State of research, feasibility, safety, acceptability, and outcomes examined on remotely delivered exercises using technology for older adult with cancer: a scoping review

INTRODUCTION

Technology-based exercise is gaining attention as a promising strategy for increasing physical activity (PA) in older adults with cancer (OACA). However, a comprehensive understanding of the interventions, their feasibility, outcomes, and safety is limited. This scoping review (1) assessed the prevalence and type of technology-based remotely delivered exercise interventions for OACA and (2) explored the feasibility, safety, acceptability, and outcomes in these interventions.

METHODS

Studies with participant mean/median age ≥ 65 reporting at least one outcome measure were included. Databases searched included the following: PubMed, CINAHL, Embase, Cochrane Library Online, SPORTDiscus, and PsycINFO. Multiple independent reviewers completed screening and data abstractions of articles in English, French, and Spanish.

RESULTS

The search yielded 2339 citations after removing duplicates. Following title and abstract screening, 96 full texts were review, and 15 were included. Study designs were heterogeneous, and sample sizes were diverse (range 14-478). The most common technologies used were website/web portal (n = 6), videos (n = 5), exergaming (n = 2), accelerometer/pedometer with video and/or website (n = 4), and live-videoconferencing (n = 2). Over half (9/15) of the studies examined feasibility using various definitions; feasibility outcomes were reached in all. Common outcomes examined include lower body function and quality of life. Adverse events were uncommon and minor were reported. Qualitative studies identified cost- and time-savings, healthcare professional support, and technology features that encourage engagement as facilitators.

CONCLUSION

Remote exercise interventions using technology appear to be feasible and acceptable in OACA.

IMPLICATIONS FOR CANCER SURVIVORS

Some remote exercise interventions may be a viable way to increase PA for OACA.

The radiation dose, clinical and anatomical implications of erect lumbar spine radiography: A single centre pre-post implementation evaluation

INTRODUCTION

Lumbar radiographs remain a common imaging examination despite strategies to reduce their use. Many authors have demonstrated benefits in changing from traditional supine and recumbent lateral projections to a prone and/or erect orientation. Despite evidence of clinical and radiation dose optimisation, widespread adoption of these strategies has stalled. This article describes the single-centre implementation and evaluation of erect PA and lateral projections.

METHOD

This was an observational study pre- and post-implementation of an erect imaging protocol. Patient BMI, image field size, source image and source object distances and DAP were collected together with assessment of radiographic spinal alignment and disc space demonstration. Effective dose was calculated with organ specific doses.

RESULTS

76 (53.5%) patients were imaged in the supine AP and recumbent lateral position, 66 (46.5%) had erect PA and lateral radiographs. Despite the larger BMI of the erect cohort and similar field sizes, effective dose was lower in the PA position by an average of 20% (p < 0.05), however, no significant difference in lateral dose. Anatomical improvements were evident with greater visualisation of intervertebral disc spaces in the PA erect (t = -9.03; p < .001) and lateral (t = -10.298; p < .001) orientations. Erect PA radiographs demonstrated a leg length discrepancy in 47.0% (0.3-4.7 cm) and a scoliosis in 21.2% of cases, with a significant link between these findings (r (64) = 0.44; p < .001).

CONCLUSION

Erect lumbar spine radiography provides information on clinical outcomes not available with recumbent projections. The improvements in anatomical visualisation and radiation dose reduction supports the local change in practice.

IMPLICATIONS FOR PRACTICE

- Erect imaging can reduce effective dose with an optimised acquisition protocol - additional pathological information can be revealed by the erect posture. - postural awareness is critical to interpret images accurately.

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

Patients presenting with acute coronary syndromes have unreported coronary artery calcium on historical CT imaging

Introduction

Ischaemic heart disease (IHD) remains the leading cause of mortality globally1. The presence and extent of coronary artery calcification (CAC) is a strong predictor of cardiovascular events, and CAC scoring has been shown to be more predictive of cardiovascular events than other traditional risk assessment scores2.

Incidental coronary calcification can be detected and quantified on non-gated CT chest scans covering the heart in the field of view3. This finding is typically not reported4 and hence an opportunity to optimise cardiovascular risk assessment and treatment is missed.

