A feasibility and pilot study of a "lifelong learning" intervention for people with dementia

BACKGROUND

Developing evidence for the use of psychosocial interventions for people with dementia is a research priority. This pilot study aimed to provide variability estimates for a set of outcome measures that would inform the development of a more extensive controlled study. The larger study will seek to explore the effect of attending a lifelong learning intervention for people with dementia compared to receiving treatment as usual. This pilot and feasibility stage also analysed how data collectors and researchers evaluated the use of the outcome measures in a sample of people with mild to moderate dementia.

METHODS

Before initiating the pilot study, a participant consultation was conducted with people with dementia, who attend a lifelong learning service known as a dementia school, and their teachers. From this consultation, the research outcomes identified were the mini-mental state examination (MMSE), Quality-of-Life Alzheimer's Disease (QoL-AD), General Self-Efficacy Scale (GSE), Rosenberg self-esteem scale, and the Friendship scale. The following study was divided into two steps. In step 1, participants were people with dementia attending a dementia school (intervention group) or usual services (control group). The participants were tested at baseline and at a 6-month follow-up. Data were collected between November 2018 and July 2019. In step 2, feasibility and acceptability issues with the recruitment of participants, data collection process, and outcome measures, identified in step 1, were evaluated through a data collector focus group.

RESULTS

Fifty-five people with dementia were included in the analysis. Step 1 provided estimates of changes from baseline to follow-up, and ancillary standard deviations were supplied for all outcome measures. Step 2 provided reflections on the feasibility and acceptability of the intervention, data collection, and outcome measures. This included views on how people with dementia experience participating in a test situation.

CONCLUSIONS

This study provided estimates of change and variability in the outcome measures. Additionally, issues regarding data collection were identified and should be addressed in future studies. The project demonstrated how to support people with dementia to participate in research that is meaningful to them.

TRIAL REGISTRATION

According to national legislation, registration with a database of clinical studies was optional, as the study evaluated existing activities rather than a clinical intervention.

In praise of postgraduate career clinics: Translating health professionals' willingness to engagement

AIM

To capture and retain healthcare staff in postgraduate courses relevant to individual career aspirations, service requirements and continuous practice development (CPD) within an English UK university.

DESIGN

Two virtual career clinics for postgraduate practitioners to engage in CPD offers within the university. An online post-enrolment online survey to explore their experiences of engagement with the university.

METHODS

Mixed: qualitative and quantitative methods. Engaging 10 participants attended the career clinics, and 42 participants with an online survey.

RESULTS

The career clinics were well received by participants who mapped CPD requirements and individual career aspirations. The surveys exposed challenges with marketing and enrolment; however, these were mitigated with support. Four recommendations are presented within this paper applicable to the international postgraduate education of all health practitioners.

Developing a dementia friendly approach to consent in dementia research

OBJECTIVES

This paper explores the process of gaining consent from the perspectives of people living with dementia, their relatives/carers, and service providers. This is developed based on new primary qualitative research and addresses a gap in critical reflection on the practice and ethical process of research consent.

METHODS

A qualitative approach was used to conduct this research through the implementation of four focus groups run with people living with dementia (n = 12), two focus groups with family members (n = 6), two focus groups with service staff (n = 5).

RESULTS

Data was analysed thematically, to identify two core themes: consent as a journey and the flexible consent approach. These identified concerns with autonomy, decision making and placing people living with dementia at the centre of the consent process. The journey of consent emerged as central to supporting participation and enhancing the consent process.

CONCLUSION

The paper presents new evidence about the lived experience of research consent in the field of dementia, presenting the process of collecting consent in research as a flexible process that is best supported through a growing knowledge of participants and participation sites.

Elevated plasma matrix metalloproteinases associate with Mycobacterium tuberculosis blood stream infection and mortality in HIV-associated tuberculosis

Mortality from HIV-associated tuberculosis (HIV-TB) is high, particularly among hospitalised patients. In 433 people living with HIV admitted to hospital with symptoms of TB, we investigated plasma matrix metalloproteinases (MMP) and matrix-derived biomarkers in relation to TB diagnosis, mortality and Mycobacterium tuberculosis (Mtb) blood stream infection (BSI). Compared to other diagnoses, MMP-8 was elevated in confirmed TB and in Mtb-BSI, positively correlating with extracellular matrix breakdown products. Baseline MMP-3, -7, -8, -10 and procollagen III N-terminal propeptide (PIIINP) associated with Mtb-BSI and 12-week mortality. These findings implicate MMP dysregulation in pathophysiology of advanced HIV-TB and support MMP inhibition as a host-directed therapeutic strategy for HIV-TB.

Advancing beyond the Hippocampus to Preserve Cognition for Patients with Brain Metastases: Dosimetric Results from a Phase 2 Trial of Memory-Avoidance Whole Brain Radiotherapy

PURPOSE/OBJECTIVE(S)

Recent advances to preserve neurocognitive function in patients treated for brain metastases include stereotactic radiosurgery (SRS), hippocampal avoidance whole brain radiation therapy (HA-WBRT), and memantine administration. However, 23% of patients receiving HA-WBRT and memantine on NRG-CC001 still experienced executive function deterioration at 4 months, with 12% experiencing total recall and delayed recognition deterioration at 6 months. The hippocampus, corpus callosum, fornix, and amygdala are key neurocognitive substructures with a low propensity for brain metastases. Herein, we report our preliminary experience using an advanced "memory-avoidance" WBRT (MA-WBRT) approach sparing these substructures for patients with multiple (>15) brain metastases.

MATERIALS/METHODS

Ten consecutive patients treated with MA-WBRT on a phase 2 clinical trial (OSU-21074) were reviewed. In each patient, the hippocampi, amygdalae, corpus callosa, and fornix were contoured. Patients were not eligible for MA-WBRT if they had metastases in these substructures. A memory- avoidance region created using a 5mm volumetric expansion around these substructures. Hotspots were avoided in the hypothalamus and pituitary gland. Dose constraints for these avoidance structures were modeled after NRG CC-001 and include a D100% ≤ 9 Gy and a D0.03 cc ≤ 16 (acceptable to 20 Gy). Coverage of brain metastases was prioritized over memory avoidance dose constraints. Linac-based volumetric modulated arc therapy (VMAT) plans were generated for a prescription dose of 30 Gy in 10 fractions.

