Lived experience of work and long COVID in healthcare staff

BACKGROUND

Healthcare workers (HCWs) had a greater occupational risk of exposure to coronavirus disease 2019 (COVID-19) and reported higher rates of long COVID (LC). This has implications for the provision of health care in already stretched health services.

AIMS

This study explored the impact of LC on a range of UK National Health Service (NHS) HCWs, their health and well-being, the effect on work patterns, and occupational support received.

METHODS

Mixed-methods study, online survey and qualitative interviews. Participants self-reporting LC symptoms were recruited through social media and NHS channels. Interviews used maximum variation sampling of 50 HCWs including healthcare professionals, ancillary and administration staff. Thematic analysis was conducted using NVivo software.

RESULTS

A total of 471 HCWs completed the online survey. Multiple LC symptoms were reported, revealing activity limitations for 90%. Two-thirds had taken sick leave, 18% were off-work and 33% reported changes in work duties. There were few differences in work practices by occupational group. Most participants were working but managing complex and dynamic symptoms, with periods of improvement and exacerbation. They engaged in a range of strategies: rest, pacing, planning and prioritizing, with work prioritized over other aspects of life. Symptom improvements were often linked to occupational medicine, managerial, colleague support and flexible workplace adjustments.

CONCLUSIONS

LC has a significant impact on the lives of HCWs suffering prolonged symptoms. Due to the variability and dynamic nature of symptoms, workplace support and flexible policies are needed to help retain staff.

Accuracy of Electron Density Mapping of a Novel kVCBCT System Designed for Planning

PURPOSE/OBJECTIVE(S)

A recently developed advanced kVCBCT system, designed for simulation and planning, includes improvements to the imaging panel and reconstruction technique, enabling more accurate electron density mapping than a typical CBCT. This study investigates the accuracy, limitations, and dosimetric impact of this new system.

MATERIALS/METHODS

CBCT images were taken of both large (pelvis) and small (head) electron density phantoms with inserts ranging from lung (0.29) to cortical bone (1.69). Images were taken with several pre-set protocols with energies of 125 kVp and 140 kVp. The effects of longitudinal buildup (for scatter due to the cone-beam geometry) and blade position were also investigated. The HU values of each insert were measured over a small region of interest. Several electron density curves were generated - pelvis protocol on the large phantom, head protocol on the small phantom, and average - and imported into a treatment planning system. Dose calculation was performed using each curve and differences were observed.

RESULTS

HU to electron density mapping was sensitive to the use of longitudinal buildup and blade position, with differences in the curves observed at both low and high electron densities, due to imager saturation effects not found in typical clinical scenarios. Subsequent studies used both longitudinal buildup and fully opened blades. Under these conditions, mapping was not sensitive to technique or phantom size at low electron densities. At higher values, the curves diverged, with the head protocol showing higher HU values and the pelvis protocol showing lower. The average curve matched very closely with the curve from our standard CT simulator. Dose calculation showed little dependence on the curve chosen, with max point dose differences of 1.2% between the pelvis and average scans, though most of the plan was <0.5% different. Results for the head protocol were similar.

CONCLUSION

The system provides reliable HU values comparable to a CT simulator, though it is important to consider the effects of imager saturation by choosing appropriate scatter and collimation. The calibration is slightly sensitive to the choice of phantom size and beam energy, though these differences led to negligible (<0.5%) differences in dose calculation accuracy.

ACR Accreditation of a Novel Linac-Based kV-CBCT System on a High-Speed Ring-Gantry

PURPOSE/OBJECTIVE(S)

An advanced kV-CBCT imaging system mounted on a high-speed ring-gantry Linac has recently been introduced, offering improved imaging hardware and reconstruction software to produce high quality CBCT images usable for treatment planning. Imaging performance of the system was assessed using the American College of Radiology (ACR) accreditation designed for diagnostic CT systems, additionally comparing its results to pre-existing diagnostic CT and Linac-based CBCT systems.

MATERIALS/METHODS

All imaging protocols on the novel imaging system were scanned with the ACR head phantom and evaluated using ACR recommended testing and passing criteria. ACR image quality parameters include contrast-to-noise ratio (CNR), spatial resolution, HU accuracy, image scaling, and HU uniformity. CNR ≥1.0 for adult head and body, ≥0.7 for pediatric head, and ≥0.4 for pediatric body imaging protocols pass ACR criteria. Spatial resolution ≥6 line-pairs/cm for head and ≥5 line-pairs/cm for body protocols pass ACR criteria. HU accuracy passing criteria includes acrylic (110 to 135 HU), air (-1005 to -970 HU), bone (850 to 970 HU), polyethylene (-107 to -84 HU), and water (-7 to 7 HU). Image scaling measurements with errors ≤5% and HU uniformity maximum differences ≤5 HU pass ACR criteria. For machine cross-comparisons, adult Head and Pelvis imaging protocols were acquired on an existing diagnostic CT and 2 Linac-based CBCT systems (1 traditional C-arm and 1 ring-gantry) and analyzed with the same ACR methodology and passing criteria, with passing rates compared.

RESULTS

On the novel imaging system, all standard patient size imaging protocols using 125 kVp (Head, H&N, Thorax, Thorax Slow, Breast, Abdomen, Pelvis, Pediatric Head, and Pediatric Abdomen) passed all ACR criteria; while 2 larger patient focused imaging protocols using 140 kVp (Abdomen Large and Pelvis Large) produced minor deviations on HU uniformity (maximum differences of 5 - 7 HU) but passed all other ACR criteria. The novel system matched passing rates of a diagnostic CT simulator, and outperformed pre-existing Linac based CBCT imaging systems.

CONCLUSION

This newly developed advanced imaging system produces high quality images, meeting diagnostic CT ACR recommendations and far surpassing the CBCT image quality currently available on pre-existing Linacs.

Transatlantic progress in measurement of cognitive outcomes in paediatric oncology trials

The importance of measuring quality of survival within paediatric oncology trials is increasingly recognised. However, capturing neuropsychological outcomes and other aspects of quality of survival in the context of large or multinational trials can be challenging. We provide examples of protocols designed to address this challenge recently employed in clinical trials in the USA and Europe. We discuss their respective strengths and challenges, obstacles encountered and future opportunities for transatlantic collaboration.