Purpose

We sought to investigate whether patients presenting to our centre with an acute coronary syndrome (ACS) event had historical CT imaging demonstrating coronary artery calcification.

Methods

We retrospectively reviewed case records for all patients referred to our centre for an invasive coronary angiogram following their first known admission with an ACS event. ACS were defined according to contemporary guidelines from the European Society of Cardiology. We reviewed a 3 month period prior to the COVID-19 pandemic (01/01/2019–31/03/2019). The national imaging database was interrogated to identify previous CT imaging that includes the heart in the field of view. The presence of coronary calcification was confirmed and quantified using an ordinal scoring method previously described3. The clinical radiology reports for the scans were reviewed to determine the frequency of CAC being reported.

Demographic information was collected from our electronic patient record including the presence of risk factors for IHD. Prescribed medication prior to admission was also recorded using the on-admission medicines reconciliation documented in the electronic patient record.

Results

385 patients with first presentation of ACS were identified. 75 (19%) had a prior non-gated CT chest imaging. The most common indication for CT was for investigation of possible malignancy. The mean interval from CT imaging to ACS admission was 36 months.

CAC was present on 67 (89%) scans. The mean ordinal score was 4.04, corresponding to moderate CAC. The distribution of CAC by coronary artery revealed the majority of disease to involve the left anterior descending artery (Table 1). Only 12/67 (18%) of clinical radiology reports mentioned coronary calcification (Figure 1).

Patients with CAC frequently had additional risk factors for IHD. Despite this only 42% were prescribed antiplatelet therapy, and only 45% prescribed a statin.

Conclusions

A significant proportion of ACS admissions have evidence of CAC on historical CT scans. This finding is often not reported and the majority of patients with demonstrated coronary artery disease are not prescribed appropriate preventative therapies. Systematic reporting of this finding may have a significant impact on the prevention of acute cardiovascular events.

Funding Acknowledgement

Type of funding sources: None. Table 1

Barriers and facilitators related to undertaking physical activities among men with prostate cancer: a scoping review

BACKGROUND

Prostate cancer (PC) and its treatments lead to significant acute, chronic, or latent adverse effects that result in declines in patients' physical functions, quality of life and reduced sense of masculinities. Robust evidence shows that physical activity (PA) can improve many health outcomes in men with PC; however, less is known about the facilitators, preferences, and barriers to PA engagement in this population. The purpose of this scoping review is to document the nature and extent of literature related to these aspects of PA participation among men with PC.

METHODS

We conducted a scoping review of PA among men with PC. Databases searched included Medline, CINAHL, Embase, Rehabilitation & Sports Medicine Source, and SportDiscus from inception to June 30, 2020. Multiple reviewers were used in all screening and data abstractions.

RESULTS

The search yielded 2788 individual citations after duplicates were removed. Following title and abstract screening, 129 underwent full-text review, and 46 articles were included. Quantitative data related to our research question showed that structured group exercise was the most commonly reported facilitator/preference among men with PC, whereas treatment-related effects and lack of time are the most common barriers. In terms of qualitative data, the most prominent theme noted related to masculinities and gender-specific needs within the context of having PC.

CONCLUSION

Men with PC have unique facilitators and barriers concerning PA. More work is needed from the research and clinical practice perspectives to enable this population to engage and remain in regular PA.

Calibration of an in-situ fluorescence-based sensor platform for reliable BOD5 measurement in wastewater

Reliance on biochemical oxygen demand (BOD₅) as an indicator of wastewater quality has hindered the development of efficient process control due to the associated uncertainty and lag-times. Surrogate measurements have been proposed, with fluorescence spectroscopy a promising technique. Yet, assessment of in-situ fluorescence sensors across multiple wastewater treatment plants (WwTPs), and at different treatment stages, is limited. In this study a multi-parameter sonde (two fluorescence peaks, turbidity, temperature and electrical conductivity) was used to provide a BOD₅ surrogate measurement. The sonde was deployed at three WwTPs, on post primary settlement tanks (PST) and final effluent (FE). Triplicate laboratory measurements of BOD₅, from independent laboratories were used to calibrate the sensor, with high variability apparent for FE samples. Site and process specific sensor calibrations yielded the best results (R²_cv = 0.76-0.86; 10-fold cross-validation) and mean BOD₅ of the three laboratory measurements improved FE calibration. When combining PST sites a reasonable calibration was still achieved (R²_cv = 0.67) suggesting transfer of sensors between WwTPs may be possible. This study highlights the potential to use online optical sensors as robust BOD₅ surrogates in WwTPs. However, careful calibration (i.e. replicated BOD₅ measurements) is required for FE as laboratory measurements can be associated with high uncertainty.

