Temporal trends of ambulance time intervals for suspected stroke/transient ischaemic attack (TIA) before and during the COVID-19 pandemic in Ireland: a quasi-experimental study

OBJECTIVES

Time is a fundamental component of acute stroke and transient ischaemic attack (TIA) care, thus minimising prehospital delays is a crucial part of the stroke chain of survival. COVID-19 restrictions were introduced in Ireland in response to the pandemic, which resulted in major societal changes. However, current research on the effects of the COVID-19 pandemic on prehospital care for stroke/TIA is limited to early COVID-19 waves. Thus, we aimed to investigate the effect of the COVID-19 pandemic on ambulance time intervals and suspected stroke/TIA call volume for adults with suspected stroke and TIA in Ireland, from 2018 to 2021.

DESIGN

We conducted a secondary data analysis with a quasi-experimental design.

SETTING

We used data from the National Ambulance Service in Ireland. We defined the COVID-19 period as '1 March 2020-31 December 2021' and the pre-COVID-19 period '1 January 2018-29 February 2020'.

PRIMARY AND SECONDARY OUTCOME MEASURES

We compared five ambulance time intervals: 'allocation performance', 'mobilisation performance', 'response time', 'on scene time' and 'conveyance time' between the two periods using descriptive and regression analyses. We also compared call volume for suspected stroke/TIA between the pre-COVID-19 and COVID-19 periods using interrupted time series analysis.

PARTICIPANTS

We included all suspected stroke/TIA cases ≥18 years who called the National Ambulance Service from 2018 to 2021.

RESULTS

40 004 cases were included: 19 826 in the pre-COVID-19 period and 19 731 in the COVID-19 period. All ambulance time intervals increased during the pandemic period compared with pre-COVID-19 (p<0.001). Call volume increased during the COVID-19-period compared with the pre-COVID-19 period (p<0.001).

CONCLUSIONS

A 'shock' like a pandemic has a negative impact on the prehospital phase of care for time-sensitive conditions like stroke/TIA. System evaluation and public awareness campaigns are required to ensure maintenance of prehospital stroke pathways amidst future healthcare crises. Thus, this research is relevant to routine and extraordinary prehospital service planning.

The Feasibility of Quality Assurance in the TOPGEAR International Phase 3 Clinical Trial of Neoadjuvant Chemoradiation Therapy for Gastric Cancer (an Intergroup Trial of the AGITG/TROG/NHMRC CTC/EORTC/CCTG)

PURPOSE

The TOPGEAR phase 3 trial hypothesized that adding preoperative chemoradiation therapy (CRT) to perioperative chemotherapy will improve survival in patients with gastric cancer. Owing to the complexity of gastric irradiation, a comprehensive radiation therapy quality assurance (RTQA) program was implemented. Our objective is to describe the RTQA methods and outcomes.

METHODS AND MATERIALS

RTQA was undertaken in real time before treatment for the first 5 patients randomized to CRT from each center. Once acceptable quality was achieved, RTQA was completed for one-third of subsequent cases. RTQA consisted of evaluating (1) clinical target volume and organ-at-risk contouring and (2) radiation therapy planning parameters. Protocol violations between high- (20+ patients enrolled) and low-volume centers were compared using the Fisher exact test.

RESULTS

TOPGEAR enrolled 574 patients, of whom 286 were randomized to receive preoperative CRT and 203 (71%) were included for RTQA. Of these, 67 (33%) and 136 (67%) patients were from high- and low-volume centers, respectively. The initial RTQA pass rate was 72%. In total, 28% of cases required resubmission. In total, 200 of 203 cases (99%) passed RTQA before treatment. Cases from low-volume centers required resubmission more often (44/136 [33%] vs 13/67 [18%]; P = .078). There was no change in the proportion of cases requiring resubmission over time. Most cases requiring resubmission had multiple protocol violations. At least 1 aspect of the clinical target volume had to be adjusted in all cases. Inadequate coverage of the duodenum was most common (53% major violation, 25% minor violation). For the remaining cases, the resubmission process was triggered secondary to poor contour/plan quality.