QOL-28. Clinico-molecular correlates of quality of survival and neurocognitive outcomes in medulloblastoma; a meta-analysis of the SIOP-UKCCSG-PNET3 and HIT-SIOP-PNET4 trials

Determinants of survivorship outcomes are emerging from limited studies of medulloblastoma (MB) survivors. We undertook an integrated analysis of biological (tumour group, host genetics) and clinico-demographic features in patients treated on the SIOP-UKCCSG-PNET3 and HIT-SIOP-PNET4 clinical trials with available quality of survival (QoS) data (n=218), to determine key correlates of survivorship, and their clinical potential. Treatment/demographic factors and molecular subgroup (MBWNT, MBSHH, MBGrp3, MBGrp4) were assessed against health status, behavioural functioning, and health-related quality of life (HrQoL). In DNA from HIT-SIOP-PNET4 (n=74), 39 candidate SNPs with known modifying effects on neurocognitive outcomes (e.g., involved in oxidative stress/inflammation) were genotyped and assessed against Wechsler Intelligence Scale (WISC) scores. As expected, MBSHH was associated with improved HrQoL, but subgroup did not associate further with QoS outcomes. SIOP-UKCCSG-PNET3 patients receiving chemotherapy before craniospinal irradiation (CSI) had significantly lower health status (p=0.021) and behavioural functioning (p&lt;0.016) compared to patients treated with CSI alone, and those treated on both arms (maintenance chemotherapy and hyperfractionated (36Gy) or standard (23.4Gy) CSI) of HIT-SIOP-PNET4. SIOP-UKCCSG-PNET3 patients receiving CSI-only had better HrQoL scores than those who received pre-CSI chemotherapy and both HIT-SIOP-PNET4 arms (p=0.004). Females reported worse HrQoL/behavioural functioning across both trials (p&lt;0.04). In HIT-SIOP-PNET4, longer intervals from diagnosis to CSI predicted worse HrQoL/health status (p&lt;0.05). Neither molecular group nor clinico-demographic features tested were associated with neurocognition. In contrast, 6 SNPs significantly associated with ≥1 WISC domain; 4/6 showed multiple associations and were independently prognostic; further associations were apparent at the gene/pathway level. This large, integrated and multi-disciplinary analysis of two independent trials cohorts has revealed multiple factors predictive of medulloblastoma survivorship including treatment (chemotherapy, time to CSI), tumour (molecular group) and host genetic factors. Assessment in further prospective series are required to determine their potential as a basis for modifications to disease management.

248 Urethral Self-Insertion of a USB Cable as Sexual Experimentation: A Case Report

Introduction

The insertion of a foreign body in the urethra is an uncommon urological emergency. A wide variety of inserted objects have been described, presenting either asymptomatically or with lower abdominal discomfort and lower urinary tract symptoms. Sexual experimentation and gratification as well as mental disorders are considered the main underlying causes. The aim of this report is to present the case of a USB wire self-insertion and its challenging urological management.

Case Presentation

A 15-year-old male patient presented to his local Accident and Emergency department with gross haematuria following self-insertion of the knotted cable of a USB wire into his urethra in the context of sexual experimentation. Endoscopic approach via rigid cystoscopy and optical urethrotomy was not effective. A suprapubic catheter was inserted, and the patient was urgently transferred to our hospital for tertiary management.

Following radiological assessment to confirm the position of the wire, a longitudinal peno-scrotal incision over the palpable foreign body was made. Urethrotomy revealed the knotted cable in the proximal aspect of the penile urethra, which was cut and removed. Urethra was subsequently closed over a urethral catheter. Postoperative recovery was uneventful, and patient was discharged home with oral antibiotics. Urethral catheter was removed following normal fluoroscopic assessment of the urethra two weeks later.

Conclusions

The management of a foreign urethral body can be challenging and usually requires tertiary expertise to achieve optimal outcomes. Poor initial management could potentially lead to devastating long-term complications such as urethral strictures and fistulas.

Augmented-reality telementoring for leg fasciotomy: a proof-of-concept study

BACKGROUND

Prolonged field care is required when casualty evacuation to a surgical facility is delayed by distance, weather or tactical constraints. This situation can occur in both civilian and military environments. In these circumstances, there are no established treatment options for extremity compartment syndrome. Telementoring by a surgeon may enable the local clinician to perform a fasciotomy to decompress the affected compartments.

METHODS

Six military clinicians were asked to perform a two-incision leg fasciotomy in synthetic models under the guidance of an orthopaedic surgeon located 380 km away. Communication occurred through commercially available software and smartglasses, which also allowed the surgeon to send augmented-reality graphics to the operators. Two blinded surgeons evaluated the specimens according to objective criteria. Control specimens were added to ensure the integrity of the evaluation process.

RESULTS

The six study participants were military physician assistants who had extensive clinical experience but had never performed a fasciotomy. The average duration of the procedure was 53 min. All six procedures were completed without major errors: release of all four compartments was achieved through full-length incisions in the skin and fascia. The only surgical complication was a laceration of the saphenous vein. All three control specimens were correctly assessed by the evaluators. None of the participants experienced adverse effects from wearing the smartglasses. Four dropped calls occurred, but the connection was re-established in all cases.

CONCLUSION

All six surgical procedures were completed successfully. We attribute the dropped calls to a mismatch between the size of the graphic files and the available bandwidth. A better technical understanding of the software by the mentoring surgeon would have avoided this problem. Important considerations for future research and practice include protocols for dropped communications, surgical skills training for the operators and communication training for the surgeons.

241 IMPLEMENTATION OF AN INTRACEREBRAL CEREBRAL HAEMORRHAGE CARE BUNDLE

Background

Mortality for Intracerebral haemorrhage (ICH) is 31% (Irish National Audit Stroke, 2019). An ICH care bundle focusing on acute anticoagulation reversal, blood pressure lowering, and a neurosurgical care pathway was associated with improved survival. Translating evidence-based medicine into clinical practice is challenging. The aim of this study was to determine feasibility and outcomes of implementation of a care bundle.

