Pace of Aging in older adults matters for healthspan and lifespan

As societies age, policy makers need tools to understand how demographic aging will affect population health and to develop programs to increase healthspan. The current metrics used for policy analysis do not distinguish differences caused by early-life factors, such as prenatal care and nutrition, from those caused by ongoing changes in people's bodies due to aging. Here we introduce an adapted Pace of Aging method designed to quantify differences between individuals and populations in the speed of aging-related health declines. The adapted Pace of Aging method, implemented in data from N=13,626 older adults in the US Health and Retirement Study, integrates longitudinal data on blood biomarkers, physical measurements, and functional tests. It reveals stark differences in rates of aging between population subgroups and demonstrates strong and consistent prospective associations with incident morbidity, disability, and mortality. Pace of Aging can advance the population science of healthy longevity.

Exploring the potential of virtual reality for the self-management of chronic pain: A scoping review of its use to address health literacy

BACKGROUND

Individuals with low health literacy struggle to manage long-term conditions. Addressing pain-related health competencies is important in the management of chronic pain. Virtual reality may be a useful tool for empowering sustainable health-related stratgies due to its unique ability to engage users in artificial environments.

OBJECTIVES

The aim of this scoping review was to explore existing research on the use of virtual reality as a tool to promote health literacy in people with chronic pain.

DESIGN

Scoping Review guided by framework proposed by Arksey & O'Malley.

METHOD

Articles related to "pain", "virtual reality" and "health literacy" were searched in four electronic databases: CINAHL, PubMed, Embase and PsycINFO using a formal search strategy. Studies were categorised based on intervention content using the Health Literacy Pathway Model which encompasses health knowledge, self-management skills, health communication and information seeking.

RESULTS

Thirteen studies met the inclusion criteria. Several elements of pain related health literacy were not addressed in the research. Interventions addressed health knowledge, self-management skills, decision making and featured content aiming to address emotional barriers to pain-related health literacy. Other components including active information seeking and use, actively communicating with health professionals and seeking and negotiating treatment options, were not explicitly addressed.

CONCLUSION

There is heterogeneity in existing research exploring the use of VR to support people with chronic pain. Existing VR tools to address pain-related health literacy do not cover several key components of health literacy. More research is required before a robust assessment of efficacy can be undertaken.

Psychotropic medicines' prevalence, patterns and effects on cognitive and physical function in older adults with intellectual disability in Ireland: longitudinal cohort study, 2009-2020

BACKGROUND

The frequent prescribing of psychotropics and high prevalence of polypharmacy among older adults with intellectual disabilities require close monitoring.

AIMS

To describe change in prevalence, predictors and health outcomes of psychotropic use during the four waves (2009/2010, 2013/2014, 2016/2017, 2019/2020) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA).

METHOD

Eligible participants were adults (≥40 years) with intellectual disabilities who participated in all four waves of IDS-TILDA and who reported medication use for the entire period. Differences between groups were tested using Cochran's Q test for binary variables and the McNemar-Bowker test for variables with more than two categories. Generalised estimating equation models were used to assess associations between psychotropic use, participants' characteristics and health outcomes.

RESULTS

Across waves (433 participants) there were no significant differences in prevalence of psychotropic use (61.2-64.2%) and psychotropic polypharmacy (42.7-38.3%). Antipsychotics were the most used subgroup, without significant change in prevalence between waves (47.6-44.6%). A significant decrease was observed for anxiolytics (26.8-17.6%; P < 0.001) and hypnotics/sedatives (14.1-9.0%; P < 0.05). A significant increase was recorded for antidepressants (28.6-35.8%; P < 0.001) and mood-stabilising agents (11.5-14.6%; P < 0.05). Psychotropic polypharmacy (≥2 psychotropics) was significantly associated with moderate to total dependence in performing activities of daily living over the 10-year period (OR = 1.80, 95% CI 1.21-2.69; P < 0.05).

CONCLUSIONS

The study indicates an increase in usage of some classes of psychotropic, a reduction in others and no change in the relatively high rate of antipsychotic use over 10 years in a cohort of older adults with intellectual disabilities and consequent risk of psychotropic polypharmacy and medication-related harm.

The impact of age on vitamin D receptor expression, vitamin D metabolism and cytokine production in ex vivo Rhodococcus equi infection of equine alveolar macrophages

Rhodococcus equi (R. equi), a pneumonia-causing intracellular bacterium, results in significant morbidity and mortality in young foals, while healthy adult horses rarely develop disease. Survival and replication within alveolar macrophages (AMφ) are the hallmarks of R. equi's pathogenicity. The vitamin D receptor (VDR) and its ligand, the active vitamin D metabolite 1,25(OH)2D, are important in immune responses to intracellular bacteria. The vitamin D/VDR pathway regulates the downstream production of cytokines in infected human AMφ. The immunomodulatory role of the vitamin D/VDR pathway in equine leukocytes is unknown. The objective of the current study was to determine the impact of R. equi infection and age on synthesis of 1,25(OH)2D, VDR expression, and cytokine production in an ex vivo model of R. equi infection in equine AMφ. AMφ were collected from ten healthy foals at 2-, 4- and 8-weeks old and from nine healthy adult horses once via bronchoalveolar lavage. AMφ were mock infected (CONTROL) or infected with a virulent laboratory strain of R. equi for 7 days (INFECTED). VDR expression was determined via RT-qPCR from cell lysates. 1,25(OH)2D and cytokines were measured in cell supernatant by immunoassays. VDR expression was impacted by age (P = 0.001) with higher expression in AMφ from 8-week-old foals than from 2-week-old foals and adults. There was no significant effect of infection in foal AMφ, but in adults, relative VDR expression was significantly lower in INFECTED AMφ compared to CONTROL AMφ (P = 0.002). There was no effect of age or infection on 1,25(OH)2D concentration (P > 0.37). Mean TNFα production was significantly higher from INFECTED compared to CONTROL AMφ from 4- and 8-week-old foals and adults (P < 0.005). Mean IFNγ production was significantly higher from AMφ from foals at 8-weeks-old compared to 2-weeks-old (P = 0.013) and higher from INFECTED AMφ than from CONTROL AMφ in foals at 4-weeks-old and in adults (P < 0.027). The proportion of samples producing IL-1β and IL-10 was also significantly higher from INFECTED compared to CONTROL AMφ isolated from 4-week-old foals (P < 0.008). Similarly, in adult samples, IL-17 was produced from a greater proportion of INFECTED compared to CONTROL samples (P = 0.031). These data document age-associated changes in VDR expression and cytokine production in equine AMφ in response to R. equi infection. This preliminary investigation supports the need for further research to fully elucidate if the vitamin D pathway has an immunomodulatory role in the horse.

Does Arterial Stiffness Predict Cardiovascular Disease in Older Adults With an Intellectual Disability?

BACKGROUND

Arterial stiffness has been associated with an increased risk of cardiovascular disease (CVD) in some patient populations.

OBJECTIVES

The aims of this study were to investigate (1) whether there is an association between arterial stiffness, as measured by the Mobil-O-Graph, and risk for CVD in a population of individuals with intellectual disability and (2) whether arterial stiffness can predict the risk for CVD.

METHODS

This cross-sectional study included 58 individuals who participated in wave 4 of the Intellectual Disability Supplement to the Irish Longitudinal Study on Aging (2019-2020). Statistical models were used to address the first aim, whereas machine learning models were used to improve the accuracy of risk predictions in the second aim.

