Does Samaritan, a Digital Support Platform, Help Improve Social Determinants of Health for Mental Health Offenders in Jacksonville, Florida?

Background The objective of this study is to evaluate if access to Samaritan, a digital support platform, improves the social determinants of health (SDOH) needs for patients enrolled in a jail diversion program in Jacksonville, FL. Methodology A total of 59 patients who were enrolled in a jail diversion program for homeless mentally ill misdemeanor offenders in Jacksonville, FL, participated in the study. Of the 59 patients, 47 individuals consented to participate in Samaritan while 12 declined participation. Demographics and the Health Leads Social Needs Screening Tool scores from the electronic health record were compared between groups along with average financial support from Samaritan. These non-normally distributed variables were compared using Wilcoxon rank-sum tests. Results The majority of study participants were male (92%, n = 43). The average age of study participants was 42 years. The average income from donors on the platform over three months for those who opted in was $48.80 (SD = 53.75). Among the individual Health Leads Social Needs Screening Tool questions, intact Housing was statistically significant (Z = -2.002, p = 0.045), suggesting access to a digital technology such as Samaritan might help improve SDOH needs. Conclusions Access to digital technologies, such as Samaritan, might help offenders with mental illness adjust to the many challenges they face upon reentry into the community. As such, these devices may represent one means for improving SDOH needs for disadvantaged mental health patients.

Early and intensive Motor Training for people with spinal cord injuries (the SCI-MT Trial): description of the intervention

STUDY DESIGN

Descriptive.

OBJECTIVES

The primary objective is to describe the intervention that will be provided in a large multi-centre randomised controlled trial titled: Early and Intensive Motor Training for people with Spinal Cord Injuries (the SCI-MT Trial). The secondary objective is to describe the strategies that will be used to operationalise and standardise the Motor Training provided to participants while keeping the intervention person-centred.

METHODS

The paper focuses on the rationale and principles of Motor Training for people with spinal cord injuries (SCI). The description of the intervention is based on the Template for Intervention Description and Replication (TIDieR) checklist. Specifically, it addresses the following 6 criteria of the TIDieR checklist: why the effectiveness of Motor Training is being examined; what, how, where and when the Motor Training will be administered; and how much Motor Training will be provided.

RESULTS

A detailed intervention manual has been developed to help standardise the delivery of the intervention.

CONCLUSIONS

This paper describes the details of a complex intervention administered as part of a large randomised controlled trial. It will facilitate the subsequent interpretation of the trial results and enable the intervention to be reproduced in clinical practice and future trials.

Approach to the diagnosis and management of snakebite envenomation in South Africa in humans: Special patient groups and surgical aspects

This article explores the management of snakebite to vulnerable patient groups, namely children and pregnant women as well as providing detail on the current best practice when caring for venom ophthalmia and surgical wounds resulting from snakebite. Finally, the optimal free-to-use medical record for accurate documentation of snakebite incidents is provided for use by South African practitioners.

Approach to the diagnosis and management of snakebite envenomation in South Africa in humans

Snake bite management is largely driven by expert opinion and consensus, however there are a few large retrospective studies and RCT's that have improved the quality of medical guidance currently available. South African snakes are different in the venomous potential and it behooves the hospital provider and the average medical practitioner to know the current best practice concepts concerning assessment, treatment and antivenom use. The recent SASS meeting in July 2022 provided an update and national consensus from which this Hospital Care document is derived.

The association of body mass index and odds of type 2 diabetes mellitus varies by race/ethnicity

OBJECTIVE

This study aimed to examine the association between body mass index (BMI; weight [kilogram]/height² [meter]) and type 2 diabetes mellitus (T2DM) among the largest three largest racial/ethnic groups in the United States.

METHODS

We compiled 10 waves of the continuous National Health and Nutrition Examination Survey from 1999-2000 through 2017-2018. Participants (N = 45,514) were those who had data on BMI, HbA_1c, and demographics. We estimated associations between BMI and prediabetes/T2DM odds for Black, Latine, and White participants.

RESULTS

BMI was associated with 10% higher odds of prediabetes/T2DM vs. having normal HbA_1c levels (odds ratio = 1.10, 95% confidence interval = 1.10-1.11) for Latine and White individuals. However, the association between BMI and prediabetes/T2DM was significantly weaker among Black individuals. When focusing on T2DM prevalence, the association with BMI for Black participants was even weaker (odds ratio = 0.97, 95% confidence interval = 0.95-0.98).

CONCLUSIONS

The unstable associations between BMI and T2DM across race indicate that BMI has received unwarranted focus as a prime predictor of T2DM. Relying on BMI introduces bias in T2DM risk estimations especially in Black individuals. Focusing on BMI places the onus on individuals to change and increases weight stigma, which can worsen health outcomes. Instead, policymakers should focus on social determinants of T2DM and its concomitant racial/ethnic disparities.