RESULTS

On average, the memory avoidance structure volume was 37.1 ccs (Range: 25.2-44.6 ccs), occupying 2.5% of the entire whole brain target volume. All treatment plans met the D100% dose constraint, and 8/10 plans met the D0.03cc constraint, with priority given to tumor coverage for the remaining 2 cases. VMAT spared the memory avoidance structures with a median dose range of 10.8-14.2 Gy and a maximum dose (D0.03cc) range of 15.6-22.7 Gy. The mean dose to the memory avoidance structures was 12.7 Gy (Range: 11.5-13.8 Gy). Target coverage (D98% > 25 Gy) and homogeneity (D2% ≤ 37.5 Gy) were achieved for all plans.

CONCLUSION

Modern VMAT techniques allow for sparing of the hippocampus, amygdala, corpus callosum, and fornix with good target coverage and homogeneity. Prospective quality of life and cognitive data including are being collected and include the Functional Assessment of Cancer Therapy - Brain (Fact-Br), Hopkins Verbal Learning Test (HLVT-R), Trail Making Test A/B (TMT-A/B) and Controlled Oral Word Association Test (COWAT). After enrollment is completed, these data will be evaluated to assess the efficacy of MA-WBRT to mitigate declines in quality of life and cognition after whole brain radiation.

Higher Temperatures in Socially Vulnerable US Communities Increasingly Limit Safe Use of Electric Fans for Cooling

As the globe warms, people will increasingly need affordable, safe methods to stay cool and minimize the worst health impacts of heat exposure. One of the cheapest cooling methods is electric fans. Recent research has recommended ambient air temperature thresholds for safe fan use in adults. Here we use hourly weather reanalysis data (1950-2021) to examine the temporal and spatial evolution of ambient climate conditions in the continental United States (CONUS) considered safe for fan use, focusing on high social vulnerability index (SVI) regions. We find that although most hours in the day are safe for fan use, there are regions that experience hundreds to thousands of hours per year that are too hot for safe fan use. Over the last several decades, the number of hours considered unsafe for fan use has increased across most of the CONUS (on average by ∼70%), with hotspots across the US West and South, suggesting that many individuals will increasingly need alternative cooling strategies. People living in high-SVI locations are 1.5-2 times more likely to experience hotter climate conditions than the overall US population. High-SVI locations also experience higher rates of warming that are approaching and exceeding important safety thresholds that relate to climate adaptation. These results highlight the need to direct additional resources to these communities for heat adaptive strategies.

Eblasakimab, a novel IL-13 receptor alpha 1 monoclonal antibody, blocks STAT6 phosphorylation with low dose in human volunteers

Eblasakimab is a first-in-class monoclonal antibody under investigation for the treatment of atopic dermatitis (AD) which targets IL-13Rα1, a subunit of the Type 2 receptor complex. IL-13Rα1 stimulates phosphorylation of signal transducer and activator of transcription 6 (STAT6) to drive inflammation. This brief report investigates the mechanistic basis of eblasakimab and its effects on IL-13Rα1 signaling as part of a phase 1a, open-label, single ascending dose study. Single ascending doses of eblasakimab were administered by intravenous or subcutaneous injection to healthy male volunteers. The impact of eblasakimab on IL-13Rα1 receptor occupancy and STAT6 phosphorylation was assessed in participant blood monocytes. No serious treatment emergent adverse events were reported. Eblasakimab effectively blocked the IL-13Rα1 receptor and inhibited STAT6 phosphorylation with single doses of 3 mg/kg intravenously and 300 mg subcutaneously. Results support further clinical development of eblasakimab as a novel biologic for AD, with potential for 2- to 4-week dosing regimens.

Observations on strategies used by people with dementia to manage being assessed using validated measures: A pilot qualitative video analysis

BACKGROUND

Analysis of video data was conducted of validated assessments with people with dementia as part of a feasibility control study comparing a lifelong learning service with other dementia services.

OBJECTIVE

The aim was to provide a new perspective on what occurs during the assessment process when using validated measures in research and explore which strategies people with dementia use to manage their participation.

DESIGN

Video recordings were made of pre- and postintervention assessments of people with dementia. An initial pilot analysis of 10 videos of the pre-assessments was conducted.

SETTING

Lifelong learning services and other dementia services situated in six municipalities in Northern Denmark took part in this study, with 55 people with dementia participating.

RESULTS

The themes identified were: 'State of mind' and 'Mental resources', showing how these aspects influenced the participants' reactions and the strategies they used.

DISCUSSION

The results are discussed in relation to how individual personality traits influence the assessment process and the way a person with dementia will manage the situation.

CONCLUSION

The assessment situation is complex and can be influenced by the strategies adopted by individuals with dementia as they try to manage the assessment process.

PATIENT OR PUBLIC CONTRIBUTION

People with dementia supported the decision-making for the choice of validated measure used within this study.

Complications of oxidised regenerated cellulose at Caesarean section: A report of two cases

Two patients underwent surgical deliveries within four months of one another at a single maternity unit. Both patients had complications of infection-like symptoms such as offensive vaginal discharge and pyrexia, months following their caesarean sections resulting in further surgery. The incidents were thought to be secondary to woven oxidised regenerated cellulose (ORC) use. ORC must be used according to its relevant product literature which can vary between brands. Surgeons must keep abreast of changes to the haemostatic material provided to them and therefore the properties of each type, especially when faced with bleeding not suitable for suturing or electrocautery.

On the adsorption and reactivity of element 114, flerovium

Flerovium (Fl, element 114) is the heaviest element chemically studied so far. To date, its interaction with gold was investigated in two gas-solid chromatography experiments, which reported two different types of interaction, however, each based on the level of a few registered atoms only. Whereas noble-gas-like properties were suggested from the first experiment, the second one pointed at a volatile-metal-like character. Here, we present further experimental data on adsorption studies of Fl on silicon oxide and gold surfaces, accounting for the inhomogeneous nature of the surface, as it was used in the experiment and analyzed as part of the reported studies. We confirm that Fl is highly volatile and the least reactive member of group 14. Our experimental observations suggest that Fl exhibits lower reactivity towards Au than the volatile metal Hg, but higher reactivity than the noble gas Rn.