RESULTS

Sample characteristics were mean (SD) age of 60.69 (10.48) years, women (62.1%), mild/moderate level of intellectual disability (91.4%), living in community group homes (53.4%), overweight/obese (84.5%), high cholesterol (46.6%), alcohol consumption (48.3%), hypertension (25.9%), diabetes (17.24%), and smokers (3.4%). Mean (SD) pulse wave velocity (arterial stiffness measured by Mobil-O-Graph) was 8.776 (1.6) m/s. Cardiovascular disease risk categories, calculated using SCORE2, were low-to-moderate risk (44.8%), high risk (46.6%), and very high risk (8.6%). Using proportional odds logistic regression, significant associations were found between arterial stiffness, diabetes diagnosis, and CVD risk SCORE2 (P < .001). We also found the Mobil-O-Graph can predict risk of CVD, with prediction accuracy of the proportional odds logistic regression model approximately 60.12% (SE, 3.2%). Machine learning models, k-nearest neighbor, and random forest improved model predictions over and above proportional odds logistic regression at 75.85% and 77.7%, respectively.

CONCLUSIONS

Arterial stiffness, as measured by the noninvasive Mobil-O-Graph, can be used to predict risk of CVD in individuals with intellectual disabilities.

Early detection of subclinical mastitis in lactating dairy cows using cow-level features

Subclinical mastitis in cows affects their health, well-being, longevity, and performance, leading to reduced productivity and profit. Early prediction of subclinical mastitis can enable dairy farmers to perform interventions to mitigate its effect. The present study investigated how well predictive models built using machine learning techniques can detect subclinical mastitis up to 7 d before its occurrence. The data set used consisted of 1,346,207 milk-day (i.e., a day when milk was collected on both morning and evening) records spanning 9 yr from 2,389 cows producing on 7 Irish research farms. Individual cow composite milk yield and maximum milk flow were available twice daily, whereas milk composition (i.e., fat, lactose, protein) and somatic cell count (SCC) were collected once per week. Other features describing parity, calving dates, predicted transmitting ability for SCC, body weight, and history of subclinical mastitis were also available. The results of the study showed that a gradient boosting machine model trained to predict the onset of subclinical mastitis 7 d before a subclinical case occurs achieved a sensitivity and specificity of 69.45 and 95.64%, respectively. Reduced data collection frequency, where milk composition and SCC were recorded only every 15, 30, 45, and 60 d was simulated by masking data, to reflect the frequency of recording of this data on commercial dairy farms in Ireland. The sensitivity and specificity scores reduced as recording frequency reduced with respective scores of 66.93 and 80.43% when milk composition and SCC were recorded just every 60 d. Results demonstrate that models built on data that could be recorded routinely available on commercial dairy farms, can achieve useful predictive ability of subclinical mastitis even with reduced frequency of milk composition and SCC recording.

P17 National antimicrobial point prevalence survey in adult inpatient mental health facilities in Ireland

Background

Antimicrobial use in mental health inpatient settings has not been extensively examined in Ireland. The Healthcare-Associated Infection and Antimicrobial Use in Long-Term Care Facilities (HALT) study 2016 found that Irish long-term care facilities caring for residents with psychiatric conditions had an antimicrobial prevalence rate of 7.7%, higher than the European average of 4.9%. National community antimicrobial prescribing guidelines are available at www.antibioticprescribing.ie. In addition, a preferred antibiotic initiative for community settings advocates prescribers to choose ‘Green’ (preferred) antibiotics over ‘Red’ (reserved) agents. Reserved agents are considered to have more adverse effects, drug interactions and potential for development of antimicrobial resistance. The patient safety implications of antimicrobial stewardship along with an ageing population, and potential drug–drug interactions between many antimicrobials and psychotropic medications prompted a review of antimicrobial use practices in mental health services.

Methods

A sample of adult inpatient mental health facilities (MHF) operated by the state's Health Service Executive (HSE) were surveyed by community antimicrobial pharmacists (AMPs) between November 2021 and January 2022. AMPs reviewed patients’ medication charts for systemic antimicrobial prescriptions in the previous 30 days in addition to medical notes and laboratory results (where available). Adherence to HSE National community antimicrobial guidelines and the systems and structures in place to support antimicrobial stewardship were assessed.

Results

In total, 1003 patients in 51 MHFs were surveyed. At the time of survey, 6.3% (n=66) patients were on a systemic antimicrobial and 15% (n=153) had received a systemic antimicrobial within the previous 30 days. Prophylaxis accounted for 50% of antibiotic use (3.3% of all patients), with the most common indication being the prevention of urinary tract infection (UTI) (58%). Prophylaxis duration exceeded six months in 61% of prescriptions. The median duration of treatment courses was seven days. The proportion of ‘Green’ (preferred) antimicrobials versus ‘Red’ (reserved) antimicrobials was 58% versus 38%. Co-amoxiclav, a ‘Red’ agent was the most commonly prescribed antibiotic for treatment of infection (31%). Adherence with choice of antimicrobial agent as per national antimicrobial guidelines was 76%; adherence of dosing regimen was 75% and adherence with recommended duration was 46%. The main themes for non-adherence with choice of agent were use of unnecessarily broad spectrum agents, nitrofurantoin prescribed in renal impairment and inappropriate formulation of nitrofurantoin chosen. Dipstick urinalysis was performed routinely (on admission and/or at designated intervals) for persons asymptomatic of UTI in 53% (n=27) of MHFs.

Conclusions

This PPS established antimicrobial use practices in HSE MHFs and identified opportunities for improvement relating to the safe and optimal use of antimicrobials. Key national recommendations from this survey were:

O02 Improving antimicrobial use in HSE older persons residential care facilities

Background

Antimicrobial use in Irish older persons residential care facilities (OP RCFs) is higher than in other European countries. In 2020/21, for the first time, an antimicrobial pharmacist (AMP) was appointed to each community healthcare organization (CHO) to monitor, develop and promote antimicrobial stewardship in community settings.

Objectives

To establish baseline antibiotic use, develop antimicrobial stewardship tools for OP RCFs, promote best practice in relation to antimicrobial stewardship (AMS) and monitor trends in antimicrobial use in HSE (state-run) OP RCFs.

Methods

A baseline point prevalence survey (PPS) of antimicrobial use was conducted across all HSE OP RCFs between October 2020 and August 2021. Following the survey, key national recommendations and AMS resources were developed in collaboration with the national Antimicrobial Resistance and Infection Control Programme. Feedback was provided to participating facilities by CHO AMPs with antimicrobial stewardship support and education for nursing and medical staff. In September 2021, monthly monitoring of antibiotic use was established in HSE OP RCFs in collaboration with local managers, to capture the proportion of antibiotics used for prophylaxis or treatment each month.

Results

A baseline PPS of antimicrobial use in 2020/21 showed that 11.9% (528/4446) of residents were on a systemic antibiotic, with 6.3% on antibiotic prophylaxis. Urinary tract infection accounted for 51% of antibiotic prescriptions. Following the baseline PPS, CHO AMPs developed an AMS toolkit for OP RCFs, engaged with nursing and medical staff to communicate PPS results, AMS resources and support implementation of AMS recommendations. Subsequently, monthly self-reporting of antimicrobial use in HSE OP RCFs was commenced in September 2021 and showed a sustained decrease in antimicrobial use with 7.9% residents on an antibiotic in Quarter 2 2022, with 2.7% on antibiotic prophylaxis.

