First Nations Peoples' perceptions, knowledge and beliefs regarding stillbirth prevention and bereavement practices: A mixed methods systematic review

BACKGROUND

First Nations Peoples endure disproportionate rates of stillbirth compared with non-First Nations Peoples. Previous interventions have aimed at reducing stillbirth in First Nations Peoples and providing better bereavement care without necessarily understanding the perceptions, knowledge and beliefs that could influence the design of the intervention and implementation.

AIM

The aim of this review was to understand the perceptions, knowledge and beliefs about stillbirth prevention and bereavement of First Nations Peoples from the US, Canada, Aotearoa/New Zealand, and Australia.

METHODS

This review was conducted in accordance with the JBI methodology for a convergent integrated mixed method systematic review. This review was overseen by an advisory board of Aboriginal Elders, researchers, and clinicians. A search of eight databases (PubMed, MEDLINE, PsycInfo, CINAHL, Embase, Emcare, Dissertations and Theses and Indigenous Health InfoNet) and grey literature was conducted. All studies were screened, extracted, and appraised for quality by two reviewers and results were categorised, and narratively summarised.

RESULTS

Ten studies were included within this review. Their findings were summarised into four categories: safeguarding baby, traditional practices of birthing and grieving, bereavement photography and post-mortem examination. The results indicate a diversity of perceptions, knowledge and beliefs primarily around smoking cessation and bereavement practices after stillbirth. However, there was a paucity of research available.

CONCLUSIONS

Further research is needed to understand the perceptions, knowledge and beliefs about stillbirth among First Nations Peoples. Without research within this area, interventions to prevent stillbirth and support bereaved parents and their communities after stillbirth may face barriers to implementation.

Looking after bubba for all our mob: Aboriginal and Torres Strait Islander community experiences and perceptions of stillbirth

The stillbirth rate among Aboriginal and Torres Strait Islander women and communities in Australia is around double that of non-Indigenous women. While the development of effective prevention strategies during pregnancy and improving care following stillbirth for women and families in communities has become a national priority, there has been limited progress in stillbirth disparities. With community permission, this study aimed to gain a better understanding of community experiences, perceptions, and priorities around stillbirth. We undertook an Indigenous researcher-led, qualitative study, with community consultations guided by a cultural protection protocol and within an unstructured research framework. A total of 18 communities were consulted face-to-face through yarning interviews, focus groups and workshops. This included 54 community member and 159 health professional participants across remote, regional, and urban areas of Queensland, Western Australia, Victoria, South Australia, and Northern Territory. Thematic analysis of consultation data identified common themes across five focus/priority areas to address stillbirth: Stillbirth or Sorry Business Baby care needs to be family-centered; using Indigenous "ways of knowing, being, and doing" to ensure cultural safety; application of Birthing on Country principles to maternal and perinatal care; and yarning approaches to improve communication and learning or education. The results underscore the critical need to co-design evidence-based, culturally appropriate, and community-acceptable resources to help reduce existing disparities in stillbirth rates.

Impact of pregnancy vaccine uptake and socio-demographic determinants on subsequent childhood Measles, Mumps and Rubella vaccine uptake: A UK birth cohort study

BACKGROUND

We examined the association between socio-demographic determinants and uptake of childhood Measles, Mumps & Rubella (MMR) vaccines and the association between pregnant women's pertussis vaccine uptake and their children's MMR vaccine uptake.

METHODS

We used nationally-representative linked mother-baby electronic records from the United Kingdom's Clinical-Practice-Research-Datalink. We created a birth cohort of children born between 01.01.2000 and 12.12.2020. We estimated the proportion vaccinated with first MMR vaccine by age 2 years and first and second MMR vaccines by age 5 years. We used survival-analysis and Cox proportional hazard models to examine the association between deprivation, ethnicity and maternal age and pertussis vaccination in pregnancy and children's MMR uptake.

RESULTS

Overall, 89.4 % (710,797/795,497) of children had first MMR by age 2 years and 92.6 % (736,495/795,497) by age 5 years. Among children still in the cohort when second MMR was due, 85.9 % (478,480/557,050) had two MMRs by age 5 years. Children from the most-deprived areas, children of Black ethnicity and children of mothers aged < 20 years had increased risk of being unvaccinated compared with children from the least-deprived areas, White children and children of mothers aged 31-40 years: first MMR by 5 years, adjusted Hazard Ratios (HR):0.86 (CI:0.85-0.87), HR:0.87 (CI:0.85-0.88) & HR:0.89 (CI:0.88-0.90) respectively. Deprivation was the determinant associated with the greatest risk of missed second MMR: adjusted HR:0.82 (CI:0.81-0.83). Children of mothers vaccinated in pregnancy were more likely than children of unvaccinated mothers to have MMR vaccines after adjusting for ethnicity, deprivation, and maternal age (First and Second MMRs adjusted HRs:1.43 (CI:1.41-1.45), 1.49 (CI:1.45-1.53).

CONCLUSION

Children from most-deprived areas are less likely to have MMR vaccines compared with children from least-deprived areas. Mothers who take up pregnancy vaccines are more likely to have their children vaccinated with MMR. Healthcare services should promote and facilitate access to both maternal and childhood vaccines during pregnancy.

Selenium and Vitamin E for Prevention of Non-Muscle-Invasive Bladder Cancer Recurrence and Progression: A Randomized Clinical Trial

Importance

Selenium and vitamin E have been identified as promising agents for the chemoprevention of recurrence and progression of non-muscle-invasive bladder cancer.

