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In September 2023, the UK Health Security Agency’s (UKHSA) South West Health Protection Team received notification of patients with Pseudomonas aeruginosa perichondritis. All five cases had attended the same cosmetic piercing studio and a multi-disciplinary outbreak control investigation was subsequently initiated. An additional five cases attending the same studio were found. Seven of the ten cases had isolates available for Variable Number Tandem Repeat (VNTR) typing at the UKHSA national reference laboratory. Clinical and environmental P. aeruginosa isolates from the patients, handwash sink, tap water and throughout the wall-mounted point-of-use water heater (including outlet water) were indistinguishable by VNTR typing (11,6,2,2,1,3,6,3,11). No additional cases were identified after control measures were implemented, which included replacing the sink and point-of-use heater.
The lack of specific recommendations to control for P. aeruginosa within Council-adopted ear-piercing byelaws or national guidance means that a cosmetic piercing artist could inadvertently overlook the risks from this bacterial pathogen despite every intention to comply with the law and follow industry best practice advice. Clinicians, Environmental Health Officers and public health professionals should remain alert for single cases of Pseudomonas perichondritis infections associated with piercings and have a low threshold for notification to local health protection teams.
The diverse implant landscape, the rising and disparate costs of implants in public healthcare institutions (PHIs), and the limited application of health technology assessment (HTA) impede fair and sustainable implant subsidies in Singapore. This study described the Agency for Care Effectiveness (ACE) Implant Subsidy List (ISL) methodology and the key enablers for supporting government subsidy of clinically effective and cost-effective implants in Singapore.
Methods
A multi-tiered implant grouping scheme on the ISL was established by adapting overseas implant classifications, consulting clinicians, and conducting HTA evaluations, with subsidy extensions at the product group tier. Implants within a product group share similar biomechanical actions and patient outcomes and are subject to the same clinical criteria and pricing requirement. Implants on the ISL must be approved by the regulatory authority. Patients who meet the clinical criteria for ISL implants are eligible for subsidy. ACE conducted value-based pricing (VBP) and partnered with the public healthcare supply chain agency to harmonize PHI implant prices. The ISL is updated three times per year.
Results
Implants listed on the ISL were deemed clinically and cost effective. Underpinned by HTA principles, the implant grouping scheme promoted parsimonious classification, while allowing the creation of new product groups for implants offering superior benefits for patients. Reasonable prices set for the product groups aided affordability and cost sustainability. The ISL clinical criteria and standardized implant identifiers encouraged the appropriate use of subsidized implants and facilitated implementation. By ISL implementation in December 2023, ACE assessed 42,165 implants and listed 22,689 ISL implants spanning 143 product groups. Industry can apply for ISL listing three times per year, which keeps the ISL updated and relevant.
Conclusions
The ISL adopts a fit-for-purpose methodology to standardize implant classifications, enable scalable application of HTA, drive appropriate use of subsidized implants, and bring cost sustainability to the government subsidy of implants in Singapore. A strategic partnership with the public healthcare supply chain agency to concurrently establish national procurement contracts reduced disparate implant prices in PHIs and provided greater leverage for better implant prices.
Attention is the backbone of cognitive systems and is requisite for many cognitive processes vital to everyday functioning, including memory, problem solving, and the cognitive control of behavior. Attention is commonly impaired following traumatic brain injury and is a critical focus of rehabilitation efforts. The development of reliable methods to assess rehabilitation-related changes are paramount. The Attention Network Test (ANT) has been used previously to identify 3 independent, yet interactive attention networks—alerting, orienting, and executive control (EC). We examined the behavioral and neurophysiological robustness and temporal stability of these networks across multiple sessions to assess the ANT’s potential utility as an effective measure of change during attention rehabilitative interventions.
Participants and Methods:
15 healthy young adults completed 4 sessions of the ANT (1 session/7-day period). ANT networks were assessed within the task by contrasting opposing stimulus conditions: cued vs. non-cued trials probed alerting, valid vs. invalid spatial cues probed orienting, and congruent vs. incongruent targets probed EC. Differences in median correct-trial reaction times (RTs) and error rates (ERs) between the condition pairs were assessed to determine attention network scores; robustness of networks effects, as determined by one-sample t-tests at each session, against a mean of 0, determining the presence of significant network effects at each session. Sixty-four-channel electroencephalography (EEG) data were acquired concurrently and processed using Matlab to create condition-related event-related potentials (ERPs)—particularly the cue- and probe-related P1, N1, and P3 deflection amplitudes, measured by using signed-area calculation in regions of interest (ROIs) determined by observation of spherical-spline voltages. This enabled us to examine the robustness of cue- and probe-attention-network ERPs.
