Influence of gastric residual assessment in preterm neonates on time to achieve enteral feeding (the GRASS trial)-Multi-centre, assessor-blinded randomised clinical trial

PURPOSE

Gastric residual measurement is routinely performed in premature infants prior to feeding despite a lack of evidence of benefit. We aimed to evaluate if the exclusion of routine gastric residual measurement and evaluation has an impact on the time taken to achieve full enteral feeding in preterm neonates.

METHODS

International multi-centre randomised controlled trial. Clinically stable, appropriate for gestational age infants between 26+0 and 30+6 weeks of gestation and less than 1.5 kg birth weight were eligible. Infants were randomised to the intervention arm (no monitoring of gastric aspirates) or control arm (routine care). Primary outcome was the achievement of enteral feeds of 100 ml/kg/day by day 5 of life.

RESULTS

Ninety-five infants were recruited with 88 included in an intention-to-treat analysis, 45 in the intervention arm and 43 in the control arm. There was no imbalance in baseline characteristics. Thirty-three (73.3%) infants in the intervention group and 32 infants (74.4%) in the control group reached full feeds by day 5 of life (p = 0.91) with no difference in median time to full feeds. There were no statistically significant differences in survival or the major morbidities of prematurity.

CONCLUSION

 There was no difference in time to attainment of enteral feeds of 100 ml/kg/day in premature infants when gastric residuals were not monitored. In the absence of a clinical benefit to routine monitoring, it may be appropriate to discontinue this practice and only monitor residuals when clinical concern of feeding intolerance or gastrointestinal pathology arises in this group of patients.

TRIAL REGISTRATION

 NCT03111329- https://clinicaltrials.gov/ . Registered 06/04/2017.

WHAT IS KNOWN

• Previous randomized trials have shown little benefit to the performance of routine assessment of gastric residuals in preterm infants. Despite this, they continue to be performed due to concerns from observational data regarding development of NEC. Meta-analysis to date has failed to answer the question regarding NEC.

WHAT IS NEW

• In very low birth weight infants who are fed using modern feeding practice of faster feed advancement, to minimize use of central access and parenteral nutrition, exclusion of routine checks of gastric residuals did not increase the proportion of infants reaching full enteral feeds by day 5. No harm was seen when residual checks were not performed. • In the absence of a clinical benefit to the routine performance of gastric residuals in very low birth weight infants, it may be appropriate to discontinue their use and instead check residuals when clinical concern of pathology arises.

Defining metabolic flexibility in hair follicle stem cell induced squamous cell carcinoma

Among the numerous changes associated with the transformation to cancer, cellular metabolism is one of the first discovered and most prominent[1, 2]. However, despite the knowledge that nearly every cancer is associated with the strong upregulation of various metabolic pathways, there has yet to be much clinical progress on the treatment of cancer by targeting a single metabolic enzyme directly[3-6]. We previously showed that inhibition of glycolysis through lactate dehydrogenase (LDHA) deletion in cancer cells of origin had no effect on the initiation or progression of cutaneous squamous cell carcinoma[7], suggesting that these cancers are metabolically flexible enough to produce the necessary metabolites required for sustained growth in the absence of glycolysis. Here we focused on glutaminolysis, another metabolic pathway frequently implicated as important for tumorigenesis in correlative studies. We genetically blocked glutaminolysis through glutaminase (GLS) deletion in cancer cells of origin, and found that this had little effect on tumorigenesis, similar to what we previously showed for blocking glycolysis. Tumors with genetic deletion of glutaminolysis instead upregulated lactate consumption and utilization for the TCA cycle, providing further evidence of metabolic flexibility. We also found that the metabolic flexibility observed upon inhibition of glycolysis or glutaminolysis is due to post-transcriptional changes in the levels of plasma membrane lactate and glutamine transporters. To define the limits of metabolic flexibility in cancer initiating hair follicle stem cells, we genetically blocked both glycolysis and glutaminolysis simultaneously and found that frank carcinoma was not compatible with abrogation of both of these carbon utilization pathways. These data point towards metabolic flexibility mediated by regulation of nutrient consumption, and suggest that treatment of cancer through metabolic manipulation will require multiple interventions on distinct pathways.

Measuring gut perfusion and blood flow in neonates using ultrasound Doppler of the superior mesenteric artery: a narrative review

The gut is a relatively silent organ in utero but takes on a major role after birth for the absorption and digestion of feed for adequate nutrition and growth. The neonatal circulation undergoes a transition period after birth, and gut perfusion increases rapidly to satisfy the oxygen demand and consumption. If this process is compromised at any stage, preterm and fetal growth restricted infants are at particular risk of gut tissue injury secondary to hypoxia, leading to necrotizing enterocolitis. Feeding can also be a challenge in these high-risk groups due to gut dysmotility. Superior mesenteric artery (SMA) Doppler is a safe, bedside investigation that could rapidly aid clinicians with feeding strategies and in monitoring high-risk infants. This article aims to establish normal patterns of gut blood flow velocity in neonates using SMA Doppler and reviews how it might be used clinically in pathologic states.

Background levels of body fluids and DNA on the shaft of the penis and associated underpants in the absence of sexual activity

This study examines the background of blood, saliva, semen and autosomal DNA on penile swabs and underpants from males in the absence of recent sexual activity. Based on the data collected by the AFSP Body Fluid Forum, the results of this study show that; there is a very low expectation of detecting blood on penile swabs and male underpants; a low expectation of detecting saliva on penile swabs and male underpants; and spermatozoa would be expected in less than a quarter of penile swabs and three quarters of male underpants. As none of the samples had detectable levels of DNA which were suitable for meaningful comparison that did not match the donor or their partner, the expectation of detecting a DNA profile from the cellular background on penile swabs or underpants from a male who has not been involved in recent sexual intercourse is very low. The results of this study are extremely informative when evaluating the significance of blood, saliva, semen and DNA detected on the penile swabs and underpants of males in cases of alleged sexual assault.