CONCLUSIONS

In a large multicenter trial, RTQA is feasible and effective in achieving high-quality treatment plans. Ongoing education should be performed to ensure consistent quality during the entire study period.

Implementation of a retrofit MRI simulator for radiation therapy planning

Magnetic resonance imaging (MRI) is being integrated into routine radiation therapy (RT) planning workflows. To reap the benefits of this imaging modality, patient positioning, image acquisition parameters and a quality assurance programme must be considered for accurate use. This paper will report on the implementation of a retrofit MRI Simulator for RT planning, demonstrating an economical, resource efficient solution to improve the accuracy of MRI in this setting.

Implementing Parenting Programs in Primary Care: A Framework and a Call for Action

Healthy parent-child relationships are clearly critical to healthy child development. Parenting programs develop caregivers' skills to support the health and well-being of children. Rigorous evidence has demonstrated the efficacy of these programs. Rising rates of child and youth depression, anxiety, grief, and suicide, both prior to and compounded by the COVID-19 pandemic, provide further reasons to implement parenting programs that support all parents in their essential roles. Parents can act as a buffer to stressors and support for children's well-being when they have the knowledge and skills to do so. Pediatric primary care practices are a natural setting for parenting programs, but challenges, including stigma, technology, workflow issues, and funding, have prevented their broad dissemination, implementation, and sustainability. In this article, we develop a framework for implementing parenting programs in primary care and present key considerations for selecting programs that fit the needs of parents, providers, patients, and the practice. We offer lessons from our experiences in overcoming these challenges, using the updated Consolidated Framework for Implementation Research to structure our discussion. We also provide an initial stepwise process which readers may use to plan their own parenting program implementation. Pediatric clinicians and practices can use this article and associated resources to plan, implement, and evaluate parenting programs in their practices as a strategy to help address the growing youth mental health crisis. Improving parenting behaviors can reduce the need for current or future mental health interventions by supporting optimal child development, emotional regulation, and parent-child relationships.

Transitions in mental health and addiction care for youth and their families: a scoping review of needs, barriers, and facilitators

INTRODUCTION

Transitional-aged youth (TAY) with mental health and/or addictions (MHA) concerns and their families experience significant challenges finding, accessing, and transitioning through needed MHA care. To develop appropriate supports that assist TAY and their families in navigating MHA care, their experiences of transitions in the MHA care system must be better understood. This scoping review identifies and explores the needs, barriers, and facilitators for TAY and their families when transitioning through MHA care.

METHODS

This scoping review commenced with a search of five relevant databases. Three research team members were involved in title, abstract, and full-text scanning and data extraction. Sources focusing on TAY anywhere between the ages of 12-29 years and meeting the study objectives were included. Extractions compiled background and narrative information about the nature and extent of the data. Analysis and synthesis of findings involved numerical description of the general information extracted (e.g., numbers of sources by country) and thematic analysis of narrative information extracted (e.g., family involvement in TAY help-seeking).

RESULTS

A total of 5894 sources were identified. Following title and abstract scanning, 1037 sources remained for full-text review. A total of 66 sources were extracted. Findings include background information about extracted sources, in addition to five themes that emerged pertaining to barriers and facilitators to access and transitions through care and the needs and roles of TAY and families in supporting help-seeking and care transitions: holistic supports, proactive preparation, empowering TAY and families, collaborative relationships, and systemic considerations. These five themes demonstrate approaches to care that can ensure TAY and families' needs are met, barriers are mitigated, and facilitators are enhanced.

CONCLUSION

This review provides essential contextual information regarding TAY with MHA concerns and their families' needs when seeking care. Such findings lend to an enhanced understanding of how MHA programs can support this population's needs, involve family members as appropriate, reduce the barriers experienced, and work to build upon existing facilitators.