Methods

An ICH care bundle was developed using an iterative process involving expert stakeholder review of the evidence-based literature. A pre-and-post quasi-experimental research design was employed to evaluate this intervention. Baseline data were collected before implementation (January 2016-June 2018). Implementation took place in a staged manner in a single university teaching hospital with multiple ‘Plan Do Study Act cycles’ (June 2018 to January 2021). Data on compliance, process measures and outcomes were collected.

Results

Systolic blood pressure (first 24-hours) and anticoagulant reversal were significantly better controlled post-implementation (χ2 (1, N = 91) = 5.34, P = 0.02), (χ2 (1, N = 25) = 5.85, P = 0.016), respectively. DNAR orders were significantly lower in the post-implementation group (χ2 (1, N = 25) = 5.85, P = 0.029). However, ‘Do Not Actively Resuscitate’ status did not significantly differ when accounting for low GCS as a surrogate measure for poor prognosis (χ2 (1, N = 34) = 0.00, P = 0.966). Modified Rankin Scale on discharge did not differ significantly pre-and-post-implementation (z = −0.075, P = 0.94). A greater proportion of patients survived in the post-implementation group; however, this was not statistically significant (χ2 (1, N = 133) = 0.77, P = 0.38). Length of stay significantly increased post implementation.

Conclusion

An ICH care bundle was developed based on expert stakeholder feedback. The feasibility of implementing this bundle of care was demonstrated in a real-world clinical practice setting. A cluster-randomized trial or a large registry study is the next step to evaluate the overall impact of this care bundle on patient outcomes.

235 THROMBOLYSIS DOSING AND WEIGHT ESTIMATION IN ACUTE STROKE: A SINGLE CENTRE AUDIT

Background

Stroke is a leading cause of death and disability. Thrombolysis with intravenous (IV) alteplase is the mainstay management of ischaemic stroke. It has a narrow therapeutic window with a high potential for adverse outcomes such as intracranial haemorrhage. The efficacy of alteplase is time and dose dependent with weight-based dosing. National clinical guidelines recommend a dose of 0.9 mg/kg, up to a maximum of 90 mg. (Irish Heart Foundation Council for Stroke 2015). In most hospitals in Ireland however, patients are not weighed prior to thrombolysis. Time pressure and lack of available suitable equipment are factors.

Methods

This retrospective clinical audit evaluated the dosing of alteplase, estimated and actual weight for a convenience sample of stroke thrombolysis patients treated between 2016–2020 at an Irish University Teaching Hospital.

Results

107 patients were audited (62 males, 45 females). Actual and estimated weights were available in 92/107. Weight was not documented (n = 15) due to severe stroke/palliative management (n = 6) or omission (n = 9). 21% (19/92) received the correct dose of 0.9 mg/kg. A further 54% (50/92) received a dose within the range of 0.81–0.99 mg/kg (±10%). 25% received a dose outside this range (&gt; ± 10%). 11% (10/92) were under-thrombolysed and 14% (13/92) over-thrombolysed. 17/92 patients had an intracranial haemorrhage. 35% (n = 6/17) of patients who had an intracranial haemorrhage received a higher dose of thrombolysis (&gt;10%).

Conclusion

A quarter of patients received inappropriate dosing of alteplase that was outside the range of ±10% of 0.9 mg/kg. While stroke thrombolysis must be completed urgently, an accurate weight should be determined to avoid errors in dosing. A process evaluation of stroke thrombolysis would provide information on how best to incorporate an objective means of weight measurement without delaying treatment.

322 Clinical Factors Predictive of Both Successful and Unsuccessful Arterial Embolization in The Management of Lower Gastrointestinal Bleeding

Aim

To develop a model of clinical factors that may predict: (1) technically and clinically successful embolization of a bleeding vessel at Digital Subtraction Angiography (DSA) for lower gastrointestinal bleed (LGIB); (2) a negative DSA in the presence of positive CT-mesenteric angiography (CTMA) for LGIB.

Method

A retrospective cohort study of all DSAs conducted with intent for embolization for acute LGIB over a 10-year period was undertaken. Pre-procedural and intra-procedural clinical variables were evaluated using uni- and multi-variate analysis.

Results

123 DSAs were evaluated. Technical success was 81% (64/78) with clinical success 78%. Technical success was associated with super-selective approach, contrast extravasation on CT, haemoglobin drop, anatomical source and time from CT to DSA on univariate analysis. On multivariate analysis time from CT to DSA was significant with a higher success probability within 120 minutes with different factors being salient depending on degree of delay. Clinical success was only associated with APTT (&lt;27.5s). Technical failure from a negative DSA following a positive CTMA was associated with anatomical source, haemodynamic stability, platelet count and time from CT to DSA on univariate analysis. The latter three remained so on multivariate analysis.

Conclusions

A triaging approach to utilising emergency DSA may be helpful. If prolonged delay between a positive CT and DSA is anticipated, with haemodynamic stability and a near normal platelet count, the DSA may not be fruitful. Technical success may be more likely if DSA occurs within 120mins. Clinical success may be more likely if APTT is within normal range.

Bilateral Permanent Childhood Hearing Loss and Health-Related Quality of Life in Adolescence

Little is known about the impact of bilateral permanent childhood hearing loss (PCHL) on health-related quality of life (HRQoL). The objective of this study was to describe preference-based and non-preference based HRQoL outcomes in adolescence, from both self and proxy perspectives, amongst participants of the Hearing Outcomes Project. The Health Utilities Index Marks II (HUI2) and III (HUI3) and the PedsQLTM Version 4.0 Generic Core Scales were used to measure HRQoL based on self and parent proxy reports in 114 adolescents aged 13-19 years, 76 with bilateral PCHL and 38 with normal hearing, recruited from a population sample that was followed up from birth to adolescence. Descriptive statistics and multivariable analyses were used to estimate the relationship between severity of PCHL and HRQoL outcomes. PCHL was associated with decrements in mean multi-attribute utility score that varied between 0.078 and 0.148 for the HUI2 (p = 0.001) and between 0.205 and 0.315 for the HUI3 (p < 0.001), dependent upon the national tariff set applied and respondent group. Multivariable analyses revealed that, after controlling for clinical and sociodemographic covariates, mean HUI3 multi-attribute utility scores were significantly lower in adolescents with moderately severe, severe and profound hearing loss than in adolescents with normal hearing. Significant differences in physical functioning, social functioning, psychosocial functioning and total PedsQLTM scores were only observed when assessments by parents were relied upon, but these dissipated in the multivariable analyses. Bilateral PCHL is associated with poorer HRQoL outcomes in adolescence. Further studies conducted are needed to understand the trajectory and underpinning mechanisms of HRQoL outcomes following PCHL.