Falls in older adults with cancer: an updated systematic review of prevalence, injurious falls, and impact on cancer treatment

PURPOSE

This update of our 2016 systematic review answers the following questions: (1) How often do older adults with cancer fall? (2) What are the predictors for falls? (3) What are the rates and predictors of injurious falls? (4) What are the circumstances and outcomes of falls? (5) How do falls in older patients affect subsequent cancer treatment? and a new research question, (6) Which fall reduction interventions are efficacious in this population?

METHODS

MEDLINE, PubMed, CINAHL, and Embase were searched (September 2015-January 25, 2019). Eligible studies included clinical trials and cohort, case-control, and cross-sectional studies published in English in which the sample (or subgroup) included adults aged ≥ 60, with cancer, in whom falls were examined as an outcome.

RESULTS

A total of 2521 titles were reviewed, 67 full-text articles were screened for eligibility, and 30 new studies were identified. The majority involved the outpatient setting (n = 19) utilizing cross-sectional method (n = 18). Sample size ranged from 21 to 17,958. Fall rates ranged from 1.52 to 3.41% per 1000 patient days (inpatient setting) and from 39%/24 months to 64%/12 months (outpatient setting). One out of the 6 research questions contributed to a new finding: one study reported that 1 in 20 older patients experienced impact on cancer treatment due to falls. No consistent predictors for falls/fall injuries and no studies on fall reduction interventions in the geriatric oncology setting were identified.

CONCLUSION

This updated review highlights a new gap in knowledge pertaining to interventions to prevent falls. Additionally, new knowledge also emerged in terms of impact of falls on cancer treatment; however, further research may increase generalizability. Falls and fall-related injuries are common in older adults with cancer and may affect subsequent cancer treatment. Further studies on predictors of falls, subsequent impacts, and fall reduction in the oncology setting are warranted.

High frequency fluorescence monitoring reveals new insights into organic matter dynamics of an urban river, Birmingham, UK

Natural organic matter (NOM) is fundamental to many biogeochemical processes in river ecosystems. Currently, however, we have limited knowledge of NOM dynamics across the spectrum of flow conditions as previous studies have focused largely on storm events. Field deployable fluorescence technology offers new opportunities to explore both stochastic and predictable diel NOM dynamics at finer time-steps and for longer periods than was hitherto possible, thus yielding new insight into NOM sources, processing, and pathways. Hourly fluorescence data (humic-like fluorescence [Peak C] and tryptophan-like fluorescence [Peak T]) and a suite of hydro-climatological variables were collected from an urban river (Birmingham, UK). We explored monthly concentration-discharge (C-Q) patterns using segmented regression and assessed hysteretic and flushing behaviour for Peak C, T and turbidity to infer source zone activation. Diel patterns were assessed during low flow periods. Wavelet analysis identified strong diurnal variations in Peak C with early morning peaks while no diel dynamics were apparent for Peak T. Using generalised linear modelling relationships between Peak C periodicity and both solar radiation and time since previous storm/scouring event were identified. Breakpoints and positive slopes for C-Q relationship highlighted chemodynamic behaviour for NOM over most of the monitoring period, with Peak T mobilised more relative to Peak C during high Q. Hysteresis patterns were highly variable but flushing behaviour of Peak T and C suggested exhaustion of humic compounds during long duration events and following successive rainfall events. Peak T flushing was correlated with Q magnitude highlighting the potential for combined sewer overflows to act as important NOM sources despite significant dilution potential. This research highlights the potential of real-time, field deployable fluorescence spectroscopy as a viable method for providing insight into diel and transport driven NOM dynamics.