Conclusions

Newly appointed CHO AMPs have successfully promoted AMS across HSE OP RCFs. Following audit, feedback, education, development and promotion of antimicrobial stewardship resources, there was a sustained decrease in the proportion of residents on antibiotics used for treatment and prophylaxis of infection.

48 EXPLORING RESIDENTS’ PERCEPTIONS OF SOCIAL AND LEISURE OCCUPATIONAL CHOICE WITHIN NATIONAL NURSING HOME CARE FACILITIES

Background

National standards state that nursing homes in Ireland must provide residents with a variety of engaging activities that accommodate their needs and preferences. Despite this, residents are at risk of experiencing occupational deprivation as a result of limited choices within these settings. Due to the subjective nature of occupational choice, the objective of this study is to analyse residents’ perceptions of leisure and social occupational choice in nursing homes in Ireland.

Methods

The study adopted a qualitative-descriptive design. Six residents from three different nursing homes participated in two semi-structured interviews that analysed their leisure and social occupational engagement within their nursing home.

Results

The data identified two main themes that were divided into six related sub-themes. Residents' felt their social and leisure occupational choice was influenced by: (1) environmental factors (the cultural, social, physical, and temporal contexts of the nursing home) and (2) personal attributes (residents' health status and personal attitudes).

Conclusion

Residents' leisure and social occupational choices are substantially influenced by the cultural context of the nursing home. This stresses the significant need for person-centred care in nursing homes, in order to promote occupational choice. The findings also highlight the benefits of accessible communal spaces to enable unstructured social interaction. Occupational therapists are essential to support the leisure and social occupational choices of nursing home residents and minimise occupational deprivation, by building residents’ skills, providing staff education and modifying tasks and/or the environment.

Dual-energy fast neutron imaging using tunable short-pulse laser-driven sources

A novel dual-energy fast neutron imaging technique is presented using short-pulse laser-driven neutron sources to leverage their inherent adaptive spectral control to enable 3D volume segmentation and reconstruction. Laser-accelerated ion beams incident onto secondary targets create directional, broadband, MeV-class neutrons. Synthetic radiographs are produced of multi-material objects using ion and neutron spectra derived from analytic and numerical models. It is demonstrated that neutron images generated from small changes to the neutron spectra, controlled by altering the initial laser conditions, are sufficient to isolate materials with differing attenuation coefficients. This is first demonstrated using a simplistic combinatorial isolation method and then by employing more advanced reconstruction algorithms to reduce artifacts and generate a segmentation volume of the constituent materials.

Supporting sAFE and GradUAl ReDuctIon of loNG-term BenzodiaZepine Receptor Agonist uSe: development of the SAFEGUARDING-BZRAs toolkit using a co-design approach

Introduction

Long-term benzodiazepine receptor agonist (BZRA) use (&gt;3 months) persists worldwide and poses risks of harm. Effective interventions are needed to address this issue.

Aim

To develop an intervention to support discontinuation of long-term benzodiazepine receptor agonist (BZRA) use.

Methods

The intervention development process built on previous qualitative work that used the Theoretical Domains Framework (TDF) to explore perceived barriers and facilitators to discontinuing long-term BZRA use (1). A co-design approach was used whereby lay individuals and professionals worked as equals during the research process based on principles of authentic participation and collaboration (2). The co-design team included five ‘experts by lived experience’ with experience of long-term BZRA use who previously provided input on other related work as patient and public involvement representatives or responded to an expression of interest call on social media. Two online co-design team meetings were held. During the first meeting, a summary of previous findings was presented together with a long-list of behaviour change techniques (BCTs) generated using established mapping matrices in which BCTs were reliably allocated to the TDF. Each team member independently documented their decision as to whether each BCT should be included in a short-list for potential inclusion in the final intervention using online polling software. The a priori decision rule was that 70% of team members had to agree regarding the inclusion/exclusion of a BCT. All other BCTs were then discussed at a follow-up meeting. A finalised list of BCTs for inclusion in the intervention was agreed at the second meeting using a consensus-based approach involving the same decision rule. Potential ways in which BCTs could be operationalised were then discussed.

Results

Thirty BCTs were discussed and six BCTs were excluded. For example, team members recommended avoiding ‘Social comparison’ as individual circumstances and experiences of discontinuation and associated withdrawal symptoms are unique and not directly comparable. Given the number of included BCTs, the co-design team recommended presenting them as a toolkit. The SAFEGUARDING-BZRAs (Supporting sAFE and GradUAl ReDuctIon of loNG-term BenzodiaZepine Receptor Agonist uSe) toolkit comprises 24 BCTs: ‘Goal setting (behaviour)’, ‘Review behaviour goal(s)’, ‘Review outcome goal(s)’, ‘Feedback on behaviour’, ‘Self-monitoring of behaviour’, ‘Social support (practical)’, ‘Social support (emotional)’, ‘Information about health consequences’, ‘Monitoring of emotional consequences’, ‘Information about emotional consequences’, ‘Prompts/cues’, ‘Habit reversal’, ‘Graded tasks’, ‘Pros and cons’, ‘Comparative imagining of future outcomes’, ‘Social reward’, ‘Self-reward’, ‘Reduce negative emotions’, ‘Distraction’, ‘Adding objects to the environment’, ‘Body changes’, ‘Verbal persuasion about capability’, ‘Focus on past success’ and ‘Credible source’. The toolkit includes recommendations targeted at primary care-based clinicians for operationalising each BCT to support BZRA discontinuation.

Conclusion

The SAFEGUARDING-BZRAs toolkit has been developed using a systematic, theory-based approach that addresses identified limitations of previous research (e.g. lack of detailed intervention description). In terms of limitations, it is possible that a different group of individuals may have developed a different type of intervention. To overcome this, a priori decision rules were used for decision making. Further research is needed to assess the toolkit’s usability and acceptability by service users and clinicians.

References

(1) Lynch et al. Health Expect. [in press] DOI: 10.1111/hex.13392.

(2) O’Donnell et al. BMC Health Serv Res. 2019;19(1):797

Pimavanserin augments the efficacy of atypical antipsychotic drugs in a mouse model of treatment-refractory negative symptoms of schizophrenia

Negative symptoms are a core, pervasive, and often treatment-refractory phenotype of schizophrenia, one which contributes to poor functional outcome, ability to work, pursue educational goals, and quality of life, as well as caretaker burden. Improvement of negative symptoms in some patients with schizophrenia has been reported with some atypical antipsychotic drugs [AAPDs], but improvement is absent in many patients and partial in others. Therefore, more effective treatments are needed, and better preclinical models of negative symptoms are needed to identify them. Sub-chronic [sc] treatment of rodents with phencyclidine [PCP], a noncompetitive N-methyl-d-aspartate [NMDAR] antagonist, produces deficits in social interactions [SI] that have been widely studied as a model of negative symptoms in schizophrenia. Acute restraint stress [ARS] also provides a model of treatment-refractory negative symptoms [TRS] to AAPDs. By themselves, in sc-PCP mice, the AAPDs, risperidone, olanzapine, and aripiprazole, but not the selective 5-HT_2AR inverse agonist, pimavanserin [PIM], rescued the SI deficit in sc-PCP mice, as did the combination of PIM with sub-effective doses of each of these AAPDs. These three AAPDs alone did not rescue SI deficit in sc-PCP+2h-ARS mice, indicating these mice were treatment refractory. However, co-administration of PIM with any of the AAPDs significantly restored SI in these mice. PIM may be an effective adjunctive therapy for treating negative symptoms of schizophrenia in some patients who have failed to respond to AAPDs, but further studies are needed.