Pilot Mental Health Offender Program Improves Participant Outcomes and Lowers Costs in a Large Urban County

Introduction

Mass incarceration, particularly of the mentally ill, continues to pervade our criminal justice system. Jails in many areas have become the largest mental health facilities, especially in large urban communities, despite increasing societal recognition that those with mental illness are not best served behind bars. Misdemeanors are an often-overlooked contributor to mass incarceration, and may be preventable for those with chronic severe mental illness.

Methods

This Northeast Florida pilot program, the Mental Health Offenders Program (MHOP), is based on the successful Miami Eleventh Circuit Court Criminal Mental Health Project. MHOP provided pretrial release from custody, through diversion with a customized plan of care to stabilize defendants, using court supervision to ensure compliance.

Results

With community partners, the MHOP pilot enrolled 20 individuals with chronic severe mental illness and recurrent misdemeanor charges; 15 were able to continue in the program with stabilization of their mental health and reduction of county costs both documented.

Conclusion

The MHOP pilot demonstrates that community resources can be successfully shifted to benefit mentally ill, non-violent offenders and the larger community by helping severely mentally ill clients achieve stability by providing healthcare, housing, and income, while decreasing costs for the community in a humane way.

A Case Report of Dissociative Amnesia Involving "Detective Work"

Dissociative amnesia is a rare psychiatric disorder presenting with sudden retrograde memory impairment and inability to recall autobiographical information that is inconsistent with normal forgetting. This case report discusses dissociative amnesia with dissociative fugue in a middle aged male that led to him becoming homeless. Because of his autobiographical forgetting, he was unable to access services, and we present here the distinctive "detective work" needed to not only help treat his symptoms, but also help him legally establish who he is and gain access to housing. This patient is unique in that he only began psychiatric treatment in his late 40s. His diagnostic picture is complicated due to a history of autism spectrum disorder, emotional trauma and memory impairment with difficulty recalling autobiographical memory. There is a temporal relationship between multiple traumatic events and his subsequent dissociation and amnesia, which could have unconsciously protected him from more stress and stabilized his symptoms of depression and anxiety.

What should every dental health professional know about electronic cigarettes?

Electronic cigarettes (E-cigarettes) have become increasingly popular around the world. Currently, dental professionals' knowledge and attitudes are varied with many clinicians unclear regarding the impact of E-cigarette products on the oral and general health of their patients. With developing social and health-related challenges, advice of dental and medical associations and other regulatory bodies on E-cigarette use is changing. Growing evidence demonstrating the risks of E-cigarette usage has prompted a review of legislation in the United Kingdom (UK), United States of America (USA), Australia and Canada to include the sale and availability of E-cigarettes, particularly those containing nicotine. Further consideration within the scientific and public health community is being given to assessing demographic usage patterns particularly uptake by non-smokers and adolescents, efficacy as a cessation tool, the impact of vapour on bystanders and direct injuries via explosions as well as emerging lung injuries. This article aims to provide a summary of the most up to date evidence relating to E-cigarette use, the latest position of dental associations and the oral health implications of E-cigarettes compared to conventional smoking. The article also aims to collate this information in order to provide dental clinicians with guidance on how to advise patients, specifically in answering common questions posed regarding E-cigarette use.

Important marine areas for the conservation of northern rockhopper penguins within the Tristan da Cunha Exclusive Economic Zone

The designation of Marine Protected Areas has become an important approach to conserving marine ecosystems that relies on robust information on the spatial distribution of biodiversity. We used GPS tracking data to identify marine Important Bird and Biodiversity Areas (IBAs) for the Endangered northern rockhopper penguin Eudyptes moseleyi within the Exclusive Economic Zone (EEZ) of Tristan da Cunha in the South Atlantic. Penguins were tracked throughout their breeding season from 3 of the 4 main islands in the Tristan da Cunha group. Foraging trips remained largely within the EEZ, with the exception of those from Gough Island during the incubation stage. We found substantial variability in trip duration and foraging range among breeding stages and islands, consistent use of areas among years and spatial segregation of the areas used by neighbouring islands. For colonies with no or insufficient tracking data, we defined marine IBAs based on the mean maximum foraging range and merged the areas identified to propose IBAs around the Tristan da Cunha archipelago and Gough Island. The 2 proposed marine IBAs encompass 2% of Tristan da Cunha’s EEZ, and are used by all northern rockhopper penguins breeding in the Tristan da Cunha group, representing ~90% of the global population. Currently, one of the main threats to northern rockhopper penguins within the Tristan da Cunha EEZ is marine pollution from shipping, and the risk of this would be reduced by declaring waters within 50 nautical miles of the coast as ‘areas to be avoided’.