"Just ask me what it means to live with dementia" - people with mild dementia's strategies and techniques shared through in-depth qualitative interviews

This article presents results from interviews with twelve persons with mild dementia about how life had changed since they received their diagnosis, exploring their experiences of dementia and how they manage life by using different strategies and techniques. Knowledge about how people with mild dementia experience life is important to explore through their unique perspective, providing clinical practice with knowledge to improve dementia care. Twelve participants were recruited at a Danish school service for people with mild dementia where they receive cognitive stimulation. Semi-structured interviews were conducted, video recorded, transcribed and analysed by using Max Van Manen's five lifeworld existentials: spatiality, corporeality, temporality, relationality and materiality. SRQR checklist was used. Five themes were identified, illustrating the dilemmas and challenges the participants experience, as all existentials are compromised in some way: living a social and active life regardless of difficulties; trying to look at the bright side of life with dementia; it takes time to adapt but at the same time, time is being lost; it is possible to learn, but it is challenging; to try to remember but keep forgetting. The article concludes that all existentials are negatively influenced by dementia, setting the lifeworld of the participants under pressure. However, they still try to live their lives regardless of the difficulties. The study shows it is possible for people with mild dementia to describe their lived experience of dementia and what strategies and techniques they use to manage life. The experienced dilemmas and challenges in the lifeworld of people with mild dementia are of great relevance to be aware of and address in clinical practice. To support people with dementia to identify relevant strategies and techniques, as expressed in the study, that can support them managing life with dementia.

Left ventricular pseudoaneurysm repair utilizing P2 segment of mitral valve: a case report

Background

Left ventricular (LV) pseudoaneurysms are a rare occurrence typically seen after myocardial infarction (MI) or in patients with prior cardiac surgery and are associated with a significant risk of rupture and mortality. Management includes primary repair, epicardial patching, or percutaneous repair with occlusive devices.

Case presentation

This case report describes a 46-year-old male with a large LV pseudoaneurysm that was surgically patched with a segment of his mitral valve. To our knowledge, there has not been a documented repair utilizing a segment of the mitral valve.

Conclusions

The applicability of this technique is limited to cases with posteriorly located pseudoaneurysms near the mitral valve, thus allowing the P2 segment to be used as a patch. This is a novel approach to LV pseudoaneurysm repair, though careful consideration towards patient selection is warranted, as comorbid conditions may contribute to morbidity and mortality.

Sexual health service adaptations to the coronavirus disease 2019 (COVID-19) pandemic in Australia: a nationwide online survey

OBJECTIVE

Examine the changes in service delivery Australian public sexual health clinics made to remain open during lockdown.

METHODS

A cross-sectional survey designed and delivered on Qualtrics was emailed to 21 directors of public sexual health clinics across Australia from July-August 2020 and asked about a variety of changes to service delivery. Descriptive statistics were calculated.

RESULTS

Twenty clinics participated, all remained open and reported service changes, including suspension of walk-in services in eight clinics. Some clinics stopped offering asymptomatic screening for varying patient populations. Most clinics transitioned to a mix of telehealth and face-to-face consultations. Nineteen clinics reported delays in testing and 13 reported limitations in testing. Most clinics changed to phone consultations for HIV medication refills (n=15) and eleven clinics prescribed longer repeat prescriptions. Fourteen clinics had staff redeployed to assist the COVID-19 response.

CONCLUSION

Public sexual health clinics pivoted service delivery to reduce risk of COVID-19 transmission in clinical settings, managed staffing reductions and delays in molecular testing, and maintained a focus on urgent and symptomatic STI presentations and those at higher risk of HIV/STI acquisition. Implications for public health: Further research is warranted to understand what impact reduced asymptomatic screening may have had on community STI transmission.

First Study on Nihonium (Nh, Element 113) Chemistry at TASCA

Nihonium (Nh, element 113) and flerovium (Fl, element 114) are the first superheavy elements in which the 7p shell is occupied. High volatility and inertness were predicted for Fl due to the strong relativistic stabilization of the closed 7p 1/2 sub-shell, which originates from a large spin-orbit splitting between the 7p 1/2 and 7p 3/2 orbitals. One unpaired electron in the outermost 7p 1/2 sub-shell in Nh is expected to give rise to a higher chemical reactivity. Theoretical predictions of Nh reactivity are discussed, along with results of the first experimental attempts to study Nh chemistry in the gas phase. The experimental observations verify a higher chemical reactivity of Nh atoms compared to its neighbor Fl and call for the development of advanced setups. First tests of a newly developed detection device miniCOMPACT with highly reactive Fr isotopes assure that effective chemical studies of Nh are within reach.

Influence of COVID-19 Building Restrictions on Physical Activity Promotion Through Increased Stair Use and Limited Elevator Access: A Quasi-Experimental Study-Sport and Physical Activity Group Active Campus Project

BACKGROUND

The aim of this study was to determine the effectiveness of UK government COVID-19 safe offices policy to increase stair use in a higher education setting during the COVID-19 pandemic.

METHODS

Automated counts at 3 ground floor staircases and the elevator entrances were used to estimate stair to elevator use ratio for ascent and descent from/to the ground floor of a university building at baseline (January to March 2020), first and second intervention months (October 2020, November 2020, respectively). Stair promoting signage and a 1-way system was implemented, in line with government policy.

RESULTS

At baseline, stair to elevator use ratio for ascent from and descent to the ground floor was 1.36 (0.02) and 1.88 (0.02) people, respectively. The ratio significantly increased in the first intervention month to 2.64 (0.09) and 3.96 (0.22) people for ascent and descent, respectively. However, the ratio decreased between the first and second intervention months to 1.63 (0.06) and 3.05 (0.52) people for ascent and descent, respectively.

CONCLUSION

The UK government COVID-19 policy was effective at increasing stair use in a higher education setting.

1065 Exposing the Incidence of Ileus in Pelvic and Acetabular Fractures: A Retrospective Case Analysis

Background

Paralytic ileus is a temporary inhibition of gastrointestinal mobility in the absence of mechanical obstruction. Ileus has previously been observed in up to 40% of patients undergoing bowel surgery, leading to increased morbidity and length of stay. Pelvic and acetabular fractures are often caused by high energy trauma and are associated with a risk of visceral injury. This is the first study to report the incidence of and risk factors for ileus following admission with pelvic and/or acetabular fractures.