Recruitment and organising 3rd year pharmacy undergraduates into summer placements in primary care in Southwest England

Introduction

Primary care is facing a workforce shortage, especially in Southwest England (SW).1 Funding for clinical pharmacist roles in GP has an impact on community pharmacy with pharmacists leaving to take up PCN positions.2 SW has higher rate of vacancies in than nationally.3 Oriel data showed that fill rate for split foundation training placements in GP is high, however, in SW is significantly low.

Aim

To increase recruitment of future pharmacists in SW by offering pharmacy undergraduates paid 5-week summer placements in GP or GP/community pharmacy partnership, gaining primary care experience, showcasing benefits of cross-sector working and encouraging development of partnerships for increased cross-sector training placements.

Objectives

Students enjoy SW area placement, Students recommend placement to other students, Students preference GP foundation placement, Supervisors express interest in a summer placement for 2022, Supervisors express interest in the GP split trainee pharmacist programme.

Methods

Expressions of interest (EOIs) sought from primary care placements in SW and 16 sites selected. Applicants shortlisted and interviewed online. 16 offered placements based on preference of location. Funding by HEE South reimbursed for student’s wages. Planning booklets provided to GPs, workbooks to students and online induction attended. During the placement, students completed an audit and case-based discussion, shadowed healthcare professionals, assisted administration and pharmacy tasks and practised basic procedural skills. Students attended end-of-placement event to share learning and sent questionnaire focusing on enjoyment of the placement and likelihood of returning to the Southwest and primary care for future employment. Supervisors sent questionnaire separately focusing on likelihood to partake in future. Questionnaires were sent, completed and analysed via Jisc. Ethics approval was not required.

Results

10 students and 11 supervisors completed the survey. 60% students enjoyed SW. 90% students would recommend placement to other students and 90% would like to see them in other areas. 70% students very likely to or definitely would apply for GP foundation placement. 63% supervisors benefitted from having a student and 81% would recommend having summer placement student. 55% supervisors would definitely EOI in future summer placement programme and 55% would definitely EOI in GP split foundation programme. 25% students chose GP/Community placements in SW, 18% other placements in SW, 12% GP placements in other regions. Oriel fill rates in SW increased from 36.67% in 2020 to 39.30% in 2021, GP/Community placements remained the same in 2021 at 28.2% and community placements increased in from 18.14% in 2020 to 18.75% in 2021.

Discussion/Conclusion

The students enjoyed their placements and would recommend to other students. Supervisors found having students useful and would have a student in the future. Although some students were successful in securing a placement in SW for foundation training, due to nature of Oriel it’s not possible to determine how many preferenced SW and GP split programme, this is a limitation to the evaluation. Oriel fill rates didn’t increase for SW community/GP placements as desired, however this was a very small cohort. This pilot will be repeated summer 2022 so fill rates can be evaluated in 2023.

References

1. NHS. The NHS Long Term Plan. Long Term Plan. [Online] 2019. Available from: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf.

2. BMA. Investment and Evolution: A five year gramework for GP contract reform to implement the NHS long term plan. England NHS. [Online] 2019. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf.

3. Community Pharmacy Workforce Development Group. A Review of the Community Pharmacy Workforce. Community Pharmacy Workforce. [Online] 2021. Available from: https://communitypharmacyworkforce.files.wordpress.com/2021/06/cpwdg-report-a-review-of-the-community-pharmacy-workforce-final.pdf.

283 AN EXPLORATION OF THE IRISH NATIONAL FRAILTY EDUCATION PROGRAMME ON PRACTICE: A FRAILTY FACILITATOR'S PERSPECTIVE

Background

Frailty is associated with a range of adverse outcomes in older adults requiring prevention, early detection and management. Interprofessional collaboration in education and practice can facilitate integrated care for older people in the management of frailty. In Ireland, an interprofessional National Frailty Education Programme (NFEP) is delivered in partnership between the National Clinical Programme for Older People (NCPOP) and The Irish Longitudinal Study on Ageing (TILDA). On completion of the NFEP, Frailty Facilitators return to their regional/local frailty networks to deliver the programme to healthcare professionals across disciplines and settings. The aim of this study is to explore the impact of the National Frailty Education Programme on practice.

Methods

A qualitative exploratory approach was adopted to elicit the perspectives of Frailty Facilitators on the impact of the NFEP on practice. Purposive sampling was employed across frailty networks nationwide. Focus groups were conducted, and data were analysed using thematic analysis.

Results

Twenty-four participants from five frailty networks took part in five focus groups across Ulster, Leinster and Connaught. Frailty Facilitators collaborated to deliver education on frailty in their local networks following the NFEP. Management support particularly that provided by the Centres for Midwifery and Nurse Education was deemed a significant enabler of frailty education. Strong interprofessional alliances were developed that enhanced communication between primary and secondary care settings in the care of older people. The medical profession were noted to have low participation in the frailty networks. The results revealed widespread use of frailty instruments for assessment and a shared understanding and language on frailty.

Conclusion

The NFEP had a clear impact on Frailty Facilitator’s practice. Conceptualisation and reflection on frailty related practice was in evidence across the frailty networks thus enabling multidisciplinary teams to manage the care of an older person with frailty in an integrated way.

