“Sometimes we can’t fix things”: a qualitative study of health care professionals’ perceptions of end of life care for patients with heart failure

Background Although heart failure has a worse prognosis than some cancers, patients often have restricted access to well-developed end of life (EoL) models of care. Studies show that patients with advanced heart failure may have a poor understanding of their condition and its outcome and, therefore, miss opportunities to discuss their wishes for EoL care and preferred place of death. We aimed to explore the perceptions and experiences of health care professionals (HCPs) working with patients with heart failure around EoL care. Design A qualitative in-depth interview study nested in a wider ethnographic study of unplanned admissions in patients with heart failure (HoldFAST). We interviewed 24 HCPs across primary, secondary and community care in three locations in England, UK – the Midlands, South Central and South West. Results The study revealed three issues impacting on EoL care for heart failure patients. Firstly, HCPs discussed approaches to communicating with patients about death and highlighted the challenges involved. HCPs would like to have conversations with patients and families about death and dying but are aware that patient preferences are not easy to predict. Secondly, professionals acknowledged difficulties recognising when patients have reached the end of their life. Lack of communication between patients and professionals can result in situations where inappropriate treatment takes place at the end of patients’ lives. Thirdly, HCPs discussed the struggle to find alternatives to hospital admission for patients at the end of their life. Patients may be hospitalised because of a lack of planning which would enable them to die at home, if they so wished. Conclusions The HCPs regarded opportunities for patients with heart failure to have ongoing discussions about their EoL care with clinicians they know as essential. These key professionals can help co-ordinate care and support in the terminal phase of the condition. Links between heart failure teams and specialist palliative care services appear to benefit patients, and further sharing of expertise between teams is recommended. Further research is needed to develop prognostic models to indicate when a transition to palliation is required and to evaluate specialist palliative care services where heart failure patients are included

Mycolactone-dependent depletion of endothelial cell thrombomodulin is strongly associated with fibrin deposition in Buruli ulcer lesions

A well-known histopathological feature of diseased skin in Buruli ulcer (BU) is coagulative necrosis caused by the Mycobacterium ulcerans macrolide exotoxin mycolactone. Since the underlying mechanism is not known, we have investigated the effect of mycolactone on endothelial cells, focussing on the expression of surface anticoagulant molecules involved in the protein C anticoagulant pathway. Congenital deficiencies in this natural anticoagulant pathway are known to induce thrombotic complications such as purpura fulimans and spontaneous necrosis. Mycolactone profoundly decreased thrombomodulin (TM) expression on the surface of human dermal microvascular endothelial cells (HDMVEC) at doses as low as 2ng/ml and as early as 8hrs after exposure. TM activates protein C by altering thrombin's substrate specificity, and exposure of HDMVEC to mycolactone for 24 hours resulted in an almost complete loss of the cells' ability to produce activated protein C. Loss of TM was shown to be due to a previously described mechanism involving mycolactone-dependent blockade of Sec61 translocation that results in proteasome-dependent degradation of newly synthesised ER-transiting proteins. Indeed, depletion from cells determined by live-cell imaging of cells stably expressing a recombinant TM-GFP fusion protein occurred at the known turnover rate. In order to determine the relevance of these findings to BU disease, immunohistochemistry of punch biopsies from 40 BU lesions (31 ulcers, nine plaques) was performed. TM abundance was profoundly reduced in the subcutis of 78% of biopsies. Furthermore, it was confirmed that fibrin deposition is a common feature of BU lesions, particularly in the necrotic areas. These findings indicate that there is decreased ability to control thrombin generation in BU skin. Mycolactone's effects on normal endothelial cell function, including its ability to activate the protein C anticoagulant pathway are strongly associated with this. Fibrin-driven tisischemia could contribute to the development of the tissue necrosis seen in BU lesions

Speed breeding in growth chambers and glasshouses for crop breeding and model plant research

‘Speed breeding’ (SB) shortens the breeding cycle and accelerates crop research through rapid generation advancement. SB can be carried out in numerous ways, one of which involves extending the duration of plants’ daily exposure to light, combined with early seed harvest, to cycle quickly from seed to seed, thereby reducing the generation times for some long-day (LD) or day-neutral crops. In this protocol, we present glasshouse and growth chamber–based SB approaches with supporting data from experimentation with several crops. We describe the conditions that promote the rapid growth of bread wheat, durum wheat, barley, oat, various Brassica species, chickpea, pea, grass pea, quinoa and Brachypodium distachyon. Points of flexibility within the protocols are highlighted, including how plant density can be increased to efficiently scale up plant numbers for single-seed descent (SSD). In addition, instructions are provided on how to perform SB on a small scale in a benchtop growth cabinet, enabling optimization of parameters at a low cost

Educating Students for the Collaborative Workplace:Facilitating Interdisciplinary Learning on Accredited Construction Courses