Effect of timing of postweaning xylanase supplementation on growth performance, nutrient digestibility, and fecal microbial composition in weanling pigs

Effect of timing of xylanase supplementation to weanling pigs and its effect on growth performance, nutrient digestibility, and fecal microbiota was investigated. A total of 128 weanling pigs [(Hampshire × Duroc) × (Yorkshire × Landrace); 6.2 ± 0.6 kg body weight (BW); weaning age: 21 d] were assigned to four treatments, with eight replicate pens and four pigs per pen. Treatments were a combination of two dietary treatments (without or with xylanase) in two periods; (period 1, days 0–14) and period 2 (days 14–42): xylanase–xylanase, xylanase–control, control–xylanase, and control–control. Fecal microbiota diversity and apparent total tract digestibility (ATTD) were determined. From days 0–14, pigs had lower (P < 0.01) BW, average daily gain (ADG), and feed efficiency when xylanase was included in the diets. The final BW (P < 0.05) and overall ADG (P < 0.02) at day 42 were greater when xylanase was supplemented from day 14 compared with supplementation from day 0. The apparent ileal digestibility and ATTD of dry matter, gross energy, nitrogen, and phosphorus were increased (P < 0.05) by xylanase. Xylanase significantly decreased (P < 0.05) the relative abundance of Veillonella spp. and tended (P = 0.08) to decrease the relative abundance of Megasphaera spp. in period 2 compared with the non-supplemented group.

Psychosocial, psychiatric and work-related risk factors associated with suicide in Ireland: optimised methodological approach of a case-control psychological autopsy study

BACKGROUND

Suicide has profound effects on families and communities, but is a statistically rare event. Psychological autopsies using a case-control design allow researchers to examine risk factors for suicide, using a variety of sources to detail the psychological and social characteristics of decedents and to compare them to controls. The Suicide Support and Information System Case Control study (SSIS-ACE) aimed to compare psychosocial, psychiatric and work-related risk factors across three groups of subjects: suicide decedents, patients presenting to hospital with a high-risk self-harm episode, and general practice controls.

METHODS

The study design includes two inter-related studies; one main case-control study: comparing suicide cases to general practice (GP) controls, and one comparative study: comparing suicide cases to patients presenting with high-risk self-harm. Consecutive cases of suicide and probable suicide are identified through coroners' registration of deaths in the defined region (Cork City and County, Ireland) and are frequency-matched for age group and gender with GP patient controls recruited from the same GP practice as the deceased. Data sources for suicide cases include coroners' records, interviews with health care professionals and proxy informants; data sources for GP controls and for high-risk self-harm controls include interviews with control, with proxy informants and with health care professionals. Interviews are semi-structured and consist of quantitative and qualitative parts. The quantitative parts include a range of validated questionnaires addressing psychiatric, psychosocial and occupational factors. The study adopts several methodological innovations, including accessing multiple data sources for suicide cases and controls simultaneously, recruiting proxy informants to examine consistency across sources.

CONCLUSIONS

The study allows for the investigation of consistency across different data sources and contributes to the methodological advancement of psychological autopsy research. The study will also inform clinical and public health practice. The comparison between suicide cases and controls will allow investigation of risk and protective factors for suicide more generally, while the comparison with high-risk self-harm patients will help to identify the factors associated specifically with a fatal outcome to a self-harm episode. A further enhancement is the particular focus on specific work-related risk factors for suicide.

Counselling in Primary Care – A General Practitioner’s Perspective

Introduction Counselling in Primary care (CIPC) is a new service introduced by the HSE in 2013, providing short-term counselling for medical-card holders, suffering from mild to moderate mental health problems. Aims To explore GP’s views on CIPC for the treatment of mild to moderate mental health disorders. Methods Qualitative semi-structured interviews were conducted with GPs who had previously utilized the CIPC service in the Cork/ Kerry region. Forty GPs were identi􀂡ed and sent invitation letters. GPs were purposefully sampled based on criteria of location (urban/rural), gender, practice size (single handed/group) and length of time quali􀂡ed. A total sample size was generated using the ‘ten plus three’ method. Interviews were carried out in person, transcribed verbatim and analyzed using the framework analysis method. Results Nineteen GPs were interviewed. Core themes emerged and were analyzed. 1. GPs unanimously agreed that CIPC has been of bene􀂡t in treating mild to moderate mental health disorders. 2. Suggested improvements to the service were made, including allowing GP visit card holders to avail of the service (n=10) and adolescents aged between 16 and 18 (n=5). 3. A majority (n=12) of GPs interviewed expressed the opinion that a combination of talk therapy and medication was associated with the best outcomes in treating mild to moderate mental health disorders. Conclusion CIPC seems to improve mental health services at a primary care level. While improvements can certainly be made to the service, GPs report positive patient outcomes and a reduction in psychiatric referrals for patients who can be suitably managed within the community.

