112 INTEGRATED CARE PROGRAMME FOR OLDER PEOPLE (ICPOP) IN A RURAL SETTING—ROLE OF ADVANCED NURSE PRACTITIONER (ANP)

Background

Sláintecare advocates for right care, in the right place at the right time. ANPs for Older Persons in the community are uniquely placed to deliver care as close as possible to the older person’s home and to lead a holistic, flexible model of care minimising admission to acute care and maximising existing local resources. A pilot programme aimed at providing ANP led comprehensive geriatric assessment (CGA) (with Geriatrician support) to older people in a defined area commenced in June 2019. This pilot was part of a larger Hub and Spoke model funded by Sláintecare which gave additional MDT support.

Methods

A referral template was designed. Criteria for referral included; age > 75 years, Rockwood Frailty Scale 4–6 (focusing on Falls, Cognitive Impairment and Complex Frailty). Older people on the cusp of requiring long term care (LTC) were also prioritised. A prospective database of patients was maintained by the ANP to evaluate the service.

Results

From June 2019 to August 2021, 156 patients received an ANP led CGA, mostly conducted in the home. 247 reviews were conducted at the local spoke clinic and 46 joint ANP/Geriatrician home visits. Majority of referrals were from GP (n = 69), hospital (n = 30), LTC reviews (n = 22) and Community Nursing Units (CNUs) (n = 19). 449 outpatient appointments have been removed from the tertiary referral centre. Independent case load management from the ANP includes further appointments, telephone follow up/advice and she is a point of contact where crises arise before referral to acute services. 99% of patients surveyed reported satisfaction with the service especially the ease of local access and home visits.

Conclusion

Older Persons’ ANP can provide longitudinal care pathways for older adults in the community in conjunction with ICPOP and local CNUs, intervening before crises emerge and providing continuity of care and an alternative to acute care.

Gauging facial feature viewing preference as a stable individual trait in autism spectrum disorder

Eye tracking provides insights into social processing deficits in autism spectrum disorder (ASD), especially in conjunction with dynamic, naturalistic free-viewing stimuli. However, the question remains whether gaze characteristics, such as preference for specific facial features, can be considered a stable individual trait, particularly in those with ASD. If so, how much data are needed for consistent estimations? To address these questions, we assessed the stability and robustness of gaze preference for facial features as incremental amounts of movie data were introduced for analysis. We trained an artificial neural network to create an object-based segmentation of naturalistic movie clips (14 s each, 7410 frames total). Thirty-three high-functioning individuals with ASD and 36 age- and IQ-equated typically developing individuals (age range: 12-30 years) viewed 22 Hollywood movie clips, each depicting a social interaction. As we evaluated combinations of one, three, five, eight, and 11 movie clips, gaze dwell times on core facial features became increasingly stable at within-subject, within-group, and between-group levels. Using a number of movie clips deemed sufficient by our analysis, we found that individuals with ASD displayed significantly less face-centered gaze (centralized on the nose; p < 0.001) but did not significantly differ from typically developing participants in eye or mouth looking times. Our findings validate gaze preference for specific facial features as a stable individual trait and highlight the possibility of misinterpretation with insufficient data. Additionally, we propose the use of a machine learning approach to stimuli segmentation to quickly and flexibly prepare dynamic stimuli for analysis. LAY SUMMARY: Using a data-driven approach to segmenting movie stimuli, we examined varying amounts of data to assess the stability of social gaze in individuals with autism spectrum disorder (ASD). We found a reduction in social fixations in participants with ASD, driven by decreased attention to the center of the face. Our findings further support the validity of gaze preference for face features as a stable individual trait when sufficient data are used.

Comparing scoring systems for prediction of mortality in patients with bloodstream infection

BACKGROUND

Blood stream infections (BSIs) are associated with significant short-term mortality. There are many different scoring systems for assessing the severity of BSI.

AIM

We studied confusion, urea, respiratory rate, blood pressure, age 65(CURB65), Confusion Respiratory Rate, Blood pressure, age 65(CRB65), quick sequential organ failure assessment (qSOFA), systemic inflammatory response syndrome (SIRS) and National Early Warning Score (NEWS) and assessed how effective they were at predicting 30-day mortality across three separate BSI cohorts.

DESIGN

A retrospective analysis was performed on three established BSI cohorts: (i) All cause BSI, (ii) Escherichia coli and (iii) Streptococcus pneumoniae.

METHODS

The performance characteristics (sensitivity, specificity, positive predictive value, negative predictive value and area under receiver operating curve [AUROC]) for the prediction of 30-day mortality were calculated for the 5 scores using clinically relevant cut-offs.

