UK Renal Registry 18th Annual Report : Chapter 12 Epidemiology of Reported Infections amongst Patients Receiving Dialysis for Established Renal Failure in England 2013 to 2014: a Joint Report from Public Health England and the UK Renal Registry

From 1st May 2013 to 30th April 2014 there were 35 episodes of Methicillin resistant Staphylococcus aureus (MRSA) bacteraemia in established renal failure patients on dialysis. This is now fairly stable year-on-year equating to a rate of 0.15 episodes per 100 dialysis patient years, following an initial decline in rates from 4.0 episodes per 100 dialysis patient years in 2005 when reporting began. Methicillin sensitive Staphylococcus aureus (MSSA) bacteraemia rates were slightly higher this year at 2.23 per 100 dialysis patient years (compared with 1.59 episodes per 100 dialysis patient years last year) with 526 episodes of blood stream infection reported. In 2005, the first year this was reported, there were 1,114 MSSA bacteraemias in 54 centres. There were 247 Clostridium difficile infection episodes with a rate of 1.05 per 100 dialysis patient years, slightly higher than last year at 0.55 episodes per 100 dialysis patient years. Escherichia coli infections occurred at a rate of 1.49 per 100 dialysis patient years, very similar to the rate reported last year (1.32 episodes per 100 dialysis patient years). This report has utilised a new methodology to identify cases, linking all established renal failure cases known to the UK Renal Registry (UKRR) with all infections reported to Public Health England and avoids the need for the local microbiology team to flag the patient as a renal patient. This may have increased the reliability of diagnosis at the UKRR level. In each infection for which access data were collected, the presence of a central venous catheter appeared to correlate with increased risk.Peer reviewedFinal Published versio

THE APPLICATION OF SUB INDEX AGGREGATION METHOD TO ASSESS THE HEALTH OF A WATER BODY

The environmental health of inland water bodies can be described using water qualityparameters that describe the physical, chemical and biological status of the water. Each ofthese parameters reflect different characteristics of the water body and can be assessed bycomparing with threshold values detaikd in water quality guidelines such as the FreshWater and Marine Water Quality Guidelines. Assessing the status of a water body using asuite of water quality parameters is cumbersome and fraught with difficulty, as for a givenlocation some parameters may fall under Ihreshold values whilst others exceed guidelinevalues. To simplify and unify the interpretation based on individual water qualityparameters, these can be combined into a single dimensionless number by considering eachmeasured water quality concentration and its corresponding guideline value. This singlenumber is called the 'water quality index' (WQI) and is used to assess the overall status ofthe water body quantitatively and objectively.Many methods have been derived over the years to determine the WQI for differentapplications. These methods are &roupedinto two categories; 'sub-index' and 'statistical'.As to-date, no guidelines have been specified on the selection of a methodology. However,it has been acknowledged that the method used to derive the WQI should retain valuableinformation from each parameter and retain its contribution to determining the overallhealth during the combining process.This paper reviews methods available to determine WQls for a range of applications. Thepaper will describe the application of the SIA method to a set of water quality data alongthe Yarra River in Victoria, Australia. The results were useful in identifying the trend inWQvariation. The Sub Indices Aggregation (SIA) method could be used by Authorities forrapid assessment of water bodies to identify their suitability for different purposes based onthe quality of water. Application of the method can also assist with locating critical areasthat could urgently require rehabilitation

Cardiac ischaemic stress in the haemodialysis patient

Haemodialysis patients experience elevated levels of cardiovascular morbidity and mortality that has a profound effect on not only their survival and quality of life but also increases the already high social and economic cost of dialysis. It is increasingly appreciated that the circulatory stress caused by dialysis is a significant contributing factor and helps to accelerate the end organ damage this group of patients is known to experience. In particular the cumulative ischaemic insult suffered by the heart during haemodialysis sessions has been suggested as one of the principal drivers of heart failure and sudden cardiac death – the two principal causes of death in this population. The importance of dialysis induced haemodynamic instability was reinforced as we explored the relationship between cardiac function and the measure of intra-dialytic hypotension most clearly associated with mortality (a blood pressure below 90mmHg) and found that the severity of dialysis induced cardiac injury was experienced across the whole range of dialysis induced hypotension. A nadir blood pressure below 90mmHg was strongly associated with established reduction in systolic contractile function. We then tested two separate interventions designed to mitigate dialysis-induced injury. The first was Remote Ischaemic Preconditioning, a technique that in pre-clinical models and numerous small clinical studies protects against the effect of the ischaemia-reperfusion injury. We found that a single application of RIPC significantly reduces dialysis induced cardiac injury for up to 28 days. The second intervention was the stepwise reduction of dialysate sodium to reduce intra-dialytic fluid accumulation and the need for aggressive ultrafiltration. We found this to be well tolerated and an effective way to reduce inter-dialytic weight gain. This intervention did not have any adverse cardiac consequences and may have resulted in a modest improvement in cardiac tolerability while still being delivered within the context of a conventional 4-hour haemodialysis treatment. Finally, to investigate if transplantation is capable of reversing any of the factors predisposing dialysis patients to increased cardiovascular events, we chose to investigate one of the risk factors that contributes to the abnormalities of the vasculature and leave patients vulnerable to dialysis induced cardiac injury. We measured the deposition of advanced glycation end-products (via the method of skin autofluorescence) in patients who had undergone renal transplantation and compared this to existing cohorts of dialysis and chronic kidney disease patients. We found that following transplantation these markers of metabolic stress regressed to levels comparable to those seen in chronic kidney disease and much lower than seen in dialysis. This finding may suggest that the dialysis procedure itself is responsible for a great deal of metabolic stress and helps to accelerate the process by which the vasculature becomes stiff and non-compliant. In conclusion, we tested two interventions that showed potential to reduce the cardiac stress dialysis patients are subject to. Remote ischaemic preconditioning directly reduces the severity of cardiac injury and the stepwise reduction of dialysate sodium decreases inter-dialytic fluid gains and produces a modest improvement in cardiac tolerability. We also confirmed that transplantation reverses advanced glycation end-product deposition, one of the key non-traditional risk factors for cardiovascular disease in dialysis patients, giving us further insight into the ways in which transplantation improves cardiovascular outcome

