Response to 'Obesity is South Africa's new HIV epidemic'

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Advancing fatigue management in healthcare: risk-based approaches that enhance health service delivery

Given the need for 24/7 healthcare services, fatigue is an inevitable consequence of work in this industry. A significant body of regulatory advice and hospital services have focused primarily on restricting work hours as the primary method of mitigating fatigue-related risk. Given the inevitability of fatigue, and the limited capacity of labour agreements to control risk, this commentary explores how the principles of fatigue risk management might be applied in a healthcare setting.

Analysis of Twitter conversations in obstetric anesthesiology using the hashtag #OBAnes during the onset of the COVID-19 pandemic

BACKGROUND

#OBAnes is the most used hashtag in obstetric anesthesiology. The primary objective of the study was to characterize #OBAnes tweets at the onset of the COVID-19 pandemic.

METHODS

Observational study of all tweets using #OBAnes between June 30, 2019 and October 19, 2020. A list of 19 topics was compiled to categorize each tweet. All Twitter users were manually assigned into one of 19 Symplur Healthcare Stakeholder categories.

RESULTS

There were 12 431 tweets with #OBAnes during the study period, posted by 1704 unique users. The top user category was Doctor (n = 1211, 71%) with 9665 (78%) tweets. The top three topics identified within Twitter conversations were neuraxial anesthesia, COVID-19, and general anesthesia.

CONCLUSIONS

Twitter facilitated thousands of obstetric anesthesia-related discussions during the onset of the COVID-19 pandemic, with most conversations centering on anesthesia type (neuraxial or general anesthesia).

Scottish Firefighters Occupational Cancer and Disease Mortality Rates: 2000-2020

BACKGROUND

Increased mortality from cancers and other diseases has been reported in USA, Canadian, and Nordic firefighters. However, UK firefighters are understudied.

AIMS

To determine whether UK firefighters suffer increased mortality from cancers and other diseases when compared with the general population.

METHODS

Mortality from cancer and other diseases in Scottish male firefighters between 2000 and 2020 was compared with the general Scottish male population and expressed as standardized mortality ratios (SMRs) (with 95% confidence intervals, CI).

RESULTS

Significant overall excess cancer mortality was found for Scottish firefighters compared with the general population (SMR 1.61, CI 1.42-1.81). Scottish firefighters were nearly three times more likely to die of malignant neoplasms (unspecified sites) (SMR 2.71, CI 1.71-4.00). Excess cancer mortality was also found for several site-specific cancers, including prostate (SMR 3.80, CI 2.56-5.29), myeloid leukaemia (SMR 3.17, CI 1.44-5.58), oesophagus (SMR 2.42, CI 1.69-3.29) and urinary system (kidney and bladder) (SMR 1.94, CI 1.16-2.91). Mortality from neoplasms of unknown behaviour was over six times greater in Scottish firefighters (SMR 6.37, CI 2.29-12.49). Additionally, significantly higher mortality was found for: acute ischaemic heart diseases (SMR 5.27, CI 1.90-10.33), stroke (SMR 2.69, CI 1.46-4.28), interstitial pulmonary diseases (SMR 3.04, CI 1.45-5.22), renal failure (SMR 3.28, CI 1.18-6.44) and musculoskeletal system diseases (SMR 5.64, CI 1.06-13.83).

CONCLUSIONS

UK firefighters suffer significant excess mortality from cancer and other diseases when compared with the general population. Preventative health monitoring and presumptive legislation are urgently required to protect UK firefighters' health.

1327 PROACTIVE COMPREHENSIVE GERIATRIC ASSESSMENT FOR CARE HOME RESIDENTS LIVING WITH FRAILTY

Introduction

Frailty is a long-term condition with potentially significant associated healthcare costs and resource usage. The gold standard evidence-based intervention is a comprehensive geriatric assessment. The NHS Long Term Plan highlights the importance of ageing well and developing proactive services in the community. Care home residents often have unmet health and social care needs, and are frequently frail.

Methods

59 patients with severe or very severe frailty (Rockwood clinical frailty score 7 or 8) across three care homes with both residential and nursing provision were reviewed in person. They were then discussed in an MDT comprised of geriatricians, GPs, community matrons, district nurses, community therapists and care home staff in order to complete a virtual CGA resulting in a personalised care plan.

Results

In the 8 weeks after MDT, compared to the 8 weeks before, there was a 49% reduction in GP contacts (28 vs 55) and a 17% reduction in ED attendances (5 vs 6). There was a 133% increase in proactive referrals (7 vs 3) and 20 advanced care plans were completed. 74 medications were reduced or stopped whilst 4 medications were started, with a cost saving of £812.58 over the 8 week follow up.