34 RELATIONSHIP BETWEEN SERUM CAROTENOID CONCENTRATIONS AND FRAILTY, PROBABLE SARCOPENIA, AND PHYSICAL FUNCTION IN THE IRISH LONGITUDINAL STUDY ON AGEING (TILDA)

Background

Lutein and zeaxanthin are antioxidant and anti-inflammatory carotenoids derived from foods such as fruit and vegetables. Serum concentrations of Lutein (Ls) and Zeaxanthin (Zs) reflect habitual dietary intake. This study examined the cross-sectional and longitudinal relationships between Ls and Zs and frailty, probable sarcopenia, and indices of physical function in TILDA.

Methods

The cross-sectional analysis included n=4672 community-dwelling adults aged ≥50 years with Ls and Zs at Wave 1 (2010). For the longitudinal analyses, changes in usual gait speed (at Wave 3, 2014), grip strength (Wave 4, 2016) and Timed Up-and-Go (TUG; Wave 5, 2018), incident probable sarcopenia (defined as grip strength <27 kg in men, <16 kg in women, at Wave 4) and incident frailty (Fried, at Wave 5) were determined. Multivariable linear and logistic regression analyses were adjusted for age, sex, waist circumference, education, malnutrition, smoking, chronic disease, alcohol intake and physical activity.

Results

Cross-sectionally, Ls and Zs were positively associated with gait speed (B [95% CI] per 100-nmol/L higher concentration: Ls 0.67 [0.22, 1.12], Zs 1.3 [0.21, 2.48] cm/s) and inversely associated with TUG time (Ls –0.07 [-0.11, –0.02], Zs –0.14 [-0.25, –0.03] s) and with frailty (OR: Ls 0.61 [0.42, 0.87], Zs 0.23 [0.08, 0.68]), all p <0.05), but not with grip strength or probable sarcopenia. Longitudinally, Ls was inversely associated incident frailty (OR 0.85 [0.04, 0.84], p=0.03), whereas Zs was not (0.83 [0.56, 1.23], p=0.36). Neither Ls or Zs were related to changes in physical function measures or incident probable sarcopenia (p>0.05).

Conclusion

Cross-sectionally, lower Ls and Zs were independently associated with frailty, slower gait speed and worse TUG performance. However, Wave 1 Ls and Zs were not predictive of changes in these outcomes over 4-8 years of follow up, with the exception of Ls which was inversely associated with incident frailty after 8 years.

67 TECHNOLOGY TO SUPPORT INDEPENDENT LIVING AT HOME: ONLINE SURVEY OF USER NEEDS AND REQUIREMENTS

Background

Technology can play a key role in supporting older adults to live independently at home. A User Needs and Requirements study including co-design workshops and an online survey was conducted to inform the development of a technological solution aimed at supporting older adults to remain living independently at home. The online survey component is reported here.

Methods

Eligibility criteria included that respondents were older adults living at home or caregiving stakeholders providing care to older adults at home e.g. family caregivers or health/social care professionals. Recruitment took place throughout Ireland through civil society organisations and age friendly networks in local councils. Quantitative and qualitative data were gathered from June to July 2020. Descriptive statistics were applied to quantitative data and inductive thematic analysis was performed on free text responses.

Results

In total, 380 respondents completed the survey (n= 235 older adults, n=77 family caregivers, n=47 healthcare professionals and n=21 home support workers). Older adults identified key issues where technology might support them to live independently, these included, home security (33% n=77), falls (30% n=69), reduced mobility (23% n=55) and loneliness (23% n=54). Thematic analysis highlighted key areas where technology could assist stakeholders in providing care for older adults living independently, these included, remote monitoring of family members (family caregivers), communication with clients (healthcare professionals) and falls (home support workers). Older adults reported that data privacy and the cost of technology were key concerns. All groups reported a high level of willingness to use technology such as ambient sensors, wearable devices and voice activated assistants to support independent living.

Conclusion

Results of this survey provide insights into user needs and requirements in combination with results from co-design workshops to inform the design, development and trial of a technology system to support independent living at home.

Association between tocilizumab treatment of hyperinflammatory patients with COVID-19 in a critical care setting and elevated incidence of hospital-acquired bacterial and invasive fungal infections

Background

Tocilizumab is an interleukin-6 inhibitor that reduces mortality and the need for invasive mechanical ventilation, while increasing the possibility of successful hospital discharge for hyperinflammatory patients with severe coronavirus disease 2019 (COVID-19). No increase in adverse events or serious infections has been reported previously.

Aim

To describe the characteristics and outcomes of patients with severe COVID-19 in critical care who received tocilizumab, and to compare mortality and length of hospital stay for patients who received tocilizumab (N=41) with those who did not (N=33).

Methods

Retrospective review of data related to patients with COVID-19 who received tocilizumab in a critical care setting from 1^st January to 31^st December 2021.

Findings

Amongst COVID-19 survivors, those who had received tocilizumab had longer intensive care unit (ICU) stays (median length 21 vs 9 days) and hospital stays (45 vs 34 days) compared with those who had not received tocilizumab. Thirty-day mortality (29% vs 36%; P=0.5196) and 60-day mortality (37% and 42%; P=0.6138) were not significantly lower in patients who received tocilizumab. Serious bacterial and fungal infections occurred at higher frequency amongst patients who received tocilizumab [odds ratio (OR) 2.67, 95% confidence interval (CI) 1.04–6.86; P=0.042], and at significantly higher frequency than in non-COVID-19 ICU admissions (OR 5.26, 95% CI 3.08–9.00; P<0.0001).

Conclusions

In this single-centre study, patients in critical care with severe COVID-19 who received tocilizumab had a greater number of serious bacterial and fungal infections, but this may not have been a direct effect of tocilizumab treatment.