QOL-17. BIOLOGICAL CORRELATES OF QUALITY OF SURVIVAL AND NEUROCOGNITIVE OUTCOMES IN MEDULLOBLASTOMA; A META-ANALYSIS OF THE SIOP-UKCCSG-PNET3 AND HIT-SIOP-PNET4 TRIALS

Relationships between biological factors (genetic, tumour molecular subgroup) and neurocognitive/Quality of Survival (QoS) outcomes in medulloblastoma survivors are emerging, based on studies of limited retrospective cohorts. Integrated investigations of the medulloblastoma late-effects pathway (considering biological, clinical and treatment factors), using larger clinically-controlled cohorts, are now essential to determine their independent significance and potential for clinical application. In a combined cohort of SIOP-UKCCSG-PNET3 and HIT-SIOP-PNET4 patients (n=150), molecular subgroup (MB_WNT, MB_SHH, MB_Grp3, MB_Grp4) was assessed against QoS measures [health status: HUI3; emotional and behavioural difficulties: SDQ; Health-related Quality of Life (HrQoL): PedsQL]. Additionally, in DNA remaining from HIT-SIOP-PNET4 (n=74), 39 candidate SNPs (involved in metabolism, DNA maintenance/repair, neural growth/repair and oxidative stress/inflammation) were genotyped by multiplexed MALDI-TOF MassArray and assessed against Wechsler Intelligence Scale (WISC) scores. Molecular subgroup was significantly associated with HrQoL and health status in univariate analyses; MB_Grp4 predicted significantly worse outcomes than MB_SHH and MB_Grp3 (p<0.05), but not in multivariate analyses taking into consideration other significant and reported QoS predictors (e.g. treatment, gender, age). In contrast, 6 SNPs were significantly associated with ≥1 WISC domain; 4/6 showed associations across domains. 3 SNPs were independently prognostic in multivariate analyses, and further significant associations were apparent at the gene (BDNF, APOE) and pathway (folate) level. This cross-discipline, international study encompassing two medulloblastoma trials has identified relationships between molecular subgroup, genotype and survivorship outcomes. These findings now require assessment in larger series, to inform our understanding of medulloblastoma survivorship outcomes and impact future disease management strategies.

QOL-32. THE PROMOTE STUDY: HEALTH-RELATED QUALITY OF LIFE COMMUNICATION NEEDS OF CHILDREN, ADOLESCENTS, AND THEIR FAMILIES ATTENDING OUTPATIENT CONSULTATIONS AFTER TREATMENT FOR A BRAIN TUMOUR

BACKGROUND

Childhood brain tumours and their treatment can reduce health-related quality of life (HRQoL) and cause anxiety and depression, withdrawal, and social isolation. Improved communication within outpatient consultations may allow early identification and treatment of these issues. We explored family communication needs in survivors of childhood brain tumours receiving six-monthly follow-up outpatient review within the English NHS.

METHODS

Semi-structured interviews were conducted with 18 families whose child aged 8–17 years had finished treatment for a brain tumour within the preceding five years. Thematic analysis used the Framework Method.

RESULTS

Adjusting to change and finding a “new normal” was the overarching theme to emerge. HRQoL issues included fatigue, coping with physical changes, challenges at school, isolation, and adjusting to changes in abilities. Survivors described a need for greater knowledge about and more support with changes in cognitive functioning. Parents spoke about the impact on the wider family and their changed role in supporting the child’s HRQoL. Communication barriers included short-term memory loss, shyness, and the need to suppress or regulate emotions evoked by these issues. Communication needs included more information regarding recovery and rehabilitation and/or help managing anxiety or emotional health.

CONCLUSION

The above communication needs and barriers should be addressed. Having a digital record to document and monitor this information systematically could improve service planning and provide patients and their families with the resources to reach their full potential and experience a better HRQoL.

QOL-33. THE PROMOTE STUDY: DEVELOPMENT AND TESTING OF KLIK-UK, AN ONLINE PLATFORM, TO ENHANCE OUTPATIENT COMMUNICATION ABOUT HEALTH-RELATED QUALITY OF LIFE (HRQOL) AT THREE UK CHILDREN’S BRAIN TUMOUR TREATMENT CENTRES (CBTTCs)

BACKGROUND

The HRQoL of survivors of childhood brain tumour is significantly reduced into adulthood but is not systematically assessed. In the UK, referral for appropriate support is often reactive rather than proactive. We developed KLIK, the online Dutch platform, for use to enable the systematic assessment of HRQoL in the UK NHS using patient-reported outcomes measures (PROMs) which could be fed back to clinicians during outpatient review appointments.

METHODS

PARTICIPANTS: Children aged 5–17.9 years, receiving outpatient care >6 monthly for a brain tumour diagnosed within preceding 5 years and their parents and clinicians. SETTING: Three UK CBTTCs – UHS, Southampton; GOSH, London; and QMC, Nottingham. PROCEDURE: KLIK-UK was developed throughout the study and barriers and opportunities for its use logged. A. Development phase: relevant PROMs were identified through systematic literature review¹ and families’ views regarding choice of PROMs, communication needs within consultations, and KLIK-UK were obtained by interview. B: Feasibility phase: KLIK-UK was tested in outpatient review appointments followed by interviews with the family and clinician.