Childcare Practitioners’ Knowledge and Perceptions of Play Therapy

This study investigated the awareness of play therapy in childcare practitioners working in the areas of health, social care, education and childcare. Questionnaires were distributed to 65 workers drawn from these occupational categories in order to investigate their understanding of issues such as the nature of play therapy, the referral process, and the distinction between play therapy and other forms of play based interventions. In addition, one child care professional from each of the four sectors was selected to take part in a follow-up interview to build on the information generated from the questionnaires. The results from the questionnaires and follow-up interviews showed that while most of the child care professionals had heard of this approach, they had a limited knowledge of the nature of play therapy. There was also much confusion amongst the child care professionals around the difference between play therapy and other play based interventions as well as around different professionals’ roles and responsibilities for referring children and young people to therapeutic interventions. The implications of these findings for the practice of play therapy are considered

Conversion of an intensified fed-batch to an integrated continuous bioprocess

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Factors associated with interest in psychiatry in UK medical students: qualitative study

Aims and method This study aimed to explore factors that positively influence UK medical students’ interest in psychiatry. Delegates and committee members of the National Student Psychiatry Conference 2018 were invited to participate in individual semi-structured interviews. Nine interviews were conducted. Qualitative data were analysed using thematic analysis. Results: Four core themes emerged: psychiatry education and exposure, role of a psychiatrist, fitting in, and factors external to medical school. All students had some degree of interest in mental health before medical school, but placement and extra-curricular factors were strongly influential. Implications Interest in psychiatry may be promoted by facilitating student exposure to enthusiastic psychiatrists and psychiatry subspecialties, encouraging extra-curricular activities and identifying early those with pre-existing interest in mental health on admission to medical school. Aspects of psychiatry that should be promoted include the potential to make a positive difference to patients’ lives and the teamworking elements of the specialty

Factors associated with interest in psychiatry in UK medical students: qualitative study

Aims and method This study aimed to explore factors that positively influence UK medical students’ interest in psychiatry. Delegates and committee members of the National Student Psychiatry Conference 2018 were invited to participate in individual semi-structured interviews. Nine interviews were conducted. Qualitative data were analysed using thematic analysis. Results: Four core themes emerged: psychiatry education and exposure, role of a psychiatrist, fitting in, and factors external to medical school. All students had some degree of interest in mental health before medical school, but placement and extra-curricular factors were strongly influential. Implications Interest in psychiatry may be promoted by facilitating student exposure to enthusiastic psychiatrists and psychiatry subspecialties, encouraging extra-curricular activities and identifying early those with pre-existing interest in mental health on admission to medical school. Aspects of psychiatry that should be promoted include the potential to make a positive difference to patients’ lives and the teamworking elements of the specialty

Assessing the sustainability of fed batch and continuous process formats for mAb manufacturing via bioprocess modeling

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The utility of modified Butler-Leggett criteria for right ventricular hypertrophy in detection of clinically significant shunt ratio in ostium secundum-type atrial septal defect in adults

Background: This study was performed to test the hypothesis that there exists a correlation between the Butler-Leggett (BL) criterion for right ventricular hypertrophy on the electrocardiogram and the Qp/Qs shunt ratio in adults with ostium secundum atrial septal defects (ASDs). Methods: Demographic, cardiac catheterization, ASD closure, and electrocardiographic data were acquired on 70 patients with secundum ASDs closed percutaneously. Simple linear regression and logistic regression models were created to test the hypothesis. Results: The mean Qp/Qs ratio and BL criterion value were 1.61 +/- 0.46 and 0.11 +/- 0.41, respectively. The BL criterion values correlated with shunt ratios (r(2) = 0.11 and P = .004). A BL criterion value greater than 0 mV predicted a significant shunt ratio (Qp/Qs \u3e or = 1.5) (odds ratio, 4.8; 95% confidence interval, 1.3, 18.1; P = or \u3c.0001) with a sensitivity of 0.68 and specificity of 0.65. Conclusion: Our results indicate that there is limited utility of the BL criterion at detecting right ventricular volume overload, although a BL criterion value greater than 0 mV being used to identify patients with significant intracardiac shunts yielded a sensitivity of 0.68 and specificity of 0.65