802 CONCURRENT PATHOLOGIES OBSERVED IN OLDER ADULTS WITH COVID-19 INFECTION

Introduction

This study aimed to look at the effect of frailty and multi morbidity on short-term outcomes in patients diagnosed with COVID-19 in a hospital setting, looking specifically at the variety of concurrent pathologies diagnosed during their admission and how these affected the course of their illness and mortality.

Methods

The study took place at Glasgow Royal Infirmary. We retrospectively collected data from 280 patients who were admitted to the medicine for the elderly department between the 1st October and 1st December 2020 and diagnosed with COVID-19.

Results

In this cohort, 65% of older adults in hospital with COVID-19 had their admissions complicated by concurrent pathologies; most commonly delirium, acute kidney injury and pulmonary embolism, also increasing mortality in this group. It was also found that 39% of patients in this group had co-pathologies that were not necessarily associated with COVID-19 disease, for example AKI, AF and stroke/TIA. 35% of older adults in this group had no concurrent medical diagnoses during their admission, however this did not correlate with reduced mortality in this group.

Conclusion

The data highlights the vulnerability of older adults with COVID-19 infection making them more susceptible to concurrent disease and contributing to further morbidity and mortality. We also found a large number of patients had co-pathologies not associated with COVID-19 disease, highlighting the importance of considering other diagnoses in frail elderly patients.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

Precise Measurement of the D^{0} and D^{+} Lifetimes at Belle II

We report a measurement of the D^{0} and D^{+} lifetimes using D^{0}→K^{-}π^{+} and D^{+}→K^{-}π^{+}π^{+} decays reconstructed in e^{+}e^{-}→cc[over ¯] data recorded by the Belle II experiment at the SuperKEKB asymmetric-energy e^{+}e^{-} collider. The data, collected at center-of-mass energies at or near the ϒ(4S) resonance, correspond to an integrated luminosity of 72  fb^{-1}. The results, τ(D^{0})=410.5±1.1(stat)±0.8(syst)  fs and τ(D^{+})=1030.4±4.7(stat)±3.1(syst)  fs, are the most precise to date and are consistent with previous determinations.

18 SEDATIVE LOAD IN COMMUNITY-DWELLING OLDER ADULTS WITH MILD–MODERATE ALZHEIMER’S DISEASE: LONGITUDINAL RELATIONSHIPS WITH ADVERSE EVENTS, DELIRIUM AND FALLS

Background

Older adults are frequently prescribed medications with sedative effects, which are associated with numerous adverse consequences. However, the use and longitudinal associations of sedative medication use in older adults with mild–moderate Alzheimer Disease (AD), has not been explored to date.

Methods

The association between Sedative Load (SL) and adverse events, unscheduled healthcare utilisation, delirium and falls over 18 months was assessed in older adults with mild–moderate AD from 9 Countries. Additionally, the impact of SL on dementia progression was evaluated.

Results

Over half (52.35%; 267/510) of those with mild–moderate ad (72.8 ± 8.26 years, 61.89%) were prescribed a regular medication with sedation as a primary effect or prominent side effect with 17.65% (90/510) having a high SL (≥3). The most common medications contributing to SL were antidepressants, antipsychotics, anxiolytics and hypnotics. Over 18 months, greater SL was associated with adverse events (IRR 1.18, 1.14–1.23, p &lt; 0.001)/serious adverse events (IRR 1.32, 1.18–1.49, p &lt; 0.001) and unscheduled GP visits (IRR 1.26, 1.15–1.38, p &lt; 0.001). Further, increasing SL was associated with greater likelihood of incident delirium (IRR 1.47, 1.25–1.73, p &lt; 0.001) and falls (IRR 1.25, 1.06–1.48, p = 0.007) which persisted after covariate adjustment. SL was not associated with accelerated cognitive decline or ad progression.

Conclusion

Most adults with mild–moderate ad are prescribed at least one drug with a sedative effect and a significant minority have a high SL. Increasing SL was associated with a greater likelihood of experiencing adverse events, delirium and falls, highlighting the need for optimal prescribing in this vulnerable cohort.

47 DOSING OF DIRECT ORAL ANTICOAGULANTS IN OLDER ADULTS

Background

Direct oral anticoagulants (DOACs) are approved for a variety of uses including prevention of stroke in non-valvular atrial fibrillation and treatment and prevention of deep vein thrombosis and pulmonary embolism. Adjustment to DOAC dosing may be required for age, weight and renal impairment. Incorrect lower dosing puts patients at risk of thromboembolic events whereas inappropriate higher dosing increases the risk of bleeding. We compared current DOAC dosing for patients admitted to our hospital and compare this against HSE best practice to determine if patients were receiving the correct dose [1].

Methods

A prospective single-centre study. Patients admitted to our hospital following a fracture and reviewed by the Orthogeriatric team between August–October 2020 were eligible for inclusion. We recorded admission DOAC dose, age, weight and renal function. We also obtained data including sex and Clinical Frailty Scale (CFS).

Results

Thirty-one patients were included. Mean age was 86 years [range 66–99] and 21(68%) were female. Apixaban was the most commonly used DOAC; 25(81%). Stroke prevention in non-valvular atrial fibrillation was the most common DOAC indication; 29(93%). Twelve patients (39%) had an inappropriate DOAC dose prescribed. Eight patients (67%) had an inappropriately low dose and 4 patients (33%) had an inappropriately high dose. The mean CFS was 5 [Range 2–7] classifying our cohort as mildly frail.

