System dynamics modelling to engage community stakeholders in addressing water and sugar sweetened beverage consumption

Background

Participatory approaches to develop community-based system dynamics models to tackle complexity are promising, but research is needed in how simulation models can be developed with community stakeholders to yield significant system insights. This study presents the results of a community-based system dynamics modelling process to increase water consumption and decrease sugar sweetened beverage consumption in Portland, Victoria, a regional town in Australia.

Methods

A series of group model building workshops with 11 community stakeholders addressing the topic of water and sugar sweetened beverage consumption was conducted in Portland. A simulating system dynamics model was built with stakeholders to inform action planning.

Results

A system dynamics model was created to provide insight into water and sugar sweetened beverage consumption in Portland. The model included six feedback loops describing the causal effects of sugar sweetened beverage consumption habits and norms, water taste, water consumption norms, public water availability, and public health benefits. For example, the sugar sweetened beverage consumption norm loop modelled how people overestimating others’ consumption may motivate an increase in their own consumption, feeding back and further amplifying an increase in sugar sweetened beverage consumption. The model contributed to the foundation of a strong partnership to improve the taste of water and educate the public on water consumption.

Conclusions

Engaging stakeholders in system dynamics modelling about water and sugar sweetened beverage consumption increased engagement and collaboration to address the problem among community stakeholders.

Policy processes leading to the adoption of 'Jamie's Ministry of Food' programme in Victoria, Australia

This study investigated the policy processes related to the 2012 adoption of the Jamie's Ministry of Food programme by the Victorian Government in Australia. The aim was to provide insight into obesity prevention policy change processes to help strengthen future health promotion action. State-level government policy processes were examined through key informant interviews and a review of relevant documentation. Data were analysed using the Multiple Streams Theory and the Advocacy Coalition Framework in order to understand influences on relevant policy processes and strategies used by policy advocates to facilitate policy adoption. We found that policy adoption was facilitated by dedicated national funding for preventive health at that time, the relatively small number of stakeholders involved in the policy development process and the anticipated support for the programme by the general public due to the association with celebrity chef, Jamie Oliver. We identified that policy brokers aligned the policy with decision-maker ideologies and broader government objectives, and proactively managed potential criticisms. Evidence of intervention effectiveness was not a major driver of policy adoption. We conclude that, iven the complexity of policy processes for obesity prevention, multiple, reinforcing strategies are likely to be needed to facilitate policy change. Support for the adoption of obesity prevention policies is likely to increase when framing of policy options aligns with decision-maker values and has broad public appeal.

Understanding the dynamics of obesity prevention policy decision-making using a systems perspective: A case study of Healthy Together Victoria

INTRODUCTION

Despite global recommendations for governments to implement a comprehensive suite of policies to address obesity, policy adoption has been deficient globally. This paper utilised political science theory and systems thinking methods to examine the dynamics underlying decisions regarding obesity prevention policy adoption within the context of the Australian state government initiative, Healthy Together Victoria (HTV) (2011-2016). The aim was to understand key influences on policy processes, and to identify potential opportunities to increase the adoption of recommended policies.

METHODS

Data describing government processes in relation to the adoption of six policy interventions considered as part of HTV were collected using interviews (n = 57), document analyses (n = 568) and field note observations. The data were analysed using multiple political science theories. A systematic method was then used to develop a Causal Loop Diagram (CLD) for each policy intervention. A simplified meta-CLD was generated from synthesis of common elements across each of the six policy interventions.

RESULTS

The dynamics of policy change could be explained using a series of feedback loops. Five interconnected balancing loops served to reduce the propensity for policy change. These pertained to an organisational norm of risk aversion, and the complexity resulting from a whole-of-government policy approach and in-depth stakeholder consultation. However, seven virtuous reinforcing loops helped overcome policy resistance through policy actor capabilities that were improved over time as policy actors gained experience in advocating for change.

CONCLUSION

Policy processes for obesity prevention are complex and resistant to change. In order to increase adoption of recommended policies, several capabilities of policy actors, including policy skills, political astuteness, negotiation skills and consensus building, should be fostered and strengthened. Strategies to facilitate effective and broad-based consultation, both across and external to government, need to be implemented in ways that do not result in substantial delays in the policy process.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

THU0438 INADEQUATE CARE FOR PATIENTS HOSPITALISED WITH GOUT: EVIDENCE THAT EULAR GUIDANCE IS NOT UTILISED

Background:

Hospitalisations due to gout have increased over the last decade, in direct contrast to declining admissions for other inflammatory arthritides including RA [1]. Gout is a treatable condition with recently published EULAR guidelines [2, 3]. Admissions could be avoided with effective use of urate-lowering therapies (ULT).