RESULTS

57 families and 10 clinicians participated. The PedsQL-Core module was preferred by families. Communication needs and barriers were identified. All clinicians reported that they could see the potential value of using KLIK-UK but views differed as to whether they could use it within their current timetable. Analysis of interviews from the feasibility phase will be reported.

CONCLUSION

KLIK-UK is ready for use in the UK but will need to be adapted according to local resources, needs, and preferences. ¹Bull et al. 2019 https://doi.org/10.1093/nop/npz064

VMMC clients' perception of increased risk of HIV infection, circumcision preferred choice of method, providers' socio-demographics and mode of service delivery

Introduction

Voluntary medical male circumcision (VMMC) is a scientifically proven HIV prevention intervention. Uganda, like many countries has been implementing VMMC for over 10 years but uptake is still low especially in northern Uganda. To attain 80% needed for public health impact, scale-up was recommended with many innovations implemented with sub-optimal results. This study therefore wanted to find out some of the correlates of VMMC uptake in Gulu district, northern Uganda.

Methods

Two studies were conducted separately but data was analyzed for this study. For the quantitative study, proportions and frequencies were used to measure perception of increased risk of HIV infection using age, gender, occupation, marital and circumcision status. Qualitative study provided data from FGDs, IDIs and KIIs were first transcribed in Acholi and then translated in English. Transcripts were uploaded in MAXDQA software for data management. A code book for emerging themes was developed.

Results

A total of 548 respondents were interviewed for the quantitative study, where two thirds (66%) of the participants perceived themselves to be at increased risk of HIV infection. For the qualitative study, 149 participants from 19 FGDs, 11 KIIs and 9 IDIs were interviewed. Data were analyzed thematically using both inductive and deductive approaches. Devices were preferred to conventional surgery while mobile services were preferred to static services. However, there were divergent views regarding circumcision service providers' socio-demographics and these were influenced mainly by age, level of education and location.

Conclusion

People in Northern Uganda perceived themselves to be at an increased risk of HIV infection. They preferred devices to conventional surgery, mobile services to static services but had varying views about the socio-demographics of the service providers.

Management of anal intraepithelial neoplasia and anal squamous cell carcinoma at a tertiary referral centre with a dedicated infectious diseases unit: an 18-year review

INTRODUCTION

Anal squamous cell carcinoma (ASCC) is a rare malignancy with rising incidence rates. Risk factors include human immunodeficiency virus (HIV) infection, high-risk sexual activity and HPV-related genitourinary dysplasia/neoplasia. There is an overlap between high-risk patients and those attending HIV Medicine/Sexual Health (HMSH) services. We hypothesised that HMSH involvement may facilitate earlier referral to colorectal surgeons, with better outcomes.

METHODS

Retrospective review of all ASCC and anal intraepithelial neoplasia (AIN) treated at a tertiary-referral hospital with a dedicated HMSH clinic between 2000 and 2018. Comparative analysis was performed of demographics, management and outcomes between HMSH and non-HMSH patients.

RESULTS

One hundred and nine patients had anal pathology, eighty-five with ASCC (78%) and twenty-four with AIN (22%). Seventy (64%) were male. Median (range) age at ASCC diagnosis was 51 years (26-88). Thirty-six percent of all patients attended HMSH services, 28% were HIV positive, and 41% of males were men-who-have-sex-with-men (MSM). Eighty-one ASCC patients (97.5%) were treated with curative intent. Sixty-seven (80%) had primary chemoradiation therapy. Fifteen (17.5%) had primary surgical excision. Twelve (14%) developed recurrent disease. Ultimately, seven required salvage APR. Overall 3-year survival (3YS) was 76%. HMSH patients were significantly younger at ASCC diagnosis (p < 0.001), with a higher prevalence of HIV, HPV and MSM. HMSH attenders also tended to be diagnosed at earlier stages, were less likely to develop recurrence and achieved better overall outcomes, with a superior overall 3YS than non-HMSH patients (92% vs 72%, p = 0.037).

CONCLUSION

ASCC incidence is increasing worldwide. The HMSH cohort has emerged as a distinct subpopulation of younger, high-risk, male patients. Collaboration between HMSH and colorectal surgeons offers an opportunity for risk reduction strategies and earlier intervention.

Period poverty in rural Uganda; an exploration of the challenges and the need for intervention

Background

Period poverty refers to a lack of access to safe means of managing menstruation. It affects the education, health and dignity of millions of women and girls globally. This study aims to identify the barriers facing menstruating girls in rural Uganda, investigate the effects of period poverty in this demographic and assess the need to implement a programme to tackle challenges identified.

Methods

A qualitative study was undertaken in a community setting. 42 Participants were selected in Bududa, Uganda using convenience sampling. School-age girls supported by The Shelo Foundation (charity no.1155142) who had begun menstruating and adults in positions of responsibility in the community were interviewed to gain a cross sectional understanding of the questions posed. Data was collected prospectively in semi-structured interviews over a four-week period in July 2013. Questions focused on access to essential hygiene materials, challenges faced when menstruating (with a focus on accessing education) and possible solutions to the barriers reported. Interview transcripts were analysed; the common concepts were identified, and conclusions drawn from the results.

Results

Inability to access sanitation products, due to financial poverty and local availability, was the main challenge highlighted throughout the analysis of the interview transcripts. The other common themes included lack of suitable hygiene facilities, absence of education on menstruation and the vulnerability of menstruating girls to abuse and stigma. Analysis found that on average girls were missing three days of school a month due to their periods, equalling 18% of the academic year.

Conclusions

Period poverty disadvantages school-aged females in Bududa, Uganda. Financial poverty, lack of education and stigma contribute to period poverty. An intervention programme including accessible sanitation products and education is recommended to tackle this gender inequality for girls in this population.

Key messages

A lack of sanitation products, subpar education and stigma contribute to period poverty in Uganda and negatively impact female education with menstruating students missing up to 18% of a school year. An intervention programme incorporating access to sanitation products alongside education is recommended to tackle period poverty in this population and improve women’s health and female education.

Radiation dose tracking in computed tomography: Red alerts and feedback. Implementing a radiation dose alert system in CT

INTRODUCTION

This study investigates instances of elevated radiation dose on a radiation tracking system to determine their aetiologies. It aimed to investigate the impact of radiographer feedback on these alerts.