Informing Strategy to Ensure Detection: Perceptions of Coronavirus Testing in a Southeastern U.S. Urban Homeless Population

Introduction

Attitudes of those in the homeless population toward testing, particularly during a pandemic, are critical to understand, so that they and their communities may be safely triaged and protected. Homeless persons are more likely to be exposed during viral epidemics, and have greater vulnerability for more severe viral illness, due to greater medical comorbidities. The literature reflects a dearth of published papers describing the perceptions, interest, and motivations of homeless people to seek or receive viral testing, despite their status as a high-risk population.

Methods

A quality improvement project consisting of a cross-sectional survey took place at 8 SARS-CoV-2 infection testing sites (local shelters and drop-in sites) within Duval County, Jacksonville, FL.

Results

The vast majority of homeless individuals approached for testing completed demographic data and a checklist of beliefs and attitudes about testing (N=764) and underwent COVID-19 nasopharyngeal swab testing (n=679). Mean age was 48; 66% were male, and the predominant race was Black (51%) with 89% of non-Hispanic ethnicity. Of the total participants, 59.2% wanted testing and 4.6% declined testing. Attitudes toward testing varied by site and by wanting vs. not wanting to be tested. Top reasons in those wanting testing included curiosity; a belief that faith would protect them from the virus; and having shelter encouragement to be tested. Top attitudes among those not wanting to be tested were: shelter encouraged me; curiosity; and receiving a gift card. For the total group of subjects, being offered a $10 gift card did not affect their desire to be tested. Those who were not faith-influenced were less likely to want testing.

Conclusion

Findings from selected literature and this quality improvement study support the use of a variety of strategies to encourage participation in testing events with large numbers of homeless individuals, including education, gift cards, shelter staff encouragement, involvement of local faith leaders and more broad support by the community. An additional qualitative study would complement these findings, as populations appear to differ in beliefs and attitudes depending on their location and other demographics. Motivational strategies to influence testing rates can be fine-tuned if beliefs, perceptions and attitudes are better understood.

Disparities in Opioid Pain Management for Long Bone Fractures

An expanding body of evidence has established that racial disparities exist in the US healthcare system, manifesting in poorer health outcomes for members of the non-white population. This study examines whether disparities exist in the type of analgesia ordered for long bone fractures and the time to medication administration in a community teaching hospital serving a large Hispanic population. We reviewed de-identified data of 115 patients from the emergency department of a community Level II Trauma Center in central Florida with diagnosed long bone fractures and examined the clinical and demographic variables associated with the type of analgesic administered and factors associated with delays in medication administration. We found that women reported higher pain scores than men, but there was no difference in the type of pain medication administered. There was no difference in pain scores between white and non-white patients; however, white patients were more likely to receive opiates for their long bone fractures compared with non-white patients (70 vs 50%, p < 0.0001). Opioid pain medications were prescribed significantly more often to adult and elderly patients compared with pediatric patients who were more likely to receive acetaminophen compared with both other patient groups (p < 0.001). In summary, we found that pain score was not associated with the class of pain medication administered, but that race and age were. This study questions the utility of the pain score for acute injuries and raises concerns about the role of physician bias in analgesia administration.

42 Screening for Atrial Fibrillation in Housebound Individuals: An Evaluation of the Use of the AliveCor Kardia Device

Background

The Croydon Rapid Response service is a multidisciplinary team providing admission avoidance support for people at crisis in their own homes or care homes. This population includes many living with frailty, the majority of whom are housebound.

Introduction

Atrial fibrillation (AF) is common, and often asymptomatic, and a significant risk factor for developing an ischaemic stroke. There is an ambition across health systems to improve identification of people with AF to better manage their risk of stroke. Screening is often performed using ECG readings typically performed in healthcare settings such as GP surgeries or hospitals.

The Croydon Rapid Response Team were provided with 10 AliveCor Kardia devices as part of a programme funded by the Health Innovation Network, with the aim to screen for AF aiming in traditionally hard-to-reach populations such as those people who are, through ill health or poor mobility, unable to leave their own home.

Methods

Activity use of the AliveCor Kardia devices were collated from centralised activity data based on the device serial numbers. Data collected were reviewed over a 12 month period. After 12 months use a survey was performed of clinician’s views on the devices.

Results

Over a 12 month period (March 2018 – February 2019) 389 recordings were performed across all Kardia devices. One device was lost within 1 month of the roll-out. Of the 389 recordings performed, possible AF was identified in 56 cases (14% of those screened). Survey results were received from 6 clinicians. 1 clinician used the device everyday in their practice. 2 staff members report using it 1-2/week, 3 staff members report using it 1-2/month.100% of respondents described the device as easy to use and helpful in clinical practice.100% of respondents agreed that they were clear how to manage a positive result.None of the respondents described increased workload due to the device and screening programme.