Objectives:

We hypothesised that the majority of patients attending hospital with acute gout attacks would not be on ULT. Furthermore, we hypothesised that the majority of patients would not be provided with a plan for ULT commencement and/or uptitration on discharge, leaving them at risk of further hospitalisations.

Methods:

We retrospectively analysed electronic health records for all patients presenting acutely with a primary admission diagnosis of gout (ICD-10 code: M10) at two hospitals in London, UK, from January – December 2017. Analyses of in-hospital gout management were performed for these patients, including to ascertain the number and proportion of patients who: i) had a known history of gout; ii) were receiving ULT at time of attendance; iii) were provided with a discharge plan for ULT commencement and/or uptitration.

Results:

Over a 12-month period, there were 234 emergency attendances for gout in 225 individuals. 80% were male, with a mean age of 58 years. 70/234 (30%) attendances resulted in admission to hospital (mean length of stay: 2 days; range: 0-31 days). 211 patients had routinely captured clinical data available for further analysis. 90/211 (43%) patients had prior diagnoses of gout, of whom 38% were on ULT at presentation (32 allopurinol, 2 febuxostat). 38% of patients were discharged with a plan for ULT commencement and/or uptitration. 20 patients re-presented to hospital with acute gout within 12 months (17/20 were not receiving ULT).

Conclusion:

Most patients hospitalised with gout were not receiving ULT, even those with a prior history of gout attacks. Few were provided with a ULT plan, leaving them at risk of re-admission to hospital. Hospital admissions are unpleasant for patients and incur a high economic burden for health services; if they are to be prevented, there must be a concerted effort to implement and follow gout management guidelines to ensure patients receive ULT at appropriate doses.

References:

[1]Russell M,et al. Return of the King: Rising Incidence of Acute Hospital Admissions due to Gout. J Rheum 2019 Sep 15.

[2]Richette P, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis 2017;76:29-42.

[3]Richette P, et al. 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout. Ann Rheum Dis 2020;79:31-38.

Disclosure of Interests: :

None declared

Understanding the LiveLighter® obesity prevention policy processes: An investigation using political science and systems thinking

The health and economic burden associated with overweight and obesity warrants comprehensive policy action; however, to date, there has been limited policy progress globally. This study sought to advance obesity prevention policy research and practice by applying theories of the policy process to study decision-making processes involved in the adoption of the contentious LiveLighter® social marketing campaign by the Victorian government in Australia. Through analysis of documents and interviews with policy makers, this qualitative study aimed to gain a better understanding of the dynamic influences on policy decision-making. Multiple theories of the policy process were used to elucidate policy drivers and Causal Loop Diagramming methods were used to illustrate the LiveLighter® policy decision-making systems. Findings highlighted a number of key influences including: various external events, evidence of the problem and intervention effectiveness, resistance from various stakeholders and the political capabilities of central policy makers. The policy systems map provided insight into the difficulties experienced by policy actors in achieving policy change, as well as to develop a conceptual framework for identifying potential leverage points to influence future obesity prevention policy decisions. Together the findings can inform future advocacy efforts for improving the implementation of obesity prevention policy action.

Impact of somatic molecular profiling on clinical trial outcomes in rare epithelial gynecologic cancer patients

OBJECTIVES

Conducting clinical trials in rare malignancies is challenging due to the limited number of patients and differences in biologic behavior. We investigated the feasibility and clinical utility of using genomic profiling for rare gynecologic malignancies.

METHODS

Rare epithelial gynecologic cancer patients were analyzed for somatic variants through an institutional molecular profiling program using the Sequenom MassArray platform or the TruSeq Amplicon Cancer Panel on the MiSeq platform. Clinical trial outcomes by RECIST 1.1, and time on treatment were evaluated.

RESULTS

From March 2012 to November 2015, 767 gynecologic patients were enrolled and 194 (27%) were classified as rare epithelial malignancies. At least one somatic mutation was identified in 72% of patients, most commonly in TP53 (39%), KRAS (28%) and PIK3CA (27%). A total of 14% of patients were treated on genotype-matched trials. There were no significant differences in overall response rate between genotype-matched versus unmatched trials, nor in median time on treatment between genotype trials and the immediate prior systemic standard treatment. Among 13 evaluable Low Grade Serous ovarian cancer patients treated on genotype-matched trials with MEK inhibitor-based targeted combinations, there were four partial responses.

CONCLUSIONS

Somatic molecular profiling is feasible and enables the identification of patients with rare gynecologic cancers who are candidates for genotype-matched clinical trials. Genotype-matched trials, predominantly MEK-based combinations in KRAS and/or NRAS mutant Low Grade Serous ovarian cancer patients, and genotype-unmatched trials, have shown potential clinical activity. Prospective trials with integrated genotyping are warranted to assess the clinical utility of next generation sequencing tests as a standard clinical application in rare malignancies.