METHODS

Over two six-month periods 11,298 CT examinations were assessed using DoseWatch. Red alerts (dose length products twice the median) were identified and two independent reviewers established whether alerts were true (unjustifiable) or false (justifiable). During the second time period radiographers used a feedback tool to state the cause of the alert. A Chi-Square test was used to assess whether red alert incidence decreased following the implementation of radiographer feedback.

RESULTS

There were 206 and 357 alerts during the first and second time periods, respectively. These occurred commonly with CT pulmonary angiography, brain, and body examinations. Procedural documentation errors and patient size accounted for 57% and 43% of false alerts, respectively. Radiographer feedback was provided for 17% of studies; this was not associated with a significant change in the number of alerts, but the number of true alerts declined (from 7 to 3) (χ2 = 4.14; p = 0.04).

CONCLUSION

Procedural documentation errors as well as patient-related factors are associated with false alerts in DoseWatch. Implementation of a radiographer feedback tool reduced true alerts.

IMPLICATIONS FOR PRACTICE

The implementation of a radiographer feedback tool reduced the rate of true dose alerts. Low uptake with dose alert systems is an issue; the workflow needs to be considered to address this.

Autosomal dominant tubulointerstitial kidney disease (ADTKD) in Ireland

Introduction: Autosomal dominant tubulointerstitial kidney disease (ADTKD) is a rare genetic cause of renal impairment resulting from mutations in the MUC1, UMOD, HNF1B, REN, and SEC61A1 genes. Neither the national or global prevalence of these diseases has been determined. We aimed to establish a database of patients with ADTKD in Ireland and report the clinical and genetic characteristics of these families.

Methods: We identified patients via the Irish Kidney Gene Project and referral to the national renal genetics clinic in Beaumont Hospital who met the clinical criteria for ADTKD (chronic kidney disease, bland urinary sediment, and autosomal dominant inheritance). Eligible patients were then invited to undergo genetic testing by a variety of methods including panel-based testing, whole exome sequencing and, in five families who met the criteria for diagnosis of ADTKD but were negative for causal genetic mutations, we analyzed urinary cell smears for the presence of MUC1fs protein.

Results: We studied 54 individuals from 16 families. We identified mutations in the MUC1 gene in three families, UMOD in five families, HNF1beta in two families, and the presence of abnormal MUC1 protein in urine smears in three families (one of which was previously known to carry the genetic mutation). We were unable to identify a mutation in 4 families (3 of whom also tested negative for urinary MUC1fs).

Conclusions: There are 4443 people with ESRD in Ireland, 24 of whom are members of the cohort described herein. We observe that ADTKD represents at least 0.54% of Irish ESRD patients.

Effects of the growth pattern of medulloblastoma on short-term neurological impairments after surgery: results from the prospective multicenter HIT-SIOP PNET 4 study

OBJECTIVE

Extensive resection of a tumor in the posterior fossa in children is associated with the risk of neurological deficits. The objective of this study was to prospectively evaluate the short-term neurological morbidity in children after medulloblastoma surgery and relate this to the tumor's growth pattern and to the extent of resection.

METHODS

In 160 patients taking part in the HIT-SIOP PNET 4 (Hyperfractionated Versus Conventionally Fractionated Radiotherapy in Standard Risk Medulloblastoma) trial, neurosurgeons prospectively responded to questions concerning the growth pattern of the tumor they had resected. The extent of resection (gross, near, or subtotal) was evaluated using MRI. The patients' neurological status before resection and around 30 days after resection was recorded.

RESULTS

Invasive tumor growth, defined as local invasion in the brain or meninges, cranial nerve, or major vessel, was reported in 58% of the patients. After surgery almost 70% of all patients were affected by one or several neurological impairments (e.g., impaired vision, impaired extraocular movements, and ataxia). However, this figure was very similar to the preoperative findings. Invasive tumor growth implied a significantly higher number of impairments after surgery (p = 0.03) and greater deterioration regarding extraocular movements (p = 0.012), facial weakness (p = 0.048), and ataxia in the arms (p = 0.014) and trunk (p = 0.025) compared with noninvasive tumor growth. This deterioration was not dependent on the extent of resection performed. Progression-free survival (PFS) at 5 years was 80% ± 4% and 76% ± 5% for patients with invasive and noninvasive tumor growth, respectively, with no difference in the 5-year PFS for extent of resection.

CONCLUSIONS

Preoperative neurological impairments and invasive tumor growth were strong predictors of deterioration in short-term neurological outcome after medulloblastoma neurosurgery, whereas the extent of resection was not. Neither tumor invasiveness nor extent of resection influenced PFS. These findings support the continuation of maximal safe resection in medulloblastoma surgery where functional risks are not taken in areas with tumor invasion.

The psychological impact of Stevens-Johnson syndrome and toxic epidermal necrolysis on patients' lives: a Critically Appraised Topic

CLINICAL SCENARIO

A 65-year-old man presented with a 12-h history of deteriorating rash. Two weeks previously he had completed a course of neoadjuvant chemotherapy for ductal carcinoma of the breast. On examination there were bullae, widespread atypical targetoid lesions and 15% epidermal detachment. There was no mucosal involvement on presentation, but subsequently it did evolve. Skin biopsy showed subepidermal blistering with epidermal necrosis. This confirmed our clinical diagnosis of overlap Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). On transfer to intensive care he was anxious and fearful.

MANAGEMENT QUESTION

What are the psychological impacts of SJS/TEN on this man's life?

BACKGROUND

SJS and TEN have devastating outcomes for those affected.

OBJECTIVES

To conduct a Critically Appraised Topic to (i) analyse existing research related to the psychological impact of SJS and TEN and (ii) apply the results to the clinical scenario.

METHODS

Seven electronic databases were searched for publications focusing on the psychological impact of SJS/TEN on adults over 18 years of age.

RESULTS

Six studies met the inclusion criteria. Healthcare practitioners' (HCPs') lack of information around the disorder was highlighted. Patients experienced undue stress and fear. Some patients had symptoms aligned to post-traumatic stress disorder (PTSD), anxiety and depression.