Results:
All three attention networks showed robust effects. However, only the EC RT and ER network scores remained significantly robust [t(14)s>13.9,ps<.001] across all sessions, indicating that EC is robust in the face of repeated exposure. Session 1 showed the greatest EC-RT robustness effect which became smaller during the subsequent sessions per ANOVAs on Session x Congruency [F(3,42)=10.21,p<.0001], reflecting persistence despite practice effects. RT robustness of the other networks varied across sessions. Alerting and EC ERs were similarly robust across all 4 sessions, but were more variable for the orienting network. ERP results: The cue-locked P1-orienting (valid vs. invalid) was generally larger to valid- than invalid-cues, but the robustness across sessions was variable (significant in only sessions 1 and 4 [t(14)s>2.13,ps<.04], as reflected in a significant main effect of session [p=.0042]. Next, target-locked EC P3s were generally smaller to congruent than incongruent targets [F(1,14)=9.40,p=.0084], showing robust effects only in sessions 3 and 4 [ps<.005].
Conclusions:
The EC network RT and ER scores were consistently robust across all sessions, suggesting that this network may be less vulnerable to practice effects across session than the other networks and may be the most reliable probe of attentional rehabilitation. ERP measures were more variable across attention networks with respect to robustness. Behavioral measures of EC-network may be most reliable for assessing progress related to attentional-rehabilitation efforts.
Valproate is a licensed medicine prescribed within mental health settings for bipolar disorder. It is a known teratogen, affecting approximately 20,000 people and costing the NHS £181 billion. This was a multidisciplinary project involving Surrey Heartlands Medicines Safety Team and Surrey and Borders Partnership NHS Foundation Trust, who developed a solution to reduce human suffering and cost by adhering to the Medicines and Healthcare Products Regulatory Agency (MHRA) valproate regulations through a clinical and digital redesign. The aim was to identify females in primary and secondary care across Surrey who take valproate for mental illness and to implement a pregnancy prevention programme for them by July 2022, using a digital clinical pathway supporting clinicians in the implementation process.
Methods
The method used was a combination of the Model for Improvement, the sequence for improvement from East London NHS Foundation Trust, UX design, and Agile project management. A valproate working group was formed with professionals from multiple disciplines to identify, understand and solve the problem. The solution was designed through co-production and project management methods that ensured a patient-centric solution.
Results
A digital registry of all females of childbearing potential who are prescribed valproate was created. A bespoke electronic GP referral form for valproate reviews was implemented. A one-stop valproate dashboard was developed to support documentation. A live digital visualisation feature was added within the secondary care electronic patient record to ensure compliance with MHRA guidelines. Easy-to-read materials for females with learning disabilities and sensitively worded appointment letters that inform patients of the risks and importance of attending annual reviews were created. In addition, collaboration with the National Valproate Patient Safety Officer allowed the implementation of Systematized Nomenclature of Medicine Clinical Terms (SNOMED) codes to simplify the exchange of clinical information between systems.
Conclusion
The project has the potential to reduce harm and improve the patient experience, serving as a template for other medications with strong regulatory controls. Collaboration between primary and secondary care, clinicians, pharmacists and digital colleagues, and co-design with people prescribed valproate were essential to the success of the project. Ongoing work is required to ensure valproate-related materials are available in an accessible format for every person prescribed valproate. Valproate has also been implicated in paternal adverse effects, and this project solution is future-proofed to identify men on valproate. Through this work, people will only be treated with valproate in a way that safeguards the health of unborn children.
The first study focusing on the composition of new plainchant in northern-French confraternities for masses and offices in honor of saints thought to have healing powers.
ABSTRACT IMPACT: Access to intracranial recording in our epileptic sample provides a unique opportunity to characterize neurological activation patterns associated with attention and implicit learning; this foundational physiological understanding will serve to better guide cognitive rehabilitation techniques in TBI patients that aim to improve functioning across these cognitive domains. OBJECTIVES/GOALS: 1) Investigate the network level interactions of attention and learning during an attention network task (ANT) and an implicit learning contextual cueing (CC) task. 2) Assess the effect that attention rehabilitation strategies have on behavioral and neural responses pre/post-attentional intervention. METHODS/STUDY POPULATION: This study involves refractory epilepsy patients (rEP) with implanted intracranial electrodes and moderate-to-severe traumatic brain injury (m/sTBI) survivors. In rEP, we are identifying network level modulations of cortical regions via the ANT, which probes components of attention (alerting, orienting, and executive control) and a CC task that probes implicit learning. We hypothesize that modulation of attention and learning can be seen at the neuronal level. In TBI we will assess improvement following two behavioral attention rehabilitation paradigms; and use our results from epileptic patients to guide measurement of treatment-related neuroplastic change via scalp electroencephalography. RESULTS/ANTICIPATED RESULTS: Preliminary behavioral results from the rEP cohort are in line with previous studies and the intracranial data is suggestive of region- and task-specific modulations in memory and attention related systems. Following completion of recruitment, we expect to more concretely identify regions and networks that exhibit modulatory effects associated with attention and implicit learning. Additionally, we anticipate that deficits in attention will be mitigated following training and hypothesize that implicit learning rate will improve in TBI patients as a result of both attentional rehabilitation paradigms. DISCUSSION/SIGNIFICANCE OF FINDINGS: Characterizing intracranial activity in epilepsy patients will give electrophysiology data unattainable in TBI patients. This intracranial perspective will enable us to propose mechanisms of action that may result from our interventions and enable critique of current rehabilitation treatments.