Objective

To determine whether selenium and/or vitamin E may prevent disease recurrence in patients with newly diagnosed NMIBC.

Design, Setting, and Participants

This multicenter, prospective, double-blinded, placebo-controlled, 2 × 2 factorial randomized clinical trial included patients with newly diagnosed NMIBC recruited from 10 secondary or tertiary care hospitals in the UK. A total of 755 patients were screened for inclusion; 484 did not meet the inclusion criteria, and 1 declined to participate. A total of 270 patients were randomly assigned to 4 groups (selenium plus placebo, vitamin E plus placebo, selenium plus vitamin E, and placebo plus placebo) in a double-blind fashion between July 17, 2007, and October 10, 2011. Eligibility included initial diagnosis of NMIBC (stages Ta, T1, or Tis); randomization within 12 months of first transurethral resection was required.

Interventions

Oral selenium (200 μg/d of high-selenium yeast) and matched vitamin E placebo, vitamin E (200 IU/d of d-alfa-tocopherol) and matched selenium placebo, selenium and vitamin E, or placebo and placebo.

Main Outcome and Measures

Recurrence-free interval (RFI) on an intention-to-treat basis (analyses completed on November 28, 2022).

Results

The study randomized 270 patients (mean [SD] age, 68.9 [10.4] years; median [IQR] age, 69 [63-77] years; 202 male [75%]), with 65 receiving selenium and vitamin E placebo, 71 receiving vitamin E and selenium placebo, 69 receiving selenium and vitamin E, and 65 receiving both placebos. Median overall follow-up was 5.5 years (IQR, 5.1-6.1 years); 228 patients (84%) were followed up for more than 5 years. Median treatment duration was 1.5 years (IQR, 0.9-2.5 years). The study was halted because of slow accrual. For selenium (n = 134) vs no selenium (n = 136), there was no difference in RFI (hazard ratio, 0.92; 95% CI, 0.65-1.31; P = .65). For vitamin E (n = 140) vs no vitamin E (n = 130), there was a statistically significant detriment to RFI (hazard ratio, 1.46; 95% CI, 1.02-2.09; P = .04). No significant differences were observed for progression-free interval or overall survival time with either supplement. Results were unchanged after Cox proportional hazards regression modeling to adjust for known prognostic factors. In total, 1957 adverse events were reported; 85 were serious adverse events, and all were considered unrelated to trial treatment.

Conclusions and Relevance

In this randomized clinical trial of selenium and vitamin E, selenium supplementation did not reduce the risk of recurrence in patients with NMIBC, but vitamin E supplementation was associated with an increased risk of recurrence. Neither selenium nor vitamin E influenced progression or overall survival. Vitamin E supplementation may be harmful to patients with NMIBC, and elucidation of the underlying biology is required.

Trial Registration

isrctn.org Identifier: ISRCTN13889738.

First Nations populations' perceptions, knowledge, attitudes, beliefs, and myths about prevention and bereavement in stillbirth: a mixed methods systematic review protocol

OBJECTIVE

The objective of this review is to investigate First Nations populations' perceptions, knowledge, attitudes, beliefs, and myths about stillbirth.

INTRODUCTION

First Nations populations experience disproportionate rates of stillbirth compared with non-First Nations populations. There has been a surge of interventions aimed at reducing stillbirth and providing better bereavement care, but these are not necessarily appropriate for First Nations populations. As a first step toward developing appropriate interventions for these populations, this review will examine current perceptions, knowledge, attitudes, beliefs, and myths about stillbirth held by First Nations people from the United States, Canada, Aotearoa/New Zealand, and Australia.

INCLUSION CRITERIA

The review will consider studies that include individuals of any age (bereaved or non-bereaved) who identify as belonging to First Nations populations. Eligible studies will include the perceptions, knowledge, attitudes, beliefs, and myths about stillbirth among First Nations populations.

METHODS

This review will follow the JBI methodology for convergent mixed methods systematic reviews. The review is supported by an advisory panel of Aboriginal elders, lived-experience stillbirth researchers, Aboriginal researchers, and clinicians. PubMed, MEDLINE (Ovid), CINAHL (EBSCOhost), Embase (Ovid), Emcare (Ovid), PsycINFO (EBSCOhost), Indigenous Health InfoNet, Trove, Informit, and ProQuest Dissertations and Theses will be searched for relevant information. Titles and abstracts of potential studies will be screened and examined for eligibility. After critical appraisal, quantitative and qualitative data will be extracted from included studies, with the former "qualitized" and the data undergoing a convergent integrated approach.

REVIEW REGISTRATION

PROSPERO CRD42023379627.

