Feasibility and evaluation of an emergency department‐based general practitioner streaming and treatment service

Rationale Offering a primary care service that can provide good quality primary care at emergency departments may reduce pressure on usual emergency department (ED) services. Aims and Objectives To evaluate the acceptability, satisfaction, and potential impacts of a co-located primary care service at an emergency department. Methods This is a prospective feasibility study and service evaluation comprising a narrative summary of activity, satisfaction, well-being, and safety, and comparisons of wait times for ED services by patient category (‘minor’, ‘majors’, ‘paediatric’ or ‘resus’) before and during the service operation. Patients and staff were asked using semistructured interview topic guides about service perception, well-being, representation within 48 h, safety concerns, and/or satisfaction. Wait times for patient categories in usual ED care service were in secondary care electronic records. Pathway changes were captured under primary care electronic records. Results Approximately 96% of general practitioner streaming and treatment (GPST) patients were seen within 1 h. There was a statistically significant reduction in ED patients with minor injuries or illnesses waiting >4 h for admission or discharge ‘breaches’ during the 3 months that GPST was operating compared with the previous 3 months (p ≤ 0.005). Wait times for other ED services did not significantly improve. A total of 769 walk-in patients received GPST consultation and 661 (86%) needed no further ED intervention. Fast discharge was a major determinant of patient satisfaction. No staff expressed dissatisfaction, but some suggested possible improvements in eligibility criteria and built environment design features. Conclusion Provision of GPST correlated with shorter waits for discharge from ED. Patient and staff experiences of GPST were positive

On the decay of turbulence in plane Couette flow

The decay of turbulent and laminar oblique bands in the lower transitional range of plane Couette flow is studied by means of direct numerical simulations of the Navier--Stokes equations. We consider systems that are extended enough for several bands to exist, thanks to mild wall-normal under-resolution considered as a consistent and well-validated modelling strategy. We point out a two-stage process involving the rupture of a band followed by a slow regression of the fragments left. Previous approaches to turbulence decay in wall-bounded flows making use of the chaotic transient paradigm are reinterpreted within a spatiotemporal perspective in terms of large deviations of an underlying stochastic process.Comment: ETC13 Conference Proceedings, 6 pages, 5 figure

On Maximal Massive 3D Supergravity

We construct, at the linearized level, the three-dimensional (3D) N = 4 supersymmetric "general massive supergravity" and the maximally supersymmetric N = 8 "new massive supergravity". We also construct the maximally supersymmetric linearized N = 7 topologically massive supergravity, although we expect N = 6 to be maximal at the non-linear level.Comment: 33 page

A refined, controlled 16S rRNA gene sequencing approach reveals limited detection of cerebrospinal fluid microbiota in children with bacterial meningitis

Advances in both laboratory and computational components of high-throughput 16S amplicon sequencing (16S HTS) have markedly increased its sensitivity and specificity. Additionally, these refinements have better delineated the limits of sensitivity, and contributions of contamination to these limits, for 16S HTS that are particularly relevant for samples with low bacterial loads, such as human cerebrospinal fluid (CSF). The objectives of this work were to (i) optimize the performance of 16S HTS in CSF samples with low bacterial loads by defining and addressing potential sources of error, and (ii) perform refined 16S HTS on CSF samples from children diagnosed with bacterial meningitis and compare results with those from microbiological cultures. Several bench and computational approaches were taken to address potential sources of error for low bacterial load samples. We compared DNA yields and sequencing results after applying three different DNA extraction approaches to an artificially constructed mock-bacterial community. We also compared two postsequencing computational contaminant removal strategies, decontam R and full contaminant sequence removal. All three extraction techniques followed by decontam R yielded similar results for the mock community. We then applied these methods to 22 CSF samples from children diagnosed with meningitis, which has low bacterial loads relative to other clinical infection samples. The refined 16S HTS pipelines identified the cultured bacterial genus as the dominant organism for only 3 of these samples. We found that all three DNA extraction techniques followed by decontam R generated similar DNA yields for mock communities at the low bacterial loads representative of CSF samples. However, the limits of detection imposed by reagent contaminants and methodologic bias precluded the accurate detection of bacteria in CSF from children with culture-confirmed meningitis using these approaches, despite rigorous controls and sophisticated computational approaches. Although we did not find current DNA-based diagnostics to be useful for pediatric meningitis samples, the utility of these methods for CSF shunt infection remains undefined. Future advances in sample processing methods to minimize or eliminate contamination will be required to improve the sensitivity and specificity of these methods for pediatric meningitis