DISCUSSION AND RECOMMENDATION

The evidence suggests that SJS and TEN impact psychologically on patients' lives. Education of HCPs, to address their lack of awareness and information on SJS/TEN, should facilitate their capacity to provide information and support to patients, thereby reducing patient anxiety. On discharge, a follow-up appointment with relevant HCPs to reduce the possibility of PTSD occurring should be considered.

A clinical diagnostic algorithm for early onset cerebellar ataxia

Early onset cerebellar Ataxia (EOAc) comprises a large group of rare heterogeneous disorders. Determination of the underlying etiology can be difficult given the broad differential diagnosis and the complexity of the genotype-phenotype relationships. This may change the diagnostic work-up into a time-consuming, costly and not always rewarding task. In this overview, the Childhood Ataxia and Cerebellar Group of the European Pediatric Neurology Society (CACG-EPNS) presents a diagnostic algorithm for EOAc patients. In seven consecutive steps, the algorithm leads the clinician through the diagnostic process, including EOA identification, application of the Inventory of Non-Ataxic Signs (INAS), consideration of the family history, neuro-imaging, laboratory investigations, genetic testing by array CGH and Next Generation Sequencing (NGS). In children with EOAc, this algorithm is intended to contribute to the diagnostic process and to allow uniform data entry in EOAc databases.

A-12 Neuroticism and Extraversion are Related to Dual Task Postural Stability in Healthy Young Adults

Objective

The relation between personality and postural stability has received little attention. This study addressed whether neuroticism and extraversion are related to changes in postural stability and cognitive functioning during a standing balance task.

Method

Thirty-two healthy young adults completed a personality measure and two cognitive tasks, a 2-back task and a weather prediction task (WPT), both while seated and in tandem stance on a foam mat. Sway was quantified via normalized path lengths, and correlation coefficients were calculated between neuroticism, extraversion and dual task changes in postural stability and cognitive functioning.

Results

Consistent with predictions, higher neuroticism was related to increased dual task sway during the 2-back task, r = 0.40, p = 0.023, and lower extraversion was related to increased dual task sway during the WPT, r = -0.43, p = 0.013.

Conclusions

The results suggest that personality is related to postural stability in healthy young adults and that personality should be considered in the prediction of individuals at risk for falling or in the treatment of individuals with balance difficulties. The task-specific nature of the relation is discussed and may be due to differences in anxiety or underlying brain mechanisms between high neuroticism and low extraversion.

Radiographic Soft Tissue Thickness Differentiating Pyogenic Flexor Tenosynovitis From Other Finger Infections

PURPOSE

Characteristic swelling has been described as a differentiating sign of pyogenic flexor tenosynovitis (PFT) but has not been validated. We conducted a retrospective study of adults with finger infections to compare radiographic parameters of soft tissue dimensions. Our hypothesis was that in patients with digit infections, radiographic soft tissue thickness measurement would differ between PFT and non-PFT infected digits.

METHODS

Patients with a finger infection and radiographic evaluation were identified retrospectively at a large academic medical center and divided into 2 groups: PFT (n = 31) and non-PFT infections (n = 31). We defined PFT as purulence in the tendon sheath or positive culture growth from the sheath at surgery. Non-PFT infections included all other finger infections such as abscesses and cellulitis. A total of 15 radiographic measurements were made on all included digits. Ratios and differences were calculated to characterize the pattern of swelling for each infected finger. Bivariate analysis was performed to identify potential predictor variables between the PFT and non-PFT groups. Logistic regression was performed to reduce confounding and model potential relationships.

RESULTS

Neither presence of diffuse swelling nor the shape of finger swelling distinguished PFT from non-PFT infections. All finger infections resulted in diffuse swelling. Pyogenic flexor tenosynovitis was distinguished by differential volar soft tissue thickness minus dorsal soft tissue thickness on radiographs at the proximal phalanx level (9 ± 1 mm for PFT vs 5 ± 1 mm for non-PFT). This was an independent predictor of PFT. The area under the receiver operating curve was 0.83 (95% confidence interval, 0.73-0.94). A difference between volar and dorsal soft tissue swelling of 7 mm or greater had a positive predictive value of 82% with a sensitivity of 84% and specificity of 74%. A difference of 10 mm predicted PFT infection with 76% probability (95% confidence interval, 73% to 99%).

CONCLUSIONS

Pyogenic flexor tenosynovitis may result in uniform finger swelling, but this does not appear to distinguish PFT from other finger infections. Acute PFT swelling is distinguished by differential volar versus dorsal radiographic soft tissue thickness at the level of the proximal phalanx. The term "fusiform swelling" is a misnomer for the appearance of acute PFT because the finger is not spindle-shaped.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

The role of hardpan formation on the reactivity of sulfidic mine tailings: A case study at Joutel mine (Québec)

The former Eagle and Telbel mine site (hereafter referred to as Joutel mine), located near the town of Joutel in the Nord-du-Québec (Canada) houses a tailings storage facility (TSF) that has been inactive since 1996. Fresh, unweathered tailings (beneath 10-30 cm of oxidized horizon) are characterized by an average sulfide content of 6-7 wt% and an average Fe-Mn-carbonate content of 20-40 wt%. The oxidation of Joutel's tailings under atmospheric conditions resulted in the precipitation of secondary phases such as ferric oxyhydroxides and gypsum. Accumulation of these secondary phases throughout the TSF caused cementation and agglomeration of grains, which decreased the porosity of the material in a horizon below the surface. This horizon, which is referred to as hardpan, is frequently encountered within fine, reactive tailings. Characterizations showed that hardpans have a highly compact texture. The formation of hardpans limits vertical water infiltration and oxygen diffusion and these layers greatly affect the global geochemical behavior of underlying tailings in the Joutel TSF by protecting the unweathered material from oxidation. As a result, the water quality of the TSF is largely controlled by the reactivity of the upper oxidized tailings horizon. Joutel's oxidized tailings showed an acidic behavior early during laboratory kinetic leaching tests despite the near absence of sulfides and neutralizing minerals. However, when unweathered tailings were added under oxidized tailings, the water became neutral and metal leaching rates were reduced. After over a year of laboratory leaching tests, hardpans formed within the columns and the natural phenomenon was reproduced under laboratory conditions.