Conclusion

Our study has shown that over one-third of our patients were on an inappropriate DOAC dose on admission with the majority (67%) due to under-dosing. Many factors may have influenced dosing choices by clinicians but our findings highlight the challenges in dosing, monitoring and the overall management of DOAC therapy in older people. Further studies and research are required to establish the most accurate and effective dosing strategies for DOACs in older adults.

Reference

1. Health Service Executive [Internet]. Ireland ‘Anticoagulation Prescribing Tips’ https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/noac-prescribing-tips-for-noacs.pdf.

Safety of elective paediatric surgery during the coronavirus disease 2019 pandemic

INTRODUCTION

Corona-virus Disease 2019 (COVID-19) has had a huge impact on the delivery of healthcare worldwide, particularly elective surgery. There is a lack of data regarding risk of postoperative COVID-19 infection in children undergoing elective surgery, and regarding the utility of pre-operative COVID-19 testing, and preoperative "cocooning" or restriction of movements. The purpose of this present study was to examine the safety of elective paediatric Otolaryngology surgery during the COVID-19 pandemic with respect to incidence of postoperative symptomatic COVID-19 infection or major respiratory complications.

MATERIALS AND METHODS

Prospective cohort study of paediatric patients undergoing elective Otolaryngology surgery between September and December 2020. Primary outcome measure was incidence of symptomatic COVID-19 or major respiratory complications within the 14 days after surgery. Parents of prospectively enrolled patients were contacted 14 days after surgery and enquiry made regarding development of postoperative symptoms, COVID-19 testing, or diagnosis of COVID-19.

RESULTS

302 patients were recruited. 125 (41.4%) underwent preoperative COVID-19 RT-PCR testing. 66 (21.8%) restricted movements prior to surgery. The peak 14-day COVID-19 incidence during the study was 302.9 cases per 100,000 population. No COVID-19 infections or major respiratory complications were reported in the 14 day follow-up period.

CONCLUSION

The results of our study support the safety of elective paediatric Otolaryngology surgery during the pandemic, in the setting of community incidence not exceeding that observed during the study period.

Search for B^{+}→K^{+}νν[over ¯] Decays Using an Inclusive Tagging Method at Belle II

A search for the flavor-changing neutral-current decay B^{+}→K^{+}νν[over ¯] is performed at the Belle II experiment at the SuperKEKB asymmetric energy electron-positron collider. The data sample corresponds to an integrated luminosity of 63  fb^{-1} collected at the ϒ(4S) resonance and a sample of 9  fb^{-1} collected at an energy 60 MeV below the resonance. Because the measurable decay signature involves only a single charged kaon, a novel measurement approach is used that exploits not only the properties of the B^{+}→K^{+}νν[over ¯] decay, but also the inclusive properties of the other B meson in the ϒ(4S)→BB[over ¯] event, to suppress the background from other B meson decays and light-quark pair production. This inclusive tagging approach offers a higher signal efficiency compared to previous searches. No significant signal is observed. An upper limit on the branching fraction of B^{+}→K^{+}νν[over ¯] of 4.1×10^{-5} is set at the 90% confidence level.

The effect of lockdown during SARS-CoV-2 pandemic on maxillofacial injuries in a level I trauma centre: a comparative study

INTRODUCTION

The SARS-CoV-2 pandemic forced many governments to impose nation-wide lockdowns. Government legislation forced limited travel on the population with restrictions on the normal way of life to limit spread of the SARS-CoV-2 virus. The aim of this study is to explore the effects of lockdown on the presentation of maxillofacial trauma in a level I trauma centre.

METHODS

Comparative analysis was carried out using prospective and retrospective review of all consecutive patients admitted with any maxillofacial fracture in the lockdown period between 15th March and 15th June 2020 with the same period in 2019 to a Regional Trauma Maxillofacial Surgery Unit. Data included basic demographics and mechanism of injury including alcohol/drug influence, polytrauma, site of injury and treatment modality including escalation of care.

RESULTS

Across both periods, there were a total of one hundred and five (n = 105) recorded episodes of traumatic fractures with fifty-three (n = 53) in the pre-lockdown cohort and fifty-two (n = 52) in the lockdown. Included patients were significantly (p = 0.024) older during lockdown (mean age 41.44 years SD 20.70, range 5-96) with no differences in gender distribution between cohorts (p = 0.270). Patients in lockdown were more likely to be involved in polytrauma (p < 0.05) and have sustained their injury by cycling/running or any outdoor related activity (p = 0.013). Lockdown saw a significant reduction in alcohol and drug related violence (p < 0.05). Significantly more patients required operative management (p = 0.038).

CONCLUSION

Local lockdowns form part of the governments public health strategy for managing future outbreaks of SARS-CoV-2. Our study showed no significant reduction in volume of trauma during lockdown. It is vital that hospitals maintain trauma capacity to ensure that patients are treated in a timely manner.

Upscaling e-mental health in Europe: a six-country qualitative analysis and policy recommendations from the eMEN project

E-mental health (eMH) encompasses the use of digital technologies to deliver, support, or enhance mental health services. Despite the growing evidence for the effectiveness of eMH interventions, the process of implementation of eMH solutions in healthcare remains slow throughout Europe. To address this issue, the e-Mental Health Innovation and Transnational Implementation Platform North-West Europe (eMEN) project was initiated to increase the dissemination and quality of eMH services in Europe. In this project, status analyses regarding eMH in the six participating countries (i.e., Belgium, France, Germany, Ireland, The Netherlands, and the UK) were conducted and eight recommendations for eMH were developed. Expert teams from the six participating countries conducted status analyses regarding the uptake of eMH based on a narrative literature review and stakeholder interviews. Based on these status analyses, the eMEN consortium developed eight policy recommendations to further support the implementation of eMH in Europe. The status analyses showed that the participating countries are in different stages of implementing eMH into mental healthcare. Some barriers to implementing eMH were common among countries (e.g., a limited legal and regulatory framework), while others were country-specific (e.g., fragmented, federal policies). The policy recommendations included fostering awareness, creating strong political commitment, and setting reliable standards related to ethics and data security. The eMEN project has provided the initial recommendations to guide political and regulatory processes regarding eMH. Further research is needed to establish well-tailored implementation strategies and to assess the generalizability of the recommendations beyond the countries involved in the eMEN project.