Conclusions

The AliveCor Kardia device is an acceptable and effective tool to aid detection of AF in housebound individuals seen by the Rapid Response team. The scheme should be considered for extension to other community teams, and further diagnostic equipment such as 12 lead ECG should be considered to complete the pathway.

97 Complexity In Croydon

Introduction

The Complex Care Support Team (CCST) are a newly-formed, integrated service, caring for Croydon residents when existing services decide additional multidisciplinary team input is required.

There is no single definition of healthcare complexity. Most cases encountered by the team have involved many different services and professionals. The team have found that by forging relationships and co-ordinating care across organisational boundaries, some of the “complexities” can be mitigated. We aim to develop our understanding of the needs of this population and the underlying drivers for complexity in Croydon.

Methods

The records on EMIS, CERNER and ePJS were reviewed from the inaugural two months of the service, for:Rockwood Frailty ScoreNumber of medicationsNumber of long-term conditionsED attendances or admissions to hospital over the preceding year.

After team discussion on every case, underlying causes of complexity were assigned to four groups: medical, psychological, social and systems failure.

Results

Of the 57 people accepted by CCST over 2 months, 39 required reviewing in person. 5 records were not completed, so 34 cases were included for evaluation. The age range of this cohort was 49-92, with 17 male and 17 female. Results revealed significant frailty, multimorbidity and polypharmacy. 91% had two or more underlying drivers for complexity, with the largest underlying driver being systems failure, in 85% of cases.

Conclusions

This work improves our understanding of the needs of the population deemed the most “complex” in Croydon. The likelihood of multiple underlying drivers for complexity was high, highlighting how complex health issues are likely to span both professional and organisational boundaries. This can in itself be a significant underlying driver for complexity, illustrated here as “systems failure”. In developing current and future services, this work reinforces the vital benefits of multidisciplinary and cross-organisational working currently occurring in CCST.

82 Virtual Reality Home Visit Simulation: Pilot Study

Introduction

There are multiple drivers to move healthcare into community settings, including people’s own homes. Traditional healthcare training, particularly medical training, is largely hospital-based, and hospital-based models of care. Few professions have explicit training in how best to assess an individual at home, and the additional elements to examine when visiting an induvial in their own home. To meet this training need Croydon Health Services were successful in a bid for funding to develop training to meet this gap. With this funding, a programme was developed and after attempts at simulation home visits in the simulation centre, a virtual reality (VR) home visit scenario was devised and filmed in the community using a professional actor to simulate a housebound individual. The recording was then professionally edited by a specialist VR team to maximise its effectiveness including interactive educational elements.

Methods

A pilot study examining the acceptability of the virtual reality home visit scenario was designed. A user group of medical staff with limited community experience participated in undertaking the virtual reality scenarios, delivered via Samsung Note 8 devices combined with Samsung Gear VR headsets. Feedback was received from participants by standardised paper-based surveys.

Results

7 responses were obtained. 100% of respondents described the scenario as easy to use, as well as agreeing that the same experience could not be gained from watching a standard video of the same scenario. 100% of respondents felt that the on-screen information was helpful.

Feedback on areas for improvement suggested a desire for greater interactivity of other aspects of home assessment, and a desire to improve interactivity with the simulated patient, including history taking.

Conclusions

Virtual reality home visit simulations are an acceptable and effective tool to introduce new concepts to staff. Further development should aim to maximise interactivity in the scenario and explore options for greater interaction with the simulated patient. Further role out of the virtual reality is planned for local and regional training sessions.

Intermittent low dose carbon monoxide inhalation does not influence glucose regulation in overweight adults: a randomized controlled crossover trial

NEW FINDINGS

What is the central question of this study? Low dose carbon monoxide (CO) inhalation plays a role in regulating proteins involved in glucose metabolism; does low dose CO improve glucose and insulin responses to an oral glucose tolerance test in overweight adults? What is the main finding and its importance? Five days of intermittent CO inhalation does not alter the glucose or insulin responses to ingestion of a glucose bolus in overweight adults. Low dose CO is utilized in various physiological assessment procedures; these findings allow researchers and clinicians to utilize these procedures without concern of altering glucose metabolism.