Evaluation and Verification of a microRNA Panel Using Quadratic Discriminant Analysis for the Classification of Human Body Fluids in DNA Extracts

There is significant interest in the use of miRNA analysis for forensic body fluid identification. Demonstrated co-extraction and detection in DNA extracts could make the use of miRNAs a more streamlined molecular body fluid identification method than other RNA-based methods. We previously reported a reverse transcription-quantitative PCR (RT-qPCR) panel of eight miRNAs that classified venous and menstrual blood, feces, urine, saliva, semen, and vaginal secretions using a quadratic discriminant analysis (QDA) model with 93% accuracy in RNA extracts. Herein, miRNA expression in DNA extracts from 50 donors of each body fluid were tested using the model. Initially, a classification rate of 87% was obtained, which increased to 92% when three additional miRNAs were added. Body fluid identification was found to be reliable across population samples of mixed ages, ethnicities, and sex, with 72-98% of the unknown samples classifying correctly. The model was then tested against compromised samples and over biological cycles, where classification accuracy varied, depending on the body fluid. In conclusion, we demonstrated the ability to classify body fluids using miRNA expression from DNA extracts, eliminating the need for RNA extraction, greatly reducing evidentiary sample consumption and processing time in forensic laboratories, but acknowledge that compromised semen and saliva samples can fail to classify properly, and mixed sample classification remains untested and may have limitations.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Maintenance of Certification in Radiology: Eliciting Radiologist Preferences Using a Discrete Choice Experiment

OBJECTIVE

To quantitatively assess radiologists' preferences for Maintenance of Certification (MOC) and Continuing Certification (CC) using a survey of attitudes and perceptions.

METHODS

A questionnaire that assessed attitudes and perceptions and included a discrete choice or trade-off task was developed by ACR staff in conjunction with an independent market research agency and the Survey Subcommittee of the ACR Task Force on Certification in Radiology. The trade-off exercise was integrated into this methodology to better understand the underlying utilities or preferences of the components of MOC-CC among respondents and to better enable specific recommendations on how to optimize the current program. The survey was administered via e-mail to 17,305 ACR members. The demographic and practice characteristics of the 1,994 (11.5%) respondents were similar to the ACR radiologist membership and correspond to a normal distribution. At a 95% confidence level, with a margin of error 2.1%, we believe that the respondent population fairly reflects the actual population.

RESULTS

Similar proportions judged the existing program as excellent or very good (36%), or fair or poor (35%), with 27% neutral. MOC-CC was perceived more often as excellent or very good by those who were grandfathered yet still participating in MOC, were in academic practice, were in an urban setting, were older, or had a role with the ABR. In contrast, MOC-CC was more often judged as fair or poor by those who were not grandfathered, were in private practice, were in a rural setting, or were younger. The current MOC-CC program is not well regarded by diplomates, with few showing preference or acceptability. The program's reception is most sensitive to the following attributes: absence or presence of a practice quality improvement requirement, Online Longitudinal Assessment content including or excluding general radiology in addition to one's specialty and inclusion or exclusion of self-assessment as part of the CME.

CONCLUSION

ACR members diverged in their attitudes toward MOC, with differences among specific demographic and practice characteristics. The current package of features of MOC-CC was widely viewed as unsatisfactory, and a more optimal feature set arose from a simulation exercise.

Anxiety disorders and age-related changes in physiology

Introduction

Anxiety disorders are leading contributors to the global disease burden, highly prevalent across the lifespan, and associated with substantially increased morbidity and early mortality.

Objectives

The aim of this study was to examine age-related changes across a wide range of physiological measures in middle-aged and older adults with a lifetime history of anxiety disorders compared to healthy controls.

Methods

The UK Biobank study recruited >500,000 adults, aged 37-73, between 2006-2010. We used generalised additive models to estimate non-linear associations between age and hand-grip strength, cardiovascular function, body composition, lung function and heel bone mineral density in cases vs. controls.

Results

The main dataset included 332,078 adults (mean age = 56.37 years; 52.65% females). In both sexes, individuals with anxiety disorders had lower hand-grip strength and blood pressure than healthy controls, while their pulse rate and body composition measures were higher. Case-control differences were larger when considering individuals with chronic and/or severe anxiety disorders, and differences in body composition were modulated by depression comorbidity status. Differences in age-related physiological changes between female anxiety disorder cases and healthy controls were most evident for blood pressure, pulse rate and body composition, while in males for hand-grip strength, blood pressure and body composition. Most differences in physiological measures between cases and controls tended to decrease with age increase.

Conclusions

Individuals with a lifetime history of anxiety disorders differed from healthy controls across multiple physiological measures, with some evidence of case-control differences by age. The differences observed varied by chronicity/severity and depression comorbidity.

Disclosure

JM receives studentship funding from the Biotechnology and Biological Sciences Research Council (BBSRC) and Eli Lilly and Company Limited. CML is a member of the Scientific Advisory Board of Myriad Neuroscience. CF and THH declare no relevant conflict of

Paediatric minor head injury applied to Paediatric Emergency Care Applied Research Network CT recommendations: An audit

Background

Traumatic brain injury (TBI) is a common cause of paediatric morbidity and mortality, with higher TBI rates in low- and middle-income countries. Non-contrast brain CT is the gold standard for diagnosing intracranial injuries; however, it exposes patients to ionising radiation. The Paediatric Emergency Care Applied Research Network (PECARN) clinical decision rule (CDR) aids clinicians in their decision-making processes whilst deciding whether a patient at very low risk of a clinically important TBI (ciTBI) requires a CT scan.

Objectives

To establish whether the introduction of the PECARN CDR would affect CT utilisation rates for paediatric patients presenting with minor blunt head injuries to an academic hospital in Gauteng, South Africa.

Method

This was an audit of paediatric patients who presented with minor blunt head injuries and were referred for CT imaging at an academic hospital in Gauteng, compared with PECARN CDR recommendations, over a 1-year period.