Outcomes of preoperative real-time polymerase chain reaction testing for SARS CoV-2 in elective otolaryngology surgical patients during the pandemic: a prospective cohort study

Real-time polymerase chain reaction (RT-PCR) is used to rule out SARS-CoV-2 prior to surgery, however few studies have evaluated patients with negative testing after surgery. Some 499 patients with negative tests were followed for 14 days after surgery, 39 were retested but none developed positive RT-PCR after operation. The risk of developing a positive RT-PCR after surgery was 0.74 per cent.

The complex multi-sectoral impacts of drought: Evidence from a mountainous basin in the Central Spanish Pyrenees

We analyzed the impacts of drought severity on a variety of sectors in a topographically complex basin (the upper Aragón basin 2181 km²) in the Central Spanish Pyrenees. Using diverse data sources including meteorological and hydrological observations, remote sensing and tree rings, we analyze the possible hydrological implications of drought occurrence and severity on water availability in various sectors, including downstream impacts on irrigation water supply for crop production. Results suggest varying responses in forest activity, secondary growth, plant phenology, and crop yield to drought impacts. Specifically, meteorological droughts have distinct impacts downstream, mainly due to water partitioning between streamflow and irrigation channels that transport water to crop producing areas. This implies that drought severity can extend beyond the physical boundaries of the basin, with impacts on crop productivity. This complex response to drought impacts makes it difficult to develop objective basin-scale operational definitions for monitoring drought severity. Moreover, given the high spatial variability in responses to drought across sectors, it is difficult to establish reliable drought thresholds from indices that are relevant across all socio-economic sectors. The anthropogenic impacts (e.g. water regulation projects, ecosystem services, land cover and land use changes) pose further challenges to assessing the response of different systems to drought severity. This study stresses the need to consider the seasonality of drought impacts and appropriate drought time scales to adequately assess and understand their complexity.

Langmuir probe array for the small angle slot divertor in DIII-D

The DIII-D small angle slot (SAS) divertor is designed for divertor physics studies with enhanced neutral confinement and special target geometries in a closed divertor. The closed nature of the SAS makes optical diagnostic measurements difficult, so a specially designed, multipurpose array of Langmuir probes has been implemented to study the plasma conditions in and around the slot. The probes are spaced to provide at least 2 mm resolution (shorter than the energy decay length) of the near scrape-off layer when mapped to the outer mid-plane. Due to space limitations at the bottom of the slot, a novel spring-loaded probe and tile design was developed to clamp several short rooftop probe tips and insulators to the cooled baseplate. Initial probe measurements revealed tile to tile edge shadowing, especially where magnetic field line surface angles were less than 1°. Additionally, it was found, using three Langmuir probes (at 90°, 180°, and 270°), that the strike point variation of ±5 mm radially around the torus was not well aligned with the circular slot geometry [Watkins et al., Nucl. Mater. Energy 18, 46 (2019)]. These issues were resolved by (1) designing tiles with all probes mounted near the tile center instead of near the edges and (2) aligning these new custom tiles to the measured strike point toroidal surface with a very accurate laser scanning alignment tool. Post-alignment Langmuir probe measurements and plasma behavior demonstrated close agreement at two separate toroidal locations that were 45° apart.

Food addiction in a large non-clinical sample of Canadians

Introduction

The concept of food addiction emerged recently due to the similarities between food overconsumption patterns and addictive drugs. This concept is not yet included into ICD or DSM as it still needs to be further investigated. Relationship between obesity and food consumption as well as the psychological indicators of food addiction are of particular interest.

Objectives

To examine the prevalence of food addiction and its relationship to obesity, quality of life and multiple indicators of impulsivity.

Methods

Cross-sectional in-person assessment of 1432 community adults (age 38.93+/-13.7; 58% female). Measurements: Yale Food Addiction Scale 2.0, anthropometrics, body composition, World Health Organization Quality of Life scale, and impulsivity measures including impulsive personality traits, delay discounting, and behavioral inhibition.

Results

The prevalence of food addiction was 9.3% and substantially below that of obesity (32.7%). Food addiction was more prevalent among obese individuals and also was associated with higher BMI among non-obese participants. It was associated with significantly lower quality of life in all domains, and significantly higher impulsive personality traits, particularly negative and positive urgency.

Conclusions

In this general community sample, food addiction was present in slightly fewer than 1 in 10 individuals, approximately one-third the prevalence of obesity, but notably the food addiction has been mostly represented within the subsample of obese individuals. Food addiction was robustly associated with substantively lower quality of life and elevations in impulsivity, particularly in deficits in emotional regulation. These data suggest food addiction may be thought of as a subtype of obesity and, in non-obese individuals, possibly a prodrome.

Disclosure

No significant relationships.

A comparison of machine learning models for predicting rehospitalisation and death after a first hospitalisation with heart failure

Background

Many machine learning models exist, including Multilayer Perceptron (MLP), Random Forest algorithm (RF), Support Vector Machine (SVM), and Gradient Boosted Machine (GBM), but their value for predicting outcome in patients with heart failure has not been compared.