Leaves as bottlenecks: The contribution of tree leaves to hydraulic resistance within the soil-plant-atmosphere continuum

Within vascular plants, the partitioning of hydraulic resistance along the soil-to-leaf continuum affects transpiration and its response to environmental conditions. In trees, the fractional contribution of leaf hydraulic resistance (R_leaf ) to total soil-to-leaf hydraulic resistance (R_total ), or fR_leaf (=R_leaf /R_total ), is thought to be large, but this has not been tested comprehensively. We compiled a multibiome data set of fR_leaf using new and previously published measurements of pressure differences within trees in situ. Across 80 samples, fR_leaf averaged 0.51 (95% confidence interval [CI] = 0.46-0.57) and it declined with tree height. We also used the allometric relationship between field-based measurements of soil-to-leaf hydraulic conductance and laboratory-based measurements of leaf hydraulic conductance to compute the average fR_leaf for 19 tree samples, which was 0.40 (95% CI = 0.29-0.56). The in situ technique produces a more accurate descriptor of fR_leaf because it accounts for dynamic leaf hydraulic conductance. Both approaches demonstrate the outsized role of leaves in controlling tree hydrodynamics. A larger fR_leaf may help stems from loss of hydraulic conductance. Thus, the decline in fR_leaf with tree height would contribute to greater drought vulnerability in taller trees and potentially to their observed disproportionate drought mortality.

Comparative effectiveness of mobile health smoking cessation approaches among underserved patients in primary care: Study protocol for the PROMOTE-UP trial

INTRODUCTION

Tobacco smoking is the leading cause of preventable disease, disability, and premature death in the United States. Recent advances have led to two efficacious mobile health (mHealth) treatments for smoking cessation: iCanQuit, an Acceptance and Commitment Therapy-based behavioral treatment promoting cessation through accepting triggers and committing to values; and Motiv8, a contingency management intervention promoting smoking cessation with financial incentives via biochemically verified abstinence. This study will evaluate the comparative effectiveness of the Florida Quitline, iCanQuit alone, and iCanQuit+Motiv8 in a pragmatic trial among patients who smoke in underserved primary care settings.

METHODS

The study will be an individually-randomized controlled trial with three arms (Florida Quitline, iCanQuit alone, iCanQuit+Motiv8 combined) conducted in multiple primary care practices affiliated with the OneFlorida+ Clinical Research Consortium. Adult patients who smoke will be randomized to one of the 3 study arms (n = 444/arm), stratified by healthcare setting (academic vs. community). The primary outcome will be 7-day point prevalence smoking abstinence at 6 months post-randomization. Secondary outcomes will be 12-month smoking abstinence, patient satisfaction with the interventions, and changes in patient quality of life and self-efficacy. The study will also assess how and for whom the interventions help sub-group patients in achieving smoking abstinence by measuring theory-derived factors that mediate smoking outcome-specific baseline moderators.

CONCLUSIONS

Results from this study will provide evidence for the comparative effectiveness of mHealth smoking cessation interventions in healthcare settings. Use of mHealth interventions can make smoking cessation resources more equitably accessible and have far-reaching impact on community and population health.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05415761, Registered 13 June 2022.

INTERGENERATIONAL TRANSMISSION OF "SEVA": ELDERS MODEL SELFLESS SERVICE IN SOUTH ASIAN HOMES FOR CHILDREN

Life course theory is a framework for examining the role of elders in modeling altruistic behavior or "seva" (selfless service) in two homes for children: Unatti (Bhaktapur, Nepal) and Ramana's Garden (Rishikesh, India). Two American women, compelled to impact the plight of children subject to poverty, trafficking and/or caste discrimination (Dalits, the former "untouchables"), each founded homes 20+ years ago and modeled selfless service exemplified by children, some now in "emerging adulthood," who are giving back to their communities. In this intergenerational/intercultural multiple case study, narratives of the program founders now in mid- to late adulthood are presented along with narratives of six young adults who continue to provide nurturance to younger children and engage in projects to educate and feed residents of the homes and nearby communities. The life course principle of time and place situates the children in areas of their countries with relatively low literacy rates. The founders saw the value of education to empower young people, especially girls, to expand their opportunities and serve as role models for children coming into the homes after them. The linked lives principle is evident through shared relationships with the founders as these young people navigate political crises, disasters like the Nepal earthquake, and health crises like the Covid-19 pandemic. Some become leaders themselves as they have been mentored over their life course. A sense of agency is experienced in their young adulthood as more choices for their lives become available as an alternative to subsistence existence and early marriage/childbearing.