178 A RETROSPECTIVE EVALUATION OF PROCESS OUTCOMES OF OLDER ADULTS REFERRED TO A COMMUNITY RE-ENABLEMENT TEAM FROM THE EMERGENCY DEPARTMENT

Background

Emergency Departments (ED) are complex and challenging environments to provide care to older adults. There is currently a paucity of high quality methodological research investigating the effectiveness of interventions focused on transitions of care from the ED to primary care services (Hughes et al, 2019). This study aims to evaluate the impact of a collaborative model of care between primary and secondary care services for older adults discharged home following ED index visit.

Methods

This was an observational retrospective study. Participants aged ≥65 years discharged home from the ED of a University Teaching Hospital and referred to a Multidisciplinary Community Intervention Team (MDCIT) were included. Referral pathways were via the OPTIMEND team (Cassarino et al, 2021) and MDCIT, which is a rapid access re-enablement team based in the community and compromises nursing staff, an occupational therapist, physiotherapist, therapy and healthcare assistants. Descriptive statistics were used to profile the baseline characteristics of study participants and to summarise data related to process outcomes. Ethical approval was granted for this study (020/2021).

Results

In the study period, January—December 2020, 54 patients were referred to the MDCIT. The mean age of participants was 80.1 years (SD 8.2), 57% were female, and the most common Manchester Triage System presenting complaint was ‘limb problems’. The median Patient Experience Time within the ED was 7.4 hours (IQR 13.1); 55% of participants were seen in their home within 24 hours of discharge. A mean of 10 interventions were delivered by the MDCIT. A 9.1% incidence rate of 30 day unscheduled hospital readmission was recorded.

Conclusion

Integrated care programmes have been advocated to improve the continuum of care from the ED into the community. This evaluation has demonstrated the feasibility of implementing such a model of care. However, further methodologically robust research is required to advance the evidence base and should also focus on patient outcomes.

125 WARD-BASED MEDICAL TEAMS: IMPACT ON THE CARE OF THE OLDER PERSON WARD

Background

The COVID-19 pandemic forced healthcare management to make structural adaptations in the interest of infection control. One such adaptation is the introduction of ward-based medical teams. The multidisciplinary team (MDT) is one of the cornerstones of geriatric medicine. Therefore, we aimed to explore the perception of the care of the older person MDT on the introduction of ward-based medical teams.

Methods

Qualitative data was collected on a geriatric ward in October 2020 via written questionnaire. The questionnaire analysed how the transition to ward based medical teams was perceived in terms of inter-professional collaboration and clinical service delivered to patients.

Results

There were 14 respondents, 10 of whom were nursing staff (71%). 86% strongly agreed that the medical team was more accessible, with most interactions occurring face-to-face. Patient care and safety was thought to have improved, 79% and 71% of respondents respectively. 93% felt they had a better rapport with the medical team. 71% felt the MDT meeting is more effective, 57% believed the meeting had greater impact on patient care.

However, 93% felt there was less workspace. 21% believed there were more daily admissions and 57% felt the majority of patient transfers from other wards were inappropriate.

Overall 86% favoured ward-based medical teams, with 57% of staff reporting that the change led to increased personal job satisfaction.

Conclusion

By increasing the geographic proximity of doctors to other professionals, doctors were more accessible, issues were tackled quicker, and there was less time wasted bleeping medical teams. Overall staff favoured a ward-based system. However, there are challenges implementing this system. Particular attention should be paid to the availability of adequate workspace, including telephones and computers. Ward transfers should be minimized as continuity of care can be compromised. Strategies should be implemented so medical charts are available to the MDT during consultant-led ward rounds.

Dental Visits for Autistic Children: A Qualitative Focus Group Study of Parental Perceptions

INTRODUCTION

Patient groups who pose behavioral challenges during dental attendance may be offered more restricted dental treatment options. Unsuccessful participation with dental visit tasks and demands has been commonly reported for autistic children.

OBJECTIVES

This study aimed to examine parental perceptions of difficulties associated with dental attendance and oral care for autistic children and young adults, to highlight reported challenges and potential adaptations, and to identify interventions that will encourage positive experiences of dental attendance.

METHODS

Qualitative data were gathered through 2 focus groups with parents of primary school and secondary school pupils with autism, interviewed in separate groups. Questions about parents' perceptions of dental attendance and oral care were asked. The groups were audio-recorded and transcribed verbatim. The transcripts were analyzed and initial codes generated. Development of subthemes and themes followed a process of thematic analysis.

RESULTS

Parental perceptions, which confirmed data from other studies, included the need for understanding and training, awareness of sensory issues, recognition of the individuality of autistic traits, time and clarity for communication, and factors affecting the confidence of parents to advocate in the clinical environment. Focus group participants identified the critical value of empathizing with an autistic perspective and highlighted the importance of positive oral health messages. They also noted the lack of understanding regarding the complexity of altering self-imposed, ritualistic dietary regimes and attempting to enact good dental preventive habits for their children.

CONCLUSIONS

Analysis of data from parent focus groups provided a greater understanding of the needs and responsivity required for successful dental visits for autistic children and young adults. A range of potential interventions was identified and incorporated within a model of needs. Interventions based on Partnership Working, System Change, and Training of Dental Staff could be effective in reducing challenges posed by dental attendance for many children with autism.

KNOWLEDGE TRANSFER STATEMENT

Sensory sensitivities, communication difficulties, comorbid intellectual disability, and dental anxiety are barriers to successful participation during dental attendance for autistic children. This research proposes that interventions supporting Partnership Working, System Change, and Training of Dental Staff can reduce challenges posed by dental attendance. The model of interventions developed as part of this project can be used by oral care teams to help reduce barriers and improve the success of dental visits for autistic children.

511 DO ORAL NUTRITIONAL SUPPLEMENTS IMPROVE QUALITY OF LIFE IN THE FRAIL ELDERLY- A SYSTEMATIC REVIEW

Background

Oral nutritional supplements (ONS) are regularly used in older frail adults to help reduced oral intake, recovery from acute illness and weight gain. As, many frailer patients have limited life expectancies the priority for treatment should be improving quality of life (QoL). We set out to find if ONS increase QoL in the frail elderly adult.

Method

We searched Embase, Medline and OVID databases for using terms for ONS, frail older adults and QoL. The two authors independently reviewed all papers with any dispute was resolved by discussion. Each paper was then reviewed by both authors to extract data and determine bias before collation.

Results

The search returned 516 papers. Each paper was briefly reviewed to check for relevance leaving 65 papers for detailed review of which 8 papers were included. Two systematic reviews were included. One was unable to draw conclusions from the 3 papers (out of 17) that included QoL as the graded evidence was too poor. The other showed no impact on QoL (in the 2 out of 12 papers that included QoL) in patients post hip fracture receiving ONS. One paper interviewed frail elderly patients about the perceived benefits of their ONS. Nursing home residents perceived that ONS improved their ability to see family which was inferred as improving QoL. Three papers assessed ONS in conjunction with physical exercise. Two showed an improvement in quality of life in the ONS group despite controls also receiving a physical exercise programme. Two papers assessed the impact of ONS on patients discharged from hospital and those chronically unwell- neither showed any difference in QoL.