Results

A total of 100 patients were referred for CT imaging. Twenty patients were classified as very low risk, none of whom had any CT findings of a TBI or ciTBI (p < 0.01). A total of 61 patients were classified as intermediate risk and 19 as high risk. In all, 23% of the intermediate and 47% of the high-risk patients had CT features of a TBI, whilst 8% and 37% had a ciTBI, respectively.

Conclusion

Computed tomography brain imaging may be omitted in patients classified as very low risk without missing a clinically important TBI. Implementing the PECARN CDR in appropriate patients would reduce CT utilisation rates.

Design and optimization of a 16S microbial qPCR multiplex for the presumptive identification of feces, saliva, vaginal and menstrual secretions

Molecular methods for body fluid identification have been extensively researched in the forensic community over the last decade, mostly focusing on RNA‐based methods. Microbial DNA analysis has long been used for forensic applications, such as postmortem interval estimations, but only recently has it been applied to body fluid identification. High‐throughput sequencing of the 16S ribosomal RNA gene by previous research groups revealed that microbial signatures and abundances vary across human body fluids at the genus and/or species taxonomic level. Since quantitative PCR is still the current technique used in forensic DNA analysis, the purpose of this study was to design a qPCR multiplex targeting the 16S gene of Bacteroides uniformis, Streptococcus salivarius, and Lactobacillus crispatus that can distinguish between feces, saliva, and vaginal/menstrual secretions, respectively. Primers and probes were designed at the species level because these bacteria are highly abundant within their respective fluid. The validated 16S triplex was evaluated in DNA extracts from thirty donors of each body fluid. A classification regression tree model resulted in 96.5% classification accuracy of the population data, which demonstrates the ability of this 16S triplex to presumptively identify these fluids with high confidence at the quantification step of the forensic workflow using minimal input volume of DNA extracted from evidentiary samples.

931 Deep Inferior Epigastric Perforator (DIEP) Flap: Impact of Early Drain Removal on Seroma Formation Rate and Duration of Inpatient Stay

Aim

Donor site seroma can follow deep inferior epigastric flap (DIEP) harvest. Post-surgery gradient technology (GTC) garments are worn by DIEP patients postoperatively following drain removal to reduce seroma formation. Early drain removal was considered a contributing factor to increased seroma formation rate. From June 2018 drain removal regardless of output was instigated at day two post-surgery. Prior to this, drains were removed when less than 30mls over 24 hours. We aim to assess the seroma rate post DIEP harvest with early drain removal.

Method

Retrospective review of prospectively managed database between June 2018 to May 2020. Surgical complications and length of stay in hospital were recorded.

Results

200 patients underwent DIEP flap breast reconstruction. The mean age of patients was 52 years (range 28-73). There was no significant difference in seroma complication rate between those who had drains removed on day 3 compared with day 2 ((1.02% (1/98) vs. (0.98% (1/102); p = 1). The mean length of stay in hospital for the 1st cohort was 3.86 days and for the 2nd cohort was 3.23 days. There were no complications related to drain removal.

Conclusions

Our data suggests that drain removal after 2 days postoperatively with DIEP reconstruction does not affect seroma complication rates. Moreover, it leads to a shorter hospital stay. These conclusions are in keeping with enhanced recovery protocols and an early drain removal surgical process could be advised.

Speech Compression: Personality Correlates of Successful Use

Blinded veterans were asked to listen to four sections of a seventh grade level biographical sketch that had been recorded at progressively faster rates (1.0, 1.5, 2.0, and 2.5 times the initial rate of 194 words per minute) through use of a commercially available electronic discrete time compressed speech device. After each section, multiple choice questions were asked. Variables such as age, use of hearing aid, education level, Wechsler Adult Intelligence Scale Verbal IQ, and scale scores of the Minnesota Multiphasic Personality Inventory and the California Psychological Inventory were analyzed for possible relationship with the subject's maximum comprehended compression rate. Younger veterans whose personality tests indicated better psychological adjustment tended to be more successful in comprehending compressed speech.

Racial disparities in prevalence of cardiovascular disease risk factors in head and neck cancer patients

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): American Heart Association Pre-doctoral Fellowship

Background

Cancer patients and survivors have higher burden of cardiovascular diseases than the age-adjusted general population. However, evidence on distribution of cardiovascular disease risk factors in cancer patients is limited.

Purpose

Our aim was to assess if racial disparities exist in prevalence of cardiovascular disease risk factors in head and neck cancer patients. 

Methods

In this clinical cohort, we included 2299 head neck squamous cell carcinoma (HNSCC) patients diagnosed between 2012-2018 at a National Cancer Institute-designated Cancer Center. We used a combination of ICD-9/10 codes, medication use and pharmacy records from electronic medical records data, to identify cardiovascular disease risk factors (hypertension, dyslipidemia and diabetes mellitus). We reported prevalence of cardiovascular disease risk factors at and one year-post HNSCC diagnosis, by race, using Chi-square or Wilcoxon test, as appropriate. 

Results

Black HNSCC patients were diagnosed at a slightly younger age (median: 60.0 vs 62.0 years, p-value 0.0745), had a higher proportion of males (p-value 0.0221) and advanced cancer stage at diagnosis (p-value 0.0033), than white HNSCC patients. At diagnosis, 32.63% of black HNSCC patients had hypertension and 34.44% had at least one cardiovascular disease risk factor, compared to 24.59% and 27.74% in whites, respectively (p-values 0.0020 and 0.0127, respectively). At one-year post HNSCC diagnosis, 84.73% of all HNSCC patients had at least one cardiovascular disease risk factor. No statistically significant racial differences were observed for hypertension and diabetes mellitus at one-year post HNSCC diagnosis, however, 37.74% of white HNSCC patients had dyslipidemia compared to 27.49% black patients (p-value 0.003). 