Aim

To predict rehospitalisation (all-cause) and death (all-cause) at 1-, 3- and 12 months after discharge from a first hospitalisation for heart failure using four machine learning models.

Methods

The National Health Service Greater Glasgow and Clyde Health Board serves a population of ∼1.1 million. We obtained de-identified administrative data, including investigations, diagnosis and prescriptions, linked to hospital admissions and deaths for anyone with a diagnosis of vascular disease or heart failure or prescribed loop diuretics, statins or neuro-endocrine antagonists at any time between 1st January 2010 and 1st June 2018. Patients who were under 18 or had no prior hospitalisation for heart failure were excluded. Four ML algorithms using 46 variables were applied.

Results

Of 360,000 people who met the above criteria between 2010–2018, 6,372 had a hospitalisation for heart failure prior to 1st January 2010 and 8,304 had a first hospitalisation for heart failure thereafter. Between 2010 and 2018 there were 3,086 re-hospitalisations over 24 hours and 3,706 patients died, with 5,070 patients experiencing the composite outcome.

GBM and RF consistently outperformed MLP and SVM when comparing AUC, sensitivity and specificity combined, with GBM performing best in all scenarios. Since GBM and RF are both tree-based models, and with SVM and MLP regularly reporting very poor sensitivity or specificity despite a similar AUC to the others, this suggests that SVM and MLP may be suffering from overfitting and might perform better in larger data-sets.

Both GBM and RF work by ordering variables, so the final model can be used to determine the most important prediction variables. Age, number of times a blood sample was taken out of hospital, length of stay, social deprivation index and haemoglobin concentration consistently ranked amongst the most important variables. Models predicted all 1-month events better than later events.

Conclusions

Some, but not all, ML models applied to this data-set predicted rehospitalisation and death with great accuracy for up to 3 months after a first hospitalisation for heart failure. The models identified several important prognostic variables that are currently seldom collected in clinical research registries but perhaps should be.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Medical Research Council

Abnormalities of the lymphatic system and impaired fluid clearance in patients with heart failure with preserved ejection fraction

Background

Coronary and skeletal muscle microvascular dysfunction have been proposed as main factors in the pathogenesis of Heart Failure with Preserved Ejection Fraction (HFpEF). However, assessment of systemic arterial function has only been indirect thus far; most importantly, no direct link between systemic microvasculature and congestion, one of the core characteristics of the syndrome, has yet been investigated.

Purpose

To provide direct functional and anatomical characterisation of the systemic microvasculature and to explore in vivo parameters of capillary fluid extravasation and lymphatic clearance in HFpEF.

Methods

In 16 patients with HFpEF and 16 age- and sex-matched healthy controls (72±6 and 68±5 years, respectively) we determined peripheral microvascular filtration coefficient (proportional to vascular permeability and area) and isovolumetric pressure (above which lymphatic drainage cannot compensate for fluid extravasation) by venous occlusion plethysmography and collected a skin biopsy for vascular immunohistochemistry and gene expression analysis (TaqMan). Additionally, we measured brachial flow-mediated dilatation (FMD) and assessed by wire myography the vascular function of resistance arteries isolated from gluteal subcutaneous fat biopsies.

Results

Skin biopsies in patients with HFpEF showed rarefaction of small blood vessels (82±31 vs 112±21 vessels/mm2; p=0.003) and in ex-vivo analysis (n=6/group) we found defective relaxation of peripheral resistance arteries (p&lt;0.001). Accordingly, post-ischaemic hyperaemic response (fold-change vs baseline, 4.6±1.6 vs 6.7±1.7; p=0.002) and FMD (3.9±2.1 vs 5.6±1.5%; p=0.014) were found to be reduced in patients with HFpEF compared to controls.

In the skin of patients with HFpEF we also observed a reduced number (85±27 vs 130±60 vessels/mm2; p=0.012) but larger average diameter of lymphatic vessels (42±19 vs 26±9 μm2; p=0.007) compared to control subjects. These changes were paralleled by reduced expression of LYVE1 (p&lt;0.05) and PROX1 (p&lt;0.001), key determinants of lymphatic differentiation and function.

Whilst patients with HFpEF had reduced peripheral capillary fluid extravasation compared to controls (microvascular filtration coefficient, leg 33.1±13.3 vs 48.4±15.2, p&lt;0.01; trend for arm 49.9±20.5 vs 66.3±30.1, p=0.09), they had lower lymphatic clearance (isovolumetric pressure: leg 22±4 vs 16±4 mmHg, p&lt;0.005; arm 25±5 vs 17±4 mmHg, p&lt;0.001).

Conclusions

We provide direct evidence of systemic dysfunction and rarefaction of small blood vessels in patients with HFpEF. Despite a reduced microvascular filtration coefficient, which is in keeping with microvascular rarefaction, the clearance of extravasated fluid in HFpEF is limited by an anatomically and functionally defective lymphatic system.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation Centre of Research Excellence Award

Improvements in Clinical Outcomes in Children with Cystic Fibrosis aged Six and 16 years

Aims Our aim was to assess if outcomes for cystic fibrosis (CF) patients at six & sixteen years of age have improved in the last 17 years looking at FEV1, BMI and death. Methods A retrospective observational study using a prospectively maintained database of CF patients at Cork University Hospital. Results 84 patients were included in the 16-year-old data and 89 patients were included in the six-year-old data. The mean FEV1 and BMI (16 years) for the 2002-2007 group was 72.9±21.0% and 18.9±2.53 respectively, 2008-2013 group was 75.4±27.2% and 19.8±2.7 and for the 2014-2018 group was 95.2±16.0% and 22.9±4.1. The percentage of patients (16 years) with chronic pseudomonas status was 37.9% (11/30) in the 2002-2007 group, 51.6 % (16/31) in the 2008-2013 group and 4.2% (1/24) in the 2014-2018 group. The relationship between FEV1 and FVC with BMI remained significant in multivariate analysis (P <0.001). The mean FEV1 (six years) for the 2002-2007 group was 90.7±16.1%, 2008-2013 group was 99.3±17.9% and for the 2014-2018 group was 100.9±15.8%. Conclusions Improvements in FEV1 and BMI aged six and 16 years are notable as well as a significant decline in the number of patients with chronic pseudomonas.