ABSTRACT

Low dose carbon monoxide (CO) inhalation upregulates several proteins important for glucose metabolism. Such changes could be clinically significant and may be relevant to those who use CO as a research tool. We hypothesized that low dose CO inhalation would improve glucose and insulin responses to an oral glucose bolus in overweight humans. Eleven young adults (5 men, 6 women; body mass index: 25-35 kg m^-2 ) were included in this randomized, placebo-controlled, single-blinded crossover study. Following screening, participants completed two 7-day protocols with a 4-week washout. Twenty-four hours prior to and following five consecutive days of either once daily CO (men: 1.2 ml (kg body mass)^-1 ; women: 1.0 ml (kg body mass)^-1 ) or placebo (room air) inhalation, participants underwent oral glucose tolerance tests (OGTT). For key outcome variables, there were no significant main effects or interactions across condition or time point (mean ± SD), including fasting glucose (mg dl^-1 : pre-placebo: 85.2 ± 10.1; post-placebo: 82.9 ± 10.6; pre-CO: 83.6 ± 7.7; post-CO: 84.0 ± 9.0), 2 h post glucose (mg dl^-1 : pre-placebo: 100.9 ± 20.0; post-placebo: 98.7 ± 13.1; pre-CO: 94.2 ± 23.2; post-CO: 94.4 ± 14.9), or the Matsuda index (pre-placebo: 16.1 ± 11.5; post-placebo: 20.3 ± 24.7; pre-CO: 15.6 ± 15.3; post-CO: 17.5 ± 16.8). In conclusion, 5 days of low dose CO administration did not influence glucose and insulin responses to an OGTT in overweight adults. Low dose CO inhalation is utilized in a variety of physiological assessment procedures; these findings allow researchers to utilize these procedures without concern of altering glucose metabolism.

Abstract PD9-05: The importance of the metastatic biopsy: Clinical and translational relevance in a real world series of patients with metastatic breast cancer

Background

Metastatic breast cancer (MBC) is a heterogeneous disease, whose clinical course and prognosis may be unpredictable, creating significant uncertainty for patients and their families. Heterogeneity is breast cancer subtypes is now well recognized as a potential reason for treatment resistance. Sampling metastatic sites at the point of diagnosis or upon progression, when safe, is recommended to better guide therapy.

Purpose

This study evaluated patients currently undergoing treatment for MBC in the clinic to determine the clinical and translational significance of a metastatic sample.

Methods

Patients currently undergoing treatment for MBC at the Olivia Newton John Centre were identified. Data was collected on patient demographics, clinicopathological information, treatment and duration of response. Translational research tissue was collected, with consent, for DNA and RNA analysis.

Results

Between January 2017 and May 2018 111 patients were identified. The mean age of MBC diagnosis was 60 years (range 30-87), with a mean follow up time of 2.4 years (range 0.8-16). Fifteen patients died during the study period. Sixty-seven (60%) patients were initially treated for early breast cancer (EBC), with a median disease free interval (DFI) 4.7 years. Half (51%) these patients relapsed after five years.

At MBC diagnosis, multiple sites of disease were identified including bone, visceral, brain, nodal and skin/chest wall disease. Bone only disease was common (25%), whereas brain disease was rare overall (9%). Metastatic tissue was collected in 67 (60%) patients, where up to four different sites were biopsied. The most commonly biopsied site was bone (n=21), followed by soft tissue (n=20), chest wall/skin disease (n=12), liver (n=9), lung (n=8) and brain (n=8). Serous disease was collected in 16 patients, including pleural, pericardial, ascitic and cerebrospinal fluid.

Based on the EBC subtype (n=67), 70% had luminal disease, 19% had Her2 positive disease and 7% had TNBC. However, based on a metastatic biopsy (n=67), only 61% of patients had luminal disease, 21% had HER2 positive, and 18% had TNBC. Paired EBC and MBC samples were available in 48 patients, with significant change in breast cancer subtype demonstrated in 12 of these patients (25%). The most common change was a loss in ER staining, which included 6 patients from ER positive, HER2 negative to TNBC and three patients who became ER negative but remained HER2 positive. Molecular profiling was performed thus far on 8 samples at the single cell and bulk level. These results highlight a large level of inter- and intra-tumoral heterogeneity, and may result in a better understanding of the molecular pathways specifically deregulated in patients at the point of progression.

Conclusion

In this single institution series of patients with MBC, over half of the cohort underwent at least one metastatic biopsy. Strikingly, a quarter of patients demonstrated a change in their breast cancer subtype, which directly guided subsequent therapy. Metastatic tissue can provide vital information to inform treatment decisions, which may be guided by translational laboratories having access to fresh tissue at the point of metastatic diagnosis or disease progression.

Citation Format: Yeo B, Molinaro T, Merino D, Berthelet J, Pouliot N, Fang C, Bell C, Anderson R. The importance of the metastatic biopsy: Clinical and translational relevance in a real world series of patients with metastatic breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD9-05.