Conclusion

Higher prevalence of hypertension and advanced cancer stage at HNSCC diagnosis in black patients highlights issues of racial disparity and unequal access to care. High prevalence of cardiovascular disease risk factors at one-year post HNSCC diagnosis and increase in dyslipidemia in white patients emphasizes the impact of therapeutic agents and need for routine personalized monitoring of cardiovascular disease risk factors and cardiovascular disease preventive services in high risk HNSCC patients.

'This won't hurt a bit!' - A descriptive review of health care professionals' pharmacological management of pain in minor trauma

BACKGROUND

Emergency Centres (ECs) have a prominent trauma burden requiring effective pain management. This study aimed to review analgesia-prescribing habits in minor trauma, reviewing the patient demographics and diagnoses, analgesia-prescribing habits of health care professionals (HCPs) managing these cases, and differences in prescribing noted by patients' age group, gender and triage code.

METHODS

A prospective, cross-sectional, descriptive study was conducted in a regional EC in KwaZulu-Natal. HCPs managing minor trauma patients completed a closed-ended questionnaire which indicated the patients' demographics, diagnosis and analgesia prescribed.

RESULTS

The study comprised of 314 cases of which the demographic most represented were male patients aged between 20-30 years with soft tissue injuries. Simple analgesics and weak opioids (paracetamol, ibuprofen and tramadol) accounted for 87.9% of prescriptions. Referral clinics prescribed less analgesics than that provided in the EC. There were mostly no significant differences in prescription habits by patients' age group, gender and triage code.

CONCLUSION

Presenting complaints in our study were varied and likely to result in mild to moderate pain. Only a minority of patients received analgesics at initial contact. Standardised protocols providing treatment guidance for nurse-initiated pain management at initial contact is thus important. There were no significant differences in analgesics prescribed for adults and the elderly, which is worrisome given the potential negative side effects of analgesics in the elderly. Similar concerns in our paediatric population were not noted. Ensuring adequate analgesia with cognisance for safety at the extremes of age is of paramount importance.

Lifetime depression and age-related changes in body composition, cardiovascular measures, grip strength and lung function

Introduction

Individuals with mental disorders, on average, die prematurely and may experience accelerated biological ageing.

Objectives

We examined sex-specific associations between age and physiological measures in individuals with lifetime depression and healthy controls.

Methods

UK Biobank recruited >500,000 participants, aged 37-73, between 2006–2010. Generalised additive models (GAMs) were used to examine associations between age and multiple cardiovascular, body composition, grip strength and lung function measures. Analyses were conducted separately in males and females with lifetime depression compared to healthy controls.

Results

Analytical samples included up to 342,393 adults (mean age = 55.87 years, SD = 8.09; 52.61% females). We found statistically significant differences between individuals with lifetime depression and healthy controls for most physiological measures, with standardised mean differences between -0.145 and 0.156. There was some evidence that age-related changes in body composition, cardiovascular measures, lung function and heel bone mineral density followed different trajectories in individuals with lifetime depression. However, these differences did not uniformly narrow or widen with age. For example, BMI in females with lifetime depression was approximately 1.1 kg/m² higher at age 40 and this difference narrowed to about 0.4 kg/m² at age 70. In males, systolic blood pressure was approximately 1 mmHg lower in individuals with lifetime depression at age 45 and this difference widened to about 2.5 mmHg at age 65.

Conclusions

Evidence of differences in ageing trajectories between individuals with lifetime depression and healthy controls was not uniform across physiological measures and differed by sex.

Disclosure

JM receives studentship funding from the Biotechnology and Biological Sciences Research Council (BBSRC) and Eli Lilly and Company Limited. CML is a member of the Scientific Advisory Board of Myriad Neuroscience.

Comparison of DNA typing success in compromised blood and touch samples based on sampling swab composition

Sample collection at the crime scene can introduce variations in DNA recovery based upon the substrate from which a sample is collected, the material of the collection device used, or the storage conditions after collection. There are many factors during this process that can degrade the sample during drying and storage, and before DNA extraction can be performed. The purpose of this study was to evaluate and compare the performance of standard cotton swab collection with the Bode BioSafe^® swab, which includes both a desiccant at the swab head and proprietary compounds to prevent degradation of the sample during sample collection and preservation. Blood and touch DNA samples were collected from porous and nonporous substrates and stored at elevated temperatures to simulate accelerated time. DNA quantification and STR profile data were used to assess the performance of the swabs. BioSafe^® swab collection resulted in similar DNA yields from blood samples and significantly higher DNA yields from touch samples when compared to collection with cotton swabs. BioSafe^® swabs also resulted in higher DNA integrity during long-term storage, increased STR profile success and improved retention of low-level contributor alleles.