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.

An interdisciplinary and catchment approach to enhancing urban flood resilience: a Melbourne case

This paper presents a novel interdisciplinary and catchment-based approach for exploring urban flood resilience. Our research identified and developed a diverse set of adaptation measures for Elwood, a suburb in Melbourne, Australia, that is vulnerable to pluvial and coastal flooding. We drew on methods from social science, urban design and environmental engineering to gain integrated insights into the opportunities for Elwood to increase its flood resilience and urban liveability. Results showed that an appropriate balance of social, infrastructural and urban design responses would be required to retreat from, accommodate and protect against flood risk. These would also deliver broader benefits such as securing water supplies through harvested stormwater and mitigating extreme heat through greener landscapes. Our interdisciplinary approach demonstrated the value of (i) engaging with the community to understand their concerns, aspirations and adaptation ideas, (ii) exploring design measures that densify and use urban forms in ways that implement adaptation measures while responding to local context, (iii) adopting modelling techniques to test the performance, robustness and economic viability of possible adaptation solutions, and (iv) innovating governance arrangements and principles needed to improve flood resilience in the Elster Creek catchment. Our research also provided valuable insight on how to operationalize interdisciplinary work in practice, highlighting the importance of sharing an impact agenda, taking a place-based approach, developing a common conceptual framework, and fostering a constructive team culture. This article is part of the theme issue 'Urban flood resilience'.

A behaviour change package to prevent hand dermatitis in nurses working in the National Health Service: results of a cluster randomized controlled trial

BACKGROUND

Occupational hand dermatitis poses a serious risk for nurses.

OBJECTIVES

To evaluate the clinical and cost-effectiveness of a complex intervention in reducing the prevalence of hand dermatitis in nurses METHODS: This was a cluster randomized controlled trial conducted at 35 hospital trusts, health boards or universities in the UK. Participants were (i) first-year student nurses with a history of atopic conditions or (ii) intensive care unit (ICU) nurses. Participants at intervention sites received access to a behavioural change programme plus moisturizing creams. Participants at control sites received usual care. The primary outcome was the change of prevalent dermatitis at follow-up (adjusted for baseline dermatitis) in the intervention vs. the control group. Randomization was blinded to everyone bar the trials unit to ensure allocation concealment. The trial was registered on the ISRCTN registry: ISRCTN53303171.

RESULTS

Fourteen sites were allocated to the intervention arm and 21 to the control arm. In total 2040 (69·5%) nurses consented to participate and were included in the intention-to-treat analysis. The baseline questionnaire was completed by 1727 (84·7%) participants. Overall, 789 (91·6%) ICU nurses and 938 (84·0%) student nurses returned completed questionnaires. Of these, 994 (57·6%) had photographs taken at baseline and follow-up (12-15 months). When adjusted for baseline prevalence of dermatitis and follow-up interval, the odds ratios (95% confidence intervals) for hand dermatitis at follow-up in the intervention group relative to the controls were 0·72 (0·33-1·55) and 0·62 (0·35-1·10) for student and ICU nurses, respectively. No harms were reported.

CONCLUSIONS

There was insufficient evidence to conclude whether our intervention was effective in reducing hand dermatitis in our populations. Linked Comment: Brans. Br J Dermatol 2020; 183:411-412.

98 The Utility of Informant History in Delineating Narratives of Gait Disorder in Older Outpatients

Background

A scholarly focus on informant history is recent in geriatric medicine, mostly focused on cognition and syncope.1 Gait disorders are common in older people and accurate diagnosis facilitates treatment.2

As there is a disparity between self-rated and ‘objective’ estimates of health among older people, and gait disorders often co-exist with cognitive impairment, there may be a significant difference between patient and informant narratives of gait disorder. We investigated the existence and extent of this disparity.

Methods

As no suitable informant measure could be sourced from the biomedical literature, inquiry with senior academic physiotherapists or through appeals on social media relating to physiotherapy, a mobility scale was designed. We included all patients with a gait disorder at serial outpatient clinics. Exclusion criteria were absence of gait disorder and dementia of sufficient severity to be unable to participate in the consent process. Paired t tests and Fischer exact test were used to analyse the data.

Results

Of 45 participants (mean age 79.8; 50% men), 35 (77.7%) had MCI or dementia. Twenty two (47.8%) informants considered an acute event precipitated an acute deterioration in mobility. Twenty seven informants (60%) had a fear of the older person falling compared to 9 (20%) of patients (p=0.0002).

Patient and informant impression of point on mobility scale differed (t=3.61, p=0.0003). Although Informants reported more falls (mean of 1.36 vs 0.91) in the previous year (t=1.63, p=0.055) this did not achieve statistical significance.

Conclusions

Our findings demonstrate a discrepancy between patient and informant narratives of level of mobility, and point to the benefit of obtaining an informant history of loss of gait stability, mobility and falls. In addition, perceptions of fear of falling may be of assistance in managing risk and independence.

References

1. Briggs R, O'Neill D. QJM 2016; 109: 301–2.

2. Briggs R, O'Neill D. Clin Med 2014; 14: 200–2.