RESULTS

528 patients were included: All cause BSI-148, E. coli-191 and S. pneumoniae-189. Overall, 30-day mortality was 22%. In predicting mortality, the AUROC for CURB65 and CRB65 were superior compared with qSOFA, SIRS and NEWS in the all cause BSI (0.72, 0.70, 0.66, 0.51 and 0.53) and E. coli cohorts (0.81, 0.76, 0.73, 0.55 and 0.71). In the pneumococcal cohort, CURB65, CRB65, qSOFA and NEWS were broadly equal (0.63, 0.65, 0.66 and 0.62), but all were superior to SIRS (0.57). CURB65, CRB65 and qSOFA had considerably higher accuracy than SIRS or NEWS across all cohorts.

CONCLUSION

CURB65 was superior to other scores in predicting 30-day mortality in the E. coli and all cause BSI cohorts. Further research is required to assess the potential of broadening the application of CURB65 beyond pneumonia.

Multiscale three-dimensional imaging of intact human organs down to the cellular scale using hierarchical phase-contrast tomography

Human organs are complex, three-dimensional and multiscale systems. Spatially mapping the human body down through its hierarchy, from entire organs to their individual functional units and specialised cells, is a major obstacle to fully understanding health and disease. To meet this challenge, we developed hierarchical phase-contrast tomography (HiP-CT), an X-ray phase propagation technique utilising the European Synchrotron Radiation Facility's Extremely Brilliant Source: the world's first high-energy 4 th generation X-ray source. HiP-CT enabled three-dimensional and non-destructive imaging at near-micron resolution in soft tissues at one hundred thousand times the voxel size whilst maintaining the organ's structure. We applied HiP-CT to image five intact human parenchymal organs: brain, lung, heart, kidney and spleen. These were hierarchically assessed with HiP-CT, providing a structural overview of the whole organ alongside detail of the organ's individual functional units and cells. The potential applications of HiP-CT were demonstrated through quantification and morphometry of glomeruli in an intact human kidney, and identification of regional changes to the architecture of the air-tissue interface and alveolar morphology in the lung of a deceased COVID-19 patient. Overall, we show that HiP-CT is a powerful tool which can provide a comprehensive picture of structural information for whole intact human organs, encompassing precise details on functional units and their constituent cells to better understand human health and disease.

Prospective multicentre cohort study of transthoracic echocardiography provision in the South West of the UK during the first wave of SARS-CoV-2 pandemic

AIMS

It was predicted internationally that transthoracic echocardiography (TTE) would be vital during the SARS-CoV-2 outbreak. We therefore, designed a study to report the demand for TTE in two large District General Hospitals during the rise in the first wave of the SARS-CoV-2 pandemic in the UK. A primary clinical outcome of 30-day mortality was also assessed.

METHODS

The TTE service across two hospitals was reconfigured to maximise access to inpatient scanning. All TTEs of suspected or confirmed SARS-CoV-2 patients over a 3-week period were included in the study. All patients were followed up until at least day 30 after their scan at which point the primary clinical outcome of mortality was recorded. Comparative analysis based on mortality was conducted for all TTE results, biochemical markers and demographics.

RESULTS

27 patients with confirmed SARS-CoV-2 had a TTE within the inclusion window. Mortality comparative analysis showed the deceased group were significantly older (mean 68.4, SD 11.9 vs 60.5, SD 13.0, p=0.03) and more commonly reported fatigue in their presenting symptoms (29.6% vs 71.4%, p=0.01). No other differences were identified in the demographic or biochemical data. Left ventricular systolic dysfunction was noted in 7.4% of patients and right ventricular impairment or dilation was seen in 18.5% patients. TTE results were not significantly different in mortality comparative analysis.

CONCLUSION

This study demonstrates an achievable approach to TTE services when under increased pressure. Data analysis supports the limited available data suggesting right ventricular abnormalities are the most commonly identified echocardiographic change in SARS-CoV-2 patients. No association can be demonstrated between mortality and TTE results.