Method

All patients over the age of 16 presenting to a major trauma centre throughout 2019 were included. Data included patient demographics, injury pattern, fracture management and presence of ileus. Previous studies identified patients as having ileus if they failed to tolerate an oral diet and open their bowels for more than three days (GI-2). Analysis assessed risk factors for ileus as well as its effect on length of stay.

Results

An incidence of ileus of 40.35% was observed in the 57 included patients. Ileus was three times more common in patients with a diagnosis of diabetes mellitus (p = 0.56) and 2.5 times more common in the presence of an open pelvic/acetabular fracture (p = 0.73). Length of stay was significantly longer in patients under 65 years identified as having ileus (p = 0.046). Gender, age, opiate use, fracture management and surgical approach were not identified as risk factors.

Conclusions

The authors have identified the essentiality of early risk factor identification and hope to encourage further research to create a prognostic tool.

965 Complication Rates in Operatively Managed Ankle Fracture/Dislocations - The Effect of Pre-Reduction Imaging and Compliance with BOAST 12 Guidance

Aim

The BOAST-12 guidelines for the management of ankle fractures aims to optimise functional recovery and reduce complications. They advise against having radiographs prior to urgent reduction of clinically deformed ankles as it could cause an unacceptable delay to subsequent management. Our study aimed to assess the effect of time to acceptable reduction on the risk of complications and time to definitive reduction.

Method

This was a retrospective observational study of patients with ankle fracture-dislocations between 2013 to 2017 at the Northern General Hospital’s Emergency Department (ED). Information collected from 2 patient groups (with and without pre-reduction radiographs), included patient demographics, time to accepted reduction, number of manipulations, operations, and subsequent complications.

Results

242 patients were identified. Time from arrival in ED to acceptable reduction was significantly longer in patients with pre-reduction radiographs versus patients without (184.5 vs 82 minutes, p < 0.00), but did not increase the overall risk of complications (p = 0.62). Pre-reduction radiographs were associated with insignificantly higher rates of post-traumatic osteoarthritis (p = 0.17) and slightly longer wait time for definitive intervention (1 vs 2 days, p = 0.72). However, this had no relationship with the number of manipulations (p = 0.53).

Conclusions

The use of pre-reduction radiographs significantly increased time to acceptable reduction of ankle fracture-dislocations. However, this was not associated with increased risk of complications or time to definitive management.

Assessing people with dementia participating in cognitive stimulation activities-A qualitative pilot video analysis exploring the importance of facilitating the participation

BACKGROUND

This pilot video analysis was part of a feasibility control study, which aimed to gain information about the size and variability of the changes in outcome measures to plan a substantive effect study. It compared a cognitive stimulation programme named Lifelong Learning with other existing dementia services.

OBJECTIVE

The pilot video analysis explored how facilitation is performed, when assessing people with dementia with standardized measures, to ensure their participation in research.

DESIGN

A test battery of five measures (Mini-Mental State Examination (MMSE), Quality of Life in Alzheimer's Disease Scale (QoL-AD), General Self-Efficacy Scale, Rosenberg Self-Esteem Scale and Hawthorn Friendship Scale) was used. Each assessment was video-recorded. The findings from a microanalysis of 10 videos are presented in this article.

SETTING

The study involved 55 active participants with mild-to-moderate dementia in six municipalities in Northern Denmark.

RESULTS

The identified themes related to supportive facilitation: Positive facilitator strategies; Creating a safe and comfortable environment; and to dilemmas in facilitation: Balancing multiple dilemmas and Balancing the MMSE test.

DISCUSSION

Results are discussed in relation to using standardized measures.

CONCLUSION

The quality of facilitation when using standardized measures is of great importance as it may influence the participant, the assessment and the answers given. The facilitation role needs to be thoroughly planned and executed with ethical consideration to improve the participation of vulnerable groups in research and ensure a person-centred approach.

PATIENT OR PUBLIC CONTRIBUTION

The identified measures were chosen based upon previous qualitative results and user-involvement workshops with people with dementia.

Perceptions of Training Pathways from Recent Cardiothoracic Surgery Graduates

BACKGROUND

There are three cardiothoracic surgery (CTS) training pathways-general surgery residency followed by a CTS residency of 2-3 years (traditional), 4 years of general surgery and 3 years of CTS residency (4+3), and an integrated 6-year pathway (I-6). The goal of this study was to survey early career cardiothoracic surgeons regarding their training experiences.

METHODS

An email-based survey was sent to cardiothoracic surgeons, who graduated between 2012-2017. Data on training pathway specific variables and overall satisfaction were collected. The primary endpoints were career preparation and satisfaction, scored on a scale from 1-100, 100 being the most positive.

RESULTS

Four hundred seventy-seven emails were sent, with a response rate of 95/477 (20%). Seventy-six of the respondents (80%) were male; the mean age was 39. Seventy-seven (81.0%) completed a traditional training pathway, 7 (7.4%) completed a 4+3 pathway, and 11 (11.6%) completed an I-6 pathway. Participants felt prepared for practice with a mean response of 79.8 (range 31-100); mean career satisfaction was 87.6.  When asked which pathway respondents would choose in the current era, 52 (54.7%) would choose a traditional pathway, 17 (17.9%) a 4+3 pathway, and 19 (20.0%) an I-6 program; 7 (7.4%) did not respond. Twenty of 72 (27.8%) traditional pathway trained and 18/18(100%) integrated pathway trained surgeons would choose an integrated pathway.

CONCLUSIONS

This is the first survey addressing perceptions of training from early-career cardiothoracic surgeons across all training pathways. Data from this study provides insights to better understand how to improve CTS training for the next generation of surgeons.

1005 Antibiotic-Impregnated Calcium Sulfate Beads Are Not Effective in the Primary Prevention of Infection in Open Femur and Tibia Fractures

Introduction

Infection is a major complication of open fractures. Antibiotic-impregnated calcium sulfate (AICS) beads are widely used as an adjuvant to systemic antibiotics. Whilst their efficacy in the secondary prevention of infection is established, we present the first retrospective study evaluating AICS beads in the primary prevention of infection in open fractures.

Method

214 open femur and tibia fractures in 207 patients were reviewed over a seven-year period. 148 fractures received only systemic antibiotic prophylaxis. 66 fractures also received AICS beads. The occurrence of acute infection (wound infection and acute osteomyelitis) was recorded, as well as that of long-term complications (chronic osteomyelitis, non-union and death).