Navigation for youth mental health and addictions: protocol for a realist review and synthesis of approaches and practices (The NavMAP standards project)

INTRODUCTION

Mental health and/or addiction (MHA) concerns affect approximately 1.2 million children and youth in Canada, yet less than 20% receive appropriate treatment for these concerns. Youth who do not receive appropriate support may disengage from care and may experience lasting MHA issues. Families of these youth also support them in finding and accessing care. Thus, system supports are needed to help youth and their families find and equitably access appropriate care. Navigation is an innovation in MHA care, providing patient-centred support and care planning that helps individuals and families overcome barriers to care. Despite the increasing availability of navigation services for youth with MHA concerns, practices and models vary, and no single source has synthesised evidence regarding approaches and outcomes for this population into comprehensive standards.

METHODS AND ANALYSIS

The proposed research will bring together evidence in youth MHA navigation, to establish this important system support as a factor that can enhance the integration and continuity of care for these youth. Our team, which includes researchers, administrators, clinical leads, an MHA navigator and youth and caregivers with lived experience, will be involved in all project stages. Realist Review and Synthesis methodology will be used, the stages of which include: defining scope, searching for evidence, appraising studies and extracting data, synthesising evidence and developing conclusions, and disseminating findings.

ETHICS AND DISSEMINATION

Ethics approval is not required, as the study involves review of existing data. Dissemination plans include scientific publications and conferences and online products for stakeholders and the general public.

Study protocol for a type III hybrid effectiveness-implementation trial to evaluate scaling interoperable clinical decision support for patient-centered chronic pain management in primary care

Background

The US continues to face public health crises related to both chronic pain and opioid overdoses. Thirty percent of Americans suffer from chronic noncancer pain at an estimated yearly cost of over $600 billion. Most patients with chronic pain turn to primary care clinicians who must choose from myriad treatment options based on relative risks and benefits, patient history, available resources, symptoms, and goals. Recently, with attention to opioid-related risks, prescribing has declined. However, clinical experts have countered with concerns that some patients for whom opioid-related benefits outweigh risks may be inappropriately discontinued from opioids. Unfortunately, primary care clinicians lack usable tools to help them partner with their patients in choosing pain treatment options that best balance risks and benefits in the context of patient history, resources, symptoms, and goals. Thus, primary care clinicians and patients would benefit from patient-centered clinical decision support (CDS) for this shared decision-making process.

Methods

The objective of this 3-year project is to study the adaptation and implementation of an existing interoperable CDS tool for pain treatment shared decision making, with tailored implementation support, in new clinical settings in the OneFlorida Clinical Research Consortium. Our central hypothesis is that tailored implementation support will increase CDS adoption and shared decision making. We further hypothesize that increases in shared decision making will lead to improved patient outcomes, specifically pain and physical function. The CDS implementation will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. The evaluation will be organized by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. We will adapt and tailor PainManager, an open source interoperable CDS tool, for implementation in primary care clinics affiliated with the OneFlorida Clinical Research Consortium. We will evaluate the effect of tailored implementation support on PainManager’s adoption for pain treatment shared decision making. This evaluation will establish the feasibility and obtain preliminary data in preparation for a multi-site pragmatic trial targeting the effectiveness of PainManager and tailored implementation support on shared decision making and patient-reported pain and physical function.

Discussion

This research will generate evidence on strategies for implementing interoperable CDS in new clinical settings across different types of electronic health records (EHRs). The study will also inform tailored implementation strategies to be further tested in a subsequent hybrid effectiveness-implementation trial. Together, these efforts will lead to important new technology and evidence that patients, clinicians, and health systems can use to improve care for millions of Americans who suffer from pain and other chronic conditions.