O Catherine, glorious among virgins, resplendent with laurel: pour out your prayers to the Lord for us, bride of Christ, for whose law you fell by the sword as martyr into the hand of the gentiles.
The text above is an alleluia verse for St. Catherine of Alexandria, which appears in a series of small sixteenth-century printed graduals entitled Misse familiares. It refers to St. Catherine's martyrdom and her ability to intercede on behalf of her supplicants, themes that we have seen in confraternity rituals throughout this book. St. Catherine continued to thrive in popular devotional consciousness well into the sixteenth century; in the various editions of the Misse familiares, she appears paired with St. Nicholas, showing the continuing relationship that the two saints had to each other. Their connection was widely recognized in Western Europe and is neatly summed up by William Caxton in his 1483 edition of the Golden Legend translated into English, where he refers to St. Catherine's virtues and her relationship to other saints:
… she was marvellous in privilege of dignity, for certain special privileges were in some saints when they died, like as the visitation of Jesu Christ was in St. John the Evangelist, the flowing of oil in St. Nicholas, the effusion of milk for blood that was in St. Paul, the preparation of the sepulchre in St. Clement, the hearing and granting of petitions in St. Margaret when she prayed for them remembering her memory. All these things together were in this blessed virgin S. Katherine as it appeareth in her legend.
The advertisements on the title and colophon pages of the Misse familiares imply that they were produced for a very broad market, which likely included Parisian trade and devotional confraternities, students at the University of Paris, and other types of religious settings. This series of printed graduals, which contain five widespread votive masses and a full kyriale, were produced in Paris during the early decades of the sixteenth century, first by Geoffrey Marnef and later by François Regnault. They were associated with a number of other small liturgical books entitled Misse solenniores (which contain a dozen Mass ordinaries for major feast days), Communes prose (which contain fifteen popular sequences), and Passiones novissime (passions according to Matthew and John).
O beautiful violet, seedling of paradise, he has crowned you, holy Barbara, with the eminent double halo of virgin and martyr: make us to be rendered worthy of the laurel of heaven.
This antiphon text is one of many examples of intercessory prayers found in popular devotions meant to establish a direct connection between saint and supplicant. It appears as part of the Office for St. Barbara in Tournai, Archives et Bibliothèque de la Cathédrale MS A 12 (B-Tc A 12), a chant manuscript with additions from the thirteenth through sixteenth centuries used by the Confraternity of the Notaries at the Cathedral of Notre Dame in Tournai. Many of the chants for the Mass and Office in liturgical books used by confraternities are in first person narrative and end with the formula “Ora pro nobis,” or “pray for us,” and indeed, this text asks the saint to “make us to be rendered worthy of the laurel of heaven.” In addition to laudatory texts like the one above, devotional literature (Books of Hours, Miracles of the Virgin, the Golden Legend) and the liturgies that developed from it encouraged the laity to identify with the suffering of the saints by focusing on the details of their martyrdom. Music, text, and image all worked together to engage the “emotional imagination,” creating a personal experience of the saint's pain and salvation. New liturgical texts and music created for confraternities in the fourteenth through sixteenth centuries were integral to this process.
In this chapter, I explore the material culture of the Confraternity of the Notaries at the Tournai cathedral—in particular, three manuscripts they owned—and what it can tell us about the development of liturgical practices in private devotional communities at this institution. In the absence of any archival documents recording the everyday acts of the confraternity (how they interacted with the diocese, payment of musicians, and all other sundry activities), these manuscripts are the only existing sources reflecting their rituals and place within the cathedral. Since the discovery of these books in the nineteenth century, scholars have investigated isolated parts of their contents but have not sought to view each one as a whole.
In the introduction to this book, I broadly explored how the movement of individuals (clerics and the laity) through different physical and social spaces could be related to the circulation of popular devotional practices cultivated by confraternities. In many cases there are no documents or confraternity registers recording the inner workings of these organizations, or informa-tion about those who were paid to compile and perform their services. Due to these limitations, I have relied on the contents of their existing liturgical books to investigate how the religious practices of these communities developed. As a result of my focus on the musical and textual contents of these sources, I have demonstrated how decentralized religious and spiritual authority was during the time period under study. As individuals, confraternity members were people who worked as merchants and artisans, clerics, and students. As communities, they had the power to develop their own corporate identities. I do not mean to imply that the laity directly challenged ecclesiastical authority. Instead, it is evident that lay authority and ecclesiastical authority were two different things, and that popular devotions, such as those promoted by confraternities, occupied a different space altogether from that of larger ecclesiastical and monastic institutions.