Adiposity covaries with signatures of asymmetric feedback learning during adaptive decisions

Unhealthy weight gain relates, in part, to how people make decisions based on prior experience. Here we conducted post hoc analysis on an archival data set to evaluate whether individual differences in adiposity, an anthropometric construct encompassing a spectrum of body types, from lean to obese, associate with signatures of asymmetric feedback learning during value-based decision-making. In a sample of neurologically healthy adults (N = 433), ventral striatal responses to rewards, measured using fMRI, were not directly associated with adiposity, but rather moderated its relationship with feedback-driven learning in the Iowa gambling task, tested outside the scanner. Using a biologically inspired model of basal ganglia-dependent decision processes, we found this moderating effect of reward reactivity to be explained by an asymmetrical use of feedback to drive learning; that is, with more plasticity for gains than for losses, stronger reward reactivity leads to decisions that minimize exploration for maximizing long-term outcomes. Follow-up analysis confirmed that individual differences in adiposity correlated with signatures of asymmetric use of feedback cues during learning, suggesting that reward reactivity may especially relate to adiposity, and possibly obesity risk, when gains impact future decisions more than losses.

Development and evaluation of a novel caregiver-report tool to assess barriers to physical healthcare for people on the autism spectrum

INTRODUCTION

People on the autism spectrum often experience poorer health than the general population despite higher engagement with the health services. This suggests a disparity in the accessibility of appropriate healthcare for autistic individuals. To improve access, barriers the autism community experience in healthcare first need to be identified. This paper aimed to: 1) develop and evaluate a caregiver-report tool; 2) identify barriers to physical healthcare for autistic individuals; and 3) identify potential contributing factors.

METHODS

A previously established taxonomy of barriers to healthcare for autistic individuals informed the development of the tool; this was then distributed to caregivers of autistic adults and children. Exploratory factor analysis (EFA) assessed validity and reliability of the tool. Multiple Regressions were performed to identify predictors of barriers.

RESULTS

In total, caregivers of 194 autistic children or adults participated in the study. The EFA produced four factors: 1) patient-level barriers; 2) healthcare provider-level (HCP) barriers; 3) healthcare system-level barriers; and 4) barriers related to managing healthcare. The greatest barriers included difficulties with identifying/reporting symptoms (endorsed by 62.4% of participants); difficulties handling the waiting area (60.3% of participants); and a lack of HCP knowledge regarding autism (52.1% of participants). Autism severity, general adjustment problems, anxiety, age and having unmet needs predicted the frequency and/or severity of barriers.

CONCLUSIONS

A tool that allows assessment of patient-, HCP-, and system-level barriers to healthcare was developed and evaluated. Patient-level barriers appear to occur frequently and pose substantial challenges. This tool will help identify areas most in need of intervention and support intervention evaluation.

Long-term outcomes of real world 'watch and wait' data for rectal cancer after neoadjuvant chemoradiotherapy

AIM

A 'watch and wait' (W&W) strategy after neoadjuvant long-course chemoradiotherapy (NACRT) remains controversial. Whilst encouraging short-term data exist, the strategy will be judged on long-term data. We present long-term, real-world UK data from a single National Health Service trust.

METHODS

An analysis was performed of a prospectively maintained W&W database over 9 years between 2010 and 2018. Outcome measures include incidence and time to regrowth and overall and disease-free survival.

RESULTS

We diagnosed 563 rectal cancers in 9 years. In all, 283 patients underwent rectal resection (50.3%). NACRT was used in 155 patients for margin-threatened tumours on staging MRI. Forty-nine patients (31.6%) experienced either a 'near complete' or a complete clinical response (cCR) at their 10 weeks post-NACRT assessment (MRI and endoscopy). The median age was 69 years (range 44-83), and the male to female ratio was 32:17. The median follow-up was 38 months (range 12-96). The median tumour distance from the anal verge was 7 cm (1-15 cm). Twenty-two patients had a cCR on initial assessment and 27 patients had a 'near' cCR. Of those 27 who experienced a 'near' cCR, 17 (63%) progressed to cCR on repeat assessment and 10 (37%) did not. Of these 10 patients, seven underwent standard surgical resection and three were unfit for surgery. R0 for the seven with delayed resection was 100%. Of 39 patients (22 cCR and 17 'near' cCR who progressed to cCR) (25.2% of those receiving NACRT), six patients experienced local regrowth (15.4%). The median time to local regrowth was 29 months (15-60 months). One of these six patients underwent salvage abdominoperineal resection, one was advised to have contact radiotherapy and four opted against surgery and also had contact radiotherapy. The overall survival was 100% at 2 years and 90% at 5 years. Disease-free survival was 90.47% at 2 years and 74.8% at 5 years.

CONCLUSION

A W&W treatment strategy was employed safely in this patient cohort with acceptable rates of local regrowth and survival.