This article addresses the provision of interdisciplinary learning opportunities for students enrolled on Built Environment, Design and Construction courses in Higher Education Institutions (HEIs), drawing from a variety of case studies based in the UK. The article cites published literature from across disciplinary boundaries, demonstrating a need for, and an interest in, interprofessional collaborative learning. Case studies of seven projects from four UK HEIs are reviewed and strategies compared. The studies demonstrate the value of such teaching; the context within which the teaching is provided; some examples of good practice; of disincentives and of barriers; and student feedback. Key shared characteristics begin to suggest a taxonomy of collaborative projects. The article concludes with suggested actions and/or strategies that could be employed by Schools, HEIs and/or Institutions to further incentivise such teaching

Parenteral Transmission of the Novel Human Parvovirus PARV4

Transmission routes of PARV4, a newly discovered human parvovirus, were investigated by determining frequencies of persistent infections using autopsy samples from different risk groups. Predominantly parenteral routes of transmission were demonstrated by infection restricted to injection drug users and persons with hemophilia and absence of infection in homosexual men with AIDS and low-risk controls

Role of filtration in managing the risk from Cryptosporidium in commercial swimming pools – a review

Most commercial swimming pools use pressurised filters, typically containing sand media, to remove suspended solids as part of the water treatment process designed to keep water attractive, clean and safe. The accidental release of faecal material by bathers presents a poorly quantified risk to the safety of swimmers using the pool. The water treatment process usually includes a combination of maintaining a residual concentration of an appropriate biocide in the pool together with filtration to physically remove particles, including microbial pathogens, from the water. However, there is uncertainty about the effectiveness of treatment processes in removing all pathogens, and there has been growing concern about the number of reported outbreaks of the gastrointestinal disease cryptosporidiosis, caused by the chlorine-resistant protozoan parasite Cryptosporidium. A number of interacting issues influence the effectiveness of filtration for the removal of Cryptosporidium oocysts from swimming pools. This review explains the mechanisms by which filters remove particles of different sizes (including oocyst-sized particles, typically 4–6 μm), factors that affect the efficiency of particle removal (such as filtration velocity), current recommended management practices, and identifies further work to support the development of a risk-based management approach for the management of waterborne disease outbreaks from swimming pools

Multisensory medical illustrations of Buruli ulcer for improved disease detection, help seeking behaviour and adherence to treatment

Buruli ulcer (BU) is a skin infection caused by Mycobacterium ulcerans and a neglected tropical disease of the skin (skin NTD). Antibiotic treatments are available but, to be effective in the absence of surgery, BU must be detected at its earliest stages (an innocuous-looking lump under the skin) and adherence to prescribed drugs must be high. This study aimed to develop multisensory medical illustrations of BU to support communication with at-risk communities. We used a Think Aloud method to explore community health workers’ (n = 6) experiences of BU with a focus on the role of their five senses, since these non-medical disease experts are familiar with the day-to-day challenges presented by BU. Thematic analysis of the transcripts identified three key themes relating to ‘Detection,’ ‘Help Seeking,’ and ‘Adherence’ with a transcending theme ‘Senses as key facilitators of health care’. New medical illustrations, for which we coin the phrase “5D illustrations” (signifying the contribution of the five senses) were then developed to reflect these themes. The senses therefore facilitated an enriched narrative enabling the production of relevant and useful visuals for health communication. The medical artist community could utilise sensory experiences to create dynamic medical illustrations for use in practice.</p

Occurrence of Cryptosporidium Oocysts in Leisure Pools in the UK, 2017, and Modelling of Oocyst Contamination Events

Cryptosporidium is a major cause of diarrhoea outbreaks linked to swimming pools, but little is known about the frequency of contamination. The primary aim was to investigate the occurrence and concentration, through sampling and modelling, of Cryptosporidium oocysts in leisure pools. Secondary aims were to compare detections with operational parameters, provide the evidence-base for guidance, and improve sampling capacity and interpretation for public health investigations. Up to 1000 L pool water was sampled during swim sessions once weekly for 10 weeks from 8 August 2017 at six volunteer pools. Oocysts were detected by microscopy in 12/59 (20%) pool water samples, at least once in each pool; 8/12 (66%) detections were in August when bather loads were highest. At three pools, 1 L filter backwash was sampled weekly and oocysts were detected in 2/29 (7%) samples, following detections in pool water. The probabilities of a bather contaminating the pool ranged from 1 in 1000 to over 1 in 10,000. Monte Carlo analysis showed that when high bather numbers caused contamination on over 70% of days, multiple events per day were more likely than single events. In these generally well-managed leisure pools, Cryptosporidium risk related to high bather loads. We conclude that public awareness campaigns for bather hygiene, and reminding pool operators of current guidance for managing faecal accidents, should be ahead of peak swim season