Experiences of refugees and asylum seekers in general practice: a qualitative study

Background: There has been much debate regarding the refugee health situation in the UK. However most of the existing literature fails to take account of the opinions of refugees themselves. This study was established to determine the views of asylum seekers and refugees on their overall experiences in primary care and to suggest improvements to their care. Methods: Qualitative study of adult asylum seekers and refugees who had entered the UK in the last 10 years. The study was set in Barnet Refugee Walk in Service, London. 11 Semi structured interviews were conducted and analysed using framework analysis. Results: Access to GPs may be more difficult for failed asylum seekers and those without support from refugee agencies or family. There may be concerns amongst some in the refugee community regarding the access to and confidentiality of professional interpreters. Most participants stated their preference for GPs who offered advice rather than prescriptions. The stigma associated with refugee status in the UK may have led to some refugees altering their help seeking behaviour. Conclusion: The problem of poor access for those with inadequate support may be improved by better education and support for GPs in how to provide for refugees. Primary Care Trusts could also supply information to newly arrived refugees on how to access services. GPs should be aware that, in some situations, professional interpreters may not always be desired and that instead, it may be advisable to reach a consensus as to who should be used as an interpreter. A better doctor-patient experience resulting from improvements in access and communication may help to reduce the stigma associated with refugee status and lead to more appropriate help seeking behaviour. Given the small nature of our investigation, larger studies need to be conducted to confirm and to quantify these results

The impact of training non-physician clinicians in Malawi on maternal and perinatal mortality : a cluster randomised controlled evaluation of the enhancing training and appropriate technologies for mothers and babies in Africa (ETATMBA) project

Background: Maternal mortality in much of sub-Saharan Africa is very high whereas there has been a steady decline in over the past 60 years in Europe. Perinatal mortality is 12 times higher than maternal mortality accounting for about 7 million neonatal deaths; many of these in sub-Saharan countries. Many of these deaths are preventable. Countries, like Malawi, do not have the resources nor highly trained medical specialists using complex technologies within their healthcare system. Much of the burden falls on healthcare staff other than doctors including non-physician clinicians (NPCs) such as clinical officers, midwives and community health-workers. The aim of this trial is to evaluate a project which is training NPCs as advanced leaders by providing them with skills and knowledge in advanced neonatal and obstetric care. Training that will hopefully be cascaded to their colleagues (other NPCs, midwives, nurses). Methods/design: This is a cluster randomised controlled trial with the unit of randomisation being the 14 districts of central and northern Malawi (one large district was divided into two giving an overall total of 15). Eight districts will be randomly allocated the intervention. Within these eight districts 50 NPCs will be selected and will be enrolled on the training programme (the intervention). Primary outcome will be maternal and perinatal (defined as until discharge from health facility) mortality. Data will be harvested from all facilities in both intervention and control districts for the lifetime of the project (3–4 years) and comparisons made. In addition a process evaluation using both quantitative and qualitative (e.g. interviews) will be undertaken to evaluate the intervention implementation. Discussion: Education and training of NPCs is a key to improving healthcare for mothers and babies in countries like Malawi. Some of the challenges faced are discussed as are the potential limitations. It is hoped that the findings from this trial will lead to a sustainable improvement in healthcare and workforce development and training. Trial registration: ISRCTN6329415