Trial registration

ClinicalTrials.gov, NCT05256394, Registered 25 February 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01217-4.

A novel method for measuring bowel motility and velocity with dynamic magnetic resonance imaging in two and three dimensions

Increasingly, dynamic magnetic resonance imaging (MRI) has potential as a noninvasive and accessible tool for diagnosing and monitoring gastrointestinal motility in healthy and diseased bowel. However, current MRI methods of measuring bowel motility have limitations: requiring bowel preparation or long acquisition times; providing mainly surrogate measures of motion; and estimating bowel-wall movement in just two dimensions. In this proof-of-concept study we apply a method that provides a quantitative measure of motion within the bowel, in both two and three dimensions, using existing, vendor-implemented MRI pulse sequences with minimal bowel preparation. This method uses a minimised cost function to fit linear vectors in the spatial and temporal domains. It is sensitised to the spatial scale of the bowel and aims to address issues relating to the low signal-to-noise in high-temporal resolution dynamic MRI scans, previously compensated for by performing thick-slice (10-mm) two-dimensional (2D) coronal scans. We applied both 2D and three-dimensional (3D) scanning protocols in two healthy volunteers. For 2D scanning, analysis yielded bi-modal velocity peaks, with a mean antegrade motion of 5.5 mm/s and an additional peak at ~9 mm/s corresponding to longitudinal peristalsis, as supported by intraoperative data from the literature. Furthermore, 3D scans indicated a mean forward motion of 4.7 mm/s, and degrees of antegrade and retrograde motion were also established. These measures show promise for the noninvasive assessment of bowel motility, and have the potential to be tuned to particular regions of interest and behaviours within the bowel.

Parentage-based tagging combined with genetic stock identification is a cost-effective and viable replacement for coded-wire tagging in large-scale assessments of marine Chinook salmon fisheries in British Columbia, Canada

Wild Pacific salmon, including Chinook salmon Oncorhynchus tshawytscha, have been supplemented with hatchery propagation for over 50 years in support of increased ocean harvest, mitigation for hydroelectric development, and conservation of threatened populations. In Canada, the Wild Salmon Policy for Pacific salmon was established with the goal of maintaining and restoring healthy and diverse Pacific salmon populations, making conservation of wild salmon and their habitats the highest priority for resource management decision-making. For policy implementation, a new approach to the assessment and management of Chinook salmon and the associated hatchery production and fisheries management are needed. Implementation of genetic stock identification (GSI) and parentage-based tagging (PBT) for marine fisheries assessment may overcome problems associated with coded-wire tag-based (CWT) assessment and management of Chinook salmon fisheries, providing at a minimum information equivalent to that derived from the CWT program. GSI and PBT were used to identify Chinook salmon sampled in 2018 and 2019 marine fisheries (18,819 individuals genotyped) in British Columbia to specific conservation units (CU), populations, and broodyears. Individuals were genotyped at 391 single nucleotide polymorphisms via direct sequencing of amplicons. Very high accuracy of assignment to population and age (>99.5%) via PBT was observed for 1994 Chinook salmon of ages 2-4 years, with a 105,722-individual, 380-population baseline available for assignment. Application of a GSI-PBT system of identification to individuals in 2019 fisheries provided high-resolution estimates of stock composition, catch, and exploitation rate by CU or population, with fishery exploitation rates directly comparable to those provided by CWTs for 13 populations. GSI and PBT provide an alternate, cheaper, and more effective method in the assessment and management of Canadian-origin Chinook salmon relative to CWTs, and an opportunity for a genetics-based system to replace the current CWT system for salmon assessment.

