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AimsOur aim was to review Bristol Royal Hospital for Children Emergency Department clinicians’ adherence to the NICE guideline ‘Fever in under 5s: assessment and management’ in children under 3 months, particularly regarding investigation with lumbar puncture (LP), in order to improve practice.MethodsWe initially carried out a retrospective case note review of all children < 3months old presenting to BRHC ED with ‘fever’, ‘temperature’ or ‘temp’ over an 8 month period. We assessed which investigations were done following reported fever (bloods, cultures, LP, urine), whether an LP was indicated by NICE guideline, LP documentation, LP result, antibiotic administration within 1 hour and final diagnosis. We re-evaluated our data set to include all children <3months old in ED who had an LP due to a large number of patients being missed in the original investigation. Concurrently, we reviewed nursing staff numbers during this period to evaluate whether this had an impact on timely LP investigation and antibiotic administration.ResultsWe reviewed 183 case notes from January - September 2021: 78 from the original data set and a further 105 following methodology review. 119 patients were investigated with an LP - 91% of LPs were done by ED and 97% occurred within 24 hours of presentation. All patients <1 month old presenting with fever were investigated with an LP, although 30% did not have a full septic screen due to missed urine sample.Only 10 LPs did not follow NICE guidance (5.4%) - 4 patients had an LP where not clearly indicated and 6 LPs were ‘missed’. 0.8% of LPs were positive in this data set, of which none were missed by ED clinicians.Only 17% lumbar punctures done in ED had complete documentation including consent, risk/benefits and a procedure note. Administration of IV antibiotics <1 hour from clinician review was 27%. There were significant nursing staffing issues during this period with an average of 46% shifts without full staffing.ConclusionBRHC ED generally adhered to NICE guidelines regarding investigation of children <3months with fever, particularly in regards to lumbar puncture, and very few patients are ‘missed’. However, LP documentation was poor and antibiotics were often not administered within 1 hour of clinician review. Nursing staff shortages were significant in this period, which may have contributed to delayed antibiotic administration. We therefore identified some areas requiring improvement. We have designed a ‘Septic screen’ proforma to be used in the notes to improve documentation; we are presenting this QIP at multiple staff education sessions; nursing staffing shortages have been escalated to a Trust level; and the risk register has been updated. We intend to re-evaluate our changes to practice in 6 months.

IntroductionCONTACT is a national multidisciplinary study assessing the impact of the COVID-19 pandemic upon diagnostic and treatment pathways among patients with pancreatic ductal adenocarcinoma (PDAC).MethodsThe treatment of consecutive patients with newly diagnosed PDAC from a pre-COVID-19 pandemic cohort (07/01/2019-03/03/2019) were compared to a cohort diagnosed during the first wave of the UK pandemic (‘COVID’ cohort, 16/03/2020-10/05/2020), with 12-month follow-up.ResultsAmong 984 patients (pre-COVID: n = 483, COVID: n = 501), the COVID cohort was less likely to receive staging investigations other than CT scanning (29.5% vs. 37.2%, p = 0.010). Among patients treated with curative intent, there was a reduction in the proportion of patients recommended surgery (54.5% vs. 76.6%, p = 0.001) and increase in the proportion recommended upfront chemotherapy (45.5% vs. 23.4%, p = 0.002). Among patients on a non-curative pathway, fewer patients were recommended (47.4% vs. 57.3%, p = 0.004) or received palliative anti-cancer therapy (20.5% vs. 26.5%, p = 0.045). Ultimately, fewer patients in the COVID cohort underwent surgical resection (6.4% vs. 9.3%, p = 0.036), whilst more patients received no anti-cancer treatment (69.3% vs. 59.2% p = 0.009). Despite these differences, there was no difference in median overall survival between the COVID and pre-COVID cohorts, (3.5 (IQR 2.8–4.1) vs. 4.4 (IQR 3.6–5.2) months, p = 0.093).ConclusionPathways for patients with PDAC were significantly disrupted during the first wave of the COVID-19 pandemic, with fewer patients receiving standard treatments. However, no significant impact on survival was discerned.

MAURICE Pennicott will be remembered by the people of Oatlands as a top sportsman and the chief of the town's fire brigade. Maurice and his late brother Kevin were outstanding sportsmen and played for the Oatlands football team. Maurice and [Tess Emery] ran the general store in Oatlands for 20 years and he was a fireman for 40 years, serving as first officer and then 20 years as superintendent.