Discussion

Quality of life has been a neglected area of study when assessing the impact of ONS on frail elderly patients. When used in conjunction with physical exercise it seems to have a positive effect.

O74: ASSESSING THE USEFULNESS OF THREE-DIMENSIONAL IMAGING AND VIRTUAL REALITY IN SURGICAL PLANNING: A MEDICAL STUDENT LED PILOT STUDY

Introduction

Nephron-sparing surgery is becoming more common as surgical techniques advance. VR and 3D visualisation appear to provide better anatomical understanding in presurgical planning than two-dimensional alone. 3D models may enable greater tissue salvation and fewer complications. 3D model preparation and advancing research is expensive and time consuming. We aim to pilot study led by medical student, create reliable anatomical kidney models and assess usefulness in surgical planning.

Method

Routine CT urograms were performed on 128 slice scanner using split bolus technique. Medical student segmented and displayed models in VR using 3DSlicer. Radiology registrar and consultant validated models. Two urology surgeons completed qualitative questionnaires.

Result

We included two patients. Only minor segmentation tweaks by radiologist ensured accurately demonstrated tumors. Tissue contrast quality varied between CT scans complicating segmentation. Both surgeons deemed models helpful in visualising hilar anatomy, predicting bleeding complications, determining laparoscopic/open and partial/full nephrectomy approach. Surgeons prioritised vasculature visualisation over collecting system. Surgeons suggested gauging tumor depth would be useful. Considering 3D printing cost, surgeons agreed VR alone may suffice.

Conclusion

Surgeons found 3D and VR enabled accurate surgical planning and patient counselling regarding nephrectomy risk. Minor CT protocol recommendations enable easier and more accurate segmentation, without increasing patient's radiation exposure. Annual leave during 8-week summer project reflects case numbers. Since, we've identified more cases to assess surgical parameters against matched cohort. We've begun work for adrenal surgery. It's feasible for medical students with minimal surgical/radiological knowledge to advance this research, gaining valuable experience.

Abbrev

Virtual Reality(VR), Three-dimensional(3D), Computerised Tomography(CT)

Take-home message

Three-dimensional imaging and virtual reality may improve surgical planning and patient counselling. Regarding nephrectomy, this could give surgeons the confidence to convert from full nephrectomy to partial nephrectomy approach, improving patient outcome.

Barriers and facilitators to discontinuing long-term use of benzodiazepine receptor agonists: a qualitative study using the Theoretical Domains Framework

Introduction

Long-term use (&gt;3 months) of benzodiazepine receptor agonists (BZRAs) persists in healthcare settings worldwide despite guidelines recommending short-term use (≤4 weeks). Potential harms of long-term BZRA use include dependence and withdrawal symptoms. A systematic review highlighted that brief interventions targeting long-term BZRA use lacked theoretical underpinning and were often poorly described (1). It is advocated that interventions should be systematically developed and reported, use an appropriate theory-base and involve key stakeholders in their development. Semi-structured interviews based on the Theoretical Domains Framework (TDF) can be used to identify patient-level barriers and facilitators that should be targeted by interventions (2).

Aim

The aim of this study was to explore the views and experiences of individuals who had previously used BZRAs on a long-term basis through semi-structured interviews and to identify key theoretical domains that acted as barriers and facilitators to discontinuing long-term BZRA use.

Methods

A multi-strand convenience sampling method was used to recruit participants through community pharmacies, general practices and social media (e.g. Twitter, Instagram). Individuals who had successfully discontinued long-term BZRA use were eligible to participate if they were ≥18 years of age, community dwelling and resident in the Republic of Ireland. Individuals with a: cognitive impairment, history of epilepsy, serious mental illness (e.g. prescribed anti-psychotics) or receiving opioid substitution treatment were excluded. Semi-structured interviews were conducted using a TDF-based topic guide (2). Questions covering each TDF domain were used to explore participants’ perceptions of barriers and facilitators to discontinuing long-term BZRA use. Data were recorded and transcribed verbatim. Transcripts were independently checked for accuracy. Data were analysed using the framework method. Interviews continued until data saturation was achieved. Ethical approval was granted by the RCSI Research Ethics Committee.

Results

Thirteen patients were interviewed (seven female; median age: 43 years; median duration of use: six years). Key barriers to discontinuing BZRA use were identified under the ‘Emotions’ and ‘Reinforcement’ domains. These included participants’ first-hand experience of withdrawal symptoms and resultant fear towards discontinuation of the medication. ‘Intentions’ and ‘Social influences’ were identified as key theoretical domains that facilitated participants in discontinuing BZRA use. For example, participants described having strong intentions to discontinue BZRA use and discussed the positive influence of healthcare professionals such as community pharmacists in supporting them.

Conclusion

The study findings indicate that individuals who have successfully discontinued long-term BZRA use often have strong intentions to do so, as well as the support of healthcare professionals. However, challenges to discontinuing BZRA use include withdrawal symptoms and negative emotions towards the discontinuation process. The main strength of this study is that it used the TDF to examine barriers and facilitators to discontinuing long-term BZRA use. A notable limitation was that none of the participants were aged ≥65 years which limits the transferability of the findings. Future work will look to examine the views and experiences of current long-term BZRA users, integrate the findings with this study and map key domains to behaviour change techniques to inform the development of an intervention to reduce long-term BZRA use.

References

1. Lynch T, Ryan C, Hughes CM, Presseau J, van Allen ZM, Bradley CP, et al. Brief interventions targeting long-term benzodiazepine and Z-drug use in primary care: a systematic review and meta-analysis. Addiction. 2020;115(9):1618–39.

2. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science. 2012;7(1):37.

A non-randomised pilot study of the Solutions for Medication Adherence Problems (S-MAP) intervention in community pharmacies to support older adults adhere to multiple medications

BACKGROUND

Older patients prescribed multiple medications commonly experience difficulties with adherence. High-quality evidence on interventions targeting older patients is lacking. Theory is rarely used to tailor adherence solutions. This study aimed to pilot test a novel intervention, developed using the Theoretical Domains Framework, which guides community pharmacists in identifying adherence barriers and delivering tailored solutions (behaviour change techniques). Key study procedures (e.g. recruitment, data collection) for a future randomised controlled trial (cRCT) were also assessed.

METHODS

Using purposive sampling, this non-randomised pilot study aimed to recruit 12 community pharmacies (six in Northern Ireland; six in London, England). Pharmacists were trained to deliver the intervention to non-adherent older patients (maximum 10 per pharmacy; target n = 60-120) aged ≥ 65 years (reduced to 50 years due to recruitment challenges) and prescribed ≥ 4 regular medicines. The intervention, guided by an iPad web-application, was delivered over 3-4 face-to-face or telephone sessions, tailored to specific barriers to adherence. We assessed the feasibility of collecting adherence data (primary outcome: self-report and dispensing records), health-related quality of life (HRQOL) and unplanned hospitalisations (secondary outcomes) at baseline and 6-months. The final decision on progressing to a cRCT, using pre-defined 'stop-amend-go' criteria, is presented.

RESULTS

Fifteen pharmacists from 12 pharmacies were recruited and trained. One pharmacy subsequently dropped out. Sixty patients were recruited (meeting the 'Amend' progression criteria), with 56 receiving the intervention. Adherence barriers were identified for 55 patients (98%) and a wide range of behaviour change solutions delivered (median: 5 per patient). Self-report and dispensing adherence data were available for 37 (61.7%) and 44 (73.3%) patients, respectively. HRQOL data were available for 35 (58.3%) patients. GP-reported and self-reported hospitalisations data were available for 47 (78.3%) and 23 (38.3%) patients, respectively. All progression concepts were met (nine 'Go' and three 'Amend' criteria).