Understanding Health Promotion Policy Processes: A Study of the Government Adoption of the Achievement Program in Victoria, Australia

Despite the growing health and economic burden associated with overweight and obesity, preventive policy progress has been deficient globally. This study investigated the policy process involved in the adoption of the Achievement Program, a settings-based health promotion intervention that was a key pillar of the Healthy Together Victoria obesity prevention initiative. The qualitative study utilised multiple theories of the policy process, as well as Causal Loop Diagramming (CLD) methods, to understand the policy systems underlying the decision to adopt the Achievement Program. Factors that impacted this obesity prevention policy adoption included problem prioritisation at Federal and state government levels; political risks regarding policy action and inaction, and framing used by policy advocates to reduce risks and highlight the opportunities related to the Achievement Program policy implementation. The use of CLD methods was advantageous to further conceptualise potential leverage points and effective ways to influence obesity prevention policy in future. As such, the findings contribute to the obesity prevention policy evidence base and toward developing a number of recommended actions for policy actors seeking to increase future policy action.

Cardiovascular, obstetric and neonatal outcomes in women with previous fontan repair

OBJECTIVES

To determine cardiovascular, obstetric and neonatal outcomes of pregnancies in women who have a Fontan circulation.

METHODS

A retrospective case note review of all women with a Fontan circulation who attended the joint obstetric cardiac antenatal clinic at St Mary's Hospital, Manchester (UK) between 2004 and 2016 was performed.

RESULTS

In total, there were 19 pregnancies in 9 women with a history of Fontan repair. 23 women with univentricular physiology attended in this time period. 10 pregnancies (53%) resulted in live births; 1 in a stillbirth at 31 weeks gestation and 8 in miscarriage. Cardiovascular complications occurred in 2 pregnancies (11%). There were no thrombotic events, arrhythmias, myocardial infarction, or endocarditis in the antenatal or postnatal period. Obstetric complications included miscarriage (26% first trimester, 16% second trimester), along with premature delivery (24-36⁺⁶) (80%) and fetal growth restriction (70%). The majority of women were delivered by caesarean section (60%).

CONCLUSIONS

Women who become pregnant following a Fontan repair carry an increased risk of cardiovascular complications. Fetal and neonatal complication rates are high and emphasize the importance of thorough, multidisciplinary, pre-conceptual assessment and counseling to allow patients to make informed decisions regarding future pregnancy.

The application of theories of the policy process to obesity prevention: a systematic review and meta-synthesis

BACKGROUND

Theories of the policy process are recommended as tools to help explain both policy stasis and change.

METHODS

A systematic review of the application of such theoretical frameworks within the field of obesity prevention policy was conducted. A meta-synthesis was also undertaken to identify the key influences on policy decision-making.

RESULTS

The review identified 17 studies of obesity prevention policy underpinned by political science theories. The majority of included studies were conducted in the United States (US), with significant heterogeneity in terms of policy level (e.g., national, state) studied, areas of focus, and methodologies used. Many of the included studies were methodologically limited, in regard to rigour and trustworthiness. Prominent themes identified included the role of groups and networks, political institutions, and political system characteristics, issue framing, the use of evidence, personal values and beliefs, prevailing political ideology, and timing.

CONCLUSIONS

The limited application of political science theories indicates a need for future theoretically based research into the complexity of policy-making and multiple influences on obesity prevention policy processes.

The Influence of Posture on Perineal Ultrasound Imaging Parameters

A prospective clinical study was carried out to evaluate the influence of posture on perineal ultrasound imaging parameters. One hundred and thirty-two consecutive women presenting with symptoms of lower urinary tract dysfunction were examined by multichannel videourodynamics and perineal ultrasound, both supine and standing. Ultrasound included color Doppler imaging when available, i.e. in a subgroup of 99 patients. The position of the bladder neck at rest was higher in the supine position (P<0.001) and it descended further on Valsalva (P < 0.001), to reach an almost identical final position. There was a higher degree of urethral rotation on supine imaging (P = 0.001). Urethral funneling on Valsalva was more likely in the erect position (P < 0.001), as was urine leakage documented by color Doppler imaging (P < 0.001). The effect of a pelvic floor contraction was not significantly influenced by posture. Imaging of the urethrovesical junction should be undertaken in both supine and erect positions to document optimally both hypermobility and funneling or leakage.