Results

Fractures that received AICS with systemic antibiotics had an overall acute infection rate of 42% (28/66), compared to 43% (63/148) in fractures that received only systemic antibiotics (p > 0.05). There was no significant difference in infection rate even when fractures were stratified by Gustilo-Anderson grade. There was also no significant difference in the rate of long-term complications.

Conclusions

Our results indicate that the adjuvant use of AICS beads is not effective for the primary prevention of acute infection or long-term complications in open leg fractures. Further research is needed to elucidate the factors influencing the outcomes of AICS use.

Carer and staff perceptions of end-of-life care provision: case of a hospice-at-home service

People requiring palliative care should have their needs met by services acting in accordance with their wishes. A hospice in the south of England provides such care via a 24/7 hospice at home service. This study aimed to establish how a nurse-led night service supported patients and family carers to remain at home and avoid hospital admissions. Semi-structured interviews were carried out with family carers (n=38) and hospice-at-home staff (n=9). Through night-time phone calls and visits, family carers felt supported by specialist hospice staff whereby only appropriate hospital admission was facilitated. Staff provided mediation between family carer and other services enabling more integrated care and support to remain at home. A hospice-at-home night service can prevent unnecessary hospital admissions and meet patient wishes through specialist care at home.

The Cost of Visit-based Home Care for up to Two Weeks in the Last Three Months of Life: APilot Study of Community Care Based at a Hospice-at-home Service in South East of England

The cost of visit-based community care based around a 24/7 hospice-at-home (HatH) service in the last 3 months of life was assessed. Thirty families completed a health and social carediary of at-home visits over two-weeks following contact with the HatH night service. Diaries captured 333 days of care provision, averaging 11 diary days per family, 708 health care professional and carer visits, lasting 604 hours at a cost of £20,192 ($24,946). Hat H care, integrated with community support, seems an economic proposition but highlights the complexities of assessing cost of end of life care.

AB1332-HPR ASSESSING THE PATIENT EXPERIENCE OF LUPUS NEPHRITIS: DEVELOPMENT OF A CONCEPTUAL MODEL AND REVIEW OF EXISTING PATIENT-REPORTED OUTCOME (PRO) MEASURES

Background:

Lupus nephritis (LN) is an autoimmune disease characterized by inflammation of the kidneys as a result of systemic lupus erythematosus (SLE). Approximately 50% of SLE patients will develop LN, which is considered to be one of the most severe manifestations of SLE and the leading cause of morbidity and mortality in SLE. While there is ample existing evidence on disease experience and PROs used in extra-renal SLE, little research has been done in LN. Qualitative interviews with patients can help identify concepts that are both important and relevant to the patient. In order to effectively evaluate treatment benefit, it is critical that PRO measures used to assess such concepts and define clinical trial endpoints are fit for purpose and have strong evidence of content validity in the specific context of use.

Objectives:

The objective of this study was to understand the patient experience of LN and to identify and characterize the signs and symptoms of LN and their impact on health-related quality of life (HRQoL) through the development of a disease-specific conceptual model. This model was then used to evaluate the content validity of existing PRO measures available for use in LN.

Methods:

A structured literature search was conducted in Medline, Embase and PsycINFO to identify qualitative research articles documenting the patient experience of LN. PRO measures developed or commonly used to assess patient experiences of LN were also identified. Semi-structured concept elicitation interviews were conducted with 15 adult patients in the US with a clinician-confirmed diagnosis of LN (defined in accordance with established clinical guidelines). Supplementary qualitative data were also collected from a review of publicly available online blogs/forums. Findings were used to inform the development of a conceptual model detailing the impact of LN signs, symptoms and HRQoL and evaluate the validity of existing measures used within LN.

Results:

Searches revealed a paucity of qualitative research conducted with LN patients, supporting the need for prospective research in LN. Consistent with existing literature in SLE, the core signs and symptoms identified from the qualitative literature review, interviews and blog/forum review included joint pain, fatigue, joint stiffness, swelling (particularly in the extremities) and skin rashes. LN patients also reported urinary frequency, urgency, foamy urine and blood in their urine. Disease impact on physical functioning, activities of daily living, emotions, social life, work/finances and sleep were reported. PRO measures commonly used to evaluate patient experiences in LN included the SF-36, LupusQOL, LupusPRO, SLE Symptom Checklist, KDQoL and KSQ. Conceptual mapping of instruments against the newly developed conceptual model (Figure 1) highlighted that no single measure provides a comprehensive assessment of all symptoms/impact important to LN patients. Furthermore, items are largely focused on impact of symptoms with few items on symptom severity.

Figure 1.

Conceptual model of lupus nephritis symptoms and associated impacts

Conclusion:

The presentation of signs and symptoms in LN patients appears similar to those reported in extra-renal SLE populations, with the addition of swelling and urinary symptoms. Qualitative research with LN patients guided the development of a comprehensive LN conceptual model outlining the disease experience from the patients’ perspective. These insights can be useful to inform PRO measurement strategies for clinical trials in LN.

Acknowledgments:

With thanks to Dr. Betty Diamond and Dr. David Wofsy for their collaboration and helpful insights

Disclosure of Interests:

Pamela Berry Employee of: Janssen, Kate Burrows Consultant of: Adelphi Values a health outcomes research company commissioned by Janssen to conduct the research reported in this abstract, Rebecca Hall Consultant of: Adelphi Values a health outcomes research company commissioned by Janssen to conduct the research reported in this abstract., Adam Gater Consultant of: Adelphi Values a health outcomes research company commissioned by Janssen to conduct the research reported in this abstract, Helena Bradley Consultant of: Adelphi Values a health outcomes research company commissioned by Janssen to conduct the research reported in this abstract, Amy Ward Consultant of: Adelphi Values a health outcomes research company commissioned by Janssen to conduct the research reported in this abstract, Chloe Tolley Consultant of: Adelphi Values a health outcomes research company commissioned by Janssen to conduct the research reported in this abstract, Patricia Delong Employee of: Janssen, Elizabeth C Hsia Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC

Prevention and treatment of venous thromboembolism in hospital and the community: a research programme including the ExACT RCT

Background

Deep-vein thrombosis and pulmonary embolism, collectively known as venous thromboembolism when clots are formed in the venous circulation, are common disorders that are often unprovoked (i.e. there is no obvious reason for the clot occurring). Some people, after having an unprovoked clot, are at a high risk of developing another, or at risk of developing a secondary clot, most importantly in the lungs. Furthermore, in the long term, some patients will develop circulation problems known as post-thrombotic syndrome. The aim of this programme was to improve the understanding of both the prevention and the treatment of thrombosis in people at the highest risk of recurrence.