CONCLUSION

This study demonstrates the feasibility of key study procedures (e.g. pharmacy recruitment) and delivery of a tailored adherence intervention in community pharmacies. However, modifications are required to enhance issues identified with patient recruitment, retention and missing data. A future definitive cRCT will explore the effectiveness of the intervention.

TRIAL REGISTRATION

ISRCTN, ISRCTN73831533 , Registered 12 January 2018.

Psoriasis severity: commonly used clinical thresholds may not adequately convey patient impact

BACKGROUND

Psoriasis severity is usually evaluated using quantitative and qualitative measures, including per cent body surface area (BSA) involvement, the Psoriasis Area and Severity Index (PASI) and the Dermatology Life Quality Index (DLQI), a patient-reported questionnaire. However, standardized definitions for psoriasis severity categories have not been well established. A PASI of 10 or 12 has remained the minimal severity threshold defining eligibility for psoriasis treatments. In the present study, the validity of this cut-off was re-evaluated in the context of quality of life.

OBJECTIVE

To determine whether the thresholds commonly used to define moderate psoriasis (PASI of 10-12 and BSA of 10) are supported by patient-reported DLQI data.

METHODS

A systematic review of randomized controlled trials that enrolled mild or moderate patients published between January 2000 and June 2017 was used to assess correlations between provider and patient-generated severity at baseline.

RESULTS

For subject groups with high impact on quality of life (DLQI > 10), the mean weighted BSA was 7.6 (Range: 7.1-8.4) and the mean weighted DLQI was 11 (Range: 10.2-12.2). Similarly, the mean weighted PASI for patients with DLQI > 10 was 8.7 (Range: 7.1-10.1) and the mean weighted DLQI was 10.9 (Range: 10.1-12.2).

CONCLUSION

Patients with PASI or BSA scores less than 10 can have major quality of life impairment. In general, the objective measures of BSA and PASI alone, when excluding DLQI, may not fully capture the impact of disease severity.

Development of a complex community pharmacy intervention package using theory-based behaviour change techniques to improve older adults' medication adherence

BACKGROUND

To improve the effectiveness of interventions targeting non-adherence in older adults, a systematic approach to intervention design is required. The content of complex interventions and design decisions are often poorly described in published reports which makes it difficult to explore why they are ineffective. This intervention development study reports on the design of a community pharmacy-based adherence intervention using 11 Behaviour Change Techniques (BCTs) which were identified from previous qualitative research with older patients using the Theoretical Domains Framework.

METHODS

Using a group consensus approach, a five-step design process was employed. This focused on decisions regarding: (1) the overall delivery format, (2) formats for delivering each BCT; (3) methods for tailoring BCTs to individual patients; (4) intervention structure; and (5) materials to support intervention delivery. The APEASE (Affordability; Practicability; Effectiveness/cost-effectiveness; Acceptability; Side effects/safety; Equity) criteria guided the selection of BCT delivery formats.

RESULTS

Formats for delivering the 11 BCTs were agreed upon, for example, a paper medicines diary was selected to deliver the BCT 'Self-monitoring of behaviour'. To help tailor the intervention, BCTs were categorised into 'Core' and 'Optional' BCTs. For example, 'Feedback on behaviour' and 'Action planning' were selected as 'Core' BCTs (delivered to all patients), whereas 'Prompts and cues' and 'Health consequences' were selected as 'Optional' BCTs. A paper-based adherence assessment tool was designed to guide intervention tailoring by mapping from identified adherence problems to BCTs. The intervention was designed for delivery over three appointments in the pharmacy including an adherence assessment at Appointment 1 and BCT delivery at Appointments 2 and 3.

CONCLUSIONS

This paper details key decision-making processes involved in moving from a list of BCTs through to a complex intervention package which aims to improve older patients' medication adherence. A novel approach to tailoring the content of a complex adherence intervention using 'Core' and 'Optional' BCT categories is also presented. The intervention is now ready for testing in a feasibility study with community pharmacists and patients to refine the content. It is hoped that this detailed report of the intervention content/design process will allow others to better interpret the future findings of this work.

A thematic literature review of innovative strategies to prepare nursing students for aged-care

BACKGROUND

The exponential rise in people living longer but requiring residential care is adding pressure to already overstretched aged care nurses. Consequently, a person-centred care culture in residential care remains aspirational, rather than a reality. For nursing students in Australia and elsewhere, clinical placements in aged care facilities are under-utilised due to negative perceptions about the likelihood for learning. Creative strategies to engage students to safely challenge ageist thinking and to inspire enthusiasm for learning in this context are needed.

OBJECTIVES

The purpose of this thematic review of the literature is to better understand challenges related to learning in aged care settings and identify innovative strategies to enhance nursing student learning experiences in residential aged care placements.

REVIEW METHODS

A literature review was undertaken in 2019 using CINAHL, PUBMED, Elsevier, Medline, ProQuest and Google Scholar. The search was limited to papers that were peer reviewed, in English, and published between 2001 and the date of review (mid-2019) in order to situate the review in the new millennium.

RESULTS

47 articles and books were included in the review that introduce solutions and innovative strategies that could be used to improve students' attitudes to learning in aged care and from older people. The literature review was categorized into three main themes, including: barriers to working with older people; the need for pedagogical change to foster empathy; and innovative strategies to address barriers.

CONCLUSION

These themes are useful to consider in designing engaging learning and teaching for nursing students to be effective in working in aged care.

Ixekizumab Results in Persistent Clinical Improvement in Moderate-to-Severe Genital Psoriasis During a 52 Week, Randomized, Placebo-Controlled, Phase 3 Clinical Trial

Ixekizumab was efficacious in treating moderate-tosevere genital psoriasis over 12 weeks. We evaluated the long-term efficacy and safety of ixekizumab for up to 52 weeks. Patients were randomized to 80 mg ixekizumab every 2 weeks or to placebo through Week 12, then received 80 mg open-label ixekizumab every 4 weeks through Week 52. In patients initially randomized to ixekizumab, clear or almost clear genital skin was achieved for 73% of patients at Week 12 and 75% at Week 52. Persistent improvements were also observed for overall psoriasis, genital itch, and the impact of genital psoriasis on the frequency of sexual activity. The safety profile was consistent with studies of ixekizumab in patients with moderate-to-severe plaque psoriasis. Ixekizumab provided rapid and persistent improvements in the signs and symptoms of genital psoriasis for up to 52 weeks of treatment.

Health-related behaviours in a remote Indigenous population with Type 2 diabetes: a Central Australian primary care survey in the Telehealth Eye and Associated Medical Services Network [TEAMSnet] project

AIM

There is a wealth of data concerning the health behaviours of Indigenous Australians, but the health behaviours of Indigenous Australians with diabetes are not systematically documented. At the clinical level, understanding a person's health behaviours can help identify and address barriers to diabetes care and promote good clinical outcomes.

METHODS

We used a novel survey tool to systematically collect health behaviour data on Smoking, Nutrition, Alcohol consumption, Physical activity and Emotional well-being (SNAPE) from Indigenous Australians with Type 2 diabetes in a remote primary care setting in Alice Springs.