The barriers to linkage and retention in care for women living with HIV in an high income setting where they comprise a minority group

Women comprise a minority population of individuals living with HIV in Australia, and are often poorly represented in research and clinical trials so their needs remain largely unknown. Data suggests that they are diagnosed later than men and start antiretroviral therapy at a lower CD4 cell count. This raises the question whether there are sex specific barriers to linkage and retention in care. This study analyzed 484 surveys received from clinicians collecting demographic, virological, and reproductive health data along with perceived barriers to linkage and retention in care. Most women (67%) were estimated to have been linked into care within 28 days of diagnosis. For women who were not linked into care for more than 28 days, the most commonly reason cited was fear of disclosure to others, followed by fear of disclosure to their partner. The main reasons given for non-retention in care were related to transport, carer responsibilities, financial pressure, health beliefs and concern about stigma or disclosure.

Routine germline BRCA1 and BRCA2 testing in patients with ovarian carcinoma: analysis of the Scottish real-life experience

OBJECTIVE

To determine the rates of germline BRCA1 and BRCA2 mutations in Scottish patients with ovarian cancer, before and after a change in testing policy.

DESIGN

Retrospective cohort study.

SETTING

Four cancer/genetics centres in Scotland.

POPULATION

Patients with ovarian cancer undergoing germline BRCA1 and BRCA2 (gBRCA1/2) sequencing before 2013 (under the 'old criteria', with selection based solely on family history), after 2013 (under the 'new criteria', with sequencing offered to newly presenting patients with non-mucinous ovarian cancer), and in the 'prevalent population' (who presented before 2013, but were not eligible for sequencing under the old criteria but were sequenced under the new criteria).

METHODS

Clinicopathological and sequence data were collected before and for 18 months after this change in selection criteria.

MAIN OUTCOME MEASURES

Frequency of germline BRCA1, BRCA2, RAD51C, and RAD51D mutations.

RESULTS

Of 599 patients sequenced, 205, 236, and 158 were in the 'old criteria', 'new criteria', and 'prevalent' populations, respectively. The frequency of gBRCA1/2 mutations was 30.7, 13.1, and 12.7%, respectively. The annual rate of gBRCA1/2 mutation detection was 4.2 before and 20.7 after the policy change. A total of 48% (15/31) 'new criteria' patients with gBRCA1/2 mutations had a Manchester score of <15 and would not have been offered sequencing based on family history criteria. In addition, 20 patients with gBRCA1/2 were identified in the prevalent population. The prevalence of gBRCA1/2 mutations in patients aged >70 years was 8.2%.

CONCLUSIONS

Sequencing all patients with non-mucinous ovarian cancer gives a much higher annual gBRCA1/2 mutation detection rate, with the frequency of positive tests still exceeding the 10% threshold upon which many family history-based models operate.

TWEETABLE ABSTRACT

BRCA sequencing all non-mucinous cancer patients increases mutation detection five fold.

First nations people's perspectives on barriers and supports for enhancing HPV vaccination: Foundations for sustainable, community-driven strategies

OBJECTIVE

In Canada, Indigenous people have higher human papillomavirus (HPV) infection rates, lower screening rates for cervical cancer, and higher rates of invasive cancer, leading to worse cervical cancer-related outcomes than observed in non-Indigenous Canadian women. Lingering harms from European colonization drive these health inequities and create public health challenges. Policy guidance is needed to optimize HPV vaccination rates and, thereby, decrease the burden of HPV-related illness, including high-morbidity surgical procedures and chemo-radiotherapy. The Enhancing HPV Vaccination In First Nations Populations in Alberta (EHVINA) project focuses on First Nations, a diverse subset of recognized Indigenous people in Canada, and seeks to increase HPV vaccination among girls and boys living in First Nation communities.

METHODS

Developing an effective strategy requires partnership with affected communities to better understand knowledge and perceptions about cancer, healthcare, and the HPV vaccine. A 2017 community gathering was convened to engage First Nations community members, health directors, and health services researchers in dialogue around unique barriers and supports to HPV vaccination in Alberta. Voices of community Elders, parents, health directors, and cancer survivors (n=24) are presented as qualitative evidence to help inform intervention design.

RESULTS

Key findings from discussions indicate barriers to HPV vaccination include resource constraints and service infrastructure gaps, historical mistrust in healthcare systems, impacts of changing modes of communication, and community sensitivities regarding sexual health promotion. Supports were identified as strengthened inter-generational relationships in communities.

CONCLUSIONS AND FUTURE DIRECTION

Ongoing dialogue and co-development of community-based strategies to increase HPV vaccine uptake are required. The identification of possible barriers to HPV vaccination in a Canadian Indigenous population contributes to limited global literature on this subject and may inform researchers and policy makers who work with Indigenous populations in other regions.