Molecular characterization of microbiota in cerebrospinal fluid from patients with CSF shunt infections using whole genome amplification followed by shotgun sequencing

Understanding the etiology of cerebrospinal fluid (CSF) shunt infections and reinfections requires detailed characterization of associated microorganisms. Traditionally, identification of bacteria present in the CSF has relied on culture methods, but recent studies have used high throughput sequencing of 16S rRNA genes. Here we evaluated the method of shotgun DNA sequencing for its potential to provide additional genomic information. CSF samples were collected from 3 patients near the beginning and end of each of 2 infection episodes. Extracted total DNA was sequenced by: (1) whole genome amplification followed by shotgun sequencing (WGA) and (2) high-throughput sequencing of the 16S rRNA V4 region (16S). Taxonomic assignments of sequences from WGA and 16S were compared with one another and with conventional microbiological cultures. While classification of bacteria was consistent among the 3 approaches, WGA provided additional insights into sample microbiological composition, such as showing relative abundances of microbial versus human DNA, identifying samples of questionable quality, and detecting significant viral load in some samples. One sample yielded sufficient non-human reads to allow assembly of a high-qualit

Four-wave-mixing microscopy reveals non-colocalisation between gold nanoparticles and fluorophore conjugates inside cells

Gold nanoparticles have been researched for many biomedical applications in diagnostics, theranostics, and as drug delivery systems. When conjugated to fluorophores, their interaction with biological cells can be studied in situ and real time using fluorescence microscopy. However, an important question that has remained elusive to answer is whether the fluorophore is a faithful reporter of the nanoparticle location. Here, our recently developed four-wave-mixing optical microscopy is applied to image individual gold nanoparticles and in turn investigate their co-localisation with fluorophores inside cells. Nanoparticles from 10 nm to 40 nm diameter were conjugated to fluorescently-labeled transferrin, for internalisation via clathrin-mediated endocytosis, or to non-targeting fluorescently-labelled antibodies. Human (HeLa) and murine (3T3-L1) cells were imaged at different time points after incubation with these conjugates. Our technique identified that, in most cases, fluorescence originated from unbound fluorophores rather than from fluorophores attached to nanoparticles. Fluorescence detection was also severely limited by photobleaching, quenching and autofluorescence background. Notably, correlative extinction/fluorescence microscopy of individual particles on a glass surface indicated that commercial constructs contain large amounts of unbound fluorophores. These findings highlight the potential problems of data interpretation when reliance is solely placed on the detection of fluorescence within the cell, and are of significant importance in the context of correlative light electron microscopy

Synthesis and characterisation of fluorescent aminophosphines and their coordination to gold(i)

Three novel fluorescent aminophosphine ligands have been synthesised that incorporate napthyl (L1), pyrenyl (L2) and anthraquinone (L3) chromophores into their structures. The ligands react with [AuCl(tht)] (tht = tetrahydrothiophene) to give neutral complexes of the form [AuCl(L1–3)]. Solid state, X-ray crystallographic data was obtained for the anthraquinone derivative, [AuCl(L3)], and showed a distorted linear coordination geometry at Au(I). The packing structure also revealed a number of intermolecular π–π interactions that involve the anthraquinone and phenyl units of the aminophosphine ligand. 31P NMR spectroscopic data revealed δP values of +42.2 (L1), +42.1 (L2) and +26.1 (L3) ppm, which shifted downfield upon coordination to Au(I) to +64.6, +64.7, and +55.8 ppm, respectively. Supporting TD-DFT studies were able to reproduce the structure and 31P NMR chemical shifts of [AuCl(L3)] as well as rationalise the HOMO–LUMO compositions. Photophysical studies showed that the appended fluorophore dominates the absorption and emission properties for the ligands and complexes, with the anthraquinone derivatives showing visible emission at ca. 570 nm which was attributed to the intramolecular charge transfer character of the phosphinoaminoanthraquinone fragment