RESULTS

At least one of the five surveys in the SNAPE tool was completed by 210 participants: 30% male, mean age 52.6 years (range 22.9 - 87.4). Fifty per cent of men and 23% of women were current smokers (P < 0.001). None of the participants reported an adequate intake of vegetables. Only 9.6% reported an adequate fruit intake. Some 49% of men and 32% of women consumed alcohol in the past year (P = 0.022), and 46% of drinkers were considered high-risk or likely-dependent drinkers. On average, participants walked 10 min or more at a time 6.0 days a week and spent 4.8 h sitting on a weekday. Mean adapted Patient Health Questionnaire 9 score was 4.61, with 34% of participants having mild depressive symptoms and 11% having moderate-severe depressive symptoms.

CONCLUSIONS

Our SNAPE survey tool results present a high-risk, disadvantaged Indigenous population with Type 2 diabetes. More resources will be needed to sustainably implement interventions with the goal of improving health behaviours and subsequent long-term health.

A pilot study of the S-MAP (Solutions for Medications Adherence Problems) intervention for older adults prescribed polypharmacy in primary care: study protocol

Background

Adhering to multiple medications as prescribed is challenging for older patients (aged ≥ 65 years) and a difficult behaviour to improve. Previous interventions designed to address this have been largely complex in nature but have shown limited effectiveness and have rarely used theory in their design. It has been recognised that theory (‘a systematic way of understanding events or situations’) can guide intervention development and help researchers better understand how complex adherence interventions work. This pilot study aims to test a novel community pharmacy-based intervention that has been systematically developed using the Theoretical Domains Framework (12-domain version) of behaviour change.

Methods

As part of a non-randomised pilot study, pharmacists in 12 community pharmacies across Northern Ireland (n = 6) and London, England (n = 6), will be trained to deliver the intervention to older patients who are prescribed ≥ 4 regular medicines and are non-adherent (self-reported). Ten patients will be recruited per pharmacy (n = 120) and offered up to four tailored one-to-one sessions, in the pharmacy or via telephone depending on their adherence, over a 3–4-month period. Guided by an electronic application (app) on iPads, the intervention content will be tailored to each patient’s underlying reasons for non-adherence and mapped to the most appropriate solutions using established behaviour change techniques. This study will assess the feasibility of collecting data on the primary outcome of medication adherence (self-report and dispensing data) and secondary outcomes (health-related quality of life and unplanned hospitalisations). An embedded process evaluation will assess training fidelity for pharmacy staff, intervention fidelity, acceptability to patients and pharmacists and the intervention’s mechanism of action. Process evaluation data will include audio-recordings of training workshops, intervention sessions, feedback interviews and patient surveys. Analysis will be largely descriptive.

Discussion

Using pre-defined progression criteria, the findings from this pilot study will guide the decision whether to proceed to a cluster randomised controlled trial to test the effectiveness of the S-MAP intervention in comparison to usual care in community pharmacies. The study will also explore how the intervention components may work to bring about change in older patients’ adherence behaviour and guide further refinement of the intervention and study procedures.

Trial registration

This study is registered at ISRCTN: 10.1186/ISRCTN73831533

P3133Single parasternal long axis echocardiography by briefly trained health workers using handheld devices for detection of rheumatic heart disease: a prospective study of diagnostic accuracy

Introduction

Echocardiographic screening can detect rheumatic heart disease (RHD) in high-risk populations,but is limited by reliance on highly-trained experts and equipment. We sought to determine the diagnostic utility of an ultra-abbreviated single parasternal-long-axis-sweep of the heart (SPLASH) echocardiography protocol to detect RHD, performed by briefly-trained health workers.

Methods

In Timor-Leste and Northern Australia, individuals aged 5–20y were offered school-based echocardiographic screening. Health workers completed online modules followed by one-week of practical training, logging 50 echocardiograms prior to study. The index test was SPLASH, performed and reported by health workers using handheld GE V-scan devices. The index test was abnormal if any mitral or aortic regurgitation was detected. The reference test was a comprehensive echocardiogram, performed by an echocardiographers or cardiologist on a GE Vivid-Q, reported according to World Heart Federation criteria. The diagnostic accuracy of the index test was determined.

Results

2590 subjects underwent index and reference tests. Prevalence of definite RHD was 3.2% (83/2590). Sensitivity and specificity of index test were 0.75 (95% CI 0.64–0.83) and 0.77 (95% CI 0.75–0.78) respectively for detection of any definite RHD, and 0.91 (95% CI 0.74–0.98) and 0.76 (95% CI 0.74–0.78) respectively for detection of moderate or severe RHD.

Conclusion

Health workers using SPLASH detected the vast majority of moderate and severe RHD cases, but lacked sensitivity for detection of mild RHD. Further analysis is underway to evaluate the learning curve and other performance indicators of health workers performing and interpreting echocardiograms. This will allow refinement of SPLASH protocol and augmentation of health worker training to increase detection rates and accuracy for future population screening initiatives.

Acknowledgement/Funding

Heart Foundation Australia Vanguard Grant, Menzies HOT-NORTH pilot project grant, Snow Foundation, Rotary, Bawinanga Aboriginal Corporation, Mala'la

Genital Psoriasis: Impact on Quality of Life and Treatment Options

Psoriasis involving the genital skin occurs in up to two-thirds of psoriasis patients but is often overlooked by physicians. Furthermore, psoriasis objective and subjective severity indexes for common plaque psoriasis often neglect the impact this small area of psoriasis can have on a patient. It can have a significant impact on patients' psychosocial function due to intrusive physical symptoms such as genital itch and pain, and a detrimental impact on sexual health and impaired relationships. The mainstay of treatment is topical therapy. In patients with genital psoriasis refractory to traditional topical treatment, biologic treatments may greatly improve patient outcomes.

Dietary Recommendations for Adults With Psoriasis or Psoriatic Arthritis From the Medical Board of the National Psoriasis Foundation: A Systematic Review

Importance

Psoriasis is a chronic, inflammatory skin disease and has significant associated morbidity and effect on quality of life. It is important to determine whether dietary interventions help reduce disease severity in patients with psoriatic diseases.

Objective

To make evidence-based dietary recommendations for adults with psoriasis and/or psoriatic arthritis from the Medical Board of the National Psoriasis Foundation.

Evidence Review

We used literature from prior systematic reviews as well as additional primary literature from the MEDLINE database from January 1, 2014, to August 31, 2017, that evaluated the impact of diet on psoriasis. We included observational and interventional studies of patients with psoriasis or psoriatic arthritis. The quality of included studies was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane Risk of Bias Tool for interventional studies. We made evidence-based dietary recommendations, which were voted on by the National Psoriasis Foundation Medical Board.

Findings

We identified 55 studies meeting the inclusion criteria for this review. These studies represent 77 557 unique participants of which 4534 have psoriasis. Based on the literature, we strongly recommend dietary weight reduction with a hypocaloric diet in overweight and obese patients with psoriasis. We weakly recommend a gluten-free diet only in patients who test positive for serologic markers of gluten sensitivity. Based on low-quality data, select foods, nutrients, and dietary patterns may affect psoriasis. For patients with psoriatic arthritis, we weakly recommend vitamin D supplementation and dietary weight reduction with a hypocaloric diet in overweight and obese patients. Dietary interventions should always be used in conjunction with standard medical therapies for psoriasis and psoriatic arthritis.