Short-term changes observed in multiparametric liver MRI following therapy with direct-acting antivirals in chronic hepatitis C virus patients

Methods

We applied multiparametric MRI to assess changes in liver composition, perfusion and blood flow in 17 patients before direct-acting antiviral (DAA) therapy and after treatment completion (within 12 weeks of last DAA tablet swallowed).

Results

We observed changes in hepatic composition indicated by a reduction in both liver longitudinal relaxation time (T1, 35 ± 4 ms), transverse relaxation time (T2, 2.5 ± 0.8 ms; T2* 3.0 ± 0.7 ms), and liver perfusion (28.1 ± 19.7 ml/100 g/min) which we suggest are linked to reduced pro-inflammatory milieu, including interstitial oedema, within the liver. No changes were observed in liver or spleen blood flow, splenic perfusion, or superior mesenteric artery blood flow.

Conclusion

For the first time, our study has shown that treatment of HCV with DAAs in patients with cirrhosis leads to an acute reduction in liver T1, T2 and T2* and an increase in liver perfusion measured using MR parameters. The ability of MRI to characterise changes in the angio-architecture of patients with cirrhosis after intervention in the short term will enhance our understanding of the natural history of regression of liver disease and potentially influence clinical decision algorithms.

Key Points

• DAAs have revolutionised the treatment of hepatitis C and achieve sustained virological response in over 95% of patients, even with liver cirrhosis.

• Currently available non-invasive measures of liver fibrosis are not accurate after HCV treatment with DAAs, this prospective single-centre study has shown that MRI can sensitively measure changes within the liver, which could reflect the reduction in inflammation with viral clearance.

• The ability of MRI to characterise changes in structural and haemodynamic MRI measures in the liver after intervention will enhance our understanding of the progression/regression of liver disease and could potentially influence clinical decision algorithms.

Knowledge is power: general practitioners prescribing of new oral anticoagulants in Ireland

OBJECTIVE

New oral anticoagulants (NOACs) aim to overcome warfarin's shortcomings, however their pharmacokinetic characteristics make prescribing complex. Thus it is imperative that general practitioners (GPs) are aware of specific treatments so as to maximise their benefits and minimise their pitfalls. This study explores GPs attitudes and experiences with prescribing NOACs in Ireland where, despite clear national prescribing guidelines advocating warfarin as first line therapy, the number of patients being prescribed NOACs for the first time is growing.

RESULTS

Using primary data collected from GPs in Ireland the factors influencing the likelihood of a GP initiating a prescription for a NOAC are determined using a probit model. Results indicate 46% of the sample initiated NOAC prescriptions and GP practice size is a significant factor influencing this. Analysis revealed no difference regarding the sources of information considered important amongst GPs when prescribing new drugs. However, there were differences in which factors were considered important when prescribing anticoagulants between initiating and non-initiating NOAC prescribers. The results of this study suggest better utilisation of existing information and education tools for GPs prescribing NOACs and managing NOAC patients is imperative, to ensure the right anticoagulant is prescribed for the right patient at the right time.

Fragmented palmar metacarpophalangeal sesamoids in dogs: a long-term evaluation

Long-term clinical and radiographicresponse to surgical and conservativemanagement of 22 dogs with fragmentedsesamoids was evaluated. Mean follow-up was 3.6 years (range = 3 monthsto 11.0 years).

Initial (retrospective) and follow-up(prospective) radiographs of the affectedpalmar sesamoids and associatedmetacarpophalangeal joints were evaluatedusing a graded scoring system. A lameness evaluation and physicalexamination were performed at followupin a blinded manner. In addition,owners were asked to complete a questionnaireregarding their pet’s thoraciclimb lameness.

There was not any difference betweengroups (sesamoidectomy, conservativemanagement, incidental finding)in age at onset, duration of lamenessprior to therapy, body weight at treatment, time to follow-up, number ofaffected joints, nor owner perceptionsof whether they thought the lamenessimproved, resolved, or recurred, andwhether or not they were pleased withthe outcome.