Sustaining obesity prevention in communities: a systematic narrative synthesis review

Obesity is a global problem for which sustainable solutions are yet to be realized. Community-based interventions have improved obesity-related behaviours and obesity in the short term. Few papers have explored how to make the interventions and their intended outcomes sustainable. The aim of this paper is to identify factors that contribute to the sustainability of community-based obesity prevention interventions and their intended outcomes. A systematic narrative synthesis review was conducted of published community-based obesity prevention interventions to identify factors contributing to intervention sustainability. Data extracted were included study authors' perspectives of intervention success and sustainability. Eighty-one papers met the inclusion criteria, and from these we identified ten factors that contribute to sustainability: resourcing, leadership, workforce development, community engagement, partnerships, policy, communications, adaptability, evaluation and governance. This review of community-based obesity prevention interventions gives rise to optimism that sustainable change is possible. We propose a framework to help practitioners build sustainability into their interventions and report on them so that others can also benefit.

Presumed tuberculosis-associated uveitis: rising incidence and widening criteria for diagnosis in a non-endemic area

PurposeTo assess the incidence, clinical ocular involvement and effectiveness of anti-tuberculous treatment in patients with chronic uveitis presumed to be associated with tuberculosis in a non-endemic community.Patients and methodsRetrospective case series of patients with uveitis and evidence of tuberculosis, with no other identified cause of uveitis, who underwent a 6-month course of standard anti-tuberculosis treatment between 2008 and 2015. The response to treatment was assessed at 6 and 12 months after initiation of treatment.ResultsForty-eight patients were included of whom 36 (75%) were born outside the United Kingdom. Only five had concurrent active pulmonary or nodal tuberculosis. There were 85 affected eyes, including 25 with granulomatous anterior uveitis, 32 with retinal vasculitis (occlusive in 21), and 20 with multifocal choroiditis or serpiginous-like retinochoroiditis. Gamma-interferon testing was positive in 95%. Complete resolution at end point was seen in only 60%, but a further 19% were inflammation-free on topical steroid only. Resolution was lower (50%) in those with panuveitis compared to other anatomical types (75%). Sixty-four eyes (75%) had a LogMAR visual acuity of 0.1 or better at the end of the study.ConclusionsThe incidence of presumed tuberculosis-associated uveitis (TBU) has almost quadrupled in this region. The efficacy of treatment has not been enhanced by the introduction of gamma-interferon testing to support diagnosis. Some patients may require more prolonged antibiotic therapy to ensure quiescence, but chronic non-infective anterior uveitis may in any case follow treated TBU.

Fracture of the medial intercondylar eminence of the tibia in horses treated by arthroscopic fragment removal (21 horses)

BACKGROUND

Fractures of the medial intercondylar eminence of the tibia (MICET) are scarcely reported in horses.

OBJECTIVES

To report the clinical and diagnostic findings, surgical treatment and outcome in a series of horses presented with MICET fracture and treated with arthroscopic fragment removal.

STUDY DESIGN

Multicentre retrospective case series.

METHODS

Case records of horses diagnosed with MICET fractures that had undergone surgical treatment were reviewed. Follow-up information was obtained from re-examination visits and/or owners.

RESULTS

Twenty-one cases were identified at 9 equine hospitals between 2004 and 2016. A history of trauma and acute onset of lameness was reported in 12 horses. All cases underwent fracture removal via arthroscopy of the medial femorotibial joint. The cranial cruciate ligament was intact in 6 horses and damaged in 15 horses (damage was ≤25% [n = 9], 25-50% [n = 4] or ≥50% [n = 2] of the cross-sectional area). The cranial ligament of the medial meniscus was damaged in 11 horses (≤25% [n = 8], 25-50% [n = 3]). The medial meniscus was damaged in 5 horses and articular cartilage damage was identified in 14 horses (mild [n = 8], moderate [n = 6]). Follow-up information (median 14 months; 4 months-6 years) was available for 20 cases; 2 horses were sound but convalescing; 13 horses were sound and returned to their previous or expected use. Of the 4 horses with the most severe changes to the articular soft tissue structures, 2 remained lame and 2 were subjected to euthanasia because of persistent lameness.

MAIN LIMITATIONS

The retrospective, multicentre nature of this study and the limited number of horses are the main limitations.

CONCLUSIONS

Fractures of the MICET are commonly associated with a traumatic event. Prompt diagnosis and early arthroscopic removal of the fracture are recommended.

H3N2 Canine Influenza Virus Infection in a Dog

In 2015, H3N2 canine influenza emerged in dogs in the greater Chicago area. During this time, a 10-year-old German Shepherd dog presented to the referring veterinarian with lethargy and coughing that quickly progressed to death. This report describes the macroscopic and microscopic lesions and the molecular testing performed to identify the novel North American H3N2 strain of canine influenza. The larynx, pharynx, and trachea were covered by a fibrinonecrotic membrane. Bilaterally, the lungs had multifocal subpleural necrosis of the caudal lung lobes with hemorrhage, congestion, and pulmonary edema. Staphylococcus pseudointermedius was isolated from the lung. Mycoplasma cynos was identified by real-time polymerase chain reaction from nasal passages, oropharynx, larynx, trachea, and cranial lung lobes. The neuraminidase gene sequence from the influenza virus isolated obtained from this dog had ≥98% homology to the strain circulating in the Chicago area.