Conclusions

Despite a small sample size and a short follow up period, these results suggest that intervention with a proactive CGA provides benefits to frail care home residents, particularly with regards to reductions in polypharmacy and improved access to advanced care planning. These results also suggest potential benefits to the wider system, with reductions in GP contacts and unplanned hospital attendance. We suggest that in future a CGA should be completed for each new resident to a care home as the basis of a personalised care plan.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

72 Medical Students’ Opinion on Academic Surgery as a Career and Access to Opportunities in Surgical Research

Introduction

The clinical academic training pathway in the United Kingdom is offering an increasing number of surgically themed roles. The understanding of research and available academic opportunities amongst applicants is variable. The aim of this study was to capture the understanding and exposure to clinical academia in surgery amongst UK medical students. Methods: We surveyed 100 medical students prior to them attending the inaugural Academic Surgery Virtual Conference based at Brighton and Sussex Medical school. Participants were sent a google survey via email the day prior to attending the conference to be completed anonymously.

Results

52 students completed the pre-conference survey; 55.8% were female, 42.3% male, 1.9% preferred not to disclose gender. Mean ages for females were 21.4 and for males 23.5. An even distribution of students from different year groups responded, from 4 deaneries encompassing different UK medical schools. All participants had an additional degree with a BSc being the most common (n=36, 69.2%). Overall, 61.5% (n=38) of students expressed an interest in an academic surgical career. Only 52.7% (n=30) had previous experience in research, and 36.5% (n=19) knew how to get involved in surgical research. The majority of students had not received any teaching in medical school on academic surgery (n=38, 73.1%).

Conclusion

This survey has identified that amongst a cohort of medical students interested in academic surgery, few had research experience or knew how to get involved in surgical research. Medical schools should provide earlier education on clinical academic pathways to meet the rising demand for clinical academics in surgery.

Bipolar Stigma in Jewish Communities in the United States

Introduction

This study investigated differences in mood disorder public stigma endorsed by Jewish adults. Specifically, it examined the association between public stigma and the symptomatology and gender of individuals with mood disorders and characteristics of respondents. The symptomatology investigated included major depressive disorder and bipolar disorder presenting with mania or depression. The public stigma factors measured for mood disorders were recovery, relationship disruption, hygiene, anxiety, and treatment/professional efficacy.

Objectives

Do symptomatology and gender predict stigma for mood disorders? For Jewish adults, do gender, age, religious characteristics, mental health history, and perceived stigma for mental illness predict their stigma toward individuals with mood disorders?

Methods

A convenience sample of 243 Jewish adults were randomly administered vignettes using a factorial design. MANCOVA was used for analysis. The Mental Illness Stigma Scale (Day et al., 2007) and the Devaluation of Consumer scale (Struening et al., 2001) were used to measure public and perceived stigma respectively.

Results

showed that recovery, relationship disruption, and hygiene stigmas were associated with vignette subject symptomatology, an interaction was found between respondent gender and age for treatability/professional efficacy stigma, and perceived stigma was correlated with public stigma factors. Consistent with previous research, the highest levels of stigma were found for individuals with bipolar disorder presenting with mania (Wolkenstein & Meyer, 2008).

Conclusions

These findings increase our knowledge of mood disorder stigma existing in the Jewish community and supports research showing that bipolar disorder presenting with mania is the most stigmatized type of mood disorder symptomatology (Wolkenstein & Meyer, 2008).

Disclosure

No significant relationships.

719 THE EFFECT OF LOCKDOWN ON THE INCIDENCE OF VTE IN HIP FRACTURE PATIENTS DURING THE COVID-19 PANDEMIC

Introduction

COVID-19 is associated with an increased risk of venous thromboembolism (VTE). We compared the incidence of VTE on a busy hip fracture unit during 2020 with previous years to identify factors that may have played a role in its development.

Methods

Data were retrospectively obtained by notes review for patients admitted with neck or shaft of femur fracture. This included baseline characteristics, comorbidities and operative risk factors for VTE.

Results

11 of 420 patients (2.6%) were diagnosed with VTE in 2020, compared with 25 of 2,115 patients (1.2%) between January 2015 and December 2019 (RR 2.2 [95% CI 1.1 to 4.5, p &lt; 0.05]). Only one patient in 2020 had confirmed COVID-19. Retrospective data between 2015–2019 were incomplete, and so statistical analysis of demographic and operative risk factors was not conducted. Descriptive statistics show there were comparable proportions of smokers and malignancy in both groups, and the majority of patients in both groups received either mechanical or pharmacological VTE prophylaxis. A higher proportion of patients were independently mobile prior to admission in 2020 (72.7% vs 28%). There was a shorter interval to development of VTE in 2020 (mean 12 days in 2020 vs 25 days in 2015–2019).