Generally, biodiversity is higher in the tropics than at the poles. This pattern is present across taxa as diverse as plants and insects. Marine mammals and birds buck this trend, however, with more species and more individuals occurring at the poles than at the equator. Grady et al. asked why this is (see the Perspective by Pyenson). They analyzed a comprehensive dataset of nearly 1000 species of shark, fish, reptiles, mammals, and birds. They found that predation on ectothermic (“cold-blooded”) prey is easier where waters are colder, which generates a larger resource base for large endothermic (“warm-blooded”) predators in polar regions. Science , this issue p. eaat4220 ; see also p. 338 Marine mammal and bird diversity is highest in polar regions, owing to the availability of cold, slow prey. Species richness of marine mammals and birds is highest in cold, temperate seas—a conspicuous exception to the general latitudinal gradient of decreasing diversity from the tropics to the poles. We compiled a comprehensive dataset for 998 species of sharks, fish, reptiles, mammals, and birds to identify and quantify inverse latitudinal gradients in diversity, and derived a theory to explain these patterns. We found that richness, phylogenetic diversity, and abundance of marine predators diverge systematically with thermoregulatory strategy and water temperature, reflecting metabolic differences between endotherms and ectotherms that drive trophic and competitive interactions. Spatial patterns of foraging support theoretical predictions, with total prey consumption by mammals increasing by a factor of 80 from the equator to the poles after controlling for productivity.

Swallowing is a complex process that involves precise coordination among oral and pharyngeal structures, which is essential to smooth transition of bolus and adequate airway protection. Tongue base retraction and hyolaryngeal excursion are two significant swallowing movements, and their related events can be examined using ultrasound imaging, which is physically and radioactively non-invasive. The present study aimed to 1) establish the temporal sequences and timing of swallowing events identified using ultrasound imaging, and 2) investigate the variability of the above temporal sequences and 3) investigate the effect of bolus type on the variability of temporal sequences in non-dysphagic individuals. Forty-one non-dysphagic young adults of both genders (19 males and 22 females) participated in the study. Ultrasound images were acquired mid-saggitally at their submental region during swallowing of boluses with different volume (i.e. 5mL or 10mL) and consistencies (i.e. IDDSI Levels 0 and 4). Timing and sequence of six events 1) displacement onset ( TBOn ), 2) maximum displacement ( TBMax ) and 3) displacement offset of tongue base retraction ( TBOff ); and, 4) displacement onset ( HBOn ), 5) maximum displacement ( HBMax ) and 6) displacement offset of the hyoid bone excursion ( HBOff ) were extracted from the ultrasound images. Out of the 161 swallows, 85.7% follow a general sequence of HBOn < TBOn < HBMax < TBMax < HBOff < TBOff . Percentage adherence to six anticipated paired-event sequences was studied. Results suggested the presence of individual variability as adherence ranged from 75.8% to 98.1% in four of the anticipated sequences, leaving only two sequences ( HBOn < TBMax and TBMax < HBOff ) obligatory (i.e. 100% adherence). For non-obligatory sequences, it was found that bolus type may have an effect on the level of adherence. Findings of the present study lay the groundwork for future studies on swallowing using ultrasound imaging and also the clinical application of ultrasonography.

Processing speed on cognitive tasks relies upon efficient communication between widespread regions of the brain. Recently, novel methods of quantifying network communication like ‘navigation efficiency’ have emerged, which aim to be more biologically plausible compared to traditional shortest path length-based measures. However, it is still unclear whether there is a direct link between these communication measures and processing speed. We tested this relationship in forty-five healthy adults (27 females), where processing speed was defined as decision-making time and measured using drift rate from the hierarchical drift diffusion model. Communication measures were calculated from a graph theoretical analysis of the whole-brain structural connectome and of a task-relevant fronto-parietal structural subnetwork, using the large-scale Desikan–Killiany atlas. We found that faster processing speed on trials that require greater cognitive control are correlated with higher navigation efficiency (of both the whole-brain and the task-relevant subnetwork). In contrast, faster processing speed on trials that require more automatic processing are correlated with shorter path length within the task-relevant subnetwork. Our findings reveal that differences in the way communication is modelled between shortest path length and navigation may be sensitive to processing of automatic and controlled responses, respectively. Further, our findings suggest that there is a relationship between the speed of cognitive processing and the structural constraints of the human brain network.