Conclusions and Relevance

Adults with psoriasis and/or psoriatic arthritis can supplement their standard medical therapies with dietary interventions to reduce disease severity. These dietary recommendations from the National Psoriasis Foundation Medical Board will help guide clinicians regarding the utility of dietary interventions in adults with psoriatic diseases.

Risankizumab compared with adalimumab in patients with moderate-to-severe plaque psoriasis (IMMvent): a randomised, double-blind, active-comparator-controlled phase 3 trial

BACKGROUND

Psoriasis is an autoimmune disease that affects approximately 100 million people worldwide, and is a disease that can be ameliorated by anti-cytokine treatment. We aimed to compare the efficacy and safety of risankizumab with adalimumab in patients with moderate-to-severe plaque psoriasis.

METHODS

IMMvent was a phase 3, randomised, double-blind, active-comparator-controlled trial completed at 66 clinics in 11 countries. Eligible patients were aged 18 years or older with moderate-to-severe chronic plaque psoriasis. Patients were randomly assigned 1:1 using interactive response technology to receive 150 mg risankizumab subcutaneously at weeks 0 and 4 or 80 mg adalimumab subcutaneously at randomisation, then 40 mg at weeks 1, 3, 5, and every other week thereafter during a 16-week double-blind treatment period (part A). For weeks 16-44 (part B), adalimumab intermediate responders were re-randomised 1:1 to continue 40 mg adalimumab or switch to 150 mg risankizumab. In part A, participants and investigators were masked to study treatment. Randomisation was stratified by weight and previous tumour necrosis factor inhibitor exposure. Co-primary endpoints in part A were a 90% improvement from baseline (PASI 90) and a static Physician's Global Assessment (sPGA) score of 0 or 1 at week 16, and for part B was PASI 90 at week 44 (non-responder imputation). Efficacy analyses were done in the intention-to-treat population and safety analyses were done in the safety population (all patients who received at least one dose of study drug or placebo). This study is registered with ClinicalTrials.gov, number NCT02694523.

FINDINGS

Between March 31, 2016, and Aug 24, 2017, 605 patients were randomly assigned to receive either risankizumab (n=301, 50%) or adalimumab (n=304, 50%). 294 (98%) of patients in the risankizumab group and 291 (96%) in the adalimumab group completed part A, and 51 (96%) of 53 patients re-randomised to risankizumab and 51 (91%) of 56 patients re-randomised to continue adalimumab completed part B. At week 16, PASI 90 was achieved in 218 (72%) of 301 patients given risankizumab and 144 (47%) of 304 patients given adalimumab (adjusted absolute difference 24·9% [95% CI 17·5-32·4]; p<0·0001), and sPGA scores of 0 or 1 were achieved in 252 (84%) patients given risankizumab and 252 (60%) patients given adalimumab (adjusted absolute difference 23·3% [16·6-30·1]; p<0·0001). In part B, among adalimumab intermediate responders, PASI 90 was achieved by 35 (66%) of 53 patients switched to risankizumab and 12 (21%) of 56 patients continuing adalimumab (adjusted absolute difference 45·0% [28·9-61·1]; p<0·0001) at week 44. Adverse events were reported in 168 (56%) of 301 patients given risankizumab and 179 (57%) of 304 patients given adalimumab in part A, and among adalimumab intermediate responders, adverse events were reported in 40 (75%) of 53 patients who switched to risankizumab and 37 (66%) of 56 patients who continued adalimumab in part B.

INTERPRETATION

Risankizumab showed significantly greater efficacy than adalimumab in providing skin clearance in patients with moderate-to-severe plaque psoriasis. No additional safety concerns were identified for patients who switched from adalimumab to risankizumab. Treatment with risankizumab provides flexibility in the long-term treatment of psoriasis.

FUNDING

AbbVie and Boehringer Ingelheim.

Recategorization of psoriasis severity: Delphi consensus from the International Psoriasis Council

BACKGROUND

Psoriasis severity categories have been important tools for clinicians to use in treatment decisions as well as to determine eligibility criteria for clinical studies. However, owing to the heterogeneity of severity classifications and their lack of consideration for the impact of psoriasis involvement of special areas or past treatment history, patients may be miscategorized, which can lead to undertreatment of psoriasis.

OBJECTIVE

To develop a consensus statement on the classification of psoriasis severity.

METHODS

A modified Delphi approach was developed by the International Psoriasis Council to define psoriasis severity.

RESULTS

After completion of the exercise, 7 severity definitions were preferentially ranked. This most preferred statement rejects the mild, moderate, and severe categories in favor of a dichotomous definition: Psoriasis patients should be classified as either candidates for topical therapy or candidates for systemic therapy; the latter are patients who meet at least one of the following criteria: (1) body surface area >10%, (2) disease involving special areas, and (3) failure of topical therapy.

LIMITATIONS

This effort might have suffered from a lack of representation by all relevant stakeholders, including patients.

CONCLUSION

The consensus statement describes 2 categories of psoriasis severity, while accounting for special circumstances where patients may require systemic therapy.

Clinical considerations for the management of psoriasis in women

The burden of psoriasis is particularly high for women, who report lower levels of happiness (women: 18.5%; men: 11.3% lower vs. general population) and are more likely to experience stress (women: > 60%; men: 42%), loneliness (women: 25-28%; men: 19-24%), stigmatization (Feelings of Stigmatization Questionnaire score; women: 93.2; men: 78.0), and reduced sexual activity (women: 33%; men: 19%) compared with men. The onset of psoriasis is bimodal, with one incidence peak (15-30 years) that coincides with the prime reproductive age for women, which poses specific challenges for their treatment. However, well-established guidelines for the treatment of women of childbearing age are lacking. Many women experience stabilization (21%) or improvement (55%) of their skin during pregnancy, but up to a quarter can experience disease worsening, and postpartum flares are common (> 50%). Therefore, balancing the risk of treatment with the risk of uncontrolled disease is important. Because half of pregnancies are unplanned, the implications of therapeutic options must be considered for all women with psoriasis who are sexually active, irrespective of intentions to start a family. Timely initiation of these discussions by health care professionals is paramount to prevent unintentional toxicity to the developing fetus. For example, acitretin, methotrexate, and oral psoralen/ultraviolet A are all contraindicated in pregnancy. Reassuringly, safety data for other psoriasis treatments during pregnancy are increasingly available, particularly for anti-tumor necrosis factor therapies. Despite encouraging data from pregnancy exposure registries and clinical studies now being included in anti-tumor necrosis factor drug labels, comfort with prescribing these therapies to pregnant women remains low (U.S. dermatologists: 21%; EU-5 dermatologists: 10%). In this article, we review issues specific to treating women of childbearing age with psoriasis and highlight the need for treatment guidelines to ensure consistent care and optimal outcomes for these patients.

Clinical Goals and Barriers to Effective Psoriasis Care

Engaging global key opinion leaders, the International Psoriasis Council (IPC) held a day-long roundtable discussion with the primary purpose to discuss the treatment goals of psoriasis patients and worldwide barriers to optimal care. Setting clear expectations might ultimately encourage undertreated psoriasis patients to seek care in an era in which great gains in therapeutic efficacy have been achieved. Here, we discuss the option for early treatment of all categories of psoriasis to alleviate disease impact while emphasizing the need for more focused attention for psoriasis patients with mild and moderate forms of this autoimmune disease. In addition, we encourage policy changes to keep pace with the innovative therapies and clinical science and highlight the demand for greater understanding of treatment barriers in resource-poor countries.