Objectives

To clarify if it is possible to identify those people at the highest risk of having a recurrent venous thromboembolism, and if it is possible to prevent this happening by giving anticoagulation treatment for longer. To clarify if it is possible to identify those people at the highest risk of developing post-thrombotic syndrome. To document the current knowledge level about prevention and treatment of venous thromboembolism. To find what the barriers are to implementing measures to prevent venous thromboembolism. To find the most cost-effective means of treating venous thromboembolism.

Design

Mixed methods, comprising a randomised controlled trial, qualitative studies, cost-effectiveness analyses and questionnaire studies, including patient preferences.

Setting

UK general practices and hospitals, predominantly from the Midlands and Shropshire.

Participants

Adults attending participating anticoagulation clinics with a diagnosis of first unprovoked deep-vein thrombosis or pulmonary embolism, and health-care professionals, patients and other stakeholders who were involved in the prevention and treatment of venous thromboembolism.

Intervention

Extended treatment with oral anticoagulation therapy (2 years) versus standard care (treatment with oral anticoagulation therapy for at least 3 months).

Results

Work package 1 demonstrated that extended anticoagulation for up to 2 years was clinically effective and cost-effective in reducing the incidence of recurrent venous thromboembolism, with a small increase in the risk of bleeding. There was no difference in post-thrombotic syndrome incidence or severity, or quality of life, between those undergoing the extended treatment and those receiving the standard care. Work package 2 identified five common themes with regard to the prevention of hospital-acquired thrombosis: communication, knowledge, role of primary care, education and training, and barriers to patient adherence. Work package 3 suggested that extended anticoagulation with novel oral anticoagulants was cost-effective only at the £20,000-per-quality-adjusted life-year level for a recurrence rate of between 17.5% and 22.5%, depending on drug acquisition costs, while identifying a strong patient preference for extended anticoagulation based on a fear of recurrent venous thromboembolism.

Limitations

The major limitation was the failure to reach the planned recruitment target for work package 1.

Conclusions

Extended anticoagulation with warfarin for a first unprovoked venous thromboembolism is clinically effective and cost-effective and is strongly preferred by patients to the alternative of not having treatment. There are significant barriers to the implementation of preventative measures for hospital-acquired thrombosis. Further research is required on identifying patients in whom it is safe to discontinue anticoagulation, and at what time point following a first unprovoked venous thromboembolism this should be done.

Trial registration

Current Controlled Trials ISRCTN73819751 and EudraCT 2101-022119-20.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 5. See the NIHR Journals Library website for further project information.

Journey of ethics - Conducting collaborative research with people with dementia

This paper explores some of the ethical considerations of working collaboratively with people with dementia within research based upon the experiences, challenges and learning from three doctoral research studies. Focus is on the research relationship with participants and gatekeepers, the importance of setting and access, the power relations within the research and ways in which people with dementia can be supported to be active and have a voice in research. This sits within an ethical framework of principalist ethics and ethics of care to guide not only how research is planned ethically and with consideration of participants, but also how this can support decisions made in situ. The aim is to share, based upon these three studies, ways of managing and working through some of the ethical consideration to support researchers in their decisions in planning and conducting research with people with dementia as active collaborators.

PSXIV-3 Expression of genes within the methionine-folate cycle are altered by glucose and one-carbon metabolite supplementation in bovine embryonic fibroblasts

We hypothesized that supplementation with one-carbon metabolites (OCM; methionine, folate, choline, and vitamin B12) in divergent glucose media would alter expression of genes in the methionine-folate cycle of DNA methylation in bovine embryonic tracheal fibroblasts. Cells were cultured in EMEM medium containing 1 g/L (Low) or 4.5 g/L (High) of glucose with no added OCM (CON), or 2.5, 5, or 10 times folate, choline, and B12 (2.5X, 5X, or 10X, respectively) in the CON media. Methionine was limited to 2X CON. The data were analyzed as a completely randomized design with a 2 × 4 factorial arrangement of treatments. Cells were passaged three times in treated media before RNA extraction. Gene expression analysis was conducted on Methionine Adenosyltransferase 2A and 2B (MAT2A and MAT2B) DNA Methyltransferase 1, 3A, and 3B (DNMT1, DNMT3A, and DNMT3B), S-Adenosylhomocysteine Hydrolase (AHCY), and Methionine Synthase (MTR). There was no glucose × OCM interaction for DNMT1, DNMT3A, DNMT3B, AHCY, or MTR (P > 0.17). Expression of MAT2B was greater (P < 0.01) in 2.5X, 5X, and 10X OCM in High media compared with all other treatments. Expression of DNMT1 was greater in CON, 5X, and 10X OCM in Low media compared with all other treatments. Expression of MTR was greater (P = 0.03) in CON and 10X OCM treatments compared with 2.5X and 5X levels. Finally, MAT2A and AHCY expression was affected by glucose level, with MAT2A being greater (P = 0.02) in Low compared with High, and AHCY being greater (P < 0.01) in High compared with Low media. These data suggest that glucose and OCM supplementation differentially affect the expression of genes in the methionine-folate cycle of DNA methylation. Additionally, these data demonstrate that additional work elucidating the changes in protein abundance of these enzymes, concentrations of methionine-folate cycle intermediates (specifically S-adenosylmethionine:S-adenosylhomocysteine), as well as changes in DNA methylation are needed.