Understanding implementation factors and participant experiences of a cluster randomised controlled trial to prevent falls among older Aboriginal people: a process evaluation protocol

INTRODUCTION

Process evaluations examining programme implementation are often conducted in conjunction with effectiveness studies. Their inclusion in studies with Aboriginal participants can give an understanding of programme delivery in Aboriginal community contexts. The Ironbark: Standing Strong and Tall programme was codesigned with Aboriginal communities and includes exercise and facilitated 'yarning' discussion about fall risk and prevention strategies. The programme pilot showed favourable outcomes and acceptability for Aboriginal people aged 45 years and over. The Ironbark: Standing Strong and Tall programme is now being compared with a 'Healthy Community' programme in a cluster randomised controlled trial within Aboriginal health and community services. An embedded process evaluation aims to explore relationships between participation and programme outcomes and the quality of programme implementation.

METHODS AND ANALYSIS

The process evaluation will use a mixed methods design, guided by Indigenous research methodology. It will evaluate quantitative data (number of completed sessions, site coaching checklist tool, participant and facilitator questionnaire data and a participant habit formation scale), as well as qualitative data (open-ended responses from project and site staff and semistructured interviews using yarning with study participants and site managers). A programme logic model was developed to explain the intended inputs, activities, outputs and outcomes, which guided this process evaluation design.

CONCLUSION

This process evaluation of a fall prevention programme for older Aboriginal people using a mixed methods design and data triangulation will allow for a comprehensive understanding of study findings. Multiple study sites allow for generalisability of findings and exploration of variation across sites.

TRIAL REGISTRATION NUMBER

ACTRN12619000349145.

The utility of serial chest X-rays for detection of delayed pneumothorax, haemothorax or haemopneumothorax following penetrating thoracic injury

Introduction

Penetrating thoracic injuries are a common presentation in Emergency Departments in South Africa with pneumothorax, haemothorax and haemopneumothorax (PTX/HTX/HPTX) a cause of morbidity and mortality. Serial chest X-rays (CXRs) are used to assess patients with penetrating thoracic injury without PTX/HTX/HPTX on initial CXR in order to increase sensitivity and thus detection of PTX/HTX/HPTX. This study aimed to assess the utility of serial CXRs to detect a delayed presentation of PTX/HTX/HPTX following penetrating thoracic injury.

Methods

This retrospective observational study analysed data from Helen Joseph Hospital Emergency Department, Johannesburg, South Africa for patients presenting with penetrating thoracic injury over a 2-year period for whom the initial CXR was negative for a PTX/HTX/HPTX to determine the utility of serial CXRs for detection of a delayed presentation of PTX/HTX/HPTX.

Results

118 patients, the majority of which had penetrating trauma secondary to a stab wound, were included in the study. Eight (7%) had a PTX/HTX/HPTX detected on subsequent investigation. Three (3%) patients with normal initial CXRs and three (3%) patients with abnormal initial CXRs had a PTX/HPX/HPTX detected on serial CXRs. Two (2%) delayed presentations of PTX/HTX/HPTX were noted on computerised tomography (CT) scan only. Six patients had an intercostal drain (ICD) inserted and were admitted; 2 patients (those with PTX/HTX/HPTX noted on CT only) were managed conservatively. Three patients (3%) had an ICD inserted to manage a delayed presentation of PTX/HTX/HPTX with a normal initial CXR.

Discussion

Only 3% of patients with normal initial CXRs required intervention.

Conclusions

It is recommended that patients for whom the presentation CXR shows an abnormality undergo serial CXRs. Given the low incidence of PTX/HTX/HPTX in patients with a normal presentation CXR, along with the resource implications of serial CXRs, it may be prudent to discharge patients with thorough counselling and advice to return for review if warranted.

Investigation of the safety and feasibility of AAV1/SERCA2a gene transfer in patients with chronic heart failure supported with a left ventricular assist device - the SERCA-LVAD TRIAL

The SERCA-LVAD trial was a phase 2a trial assessing the safety and feasibility of delivering an adeno-associated vector 1 carrying the cardiac isoform of the sarcoplasmic reticulum calcium ATPase (AAV1/SERCA2a) to adult chronic heart failure patients implanted with a left ventricular assist device. The SERCA-LVAD trial was one of a program of AAV1/SERCA2a cardiac gene therapy trials including CUPID1, CUPID 2 and AGENT trials. Enroled subjects were randomised to receive a single intracoronary infusion of 1 × 10¹³ DNase-resistant AAV1/SERCA2a particles or a placebo solution in a double-blinded design, stratified by presence of neutralising antibodies to AAV. Elective endomyocardial biopsy was performed at 6 months unless the subject had undergone cardiac transplantation, with myocardial samples assessed for the presence of exogenous viral DNA from the treatment vector. Safety assessments including ELISPOT were serially performed. Although designed as a 24 subject trial, recruitment was stopped after five subjects had been randomised and received infusion due to the neutral result from the CUPID 2 trial. Here we describe the results from the 5 patients at 3 years follow up, which confirmed that viral DNA was delivered to the failing human heart in 2 patients receiving gene therapy with vector detectable at follow up endomyocardial biopsy or cardiac transplantation. Absolute levels of detectable transgene DNA were low, and no functional benefit was observed. There were no safety concerns in this small cohort. This trial identified some of the challenges of performing gene therapy trials in this LVAD patient cohort which may help guide future trial design.

ENHANCED RECOVERY PROTOCOL FOLLOWING AUTOLOGOUS FREE TISSUE BREAST RECONSTRUCTION

BACKGROUND

Enhanced recovery after surgery (ERAS) aims to achieve earlier recovery, reduced hospital length of stay (LOS) and improved outcomes. Following the introduction of our ERAS protocol, we sought to review our ERAS experience. Our aims were to evaluate the LOS, post-operative complications, discharge analgesia, patient satisfaction and our ERAS protocol compared to the literature.