Distinct neural mechanisms of social orienting and mentalizing revealed by independent measures of neural and eye movement typicality

Extensive study of typically developing individuals and those on the autism spectrum has identified a large number of brain regions associated with our ability to navigate the social world. Although it is widely appreciated that this so-called "social brain" is composed of distinct, interacting systems, these component parts have yet to be clearly elucidated. Here we used measures of eye movement and neural typicality-based on the degree to which subjects deviated from the norm-while typically developing (N = 62) and individuals with autism (N = 36) watched a large battery of movies depicting social interactions. Our findings provide clear evidence for distinct, but overlapping, neural systems underpinning two major components of the "social brain," social orienting, and inferring the mental state of others.

Changes in temperament over time in young children with autism spectrum disorder and other developmental delays: a follow-up comparison study

BACKGROUND

Although in the last decade some research has emerged on temperament in autism spectrum disorder (ASD), this research has primarily focused on the differences between children with ASD and their typically developing peers rather than the stability or change in temperament in this population. Thus, the goal of this study was to examine temperament over time in children with ASD, developmental delays (DD) and typical development (TD). Temperament differences were also compared among the three groups.

METHODS

To accomplish this, parents rated children's temperament at Time 1 (T1) and Time 2 (T2) using the Carey Temperament Scales (CTS).

RESULTS

Results from the study showed that at T1, parents of children with ASD rated their children as more withdrawn (i.e. approach), and emotionally negative (i.e. mood), and less distractible and adaptable than parents of children with TD and DD. Also, children with ASD were rated as more intense and children with DD as less distractible than their TD peers. Similarly, at T2, children with ASD were rated more withdrawn, and emotionally negative, and less persistent, rhythmic, adaptable and distractible than children with TD and DD. Also, children with ASD were rated as more active than their DD peers. Regarding stability, parent ratings of temperament appeared stable over time in the TD group, but ratings varied substantially in the ASD or DD groups. That is, for the ASD group, activity and approach at T1 were significantly associated with their corresponding dimensions at T2. However, for the TD group, rhythmicity, approach, intensity and mood at T1 were significantly associated with those dimensions at T2. No associations were found in the DD group. Regarding change, parents reported change in rhythmicity, persistence and threshold between T1 and T2 in the ASD group. Similarly, parents reported change in rhythmicity, approach and threshold between T1 and T2 in the DD group. Lastly, parents of TD children reported change in adaptability, persistence and distractibility between T1 and T2.

CONCLUSIONS

These findings are novel in that children with ASD appear to have less stable temperament profile and different change patterns than children with TD or DD. Similar to previous research, children with ASD were described by their parents as experiencing more temperamental difficulties.

Local Entanglement Entropy and Mutual Information across the Mott Transition in the Two-Dimensional Hubbard Model

Entanglement and information are powerful lenses to probe phases transitions in many-body systems. Motivated by recent cold atom experiments, which are now able to measure the corresponding information-theoretic quantities, we study the Mott transition in the half-filled two-dimensional Hubbard model using cellular dynamical mean-field theory, and focus on two key measures of quantum correlations: entanglement entropy and a measure of total mutual information. We show that they detect the first-order nature of the transition, the universality class of the end point, and the crossover emanating from the end point.

Psychometric evaluation of a measure of factors influencing hand hygiene behaviour to inform intervention

BACKGROUND

Although the hand hygiene (HH) procedure is simple, the related behaviour is complex and is not readily understood, explained or changed. There is a need for practical tools to provide data that can guide healthcare managers and practitioners not only on the 'what' (the standards that must be met), but also the 'how' (guidance on how to achieve the standards).

AIM

To develop a valid questionnaire to evaluate attitudes to the factors that influence engagement in HH behaviour that can be readily completed, administered and analysed by healthcare professionals to identify appropriate intervention strategies. Construct validity was assessed using confirmatory factor analysis, predictive validity was assessed through comparison with self-reported HH behaviour, and convergent validity was assessed through direct unit-level observation of HH behaviour.

METHODS

The Capability, Opportunity, Motivation-Behaviour (COM-B) model was used to design a 25-item questionnaire that was distributed to intensive care unit (ICU) personnel in Ireland. Direct observation of HH behaviour was carried out at two ICUs.

FINDINGS

In total, 292 responses to the survey (response rate 41.0%) were included in the analysis. Confirmatory factor analysis resulted in a 17-item questionnaire. Multiple regression revealed that a model including capability, opportunity and motivation was a significant predictor of self-reported behavioural intention [F(3,209)=22.58, P<0.001]. However, the opportunity factor was not found to make a significant contribution to the regression model.

CONCLUSION

The COM-B HH questionnaire is reliable and valid, and provides data to support the development and evaluation of HH interventions that meet the needs of specific healthcare units.