Conclusion

Following hip fracture surgery patients were twice as likely to develop venous thromboembolism in 2020 than in the previous five years. There was also a shorter time to development of VTE. This was despite a higher reported level of premorbid mobility in 2020 in otherwise similar patient groups. We hypothesise that isolation due to the COVID-19 lockdown contributed to this result. This suggests a need for enhanced vigilance and prompt VTE prophylaxis in this vulnerable population in the event of further pandemic waves and lockdowns.

OPTN/SRTR 2020 Annual Data Report: Kidney

The year 2020 presented significant challenges to the field of kidney transplantation. After increasing each year since 2015 and reaching the highest annual count to date in 2019, the total number of kidney trans- plants decreased slightly, to 23642, in 2020. The decrease in total kidney transplants was due to a decrease in living donor transplants; the number of deceased donor transplants rose in 2020. The number of patients waiting for a kidney transplant in the United States declined slightly in 2020, driven by a slight drop in the number of new candidates added in 2020 and an increase in patients removed from the waiting list owing to death-important patterns that correlated with the COVID-19 pandemic. The complexities of the pandemic were accompanied by other ongoing challenges. Nationwide, only about a quarter of waitlisted patients receive a deceased donor kidney transplant within 5 years, a proportion that varies dramatically by donation service area, from 14.8% to 73.0%. The nonutilization (discard) rate of recovered organs rose to its highest value, at 21.3%, despite a dramatic decline in the discard of organs from hepatitis C-positive donors. Nonutilization rates remain particularly high for Kidney Donor Profile Index ≥85% kidneys and kidneys from which a biopsy specimen was obtained. Due to pandemic-related disruption of living donation in spring 2020, the number of living donor transplants in 2020 declined below annual counts over the last decade. In this context, only a small proportion of the waiting list receives living donor transplants each year, and racial disparities in living donor transplant access persist. As both graft and patient survival continue to improve incrementally, the total number of living kidney transplant recipients with a functioning graft exceeded 250,000 in 2020. Pediatric transplant numbers seem to have been impacted by the COVID-19 pandemic. The total number of pediatric kidney transplants performed decreased to 715 in 2020, from a peak of 872 in 2009. Despite numerous efforts, living donor kidney transplant remains low among pediatric recipients, with continued racial disparities among recipients. Of concern, the rate of deceased donor transplant among pediatric waitlisted candidates continued to decrease, reaching its lowest point in 2020. While this may be partly explained by the COVID-19 pandemic, close attention to this trend is critically important. Congenital anomalies of the kidney and urinary tract remain the leading cause of kidney disease in the pediatric population. While most pediatric de- ceased donor recipients receive a kidney from a donor with KDPI less than 35%, most pediatric deceased donor recipients had four or more HLA mis- matches. Graft survival continues to improve, with superior survival for living donor recipients versus deceased donor recipients.

168 ANXIETY SYMPTOMS AMONG OLDER PEOPLE DURING THE COVID-19 PANDEMIC: PREVALENCE AND ASSOCIATED FACTORS

Background

There are concerns that the COVID-19 pandemic could lead to a rise in mental health problems including anxiety amongst older people, especially those shielding alone during the pandemic.

The aim of this study therefore is to examine the prevalence of anxiety symptoms during the COVID-19 pandemic amongst older people and clarify factors associated with higher burden of symptoms.

Methods

We analysed data from the COVID-19 study of The Irish Longitudinal Study on Ageing, conducted on over 3,100 community dwelling people aged ≥60 years from July–November 2020.

Anxiety symptoms were measured with the Generalised Anxiety Disorder-7 Questionnaire with a score ≥ 10 indicating moderate–severe anxiety.

Linear regression models were used to assess the association of variables of interest with anxiety symptoms.

Results

Almost 9% of participants (n = 3,128; mean age 71 years) had moderate–severe symptoms of anxiety.

Factors independently associated with a higher burden of anxiety symptoms included female sex (β = 0.60 (0.33–0.87)); living alone (β = 0.72 (0.41–1.02)); ≥2 chronic diseases (β = 0.85 (0.41–1.30); heart disease (β = 0.95 (0.45–1.46)) and reporting frequent loneliness (β = 6.59 (6.03–7.16)). Age ≥ 80 years (β = −0.77 (−1.16—0.37)) and tertiary level education (β = −0.48 (−0.86—-0.10)) were associated with lower anxiety symptom burden.

Conclusion

Almost 1 in 10 of this population-representative sample of older people had moderate to severe anxiety symptoms during the COVID-19 pandemic.

Strategies to address loneliness, which was particularly strongly associated with anxiety symptoms during the pandemic, should be a priority.

1245 Enhanced Recovery Program in Colorectal Surgery at Basildon And Thurrock University Hospital

Introduction

Enhanced recovery program (ERP) is an integrated multidisciplinary approach that requires participation and commitment from different member of staff, and the patient. This is an evidence-based protocol designed to standardize medical care, improve outcomes, and lower care costs. The aim of this study is to observe how ERP protocol is followed in our institution, and to monitor different outcomes. Data was compared to NICE guideline.

Method

We reviewed all patients who underwent elective colorectal resection for cancer between June 2018 and May 2019. data was collected retrospectively from patient electronic case notes. We monitored compliance with ERP protocol (NICE), as well as outcomes

Results

114 patients were included in our study. We noted that just 35% of patients had intraoperative nasogastric tube. Antibiotics: 74.56%, Catheter 98.24%, PCA 79.82%, Spinal anaesthesia 52.63%, Drain 38.59%. In the post op period, patients were mobilized at 1.89 day (1.27) [mean (SD)], NGT removal: 1.81 day (2.31) Refeeding: 1.36 day (1.01). It has been proven that patients with inadequate perioperative analgesia are more prone to develop ileus, to have a prolonged hospital stay, and have an overall higher mortality (p0.001)

Conclusions

It seems that there is a room for improvement especially in analgesia and prophylactic antibiotics. Following ERP protocols improves overall outcomes.

A Kinetic Approach for Assessing the Uptake of Ag from Pristine and Sulfidized Ag Nanomaterials to Plants

Nanomaterials (NMs) are thermodynamically unstable by nature, and exposure of soil organisms to NMs in the terrestrial environment cannot be assumed constant. Thus, steady-state conditions may not apply to NMs, and bioaccumulation modeling for uptake should follow a dynamic approach. The one-compartment model allows the uptake and elimination of a chemical to be determined, while also permitting changes in exposure and growth to be taken into account. The aim of the present study was to investigate the accumulation of Ag from different Ag NM types (20 nm Ag⁰ NMs, 50 nm Ag⁰ NMs, and 25 nm Ag₂ S NMs) in the crop plant wheat (Triticum aestivum). Seeds were emerged in contaminated soils (3 or 10 mg Ag/kg dry soil, nominal) and plants grown for up to 42 d postemergence. Plant roots and shoots were collected after 1, 7, 14, 21, and 42 d postemergence; and total Ag was measured. Soil porewater Ag concentrations were also measured at each sampling time. Using the plant growth rates in the different treatments and the changing porewater concentrations as parameters, the one-compartment model was used to estimate the uptake and elimination of Ag from the plant tissues. The best fit of the model to the data included growth rate and porewater concentration decline, while showing elimination of Ag to be close to zero. Uptake was highest for Ag⁰ NMs, and size did not influence their uptake rates. Accumulation of Ag from Ag₂ S NMs was lower, as reflected by the lower porewater concentrations. Environ Toxicol Chem 2021;40:1861-1872. © 2021 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

475 DEVELOPING A VIRTUAL CARE HOME SUPPORT FORUM DURING THE COVID-19 PANDEMIC

Introduction

COVID-19 has had a devastating effect on care homes, increasing both morbidity and mortality of residents and staff. Between 2 March and 12 June 2020, COVID-19 was the main cause of death in male care home residents (33.5%) and second for female (26.6%).1 By 1 May 2020, the death rate from all causes in care homes exceeded that in hospital (6,409 versus 6,397).2 Thus, care homes had to rapidly adapt to facilitate safe care of patients and staff.

Method

An expert outreach team visited a number of care homes in Surrey and Sussex to explore COVID-19 issues in care homes. Key themes were identified that informed topics for the Virtual Care Home Forum, where a series of virtual teaching, training and peer support sessions were hosted either live or on-demand, accessible for all care home staff.

Results

12 sessions were held with an average attendance of 25 people, predominantly care home managers and community healthcare professionals. Real time qualitative feedback was collected and an electronic survey was completed at the end of the series which showed 100% felt the sessions had improved their understanding of the topic, 100% felt the knowledge and skills obtained from the sessions would be useful in their job, 87.5% agreed the sessions would impact or change their practise and 100% felt more supported during the pandemic.

Conclusion

It has been an unprecedented year for the NHS, and the care home sector has suffered significantly. In order to provide the best level of care for patients and support for our community colleagues, we must work collaboratively, including provision of education and training. To ensure equal access for all, maintaining user-safety and compliance with government legislation, virtual webinars proved to be an excellent modality. We plan to continue providing training, teaching and support through this means in the future.