Confraternity liturgies were created and mediated by individuals and communities and were heavily influenced by contact between different networks. The various types of interactions between these entities could have been responsible for the dissemination of religious ideas, and particularly in times of plague, widespread beliefs concerning the healing attributes of certain saints. Those most commonly revered at the time were the fourteen holy helpers, which in northern France included St. Barbara, St. Catherine, and St. Nicholas. The popular devotional practices in this study did not travel in direct, easily traceable lines, but instead through constellations of individuals and communities, all of which were marked by movement—physical, social, and spiritual—resulting in the formation of different identities, with music playing a central role. While my interest has been northern France, looking at these types of movement would be a useful tool for investigations into other geographical areas further north in the Low Countries, east in the Hapsburg lands, and south in Italy. Below, I recap some of the examples from the present work that illustrate each type of movement.
This appendix records all the manuscript and printed liturgical books containing music that were used by confraternities at various institutions in Tournai through the end of the sixteenth century. Because musical sources from Tournai have not been the object of an in-depth study, sources used in the main sanctuary of the cathedral, as well as those used in other chapels at this institution, are included in the appendix with truncated descriptions. Within the inventories, all Mass ordinary chants are listed in the order in which they appear in the manuscript or printed book, along with a “C” number that has been assigned solely for the purposes of the present study. The appendix also takes special care to indicate sequences appearing outside of the Mass in these sources. The numbering system in this appendix corresponds to the numbers assigned to the sources in appendix 1, which are used for all comparison tables in the chapters and appendices throughout the present study.
Liturgical Books Used by Confraternities in Tournai
10. Archives et Bibliothèque de la Cathédrale de Tournai, Manuscript 12 (B-Tc A 12). 270 x 185 mm. Late fourteenth- or early fifteenth-century binding (a date determined based on the index of the source's contents, discussed in chapter 1), consisting of brown leather over wooden boards, with evidence of missing clasps. 1 unnumbered parchment flyleaf + 216 numbered parchment folios. Foliation in a modern hand beginning on the second parchment folio in pencil, using Arabic numerals written only on the recto of each leaf in the lower right-hand margin. Penwork initials, and use of red, blue, and yellow throughout. No illuminations. The music notation, which appears on red four-lined staves, consists primarily of a hybrid form commonly found in the southern Low Countries, which mixes elements of French and German neumes. There is also square chant notation on four-lined red staves throughout.
Antiphoner and gradual used by the Confraternity of the Notaries at the Cathedral of Tournai, with original contents and later additions dating from the thirteenth through sixteenth centuries. There is a card glued to the front of the book in the nineteenth century indicating the source's place of origin, “Cathedral de Tournay” [sic].
Illustrious martyr, glory of the soldiery, champion of Christ, born in the sight of God in order that he might avert for us God's anger. Martyr who piously poured out judgments so that the epidemic may not be harmful. In this fatherland and in others which request your help. Hear [your] praises. And with pious prayer may rewards be given. Quick, soldier, help us. Alleluya.
This is a Mass offertory for St. Sebastian found in Paris, Bibliothèque de l’Arsenal MS 204 (F-Pa 204), a fifteenth-century Parisian liturgical book for the Confraternity of the Bourgeois Archers. This organization comprised men of different trades, who resided in neighborhoods throughout the city but came together to function as the citizen's guard of Paris. It is personal and urgent in nature, calling upon the saint directly with the plea, “Quick, soldier, help us.” This prayer to St. Sebastian alludes to his power as a plague saint and healer, which is based on his ability to deflect the anger of God. It is not unlike the other laudatory texts discussed in chapters 1 and 2 that made references to a saint's healing ability, martyrdom, and miracles. St. Sebastian was one of the most revered plague saints in northern France, along with others counted among the fourteen holy helpers in this geographical area. The contents of this confraternity manuscript reveal St. Sebastian to be the most important figure of veneration for the archers, for the saint himself was shot with arrows in an attempted execution at the hands of the Roman emperor Diocletian. This is the only source in the present study that is devoted exclusively to plague saints, as it also contains masses for St. Roche, St. Anthony the Abbot, and St. Genevieve. In this chapter I explore how Parisian confraternities in the fifteenth century refashioned St. Sebastian into a local protector through textual and melodic references to historical persons and places—and in particular, places that held relics.
In addition to the text's allusion to healing, it has a notable reference to place through the line “In this fatherland and in others which request your help.”