METHODS

This was a retrospective review of all our prospectively managed database between January 2016 and December 2016. Patient demographics, LOS, discharge analgesia and complications were collected. Patient satisfaction was determined using a 10-point Likert scale questionnaire.

RESULTS

A total of 70 patients underwent breast reconstruction using free deep inferior epigastric artery (DIEP) flaps. The mean age at surgery was 51 years (range 23-71). The mean LOS was 4.89 days (range 4-10). 61 patients (87%) were discharged within 5 days. 65 patients (93%) were discharged home on no controlled opioids. Major and minor complications were encountered in 3 patients (4%) and 5 (7%) patients respectively. There were no cases of complete or partial flap failure. 30-day patient satisfaction was high (&gt;9/10) across all domains but patients complained of nausea & vomiting.

CONCLUSION

The adoption of our enhanced recovery protocol for autologous breast reconstruction has resulted in a mean LOS and opioid use reduction similar to contemporary literature. However, we have seen that there are further refinements that can be made to our ERAS protocol and there is still a need to develop a stronger evidence base to support our practices. This is in parallel with ongoing education and audit cycles to foster a culture of ERAS that can safely optimise patient outcomes.

Internet-delivered cognitive behavioural therapy for post-traumatic stress disorder: systematic review and meta-analysis

OBJECTIVE

To determine whether Internet-delivered cognitive behavioural therapy (i-CBT) is an effective treatment for those who meet diagnostic criteria for post-traumatic stress disorder (PTSD).

METHOD

A systematic review was undertaken according to Cochrane Collaboration Guidelines. The primary outcome measures were reduction in PTSD symptoms and drop-out. Categorical outcomes were meta-analysed as risk ratios (RRs) and continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs).

RESULTS

Ten studies with 720 participants were included. Evidence showed that i-CBT may be associated with a clinically important reduction in post-treatment PTSD symptoms compared with wait list (SMD -0.60, 95% confidence interval -0.97 to -0.24; N = 560); however, only three studies reported follow-up data, and there was no evidence to support the maintenance of symptom improvement at follow-up of 3-6 months. There was no evidence of a difference in PTSD symptoms between i-CBT and Internet-delivered non-CBT post-treatment. There was evidence of greater treatment effect from trauma-focused i-CBT than i-CBT without a trauma focus, as well as evidence that treatment effect was increased by the provision of guidance.

CONCLUSIONS

While the review found some beneficial effects of i-CBT for PTSD post-treatment, the quality of the evidence was very low because of the small number of included trials and there was insufficient evidence to support the maintenance of improvement at follow-up of 3-6 months. Further work is required to establish non-inferiority to current first-line interventions; to determine long-term efficacy; to explore mechanisms of effect; and to establish optimal levels of guidance.

Minimally invasive perinatal and pediatric autopsy with laparoscopically assisted tissue sampling: feasibility and experience of the MinImAL procedure

OBJECTIVE

Less invasive autopsy techniques in cases of fetal or infant death have good acceptability among parents, but the published sampling adequacy in needle biopsy studies is generally poor. Minimally Invasive Autopsy with Laparoscopically assisted sampling (MinImAL) has the potential to increase the diagnostic yield of less invasive autopsy by improving the quality and quantity of tissue samples obtained, whilst permitting visualization, extraction and examination of internal organs through a small incision. The aim of this study was to present the findings of our experience with the MinImAL procedure in cases of fetal, neonatal and pediatric death.

METHODS

This was a retrospective analysis of 103 prospectively recruited unselected cases of fetal, neonatal or pediatric death that underwent the MinImAL procedure at a tertiary referral center over a 5-year period. Following preprocedure 1.5-T whole-body postmortem magnetic resonance imaging, MinImAL autopsy was performed. Procedure duration, sampling adequacy and cause of death were assessed. Chi-square analysis was used to compare the 'unexplained' rate of intrauterine deaths in the cohort with that in a previously published cohort of > 1000 cases of intrauterine death examined by standard autopsy.

RESULTS

MinImAL autopsy was performed successfully in 97.8% (91/93) of the cases undergoing a complete procedure. There was a satisfactory rate of adequate histological sampling in most major organs; heart (100%, 91 cases), lung (100%, 91 cases), kidney (100%, 91 cases), liver (96.7%, 88 cases), spleen (94.5%, 86 cases), adrenal glands (89.0%, 81 cases), pancreas (82.4%, 75 cases) and thymus (56.0%, 51 cases). Procedure duration was similar to that of standard autopsy in a previously published cohort of intrauterine deaths. The unexplained rate in stillbirths and intrauterine fetal deaths that underwent MinImAL autopsy was not significantly different from that following standard autopsy.

CONCLUSIONS

The MinImAL procedure provides good histological yield from major organs with minimal cosmetic damage and can be learned by an autopsy practitioner. The MinImAL procedure is an appropriate minimally invasive alternative for the investigation of perinatal and pediatric deaths in which consent to full autopsy is withheld, and may have applications in both high- and low/middle-income settings. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Locally produced chicken eggs-a source of dietary lead for an Australian community living with an active lead smelter?

