of these offers an alternative to mainstream consumer practices. Fourth, we assess the potential emission reductions from subsets of these disruptive low-carbon innovations using two methods: a survey eliciting experts’ perceptions and a quantitative scaling-up of evidence from early-adopting niches to matched segments of the UK population. We conclude that disruptive low-carbon innovations which appeal to consumers can help efforts to limit warming to 1.5 °C

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

Introduction: The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures. Methods: In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025. Findings: Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2–6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5–5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4–10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32–4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23–11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation. Interpretation: After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification

Clinical associations of Human T-Lymphotropic Virus type 1 infection in an indigenous Australian population.

International audienceIn resource-poor areas, infectious diseases may be important causes of morbidity among individuals infected with the Human T-Lymphotropic Virus type 1 (HTLV-1). We report the clinical associations of HTLV-1 infection among socially disadvantaged Indigenous adults in central Australia. HTLV-1 serological results for Indigenous adults admitted 1(st) January 2000 to 31(st) December 2010 were obtained from the Alice Springs Hospital pathology database. Infections, comorbid conditions and HTLV-1 related diseases were identified using ICD-10 AM discharge morbidity codes. Relevant pathology and imaging results were reviewed. Disease associations, admission rates and risk factors for death were compared according to HTLV-1 serostatus. HTLV-1 western blots were positive for 531 (33.3%) of 1595 Indigenous adults tested. Clinical associations of HTLV-1 infection included bronchiectasis (adjusted Risk Ratio, 1.35; 95% CI, 1.14-1.60), blood stream infections (BSI) with enteric organisms (aRR, 1.36; 95% CI, 1.05-1.77) and admission with strongyloidiasis (aRR 1.38; 95% CI, 1.16-1.64). After adjusting for covariates, HTLV-1 infection remained associated with increased numbers of BSI episodes (adjusted negative binomial regression, coefficient, 0.21; 95% CI, 0.02-0.41) and increased admission numbers with strongyloidiasis (coefficient, 0.563; 95% CI, 0.17-0.95) and respiratory conditions including asthma (coefficient, 0.99; 95% CI, 0.27-1.7), lower respiratory tract infections (coefficient, 0.19; 95% CI, 0.04-0.34) and bronchiectasis (coefficient, 0.60; 95% CI, 0.02-1.18). Two patients were admitted with adult T-cell Leukemia/Lymphoma, four with probable HTLV-1 associated myelopathy and another with infective dermatitis. Independent predictors of mortality included BSI with enteric organisms (aRR 1.78; 95% CI, 1.15-2.74) and bronchiectasis (aRR 2.07; 95% CI, 1.45-2.98). HTLV-1 infection contributes to morbidity among socially disadvantaged Indigenous adults in central Australia. This is largely due to an increased risk of other infections and respiratory disease. The spectrum of HTLV-1 related diseases may vary according to the social circumstances of the affected population

Adjusted Poisson modeling of predictors of HTLV-1 infection.

<p>^a Residence in remote communities relative to the regional center of Alice Springs.</p><p>^b Patients for whom an ICD-10 AM discharge morbidity code of bronchiectasis was recorded and where this was confirmed by HRCT.</p><p>^c Conditions identified from discharge morbidity codes.</p><p>^d Excluding hematological malignancies.</p><p>^e Strongyloides identified by ICD-10 AM code.</p><p>^f Blood stream infections identified from blood cultures. Enteric pathogens, Enterobacteriaceae other than <i>Escherichia coli</i>; skin pathogens, <i>Staphylococcus aureas</i> and <i>Streptococcus pyogenes</i>; respiratory pathogens, <i>Streptococcus pneumoniae</i> and <i>Haemophilus influenzae</i>.</p><p>Abbreviations: BSI, blood stream infection; HBsAg, Hepatitis B surface antigen positive.</p

Results of microbiological tests for 1451 Indigenous Adults admitted 2005–2010^a.

<p>^a Pair-wise comparisons of Strongyloides serological results were Bonferroni-corrected.</p><p>Abbreviations: HBV, hepatitis B virus; anti-HBc, hepatitis B core antibody positive; HBeAg, hepatitis B e antigen positive; HBsAg, hepatitis B surface antigen positive; WB, Western blot.</p