Generic Feature Selection with Short Fat Data

Consider a regression problem in which there are many more explanatory variables than data points, i.e., p ≫ n. Essentially, without reducing the number of variables inference is impossible. So, we group the p explanatory variables into blocks by clustering, evaluate statistics on the blocks and then regress the response on these statistics under a penalized error criterion to obtain estimates of the regression coefficients. We examine the performance of this approach for a variety of choices of n, p, classes of statistics, clustering algorithms, penalty terms, and data types. When n is not large, the discrimination over number of statistics is weak, but computations suggest regressing on approximately [n/K] statistics where K is the number of blocks formed by a clustering algorithm. Small deviations from this are observed when the blocks of variables are of very different sizes. Larger deviations are observed when the penalty term is an L^q norm with high enough q.

Psychosocial issues of women with type 1 diabetes transitioning to motherhood: a structured literature review

BACKGROUND

Life transitions often involve complex decisions, challenges and changes that affect diabetes management. Transition to motherhood is a major life event accompanied by increased risk that the pregnancy will lead to or accelerate existing diabetes-related complications, as well as risk of adverse pregnancy outcomes, all of which inevitably increase anxiety. The frequency of hyperglycaemia and hypoglycaemia often increases during pregnancy, which causes concern for the health and physical well-being of the mother and unborn child. This review aimed to examine the experiences of women with T1DM focusing on the pregnancy and postnatal phases of their transition to motherhood.

METHODS

The structured literature review comprised a comprehensive search strategy identifying primary studies published in English between 1990-2012. Standard literature databases were searched along with the contents of diabetes-specific journals. Reference lists of included studies were checked. Search terms included: 'diabetes', 'type 1', 'pregnancy', 'motherhood', 'transition', 'social support', 'quality of life' and 'psychological well-being'.

RESULT

Of 112 abstracts returned, 62 articles were reviewed in full-text, and 16 met the inclusion criteria. There was a high level of diversity among these studies but three common key themes were identified. They related to physical (maternal and fetal) well-being, psychological well-being and social environment. The results were synthesized narratively.

CONCLUSION

Women with type 1 diabetes experience a variety of psychosocial issues in their transition to motherhood: increased levels of anxiety, diabetes-related distress, guilt, a sense of disconnectedness from health professionals, and a focus on medicalisation of pregnancy rather than the positive transition to motherhood. A trusting relationship with health professionals, sharing experiences with other women with diabetes, active social support, shared decision and responsibilities for diabetes management assisted the women to make a positive transition. Health professionals can promote a positive transition to motherhood by proactively supporting women with T1DM in informed decision-making, by facilitating communication within the healthcare team and co-ordinating care for women with type 1 diabetes transitioning to motherhood.

A phase I study of the combination of ro4929097 and cediranib in patients with advanced solid tumours (PJC-004/NCI 8503)

Background:

The Notch signalling pathway has been implicated in tumour initiation, progression, angiogenesis and development of resistance to vascular endothelial growth factor (VEGF) targeting, providing a rationale for the combination of RO4929097, a γ-secretase inhibitor, and cediranib, a VEGF receptor tyrosine kinase inhibitor.

Methods:

Patients received escalating doses of RO4929097 (on a 3 days-on and 4 days-off schedule) in combination with cediranib (once daily). Cycle 1 was 42 days long with RO4929097 given alone for the first 3 weeks followed by the co-administration of both RO4929097 and cediranib starting from day 22. Cycle 2 and onwards were 21 days long. Soluble markers of angiogenesis were measured in plasma samples. Archival tumour specimens were assessed for expression of three different components of Notch signalling pathway and genotyping.

Results:

In total, 20 patients were treated in three dose levels (DLs). The recommended phase II dose was defined as 20 mg for RO4929097 on 3 days-on and 4 days-off schedule and 30 mg daily for cediranib. The most frequent treatment-related adverse events (AEs) were diarrhoea, hypertension, fatigue and nausea. Eleven patients had a best response of stable disease and one patient achieved partial response. We did not detect any correlation between tested biomarkers of angiogenesis or the Notch pathway and treatment effect. There was no correlation between mutational status and time to treatment failure.

Conclusion:

RO4929097 in combination with cediranib is generally well tolerated at the DLs tested. Preliminary evidence of antitumour efficacy with prolonged disease stabilisation in some patients with progressive malignancies warrants further clinical investigation of this treatment strategy.

Gravity Probe B: final results of a space experiment to test general relativity

Gravity Probe B, launched 20 April 2004, is a space experiment testing two fundamental predictions of Einstein's theory of general relativity (GR), the geodetic and frame-dragging effects, by means of cryogenic gyroscopes in Earth orbit. Data collection started 28 August 2004 and ended 14 August 2005. Analysis of the data from all four gyroscopes results in a geodetic drift rate of -6601.8±18.3  mas/yr and a frame-dragging drift rate of -37.2±7.2  mas/yr, to be compared with the GR predictions of -6606.1  mas/yr and -39.2  mas/yr, respectively ("mas" is milliarcsecond; 1  mas=4.848×10(-9)  rad).