The South Australian regional city of Port Pirie has a long history of environmental lead contamination caused by smelting operations that have resulted in elevated blood lead levels in local children. This study examines the potential exposure of children to lead as a result of consuming eggs produced by domestic chickens kept in a lead-contaminated environment. Lead concentrations were measured in eggs, chicken enclosure soil, chicken feed and forage vegetation collected from a domestic site in Port Pirie. Eggs produced in the vicinity of the operating smelter had higher whole-egg lead concentrations (median: 0.09 mg/kg; range: 0.03-0.19 mg/kg) than control eggs (median: 0.002 mg/kg; range: 0.002-0.005 mg/kg). Soil and forage vegetation were identified as potential lead sources for the chickens in this study. The impact of remediating potential lead sources accessed by the chickens was examined and remedial actions were found to be only partly effective with a three-fold reduction in lead concentrations in eggs. Estimated lead intake for a 2-year-old child consuming these eggs indicated that a diet rich in eggs could more than double the child's daily lead exposure from dietary sources. Eggs produced by chickens housed in residential backyards are a readily avoidable additional source of lead exposure for children living in this industrial community, where all environmental lead sources contribute to an unacceptable daily intake.

Hyperlactataemia with acute kidney injury following community assault: cause or effect?

BACKGROUND

Crush injury is a common presenting clinical problem in South African trauma patients, causing acute kidney injury (AKI). It has been theorised previously that the AKI was not due to an anaerobic phenomenon. A previous local study noted the presence of a mild hyperlactataemia among patients with crush syndrome, but the significance and causes of this was not fully explored. This study aimed to examine the incidence of hyperlactataemia in patients with crush syndrome presenting to a busy emergency department (ED) in rural South Africa.

METHOD

The study was conducted at Edendale Hospital in KwaZulu-Natal province in South Africa from 1 June 2016 to 31 December 2017. All patients from the ED who had sustained a crush injury secondary to a mob assault were included in the study. Patients with GCS on arrival of < 13 or polytrauma were excluded from analysis. The primary outcome of interest was the presence of hyperlactataemia (> 2.0mmol/L) on presentation. The Kidney Disease Improving Global Outcomes (KDIGO) criteria were used to diagnose and stage AKI as a secondary outcome.

RESULTS

A total of 84 patients were eligible for analysis. Sixty-nine (82%) patients presented with hyperlactataemia. The median serum lactate was 4.9mmol/L (IQR 2.3-7.2mmol/L). Fifteen (18%) patients were diagnosed with AKI on presentation according to serum creatinine. Ten patients were diagnosed as Stage 1, three were Stage 2 and two Stage 3 AKI respectively. There was no difference in the incidence of AKI in patients with or without hyperlactataemia (p = 0.428). Time from injury to presentation was a median 365 minutes (IQR 180-750 minutes). Six (7%) patients were admitted to high care unit and nine (11%) were admitted to the intensive care unit (ICU). No patients died within 48 hours of admission. Two patients received renal replacement therapy during the first 48 hours of admission to hospital.

CONCLUSION

Hyperlactataemia is a common feature of patients presenting to the ED following crush syndrome secondary to beatings received during interpersonal violence. The origin of this hyperlactataemia is currently unknown. Further research needs to be conducted into the origin of the hyperlactataemia and its clinical significance. In this cohort, the utilisation of RRT was low but the incidence of AKI was high and developed rapidly following the injury. The utilisation of RRT also needs to be further studied in larger patient populations in South Africa to make local clinical recommendations for use.

Availability of less invasive prenatal, perinatal and paediatric autopsy will improve uptake rates: a mixed-methods study with bereaved parents

Objective

To investigate whether less invasive methods of autopsy would be acceptable to bereaved parents and likely to increase uptake.

Design

Mixed methods study.

Setting

Bereaved parents recruited prospectively across seven hospitals in England and retrospectively through four parent support organisations.

Sample

Eight hundred and fifty‐nine surveys and 20 interviews with bereaved parents.

Methods

Cross‐sectional survey and qualitative semi‐structured telephone interviews.

Main outcome measures

Likely uptake, preferences, factors impacting decision‐making, views on different autopsy methods.

Results

Overall, 90.5% of participants indicated that they would consent to some form of less invasive autopsy [either minimally invasive autopsy (MIA), non‐invasive autopsy (NIA) or both]; 53.8% would consent to standard autopsy, 74.3% to MIA and 77.3% to NIA. Regarding parental preferences, 45.5% preferred MIA, 30.8% preferred NIA and 14.3% preferred standard autopsy. Participants who indicated they would decline standard autopsy but would consent to a less invasive option were significantly more likely to have a lower educational level (odds ratio 0.49; 95% CI 0.35–0.70; P = 0.000062). Qualitative findings suggest that parents value NIA because of the lack of any incision and MIA is considered a good compromise as it enables tissue sampling while easing the parental burden associated with consenting to standard autopsy.

Conclusion

Less invasive methods of autopsy are acceptable alternatives for bereaved parents, and if offered, are likely to increase uptake and improve parental experience. Further health economic, validation and implementation studies are now required to assess the viability of offering these in routine widespread clinical care.

Tweetable abstract

Mixed methods UK study finds less invasive methods of autopsy are acceptable alternatives for bereaved parents, and if offered, are likely to increase uptake and improve parental experience.

Mixed methods UK study finds less invasive methods of autopsy are acceptable alternatives for bereaved parents, and if offered, are likely to increase uptake and improve parental experience.