Sesamoid fragmentation treated bysesamoidectomy resulted in significantlygreater progression of radiographicchanges that were consistentwith degenerative joint disease.

Chronic lameness resolved or improvedto the point of owner satisfactionwith conservative therapy in most cases. Continued lameness, or recurrent,although improved lameness associatedwith heavy activity, occurred followingsurgical extirpation of the affectedsesamoids in many cases. Given thesefindings, a more conservative approachto the treatment of chronic lamenessassociated with sesamoid fragmentationmay be warranted.

Long-term clinical and radiographic response to surgical and conservative management of 22 dogs with fragmented sesamoids was evaluated. Mean follow-up was 3.6 years. Sesamoid fragmentation treated by sesamoidectomy resulted in significantly greater progression of radiographic changes that were consistent with degenerative joint disease. Chronic lameness resolved or improved to the point of owner satisfaction with conservative therapy in most cases. Continued or recurrent lameness was common following sesamoidectomy. Conservative therapy should be attempted prior to sesamoidectomy for dogs with chronic lameness associated with palmar metacarpophalangeal sesamoid fragmentation.

Costs of potentially inappropriate medication use in residential aged care facilities

Background

The potential harms of some medications may outweigh their potential benefits (inappropriate medication use). Despite recommendations to avoid the use of potentially inappropriate medications (PIMs) in older adults, the prevalence of PIM use is high in different settings including residential aged care. However, it remains unclear what the costs of these medications are in this setting. The main objective of this study was to determine the costs of PIMs in older adults living in residential care. A secondary objective was to examine if there was a difference in costs of PIMs in a home-like model of residential care compared to an Australian standard model of care.

Methods

Participants included 541 participants from the Investigation Services Provided in the Residential Environment for Dementia (INSPIRED) Study. The INSPIRED study is a cross-sectional study of 17 residential aged care facilities in Australia. 12 month medication costs were determined for the participants and PIMs were identified using the 2015 updated Beers Criteria for older adults.

Results

Of all of the medications dispensed in 1 year, 15.9% were PIMs and 81.4% of the participants had been exposed to a PIM. Log-linear models showed exposure to a PIM was associated with higher total medication costs (Adjusted β = 0.307, 95% CI 0.235 to 0.379, p < 0.001). The mean proportion (±SD) of medication costs that were spent on PIMs in 1 year was 17.5% (±17.8) (AUD$410.89 ± 479.45 per participant exposed to a PIM). The largest PIM costs arose from proton-pump inhibitors (34.4%), antipsychotics (21.0%) and benzodiazepines (18.7%). The odds of incurring costs from PIMs were 52% lower for those residing in a home-like model of care compared to a standard model of care.

Conclusions

The use of PIMs for older adults in residential care facilities is high and these medications represent a substantial cost which has the potential to be lowered. Further research should investigate whether medication reviews in this population could lead to potential cost savings and improvement in clinical outcomes. Adopting a home-like model of residential care may be associated with reduced prevalence and costs of PIMs.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0704-8) contains supplementary material, which is available to authorized users.

Cholangitis and Cholangiohepatitis in Dogs: A Descriptive Study of 54 Cases Based on Histopathologic Diagnosis (2004-2014)

Background

Cholangitis in dogs appears to be more common than previously thought, but understanding of the disease remains incomplete.

Objective

To describe a population of dogs with cholangitis or cholangiohepatitis.

Animals

Fifty‐four client‐owned dogs with cholangitis or cholangiohepatitis.

Methods

Medical records of dogs with cholangitis or cholangiohepatitis confirmed by histopathology between January 2004 and December 2014 were identified using a computer‐based search and retrospectively reviewed.