Adult North Star Network (ANSN): Consensus Guideline For The Standard Of Care Of Adults With Duchenne Muscular Dystrophy

There are growing numbers of adults with Duchenne Muscular Dystrophy living well into their fourth decade. These patients have complex medical needs that to date have not been addressed in the International standards of care. We sought to create a consensus based standard of care through a series of multi-disciplinary workshops with specialists from a wide range of clinical areas: Neurology, Cardiology, Respiratory Medicine, Gastroenterology, Endocrinology, Palliative Care Medicine, Rehabilitation, Renal, Anaesthetics and Clinical Psychology. Detailed reports of evidence reviewed and the consensus building process were produced following each workshop and condensed into this final document which was approved by all members of the Adult North Star Network including service users. The aim of this document is to provide a framework to improve clinical services and multi-disciplinary care for adults living with Duchenne Muscular Dystrophy.

Insights on the concept of indicator populations derived from parentage-based tagging in a large-scale coho salmon application in British Columbia, Canada

For Pacific salmon, the key fisheries management goal in British Columbia (BC) is to maintain and restore healthy and diverse Pacific salmon populations, making conservation of salmon biodiversity the highest priority for resource management decision-making. Salmon status assessments are often conducted on coded-wire-tagged subsets of indicator populations based on assumptions of little differentiation within or among proximal populations. In the current study of southern BC coho salmon (Oncorhynchus kisutch) populations, parentage-based tagging (PBT) analysis provided novel information on migration and life-history patterns to test the assumptions of biological homogeneity over limited (generally < 100 km) geographic distances and, potentially, to inform management of fisheries and hatchery broodstocks. Heterogeneity for location and timing of fishery captures, family productivity, and exploitation rate was observed over small geographic scales, within regions that are, or might be expected to be, within the area encompassed by a single-tagged indicator population. These results provide little support for the suggestion that information gained from tagged indicator populations is representative of marine distribution, productivity, and exploitation patterns of proximal populations.

0986 Positive Airway Pressure Care And Cleaning Practices In The Pediatric Home

Introduction

The Sleep Clinic at Arkansas Children’s follows approximately 300 children who require positive airway pressure (PAP) at home. The clinic respiratory therapist provides oral and written cleaning instructions while some physicians choose to provide their own instructions. The home equipment company who supplies PAP in the home also gives cleaning instructions. The different routes of information given may result in inconsistent practices. It is extremely important to clean PAP equipment as directed as infection and illness may result from improper cleaning.

Methods

Caregivers of children who utilize home PAP devices were invited to complete an anonymous survey regarding cleaning practices during a Sleep clinic appointment. Data were collected electronically. Descriptive statistics were utilized to summarize results.

Results

There were 96 participants of whom 90% (87/96) were parents/caregivers. The mean age of the equipment user was 12 years and most were male (69%, 66/96). The mean length of time the equipment had been used was 2.6 years (SD 3.2). The majority of respondents, 67% (64/95), identified the parent/caregiver as responsible for cleaning. Only 25% (24/96) reported cleaning the mask daily as recommended; 43% (41/96) of participants reported cleaning tubing weekly; 27% (26/96) reported cleaning the water chamber daily by while most reported at least weekly (47%, 45/96). The majority, 58% (56/96) reported emptying the water chamber daily and using distilled water (81%, 74/96). Most respondents did not note respiratory symptoms starting/increasing with PAP (67%, 64/96). Of those with respiratory symptoms attributed to PAP, congestion was the most common (79%, 11/14).

Conclusion

There is a discrepancy between recommended and actual practices for cleaning PAP equipment. No significant association was found between the duration of PAP use and cleaning practices. However, a moderately low correlation between age and cleaning was identified. Increased age was associated with decreased cleaning practices.

Support

 

Paediatric image-guided radiation therapy: determining and evaluating appropriate kilovoltage planar exposure factors for the Varian on-board imager

INTRODUCTION

Kilovoltage (kV) orthogonal imaging is commonly used for image-guided radiation therapy (IGRT) in paediatrics. Paediatrics have an increased sensitivity to radiation. Exposure factors need to be optimised so that imaging dose is kept as low as reasonably achievable (ALARA).

METHODS

A table of low-dose IGRT radiographic exposure factors for paediatric IGRT was determined through a phantom study. