Developing the embedded researcher role: Learning from the first year of the National Institute for Health and Care Research (NIHR), Health Determinants Research Collaboration (HDRC), Doncaster, UK

Background

Strategies to embed research knowledge into decision making contexts include the Embedded Research (ER) model, which involves the collocation of academic researchers in non-academic organisations such as hospitals and local authorities. A local authority in Doncaster, United Kingdom (UK) has adopted an embedded researcher model within the National Institute for Health and Care Research (NIHR), Health Determinants Research Collaboration (HDRC). This five-year collaboration enables universities and local authorities to work together to reduce health inequalities and target the social determinants of health. Building on previous embedded research models, this approach is unique due to its significant scale and long-term investment. In this opinion paper Embedded Researchers (ERs) reflect on their experiences of the first year of the collaboration.

Study design

A reflective consultation exercise.

Methods

Observation of HDRC delivery meetings, as well as informal discussions and a short proforma with ERs (N = 8).

Results

ERs valued the five-year timeframe which provided a unique opportunity for strengthened relationships and to apply formative learning as the programme progressed. However, differences in knowledge of undertaking research across the HDRC team and between practitioners and academics require each to respect different professional experiences and to avoid potential power imbalances. Diverse projects required researchers to be generalists, applying their expertise to multiple topics. This requires careful priority setting alongside workload and expectation management.

Conclusions

The significant scale and investment of the HDRC provides a unique opportunity for developing the ER role by applying formative learning as the programme progresses. However, success will require careful management of workload allocation and relationships between ERs and practitioners. Further learning on how to embed ERs within local authority contexts will emerge as the programme matures.

High-Intensity Aphasia Therapy Is Cost-Effective in People With Poststroke Aphasia: Evidence From the COMPARE Trial

BACKGROUND

Evidence from systematic reviews confirms that speech and language interventions for people with aphasia during the chronic phase after stroke (>6 months) improve word retrieval, functional communication, and communication-related quality of life. However, there is limited evidence of their cost-effectiveness. We aimed to estimate the cost per quality-adjusted life year gained from 2 speech and language therapies compared with usual care in people with aphasia during the chronic phase (median, 2.9 years) after stroke.

METHODS

A 3-arm, randomized controlled trial compared constraint-induced aphasia therapy plus (CIAT-Plus) and multimodality aphasia therapy (M-MAT) with usual care in 216 people with chronic aphasia. Participants were administered a standardized questionnaire before intervention and at 12 weeks after the 2-week intervention/control period to ascertain health service utilization, employment changes, and informal caregiver burden. Unit prices from Australian sources were used to estimate costs in 2020. Quality-adjusted life years were estimated using responses to the EuroQol-5 Dimension-3 Level questionnaire. To test uncertainty around the differences in costs and outcomes between groups, bootstrapping was used with the cohorts resampled 1000 times.

RESULTS

Overall 201/216 participants were included (mean age, 63 years, 29% moderate or severe aphasia, 61 usual care, 70 CIAT-Plus, 70 M-MAT). There were no statistically significant differences in mean total costs ($13 797 usual care, $17 478 CIAT-Plus, $11 113 M-MAT) and quality-adjusted life years (0.19 usual care, 0.20 CIAT-Plus, 0.20 M-MAT) between groups. In bootstrapped analysis of CIAT-Plus, 21.5% of iterations were likely to result in better outcomes and be cost saving (dominant) compared with usual care. In contrast, 72.4% of iterations were more favorable for M-MAT than usual care.

CONCLUSIONS

We observed that both treatments, but especially M-MAT, may result in better outcomes at an acceptable additional cost, or potentially with cost savings. These findings are relevant in advocating for the use of these therapies for chronic aphasia after stroke.

Identifying communication difficulty and context-specific communication supports for patient-provider communication in a sub-acute setting: A prospective mixed methods study

PURPOSE

To identify the sub-acute rehabilitation inpatients who have communication difficulty and the range of communication supports that can facilitate communicative success.

METHOD

A prospective cohort mixed methods study was conducted on two inpatient sub-acute rehabilitation wards. Nurses screened all new admissions for communication difficulty using the Inpatient Functional Communication Interview, Screening Questionnaire (IFCI-SQ). Patients identified as having communication difficulty were interviewed by a speech-language pathologist (SLP) using the Inpatient Functional Communication Interview (IFCI). During the interview, the SLP trialled different communication supports. The number of patients who had communication difficulty on the IFCI-SQ was calculated. The number and type of communication supports that improved communication within the patient-SLP interview were calculated. Deductive-dominant qualitative content analysis was conducted on the communication supports used during the IFCI.

RESULT

Seventy patients were screened. Nurses reported communication difficulty in 45/70 (64%) of patients. A total of 15/45 patients were interviewed by an SLP using the IFCI. The provision of communication supports improved communication for all patients within the context of the patient-SLP interview.

CONCLUSION

Many sub-acute rehabilitation inpatients have communication difficulty in the hospital setting. A range of communication supports facilitated communication. These insights could inform future communication partner training (CPT) programs.

Acceptability, feasibility and preliminary efficacy of low-moderate intensity Constraint Induced Aphasia Therapy and Multi-Modality Aphasia Therapy in chronic aphasia after stroke

BACKGROUND

High-intensity Constraint-Induced Aphasia Therapy Plus (CIAT-Plus) and Multi-Modality Aphasia Therapy (M-MAT) are effective interventions for chronic post-stroke aphasia but challenging to provide in clinical practice. Providing these interventions may be more feasible at lower intensities, but comparative evidence is lacking. We therefore explored feasibility, acceptability, and preliminary efficacy of the treatments at a lower intensity.

METHODS

A multisite, single-blinded, randomized Phase II trial was conducted within the Phase III COMPARE trial. Groups of participants with chronic aphasia from the usual care arm of the COMPARE trial were randomized to M-MAT or CIAT-Plus, delivered at the same dose as the COMPARE trial but at lower intensity (6 hours/week × 5 weeks rather than 15 hours/week × 2 weeks). Blinded assessors measured aphasia severity (Western Aphasia Battery-Revised Aphasia Quotient), word retrieval, connected speech, multimodal communication, functional communication, and quality of life immediately post interventions and after 12 weeks. Feasibility and acceptability were explored.

RESULTS

Of 70 eligible participants, 77% consented to the trial; 78% of randomized participants completed intervention and 98% of assessment visits were conducted. Fatigue and distress ratings were low with no related withdrawals. Adverse events related to the trial (n = 4) were mild in severity. Statistically significant treatment effects were demonstrated on word retrieval and functional communication and both interventions were equally effective.

CONCLUSIONS

Low-moderateintensity CIAT-Plus and M-MAT were feasible and acceptable. Both interventions show preliminary efficacy at a low-moderate intensity. These results support a powered trial investigating these interventions at a low-moderate intensity.

PUF60-related developmental disorder: A case series and phenotypic analysis of 10 additional patients with monoallelic PUF60 variants

PUF60-related developmental disorder (also referred to as Verheij syndrome), resulting from haploinsufficiency of PUF60, is associated with multiple congenital anomalies affecting a wide range of body systems. These anomalies include ophthalmic coloboma, and congenital anomalies of the heart, kidney, and musculoskeletal system. Behavioral and intellectual difficulties are also observed. While less common than other features associated with PUF60-related developmental disorder, for instance hearing impairment and short stature, identification of specific anomalies such as ophthalmic coloboma can aid with diagnostic identification given the limited spectrum of genes linked with this feature. We describe 10 patients with PUF60 gene variants, bringing the total number reported in the literature, to varying levels of details, to 56 patients. Patients were recruited both via locally based exome sequencing from international sites and from the DDD study in the United Kingdom. Eight of the variants reported were novel PUF60 variants. The addition of a further patient with a reported c449-457del variant to the existing literature highlights this as a recurrent variant. One variant was inherited from an affected parent. This is the first example in the literature of an inherited variant resulting in PUF60-related developmental disorder. Two patients (20%) were reported to have a renal anomaly consistent with 22% of cases in previously reported literature. Two patients received specialist endocrine treatment. More commonly observed were clinical features such as: cardiac anomalies (40%), ocular abnormalities (70%), intellectual disability (60%), and skeletal abnormalities (80%). Facial features did not demonstrate a recognizable gestalt. Of note, but remaining of unclear causality, we describe a single pediatric patient with pineoblastoma. We recommend that stature and pubertal progress should be monitored in PUF60-related developmental disorder with a low threshold for endocrine investigations as hormone therapy may be indicated. Our study reports an inherited case with PUF60-related developmental disorder which has important genetic counseling implications for families.

Glutamine deamidation does not increase the immunogenicity of C-peptide in people with type 1 diabetes

Type 1 diabetes (T1D) is a T-cell mediated autoimmune disease in which the insulin-producing beta cells are destroyed. While it is clear that full-length C-peptide, derived from proinsulin, is a major antigen in human T1D it is not clear how and why C-peptide becomes a target of the autoimmune CD4⁺ T-cell responses in T1D. Neoepitopes formed by the conversion of glutamine (Q) residues to glutamic acid (E) by deamidation are central to the immune pathogenesis of coeliac disease and have been implicated in autoimmune responses in T1D. Here, we asked if the immunogenicity of full-length C-peptide, which comprises four glutamine residues, was enhanced by deamidation, which we mimicked by substituting glutamic acid for glutamine residue. First, we used a panel of 18 well characterized CD4⁺ T-cell lines specific for epitopes derived from human C-peptide. In all cases, when the substitution fell within the cognate epitope the response was diminished, or in a few cases unchanged. In contrast, when the substitution fell outside the epitope recognized by the TCR responses were unchanged or slightly augmented. Second, we compared CD4⁺ T-cell proliferation responses, against deamidated and unmodified C-peptide, in the peripheral blood of people with or without T1D using the CFSE-based proliferation assay. While, as reported previously, responses were detected to unmodified C-peptide, no deamidated C-peptide was consistently more stimulatory than native C-peptide. Overall responses were weaker to deamidated C-peptide compared to unmodified C-peptide. Hence, we conclude that deamidated C-peptide does not play a role in beta-cell autoimmunity in people with T1D.

C, Renkin J, Maes F, Beauloye C, Lengelé JP, Huyberechts D, Bouvie A, Witkowski A, Januszewicz A, Kądziela J, Prejbisj A, Hering D, Ciecwierz D, Jaguszewski MJ, Owczuk R. Effects of Renal Denervation vs Sham in Resistant Hypertension After Medication Escalation: Prespecified Analysis at 6 Months of the RADIANCE-HTN TRIO Randomized Clinical Trial

Importance

Although early trials of endovascular renal denervation (RDN) for patients with resistant hypertension (RHTN) reported inconsistent results, ultrasound RDN (uRDN) was found to decrease blood pressure (BP) vs sham at 2 months in patients with RHTN taking stable background medications in the Study of the ReCor Medical Paradise System in Clinical Hypertension (RADIANCE-HTN TRIO) trial.

Objectives

To report the prespecified analysis of the persistence of the BP effects and safety of uRDN vs sham at 6 months in conjunction with escalating antihypertensive medications.

Design, Setting, and Participants

This randomized, sham-controlled, clinical trial with outcome assessors and patients blinded to treatment assignment, enrolled patients from March 11, 2016, to March 13, 2020. This was an international, multicenter study conducted in the US and Europe. Participants with daytime ambulatory BP of 135/85 mm Hg or higher after 4 weeks of single-pill triple-combination treatment (angiotensin-receptor blocker, calcium channel blocker, and thiazide diuretic) with estimated glomerular filtration rate (eGFR) of 40 mL/min/1.73 m2 or greater were randomly assigned to uRDN or sham with medications unchanged through 2 months. From 2 to 5 months, if monthly home BP was 135/85 mm Hg or higher, standardized stepped-care antihypertensive treatment starting with aldosterone antagonists was initiated under blinding to treatment assignment.

Interventions

uRDN vs sham procedure in conjunction with added medications to target BP control.

Main Outcomes and Measures

Six-month change in medications, change in daytime ambulatory systolic BP, change in home systolic BP adjusted for baseline BP and medications, and safety.

Results

A total of 65 of 69 participants in the uRDN group and 64 of 67 participants in the sham group (mean [SD] age, 52.4 [8.3] years; 104 male [80.6%]) with a mean (SD) eGFR of 81.5 (22.8) mL/min/1.73 m2 had 6-month daytime ambulatory BP measurements. Fewer medications were added in the uRDN group (mean [SD], 0.7 [1.0] medications) vs sham (mean [SD], 1.1 [1.1] medications; P = .045) and fewer patients in the uRDN group received aldosterone antagonists at 6 months (26 of 65 [40.0%] vs 39 of 64 [60.9%]; P = .02). Despite less intensive standardized stepped-care antihypertensive treatment, mean (SD) daytime ambulatory BP at 6 months was 138.3 (15.1) mm Hg with uRDN vs 139.0 (14.3) mm Hg with sham (additional decreases of -2.4 [16.6] vs -7.0 [16.7] mm Hg from month 2, respectively), whereas home SBP was lowered to a greater extent with uRDN by 4.3 mm Hg (95% CI, 0.5-8.1 mm Hg; P = .03) in a mixed model adjusting for baseline and number of medications. Adverse events were infrequent and similar between groups.

Conclusions and Relevance

In this study, in patients with RHTN initially randomly assigned to uRDN or a sham procedure and who had persistent elevation of BP at 2 months after the procedure, standardized stepped-care antihypertensive treatment escalation resulted in similar BP reduction in both groups at 6 months, with fewer additional medications required in the uRDN group.

Trial Registration

ClinicalTrials.gov Identifier: NCT02649426.

Learning from the challenges of undertaking an evaluation of a multi-partner housing support initiative delivered within a hospital setting

Objectives

We present learning from a mixed-methods evaluation of a housing support initiative for hospital inpatients.

Study design

A mixed-methods process evaluation.

Methods

A social housing provider delivered a housing support service in two hospitals (mental health unit and general hospital). Healthcare providers, the social housing provider and academic researchers designed and undertook a co-produced, mixed-methods process evaluation of the intervention. The evaluation included questionnaires, semi-structured interviews, analysis of routinely collected data and economic analysis. Despite commitment from the partners, the evaluation faced challenges. We reflect on the lessons learnt within our discussion paper.

Results

Despite the commitment of the partners, we faced several challenges.

We took an iterative approach to the design and processes of the evaluation to respond to arising challenges. Recruitment of service-users was more difficult than anticipated, requiring additional staff resources. Given the small-scale nature of the intervention, and the quality of data recorded in hospital records, the planned economic analysis was not feasible. Positive factors facilitating evaluation included involvement of staff delivering the intervention, as well as managers. Being able to offer payment to partner organisations for staff time also facilitated ongoing engagement.

Conclusions

Multi-partner evaluations are useful, however, researchers and partners need to be prepared to take an iterative, resource intensive approach. Both availability and quality of routine data, and the resources required to support data collection, may limit feasibility of specific methods when evaluating small-scale cross-sector initiatives. Thus, this necessitates a flexible approach to design and analysis.

Results of the COMPARE trial of Constraint-induced or Multimodality Aphasia Therapy compared with usual care in chronic post-stroke aphasia

BACKGROUND

While meta-analyses confirm treatment for chronic post-stroke aphasia is effective, a lack of comparative evidence for different interventions limits prescription accuracy. We investigated whether Constraint-Induced Aphasia Therapy Plus (CIAT-plus) and/or Multimodality Aphasia Therapy (M-MAT) provided greater therapeutic benefit compared with usual community care and were differentially effective according to baseline aphasia severity.

METHODS

We conducted a three-arm, multicentre, parallel group, open-label, blinded endpoint, phase III, randomised-controlled trial. We stratified eligible participants by baseline aphasia on the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ). Groups of three participants were randomly assigned (1:1:1) to 30 hours of CIAT-Plus or M-MAT or to usual care (UC). Primary outcome was change in aphasia severity (WAB-R-AQ) from baseline to therapy completion analysed in the intention-to-treat population. Secondary outcomes included word retrieval, connected speech, functional communication, multimodal communication, quality of life and costs.

RESULTS

We analysed 201 participants (70 in CIAT-Plus, 70 in M-MAT and 61 in UC). Aphasia severity was not significantly different between groups at postintervention: 1.05 points (95% CI -0.78 to 2.88; p=0.36) UC group vs CIAT-Plus; 1.06 points (95% CI -0.78 to 2.89; p=0.36) UC group vs M-MAT; 0.004 points (95% CI -1.76 to 1.77; p=1.00) CIAT-Plus vs M-MAT. Word retrieval, functional communication and communication-related quality of life were significantly improved following CIAT-Plus and M-MAT. Word retrieval benefits were maintained at 12-week follow-up.

CONCLUSIONS

CIAT-Plus and M-MAT were effective for word retrieval, functional communication, and quality of life, while UC was not. Future studies should explore predictive characteristics of responders and impacts of maintenance doses.

TRIAL REGISTRATION NUMBER

ACTRN 2615000618550.

Patterns of nesting behaviour and nesting success for green turtles at Raine Island, Australia

To understand how turtles use the nesting habitat at Raine Island across a nesting season, and how the turtles respond to the restoration of the island’s dune systems, we identified 534 nesting events for 39 green turtles Chelonia mydas across 2 breeding seasons using data derived from satellite tags. Tracked turtles laid between 4 and 10 clutches of eggs. Patterns of nesting success varied between individuals, within and between seasons. Nesting success was higher in 2018-19 (57%) than 2017-18 (45%), and in both years, nesting success was lowest between October and early January (<50%). In 2017-18, increased rainfall in January corresponded with increased nesting success (>50%). The density of female turtles ashore was lower in 2018-19, and likely explains higher nesting success in 2018-19 because competition for nest space was lower. In 2017-18, females had more attempts per clutch, and the attempts were around 90 min longer. Consequently, energy required to lay a clutch of eggs in 2017-18 was significantly higher than in 2018-19, highlighting potential costs of lower nesting success rates on reproductive output. The area of beach re-profiled as an intervention in 2014 and 2017 was a nesting hotspot in 2017-18. However, in 2018-19, the area was not used to the same extent, and the nesting hotspot occurred on the north-eastern unaltered beach. Collectively, the tracking of turtles across the whole nesting season enabled us to assess overall beach use and nesting site fidelity of green turtles at Raine Island. Results will aid future planning and management of beach restoration activities at turtle nesting sites.

One year outcomes of heart failure multispecialty multidisciplinary team virtual meetings

 

Heart Failure is frequently associated with several comorbidities such as ischaemic heard disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease and frailty. This level of complexity is best dealt with by a multispecialty multidisciplinary team (MDT) model.

This was a single centre observational study (January 2020-December 2020) that was undertaken in a British university hospital looking at effect of HF multispecialty virtual MDT meetings on HF outcomes. Patients acted as their own controls outcomes compared for equal period pre versus post MDT meeting. The multi-specialty meeting was conducted once monthly via video-conferencing. It consisted of heart failure cardiologists (from primary secondary and tertiary care), heart failure specialist nurses (hospital and community), nephrologist, endocrinologist, palliative care specialists, chest physician, pharmacist, pharmacologist and geriatrician. Recommendations were made as consensus from the multispecialty meeting. The main outcome measures were 1) number of hospitalisations and 2) outpatient clinic attendances 3) cost savings.

A total of 189 patients were discussed from January-December 2020. This was uninterrupted during the COVID-19 pandemic. The mean age was 70.3±18.1 years and median follow-up 6 months (range 1–13 months). The mean Charlson Co-morbidity score was 5.3±1.2 and Rockwood Frailty Score was 4.9±1. The mean number of outpatient clinic attendances avoided was 1.7±0.4. This reduced inconvenience to patients, saved patients money (transport and parking costs) and led to carbon footprint reduction. The MDT meeting total costs were £15,400 and the 31 clinic appointments they generated cost an estimated £3720. However, the MDT meetings prevented 277 clinic appointments (cost saving £33,352). Finally, the mean number of hospitalisations pre-MDT was 0.7 Vs 0.2 post MDT (p&lt;0.01) with a saving of around 730 bed days (estimated cost-saving £260,000).

The HF multispecialty virtual MDT approach provides seamless integration of primary care community services with secondary and tertiary care. Consensus decision from MDT meetings provides holistic approach for HF patients with comorbidities and frailty, and reduces inconvenience to patients by preventing the need to attend multiple specialty clinics. This approach can also lead to significant cost-savings to the healthcare system.

Funding Acknowledgement

Type of funding sources: None.

POS0739 DEVELOPMENT OF A CONCEPTUAL MODEL TO UNDERSTAND DISEASE BURDEN IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND LONG-TERM ORGAN DAMAGE

Background:

Systemic lupus erythematosus (SLE) is a chronic, multisystem, autoimmune disease resulting in increased morbidity and mortality and reduced health-related quality of life (HRQoL). Patients with SLE are at risk of developing irreversible long-term organ damage (LTOD) caused by both disease activity and cumulative medication toxicities. Data regarding the overall disease burden and impact of LTOD in patients with SLE are limited.

Objectives:

The primary objective of this qualitative study was to develop a conceptual model to describe the burden experienced by patients with SLE and LTOD.

Methods:

This study (GSK Study 209754) was conducted in three phases. First, a targeted literature review was performed to aid the development of an initial draft conceptual model. Key opinion leaders (KOLs) with experience in SLE and LTOD were then interviewed to assess the clarity, language, comprehensibility, and potential use of the conceptual model, and to help shape the patient interview materials. Finally, one-on-one interviews were performed with patients with SLE and LTOD in any of the 12 organ areas (defined by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index [SDI]), to gather patient perspectives on the common symptoms, functional impacts, treatment experiences, and HRQoL factors associated with LTOD. Data from the interviews were coded and analysed using NVivo software to identify patterns in responses concerning the key concepts of the overall patient burden of LTOD, and used to identify concepts to include in the model.

Results:

The literature review produced the preliminary conceptual model of LTOD. Results of the KOL interviews (n=5 clinicians and n=1 patient advocate) indicated that the preliminary conceptual model broadly captured the patient experience of LTOD. KOLs emphasised the difference between SLE activity (flares) and LTOD; the conceptual model was subsequently updated in accordance with these recommendations. Interviews conducted with patients with confirmed single (n=9) and multiple LTOD (n=31) indicated that the burden of LTOD associated with SLE was more severe, debilitating, and life threatening than that caused by SLE flares. Almost all patients (39/40) reported aspects of their lives that were more severely affected since their LTOD diagnosis. All 40 patients reported LTOD-related physical impacts, which often affected patients’ ability to perform everyday tasks. The most frequent physical impacts reported were a loss of vitality (39/40), long-term complications (e.g. unstable blood pressure, extreme pain, poor mobility, inflammation, dialysis, infection; 36/40), and severe fatigue (29/40). Cognitive impairments that became more pronounced after their LTOD diagnosis were reported by 27/40 of patients. Typically characterised as “brain fog”, these impairments were described as slower cognitive processing, forgetfulness, confusion, and aphasia. Economic impacts associated with LTOD included patients’ inability to work (31/40), costs of care (33/40), and non-medical-related costs (17/30). Psychosocial impacts reported by patients with LTOD affected their emotional state (39/40), ability to socialise (40/40) and relationships (30/40). Additionally, 30/40 patients reported symptoms as more severe since their LTOD diagnosis, including pain (14/40), fatigue (9/40), and oedema (8/40). Patients’ treatment goals were largely aligned with their experienced impacts of LTOD, including managing the disease and symptoms (25/40), limiting further organ damage (15/40), and improving HRQoL (11/40).

Conclusion:

The findings from this research clearly indicate that the patient burden of LTOD far surpasses that of SLE without LTOD. These data were incorporated and refined into a conceptual model that fully represents the patient experience of LTOD. The model will help researchers, clinicians, and patients to better understand the impact of SLE-related LTOD progression.

Funding:

GSK

Acknowledgements:

Medical writing assistance was provided by Casmira Brazaitis, PhD, Fishawack Indicia Ltd., UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests:

Lynne Broderick Consultant of: GSK, Wen-Hung Chen Shareholder of: GSK, Employee of: GSK, Roger Levy Shareholder of: GSK, Employee of: GSK, April Foster Consultant of: GSK, Cindy Umanzor Consultant of: GSK, Deven Chauhan Shareholder of: GSK, Employee of: GSK

244 Does Direct Admission to ICU In Emergency Laparotomy Patients with A NELA Score ≥ 10% Affect Outcome at Fiona Stanley Hospital?

Introduction

The Australian and New Zealand Emergency Laparotomy Audit (ANZELA) is a quality improvement project based on UK NELA. Direct admission to ICU post-operatively for patients with a NELA ≥ 10% is recommended. In the current pandemic, the use of critical care beds must be rationalised. We investigated if patients with NELA ≥ 10% experienced worse outcomes if admitted to the ward post-operatively (instead of ICU).

Method

We performed a retrospective audit of emergency laparotomies at Fiona Stanley Hospital over 6 months December 2019 – May 2020. NELA scores were obtained from the ANZELA database and patient notes reviewed to identify post-operative unplanned ICU admissions and mortalities.

Results

Twenty-four (30%) emergency laparotomy patients had a NELA ≥ 10%. Ten (42%) patients were admitted to the ward post-operatively. There were no unplanned ICU admissions in this group. Two (20%) patients had a documented ‘code blue’ but were managed conservatively on the ward. No patients in this group died within 30 days.

Conclusions

Post-operative ward admission in selected patients with NELA ≥ 10% does not result in unplanned ICU admissions or increased mortality at a tertiary Acute Surgical Unit. This data is reassuring as we expect future ICU bed shortages for non-COVID surgical patients during the pandemic.

Development, behaviour and sensory processing in Marshall-Smith syndrome and Malan syndrome: phenotype comparison in two related syndromes

BACKGROUND

Ultrarare Marshall-Smith and Malan syndromes, caused by changes of the gene nuclear factor I X (NFIX), are characterised by intellectual disability (ID) and behavioural problems, although questions remain. Here, development and behaviour are studied and compared in a cross-sectional study, and results are presented with genetic findings.

METHODS

Behavioural phenotypes are compared of eight individuals with Marshall-Smith syndrome (three male individuals) and seven with Malan syndrome (four male individuals). Long-term follow-up assessment of cognition and adaptive behaviour was possible in three individuals with Marshall-Smith syndrome.

RESULTS

Marshall-Smith syndrome individuals have more severe ID, less adaptive behaviour, more impaired speech and less reciprocal interaction compared with individuals with Malan syndrome. Sensory processing difficulties occur in both syndromes. Follow-up measurement of cognition and adaptive behaviour in Marshall-Smith syndrome shows different individual learning curves over time.

CONCLUSIONS

Results show significant between and within syndrome variability. Different NFIX variants underlie distinct clinical phenotypes leading to separate entities. Cognitive, adaptive and sensory impairments are common in both syndromes and increase the risk of challenging behaviour. This study highlights the value of considering behaviour within developmental and environmental context. To improve quality of life, adaptations to environment and treatment are suggested to create a better person-environment fit.

Broadband, millimeter-wave antireflection coatings for large-format, cryogenic aluminum oxide optics

We present two prescriptions for broadband ($ {\sim} 77 - 252\;{\rm GHz} $), millimeter-wave antireflection coatings for cryogenic, sintered polycrystalline aluminum oxide optics: one for large-format (700 mm diameter) planar and plano-convex elements, the other for densely packed arrays of quasi-optical elements-in our case, 5 mm diameter half-spheres (called "lenslets"). The coatings comprise three layers of commercially available, polytetrafluoroethylene-based, dielectric sheet material. The lenslet coating is molded to fit the 150 mm diameter arrays directly, while the large-diameter lenses are coated using a tiled approach. We review the fabrication processes for both prescriptions, then discuss laboratory measurements of their transmittance and reflectance. In addition, we present the inferred refractive indices and loss tangents for the coating materials and the aluminum oxide substrate. We find that at 150 GHz and 300 K the large-format coating sample achieves $ (97 \pm 2)\% $ transmittance, and the lenslet coating sample achieves $ (94 \pm 3)\% $ transmittance.

A198 EOSINOPHILIC ESOPHAGITIS WITH STRICTURE PRESENTING SHORTING AFTER INITIATION OF ORAL PEANUT IMMUNOTHERAPY

Background

Oral immunotherapy (OIT) is increasingly practiced outside of research settings with reasonable success (Soller 2019).

With OIT, a patient eats their food allergen daily, gradually increasing the dose, with the goal to prevent or reduce the severity of an anaphylactic reaction.

One of the described adverse events of OIT is a risk of developing Eosinophilic Esophagitis (EoE), with cited frequency of 2.7% (Lucendo 2014). In addition, OIT is typically contraindicated in patients with known EoE but patients are not routinely screened for EoE prior to initiation of OIT.

Aims

To present a case of a 12 year old boy with peanut anaphylaxis who developed eosinophilic esophagitis and an esophageal stricture shortly after starting peanut immunotherapy

Methods

Patient chart review was conducted. A literature review was done using the words “eosinophilic esophagitis” and “immunotherapy”.

Results

A12 year old boy with asthma, allergic rhinitis and multiple anaphylactic food allergies, started peanut OIT with an allergist. Prior to OIT, the patient had no symptoms suggestive of EoE such as dysphagia, heartburn, chest pain or washing of food. Approximately 3.5 weeks into treatment, the patient developed daily vomiting. The patient was advised to stop the peanut OIT three days after symptom onset, but the vomiting continued for another 8 days. By the time of endoscopy (16 days after onset of vomiting), the vomiting had completely subsided for the previous five days.

The upper GI endoscopy demonstrated signs of EoE throughout the length of the esophagus. In the mid esophagus there was resistance where the 9.8 mm gastroscope was unable to pass. A smaller gastroscope with a 5.9 mm width was easily able to pass through the stricture. Histology showed marked eosinophilia throughout the esophagus with basal cell hyperplasia, spongiosis, superficial microabscesses and stromal fibrosis consistent with EoE. The patient continued to be ‘asymptomatic’ at the time of endoscopy and after despite the presence of a stricture. After discussion, the patient was started on oral viscous budesonide (OVB) 1mg PO BID.