Results

Clinical signs included vomiting (72.2%), lethargy (70.4%), and inappetence (64.8%). Most dogs (49/50) had increased liver enzyme activities, hyperbilirubinemia (32/50), and hypercholesterolemia (24/43). Ultrasonographic abnormalities of the hepatobiliary system were seen in 84% of cases. On histopathology, 53 of 54 affected dogs had neutrophilic cholangitis (NC) or cholangiohepatitis, whereas 1 dog had lymphocytic cholangitis. Most cases (42/54) were chronic. Evidence of concurrent biliary disease (46.2%) and biliary tract obstruction (42.6%) was common. Seventeen of 36 biliary and 11 of 25 liver cultures were positive for bacterial growth; Escherichia coli and Enterococcus spp. were most common. Median patient survival was 671 days (95% confidence interval [CI]: 114–1,426). On Cox regression, dogs that did not have a cholecystectomy performed had a 2.1 greater hazard for death (P = 0.037; 95% CI: 1.0–4.3) compared to cholecystectomized dogs. Dogs >13 years old had a 5.0 greater hazard for death (P = 0.001; 95% CI: 1.9–13.2) compared to younger dogs.

Conclusions and Clinical Significance

Chronic NC or cholangiohepatitis was most common. Cholecystitis and biliary tract obstruction often occurred in conjunction with cholangitis. Cholecystectomized dogs had decreased risk of death; thus, cholecystectomy may improve patient outcome.

Adhesion of Oxides Grown in Supercritical Water on Selected Austenitic and Ferritic/Martensitic Alloys

A series of austenitic alloys (800H, H214, I625, 310S, and 347) with different surface finishes were exposed to supercritical water (SCW) at 550 °C and 2.5 × 107 Pa for 120 h, 260 h, and 450 h in a static autoclave with an initial level of dissolved oxygen of 8 ppm. Indentation with a hardness indenter was used for assessment of oxide adhesion. This was compared with the results of a similar test on SCW-oxidized ferritic alloys. Delamination in all the tested ferritic alloys was insufficient for quantification of the results but allowed for qualitative comparison within this group. In the set of austenitic alloys, oxide on stainless steel (SS) 347 exfoliated during cooling from 550 °C, and from the remaining four alloys, only oxide on H214 delaminated, which made the qualitative comparison across the whole group impossible. Energy dispersive X-ray spectroscopy (EDX) revealed that under delaminated external Cr2O3 on H214 alloy, there was a submicron thick layer of Al-rich oxide. To investigate a possible oxide spallation on austenitic samples during exposure, mass loss obtained through descaling was compared with mass gain due to SCW exposure. The results indicated that the applied descaling procedure did not, in most cases, fully remove the scale. Apart from one case (SS 347 with alumina surface finish), there was no clear indication of oxide spallation.

Validation of Constant Load C-Ring Apex Stresses for Stress Corrosion Cracking Testing in Supercritical Water

In selecting the materials for the Canadian supercritical water-cooled reactor (SCWR), the effects and extent of stress corrosion cracking (SCC) on candidate alloys of construction, under various operational conditions, must be considered. Several methods of applying stress to a corroding material are available for investigating SCC and each have their benefits and drawbacks; for simplicity of the experimental setup at University of New Brunswick (UNB), a constant load C-ring assembly has been used with Inconel 718 Belleville washers acting as a spring to deliver a near-constant load to the sample. To predict the stress at the apex of the C-ring, a mechanistic model has been developed to determine the force applied by the spring due to the thermal expansion of each component constrained within a fixed length when the temperature of the assembly is increased from ambient conditions to SCWR operational temperatures. In an attempt to validate the mechanistic model, trials to measure the force applied by the washers as the assembly thermally expanded were performed using an Instron machine and an environmental chamber. Accounting for the thermal expansion of the pull rods, the force was measured as temperature was increased while maintaining a constant displacement between the platens holding the C-ring. Results showed the initial model to be insufficient as it could not predict the force measured through this simple experiment. The revised model presented here considers the thermal expansion of the C-ring and all the components of the testing apparatus including the tree, backing washers, and Belleville washers. Further validation using the commercial finite element (FE) package abaqus is presented, as are preliminary results from the use of the apparatus to study the SCC of a zirconium-modified 310 s SS exposed to supercritical water.

Quality of life, symptoms and treatment satisfaction in patients with aortic aneurysm using new abdominal aortic aneurysm-specific patient-reported outcome measures

Background

The aim of this study was to present preliminary data on quality of life (QoL), symptoms and treatment satisfaction gathered using three new abdominal aortic aneurysm (AAA)-specific patient-reported outcome measures (PROMs).