Formula Feeding Predisposes Gut to NSAID-Induced Small Intestinal Injury

Objectives

Breast feeding protects infants from many diseases, including necrotizing enterocolitis, peptic ulceration and infectious diarrhea. Conversely, maternal separation stress and Non-Steroidal Anti-Inflammatory Drugs (NSAID's) can induce intestinal injury and bleeding. This study aimed to evaluate in suckling rats if maternal separation/formula feeding leads to increased intestinal sensitivity to indomethacin (indo)-induced intestinal injury and to look at potential mechanisms involved.

Methods

Nine-day-old rats were dam-fed or separated/trained to formula-feed for 6 days prior to indo administration (5 mg/kg/day) or saline (control) for 3 days. Intestinal bleeding and injury were assessed by measuring luminal and Fecal Hemoglobin (Hob) and jejunal histology. Maturation of the intestine was assessed by measuring luminal bile acids, jejunal sucrase, serum corticosterone, and mRNA expression of ileal Apical Sodium-Dependent Bile Acid Transporter (ASBT).

Results

At 17 days, formula-fed indo-treated pups had a 2-fold increase in luminal Hb compared to formula-fed control pups and had evidence of morphological injury to the small intestinal mucosa as observed at the light microscopic level, whereas indo had no effect on dam-fed littermates. In addition, formula-fed rats had significant increases in luminal bile acid, sucrase specific activity, serum corticosterone, and expression of ASBT mRNA compared to dam-fed rats.

Conclusion

Maternal separation stress may cause early intestinal maturational changes induced by corticosteroid release, including increased epithelial exposure to bile acids. These maturational changes may have a sensitizing rather than protective effect against indo-induced injury in the new-born.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Persistent sexual arousal in a woman with associated cardiac defects and raised atrial natriuretic peptide

The persistent sexual arousal syndrome (PSAS) is a newly described entity where the woman becomes involuntarily genitally aroused for extended periods of time in the absence of sexual desire and is distressed by this situation. The cause of this sexual problem is not well understood. We describe such a case where the subjective feelings were confirmed by observing genital engorgement. In her case, PSAS came on after initiation of fludrocortisone given for hypotension and bradycardia that was associated with an atrial septal defect (ASD). We argue that the combined effect of the ASD and fludrocortisone may be associated with an increase in her levels of atrial natriuretic peptide (ANP). ANP causes profound vasodilation and vascular leakage. We postulate that the high serum levels of ANP in her case may be contributory to her PSAS.

Quantifying alcohol-related emergency admissions in a UK tertiary referral hospital: a cross-sectional study of chronic alcohol dependency and acute alcohol intoxication

OBJECTIVES

Alcohol is responsible for a proportion of emergency admissions to hospital, with acute alcohol intoxication and chronic alcohol dependency (CAD) implicated. This study aims to quantify the proportion of hospital admissions through our emergency department (ED) which were thought by the admitting doctor to be (largely or partially) a result of alcohol consumption.

SETTING

ED of a UK tertiary referral hospital.

PARTICIPANTS

All ED admissions occurring over 14 weeks from 1 September to 8 December 2012. Data obtained for 5497 of 5746 admissions (95.67%).

PRIMARY OUTCOME MEASURES

Proportion of emergency admissions related to alcohol as defined by the admitting ED clinician.

SECONDARY OUTCOME MEASURES

Proportion of emergency admissions due to alcohol diagnosed with acute alcohol intoxication or CAD according to ICD-10 criteria.

RESULTS

1152 (21.0%, 95% CI 19.9% to 22.0%) of emergency admissions were thought to be due to alcohol. 74.6% of patients admitted due to alcohol had CAD, and significantly greater than the 26.4% with 'Severe' or 'Very Severe' acute alcohol intoxication (p<0.001). Admissions due to alcohol differed to admissions not due to alcohol being on average younger (45 vs 56 years, p<0.001) more often male (73.4% vs 45.1% males, p<0.001) and more likely to have a diagnosis synonymous with alcohol or related to recreational drug use, pancreatitis, deliberate self-harm, head injury, gastritis, suicidal ideation, upper gastrointestinal bleeds or seizures (p<0.001). An increase in admissions due to alcohol on Saturdays reflects a surge in admissions with acute alcohol intoxication above the weekly average (p=0.003).

CONCLUSIONS

Alcohol was thought to be implicated in 21% of emergency admissions in this cohort. CAD is responsible for a significantly greater proportion of admissions due to alcohol than acute intoxication. Interventions designed to reduce alcohol-related admissions must incorporate measures to tackle CAD.