Paediatric neuro-oncology rehabilitation in the UK: carer and provider perspectives

OBJECTIVE

The provision of rehabilitation services after childhood brain tumour has not been established, despite a recent parliamentary call for urgent action. This service evaluation aimed to determine what specialist paediatric neuro-oncology rehabilitation services were available across the UK at the time of the surveys and whether the needs of patients and their families were being met.

DESIGN

Cross-sectional on-line surveys.

PARTICIPANTS

Survey 1: neuro-oncologist and nurse specialist members of the Children's Cancer and Leukaemia Group (CCLG) at Children's Principle Treatment Centres (PTCs) in the UK; Survey 2: parents of paediatric neuro-oncology patients belonging to The Brain Tumour Charity (TBTC) Research Involvement Network (RIN).

RESULTS

17 of the 20 (85%) PTCs in the UK and two teenagers and young adult cancer units responded to Survey 1, and 17 members of TBTC's RIN responded to Survey 2. Access to inpatient and outpatient neuro-oncology rehabilitation services after treatment for a central nervous system (CNS) tumour varied across regions in the UK. Service users in the RIN identified a need for an established neuro-oncology rehabilitation service for young people, a need for better communication across services and with families, and a need to fill gaps in multidisciplinary teams.

CONCLUSION

The urgent need for specialist paediatric, teenage and young adult neuro-oncology rehabilitation services in the UK is often unmet, particularly for outpatients. Where services are not provided for those children and young people disadvantaged by the diagnosis of a CNS tumour, in clear breach of current guidelines, remedial action needs to be taken to ensure appropriate and equal access.

Predicting reading ability in teenagers who are deaf or hard of hearing: A longitudinal analysis of language and reading

BACKGROUND

Deaf and hard of hearing (D/HH) children and young people are known to show group-level deficits in spoken language and reading abilities relative to their hearing peers. However, there is little evidence on the longitudinal predictive relationships between language and reading in this population.

AIMS

To determine the extent to which differences in spoken language ability in childhood predict reading ability in D/HH adolescents.

METHODS

and procedures: Participants were drawn from a population-based cohort study and comprised 53 D/HH teenagers, who used spoken language, and a comparison group of 38 normally hearing teenagers. All had completed standardised measures of spoken language (expression and comprehension) and reading (accuracy and comprehension) at 6-10 and 13-19 years of age.

OUTCOMES

and results: Forced entry stepwise regression showed that, after taking reading ability at age 8 years into account, language scores at age 8 years did not add significantly to the prediction of Reading Accuracy z-scores at age 17 years (change in R² = 0.01, p = .459) but did make a significant contribution to the prediction of Reading Comprehension z-scores at age 17 years (change in R²  = 0.17, p < .001).

CONCLUSIONS

and implications: In D/HH individuals who are spoken language users, expressive and receptive language skills in middle childhood predict reading comprehension ability in adolescence. Continued intervention to support language development beyond primary school has the potential to benefit reading comprehension and hence educational access for D/HH adolescents.

Home haemodialysis in Ireland

BACKGROUND

Home haemodialysis (HHD) has the potential to impact positively on patient outcomes and health resource management. There has been rejuvenated international interest in HHD in recent years.

AIM

We aimed to review the activity and outcomes of the Irish HHD Programme since inception (2009-16).

DESIGN

Retrospective review.

METHODS

Patient data were collected using the national electronic Renal Patient database (eMEDRenal version 3.2.1) and individual centre records. All data were recorded in a coded fashion on a Microsoft Excel Spread-sheet and analysed with Stata SE software.

RESULTS

One hundred and one patients completed training and commenced HHD; a further fourty-five patients were assessed for HHD suitability but did not ultimately dialyse at home. Twenty patients switched to nocturnal HHD when this resource became available. The switch from conventional in-centre dialysis to HHD led to an increase in the mean weekly hours on haemodialysis (HD) and a reduction in medication burden for the majority of patients. The overall rate of arteriovenous fistula (AVF) as primary vascular access was 62%. Most HHD complications were related to access function or access-related infection. Over the 7-years, 29 HHD patients were transplanted and 9 patients died. No deaths resulted directly from a HHD complication or technical issue.

CONCLUSIONS

Patient and technique survival rates compared favourably to published international reports. However, we identified several aspects that require attention. A small number of patients were receiving inadequate dialysis and require targeted education. Ongoing efforts to increase AVF and self-needling rates in HD units must continue. Psychosocial support is critical during the transition between dialysis modalities.

Language and reading comprehension in middle childhood predicts emotional and behaviour difficulties in adolescence for those with permanent childhood hearing loss

BACKGROUND

Permanent childhood hearing loss (PCHL) is associated with an elevated level of emotional and behaviour difficulties (EBD). In children and adolescents with PCHL, EBD has been found to be linked to language ability in children with PCHL. The present study was designed to test whether childhood language and/or reading comprehension abilities of children with PCHL predict subsequent EBD in adolescence.

METHODS

Language comprehension (LC) and reading comprehension (RC) were measured at ages 6-10 years (Time 1) and 13-20 years (Time 2) in participants with PCHL who preferred to communicate using spoken language (n = 57) and a hearing comparison group (n = 38). EBD was measured at both time points by parent and by teacher ratings on the Strengths and Difficulties Questionnaire.

RESULTS

Within the PCHL group there were negative correlations between EBD scores and concurrent LC and RC scores at Time 1 and at Time 2. Cross-lagged latent variable models fitted to the longitudinal data indicated that the associations between LC, RC and teacher-rated EBD were more likely to arise from the impact of LC and RC on behaviour rather than the other way around.

CONCLUSIONS

In those with PCHL, poor language and reading comprehension in middle childhood increased the risk of emotional and behaviour difficulties at school in the teenage years. The results suggest that effective language and literacy interventions for children with hearing loss may also bring benefits to their mental health.