The patient was re-scoped 4 weeks into OVB therapy with complete resolution of the stricture with neither macroscopic nor histologic findings of EoE. Patient is now off OVB for over a month, remains asymptomatic, and will undergo repeat endoscopy in the upcoming month to ensure normal histology

Conclusions

This is the first case describing EoE with an esophageal stricture shortly after initiation of OIT. Pediatric Gastroenterologists need to be increasingly aware that patients undergoing OIT are at an increasing risk of ‘developing’ or at least ‘unmasking’ EoE. More research is required to evaluate whether EoE screening, by symptom questionnaire or endoscopy is warranted prior to beginning OIT, and whether OIT is truly needed.

Funding Agencies

CAG

Constraint-induced or multi-modal personalized aphasia rehabilitation (COMPARE): A randomized controlled trial for stroke-related chronic aphasia

RATIONALE

The comparative efficacy and cost-effectiveness of constraint-induced and multi-modality aphasia therapy in chronic stroke are unknown.

AIMS AND HYPOTHESES

In the COMPARE trial, we aim to determine whether Multi-Modal Aphasia Treatment (M-MAT) and Constraint-Induced Aphasia Therapy Plus (CIAT-Plus) are superior to usual care (UC) for chronic post-stroke aphasia. Primary hypothesis: CIAT-Plus and M-MAT will reduce aphasia severity (Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ)) compared with UC: CIAT-Plus superior for moderate aphasia; M-MAT superior for mild and severe aphasia.

SAMPLE SIZE ESTIMATES

A total of 216 participants (72 per arm) will provide 90% power to detect a 5-point difference on the WAB-R-AQ between CIAT-Plus or M-MAT and UC at α = 0.05.

METHODS AND DESIGN

Prospective, randomized, parallel group, open-label, assessor blinded trial. Participants: Stroke >6 months; aphasia severity categorized using WAB-R-AQ. Computer-generated blocked and stratified randomization by aphasia severity (mild, moderate, and severe), to 3 arms: CIAT-Plus, M-MAT (both 30 h therapy over two weeks); UC (self-reported usual community care).

STUDY OUTCOMES

WAB-R-AQ immediately post-intervention. Secondary outcomes: WAB-R-AQ at 12-week follow-up; naming scores, discourse measures, Communicative Effectiveness Index, Scenario Test, and Stroke and Aphasia Quality of Life Scale-39 g immediately and at 12 weeks post-intervention; incremental cost-effectiveness ratios compared with UC at 12 weeks.

DISCUSSION

This trial will determine whether CIAT-Plus and M-MAT are superior and more cost-effective than UC in chronic aphasia. Participant subgroups with the greatest response to CIAT-Plus and M-MAT will be described.

Stroke communication partner training: a national survey of 122 clinicians on current practice patterns and perceived implementation barriers and facilitators

BACKGROUND

Communication partners (CPs) find it challenging to communicate with people with communication disorders post-stroke. Stroke communication partner training (CPT) can enhance CPs' ability to support the communication and participation of people post-stroke. While evidence for the efficacy of aphasia-based CPT is strong, implementation in healthcare settings is unclear.

AIMS

To investigate Australian speech pathologists' current stroke CPT practices, factors influencing the implementation of CPT and how reported practice compares with the research evidence.

METHODS & PROCEDURES

Speech pathologists in Australia who had worked with people post-stroke were invited to complete a 99-item online survey. The survey was informed by a comprehensive review of the literature review, the Template for Intervention Description and Replication (TIDieR) intervention taxonomy, and the theoretical domains framework. data were analyzed using descriptive statistics and content analysis.

OUTCOMES & RESULTS

A total of 122 clinicians were surveyed. Most participants reported providing CPT to treat a range of post-stroke communication disorders. While 98.3% reported training familiar CPs, only 66.1% reported training unfamiliar CPs. Current stroke CPT practice is characterized by one to two < 1 h sessions of informal face-to-face education and skills training. Only 13.3% and 10.0% of participants used evidence-based published programmes with unfamiliar and familiar CPs respectively. The main barriers included the perceived lack of behavioural regulation, skills, reinforcement, beliefs about consequences, positive social influences and resources. The main facilitators included clinicians' intentions to provide CPT, perception of CPT as part of their role and perceived compatibility of CPT with clinical practice.

CONCLUSION & IMPLICATIONS

A significant evidence-practice gap exists. Research exploring the implementation of stroke CPT in healthcare settings, expanding evidence to support CPT for the range of post-stroke communication disorders, developing freely accessible step-by-step CPT programmes that consider restrictions in current practice and providing explicit instructions of CPT best practice are warranted. A supportive workplace culture and freely accessible formal training opportunities are also needed.