Methods

Patients with AAA were recruited from five National Health Service Trusts to complete the three new PROMs: the AneurysmDQoL, AneurysmSRQ and AneurysmTSQ. Patients were either under surveillance or had undergone AAA repair (open or endovascular) during the preceding 24 months. Data were initially collected as part of a study assessing the psychometric properties of the new measures, before being used in the observational analysis of outcomes presented here.

Results

Results, although largely non-significant, showed interesting trends. The impact of AAA repair on QoL appeared to worsen progressively after open repair (OR) and improve progressively after endovascular aneurysm repair (EVAR). Conversely, symptoms seemed to become progressively worse after EVAR and progressively better after OR. Information and understanding were key sources of dissatisfaction before the intervention, whereas postoperative dissatisfaction was related to bother from symptoms, follow-up and feedback about scan results.

Conclusion

Although a larger, prospective data set is necessary to explore outcomes more fully with the new AAA-specific PROMs, the observational data presented here suggest there may be clinically important differences in the symptoms, impact on QoL and treatment satisfaction associated with OR and EVAR.

Design of new patient-reported outcome measures to assess quality of life, symptoms and treatment satisfaction in patients with abdominal aortic aneurysm

Background

No condition-specific patient-reported outcome measures exist for patients with abdominal aortic aneurysm (AAA). The aim of this work was to develop three questionnaires to assess quality of life (QoL), symptoms and treatment satisfaction in patients with AAA.

Methods

Semistructured interview techniques were used to explore patients' experiences of having an AAA in a series of focus groups and in-depth interviews. The information gathered was used to inform design and selection of items for the new tools; the overall structure of the new questionnaires was based on tools developed previously for patients with diabetes and other conditions.

Results

Fifty-four patients (51 men, 3 women; mean age 71·9 years) were recruited from four NHS Trusts to participate in focus groups or interviews, either while under surveillance, or following AAA repair (using open or endovascular techniques). The Aneurysm-Dependent Quality of Life Questionnaire (AneurysmDQoL) is an individualized measure of the impact of AAA on patients' QoL. Twenty-three domains were chosen specifically for their relevance to patients with AAA, with a further two overview items to assess overall QoL and the impact of AAA on QoL. The Aneurysm Symptom Rating Questionnaire (AneurysmSRQ) is a 44-item measure assessing physical and psychological symptoms reported by patients with AAA. The Aneurysm Treatment Satisfaction Questionnaire (AneurysmTSQ) contains 11 items, suitable for patients before and after surgical intervention.

Conclusion

The iterative development process reported here has confirmed that these three new tools have good face and content validity for patients with AAA.

Hypoglycaemic episodes in patients with type 2 diabetes--risk factors and associations with patient-reported outcomes: The PANORAMA Study

AIM

To explore the frequency of hypoglycaemic episodes, their risk factors, and associations with patient-reported outcomes in patients with type 2 diabetes enrolled in the PANORAMA cross-sectional study.

METHODS

Five thousand seven hundred and eighty-three patients aged ≥ 40 years with type 2 diabetes duration ≥ 1 year were recruited in nine European countries. Patients reported severe and non-severe hypoglycaemic episodes during the past year at a single study visit. Patient-reported outcomes were measured by the Audit of Diabetes-Dependent Quality of Life, Diabetes Treatment Satisfaction Questionnaires, Hypoglycaemia Fear Survey-II, and EQ-5D Visual Analog Scale.

RESULTS

During the previous year, 4.4% of the patients experienced ≥ 1 severe hypoglycaemic episode; among those without severe hypoglycaemia, 15.7% experienced ≥ 1 non-severe episode. Patients experiencing any hypoglycaemic episode reported a greater negative impact of diabetes on quality of life, greater fear of hypoglycaemia, less treatment satisfaction and worse health status than those with no episodes. In multivariate analyses hypoglycaemia was significantly associated with longer diabetes duration; presence of microvascular and, to a lesser extent, macrovascular complications; treatment with insulin, glinides or sulfonylureas; and use of self-monitoring blood glucose.

CONCLUSION

In patients with type 2 diabetes, severe hypoglycaemic episodes were not uncommon and one in five experienced some form of hypoglycaemia during the previous year. Hypoglycaemia was associated with more negative patient-reported outcomes. The risk of hypoglycaemia increased with diabetes duration, presence of diabetes-related complications, use of self-monitoring blood glucose, insulin secretagogues, and insulin treatment.