PSIV-11 The effect of a high sugar supplement versus a beef supplement during pregnancy on offspring hepatic gene expression in a swine biomedical model

Our objective was to investigate the effect of a maternal supplemental calorie source, (high protein or high sugar) on offspring developmental programming of metabolic gene expression. Multiparous sows (n = 35) were bred to one of two full-sibling boars. Sows were fed a corn and soybean meal-based diet and randomly assigned to one of four isocaloric supplement treatments: 126 g of the basal diet, (CON, n = 5); 85 g of crystalized sugar (SUGAR, n = 5); 110 g of cooked ground beef (BEEF, n = 6); or a combination of 55 g cooked beef and 43 g of crystalized sugar (B+S, n = 5). Supplements were fed three times daily from d 40 of gestation through d 18 of weaning. A male and female offspring of median weight from each sow were individually housed and phase fed standard production diets. Offspring were harvested at d 160 of age and a liver tissue sample collected. Expression of the following genes was quantified via qPCR with hypoxanthine phosphoribosyltransferase 1 (HPRT1) as the reference gene: pyruvate carboxylase (PC); phosphoenolpyruvate carboxykinase 1 (PCK1); lipase C hepatic type (LIPC); fibroblast growth factor 21 (FGF21); glucose-6 phosphatase catalytic subunit (G6PC); and fructose 1, 6-biphosphate (FBFase). Genes were selected based on their function in hepatic metabolism. Data were analyzed using the GLM procedure of SAS with sex, treatment, and interaction as fixed effects. Sex influenced (P < 0.05) expression of PC and FBFase, with males having greater expression than females (1.38 vs. 0.63 ± 0.14 and 1.15 vs. 0.82 ± 0.09, respectively). However, there was no effect of treatment or sex by treatment interaction on hepatic expression of the genes studied (P > 0.05). Therefore, we conclude that supplemental caloric source during pregnancy does not alter developmental programming of the stated liver metabolic genes in peripubertal offspring.

Predicting Early Stages of Beef Respiratory Disease Using Thermal Imaging Technology

ObjectivesThe objective of this research was to utilize thermal imaging technology to estimate body temperature, so that an early stage of BRD can be detected.Materials and MethodsNinety-two steers were restrained in a squeeze chute that is housed in an indoor handling facility on 6 separate occasions. At least one image was taken of each side of the head using a thermal infrared camera (FLIR E8 WiFi, FLIR, Wilsonville, OR). The distance at which the images were taken was approximately 1 m from the steer. The rectal temperature was used as the control method to compare thermal imaging data. After thermal image acquisition, images were analyzed using the FLIR ResearchIR Max software (v. 4.40.8.28, FLIR, Wilsonville, OR), with the regions of interest being the eye and nasal cavity.ResultsThe analysis focused on minimum (MIN), maximum (MAX), mean, standard deviation (SD), and range of temperatures in the regions of interest. The REG procedure in SAS (v. 9.4, SAS Institute, Inc., Cary, NC) was used to perform stepwise regression to predict rectal temperature from the outdoor temperature (OTEMP) and all imaging features. When OTEMP was greater than –17.8°C, the regression model contained OTEMP, left nasal MAX, left nasal SD, and left eye MAX temperature and right eye temperature range, with an R2 of 0.24. When OTEMP was above freezing (0°C), the regression model contained left nasal temperature range, right eye temperature range, and average nasal mean temperature, with an R2 increase to 0.50. When using all data, the regression model fit left nasal MAX, right nasal MIN, average nasal mean, and left eye MAX temperatures and right eye temperature range, with an R2 of 0.08. These results show that thermal imaging technology has higher prediction accuracy in warmer temperature ranges than extreme cold conditions.ConclusionMore validation research on this thermal imaging technology needs to be conducted at warmer temperatures since all the current data was collected on cold winter days and a large portion of U.S. cattle are reared in more temperate and warmer areas than North Dakota such as Nebraska, Kansas, Texas, Oklahoma, and Florida. Overall, these results show promise for using thermal imaging technology to help detect BRD in an earlier stage by detecting fever before other clinical signs of BRD are present.

Effect of Feeding a Low Vitamin a Diet to Beef Steers on Calpain 1 Activation during Meat Aging

ObjectivesThe objective of the study was to determine if a vitamin A deficient diet during beef finishing influences calpain 1 activation during meat aging.Materials and MethodsSixty-four steers of approximately 7 mo of age were subjected to a 14-d acclimation period followed by a 95-d growing period on a low vitamin A diet (1017 IU vitamin A/kg DM) designed to deplete liver vitamin A stores. Steers were assigned to a randomized complete blocked design with a 2 × 2 arrangement of treatments (breed: commercial Angus, n = 32, and purebred Simmental, n = 32; and a Low Vitamin A diet or a control diet). The low Vitamin A (LVA) treatment was a finishing diet with no supplemental vitamin A (723 IU vitamin A/kg DM). The control (CON) treatment was the LVA diet plus supplementation with 2200 IU vitamin A/kg DM for a total of 2923 IU vitamin A/kg DM. Serum retinol concentrations were monitored at the beginning and end of treatment. Upon completion of finishing, steers were slaughtered in two groups at a commercial plant. After fabrication, boneless strip loins (IMPS 180) were collected and transported to NDSU. Samples (approximately 40 g) were collected from the anterior portion of the strip loin on d-2 and d-7 of aging and immediately frozen. Protein was extracted from meat samples in fractionation buffers to yield sarcoplasmic and myofibrillar portions, separated by SDS-PAGE, and transferred to PVDF membranes. Immunoblot analysis was done using anti-desmin (d-2 and d-7) and anti-calpain 1 (d-2) antibodies, and results were visualized and documented. A pooled control was run on all membranes and set to a value of one for normalizing results. All experimental data were analyzed using the Proc Mixed procedure of SAS with breed of steers, dietary treatments, their interaction and slaughter date used as a fixed effect.ResultsCalpain 1 autolysis in the sarcoplasmic protein fraction of the d-2 aged loin samples were not affected by treatment or breed. The myofibrillar protein fraction from Angus loins had greater (P = 0.02) accumulation of the 76 kDa calpain 1 autolysis product than that from the Simmental loins; the myofibrillar fraction of the loins from the LVA treatment tended (P = 0.07) to have more 76 kDa calpain 1 autolysis product than that from the CON. There were not any differences (P > 0.19) in the 80 kDa calpain 1 band or the 78 kDa calpain 1 intermediate autolysis product in the myofibrillar fraction. There was a treatment by breed interaction (P = 0.01) for desmin in the d-7 aged loins where Angus loins from the CON treatment had less accumulation of the 46 kDa band than Angus loins on the LVA treatment and Simmental loins from either treatment.ConclusionVitamin A restriction increased protein proteolysis in Angus but not in Simmental steers. The increased calpain 1 autolysis in Angus vs. Simmental, regardless of Vitamin A treatment, indicates a genetic difference that may be the driver for the increased protein degradation in steers a restricted vitamin A diet.

Modelling methane emission mitigation by anaerobic digestion: effect of storage conditions and co-digestion

In this work the methane conversion factor (MCF) of untreated and anaerobically digested cattle manure (CM) as a function of storage temperature, time and co-digestion was measured in an in vitro experiment and modelled based on IPCC (2006) methodology (Tier 2). For this, one sample of untreated CM, one sample of mono-digested CM and three samples of CM co-digested with grass were incubated at seven different temperatures (from 5°C to 50°C) over 346 days. The main results showed that ultimate methane yield (B₀) of CM is higher than the B₀ reported by the IPCC (2006). Two temperature ranges should be considered for MCF evolution, below 15°C very low MCF was measured in this work for untreated CM, mono and co-digested samples. At higher temperatures, MCF obtained in this work and that provided by the IPCC could be comparable depending on storage time. Anaerobic mono-digestion decreased MCF compared to untreated CM at all temperatures and times, except in the temperature range between 20°C and 25°C if storage time is low, due to a lag phase observed in CM. This lag phase would probably not happen in real storage conditions depending on the proportion of old manure remaining in the storage tank. Co-digestion with grass-decreased MCF compared to mono-digestion, but increased CH₄ production in terms of fresh matter due to the higher B₀ of the mixture. Storage time, temperature and co-digestion should be considered in the quantification of CH₄ emission from digested material.

Trends and predictors of recent HIV testing over 22 years among a clinic sample of men who have sex with men in South Australia

Increasing the frequency of HIV testing is crucial for effective HIV prevention and care. The aim of the present study was to determine whether there has been a change in HIV testing among men who have sex with men (MSM) at the South Australia Specialist Sexual Health (SASSH) clinic over the past two decades.

METHODS

Computerised medical records of MSM who attended the SASSH at their first visit between 1994 and 2015 were used to determine whether HIV testing had changed among MSM. First HIV tests in each calendar year and return tests within 12 months were analysed. Factors associated with recent HIV testing were also examined.

RESULTS

There were 24036 HIV tests conducted among 8163 individual MSM over the study period. The proportion of newly registered MSM who reported ever being tested for HIV declined (P_trend=0.030), the proportion who reported recent HIV testing did not change (P_trend=0.955) and the proportion who have had current HIV testing increased (P_trend=0.008). The proportion of MSM who returned to the clinic for HIV testing within 12 months did not change (P_trend >0.05), with less than 40% of MSM returning for HIV testing. Factors independently associated with recent HIV testing included MSM aged ≥20 years, (odds ratio (OR) 1.79; 95% confidence interval (CI) 1.53-2.10), higher education (OR 1.28; 95% CI 1.12-1.45), non-Caucasian (African OR 1.68; 95% CI 1.30-2.17), having multiple sex partners (OR 1.47; 95% CI 1.29-1.69), having had sex interstate (OR 1.61; 95% CI 1.42-1.82) or overseas (OR 1.53; 95% CI 1.33-1.76) and injecting drug use (OR 1.56; 95% CI 1.29-1.88).

CONCLUSIONS

HIV testing rate among MSM attending SASSH was suboptimal. New approaches are needed to increase the uptake and early detection of HIV infection among the high-priority MSM population.

Mixed-methods feasibility study of blood pressure self-screening for hypertension detection

OBJECTIVE

To assess the feasibility of using a blood pressure (BP) self-measurement kiosk-a solid-cuff sphygmomanometer combined with technology to integrate the BP readings into patient electronic medical records- to improve hypertension detection.

DESIGN

A concurrent mixed-methods feasibility study incorporating observational and qualitative interview components.

SETTING

Two English general practitioner (GP) surgeries.

PARTICIPANTS

Adult patients registered at participating surgeries. Staff working at these sites.

INTERVENTIONS

BP self-measurement kiosks were placed in the waiting rooms for a 12-month period between 2015 and 2016 and compared with a 12-month control period prior to installation.

OUTCOME MEASURES

(1) The number of patients using the kiosk and agreeing to transfer of their data into their electronic medical records; (2) the cost of using a kiosk compared with GP/practice nurse BP screening; (3) qualitative themes regarding use of the equipment.

RESULTS

Out of 15 624 eligible patients, only 186 (1.2%, 95% CI 1.0% to 1.4%) successfully used the kiosk to directly transfer a BP reading into their medical record. For a considerable portion of the intervention period, no readings were transferred, possibly indicating technical problems with the transfer link. A comparison of costs suggests that at least 52.6% of eligible patients would need to self-screen in order to bring costs below that of screening by GPs and practice nurses. Qualitative interviews confirmed that both patients and staff experienced technical difficulties, and used alternative methods to enter BP results into the medical record.

CONCLUSIONS

While interviewees were generally positive about checking BP in the waiting room, the electronic transfer system as tested was neither robust, effective nor likely to be a cost-effective approach, thus may not be appropriate for a primary care environment. Since most of the cost of a kiosk system lies in the transfer mechanism, a solid-cuff sphygmomanometer and manual entry of results may be a suitable alternative.

Mapping Semaphorins and Netrins in the Pathogenesis of Human Thoracic Aortic Aneurysms

Thoracic aortic aneurysm (TAA) is a complex life-threatening disease characterized by extensive extracellular matrix (ECM) fragmentation and persistent inflammation, culminating in a weakened aorta. Although evidence suggests defective canonical signaling pathways in TAA, the full spectrum of mechanisms contributing to TAA is poorly understood, therefore limiting the scope of drug-based treatment. Here, we used a sensitive RNA sequencing approach to profile the transcriptomic atlas of human TAA. Pathway analysis revealed upregulation of key matrix-degrading enzymes and inflammation coincident with the axonal guidance pathway. We uncovered their novel association with TAA and focused on the expression of Semaphorins and Netrins. Comprehensive analysis of this pathway showed that several members were differentially expressed in TAA compared to controls. Immunohistochemistry revealed that Semaphorin4D and its receptor PlexinB1, similar to Netrin-1 proteins were highly expressed in damaged areas of TAA tissues but faintly detected in the vessel wall of non-diseased sections. It should be considered that the current study is limited by its sample size and the use of internal thoracic artery as control for TAA for the sequencing dataset. Our data determines important neuronal regulators of vascular inflammatory events and suggest Netrins and Semaphorins as potential key contributors of ECM degradation in TAA.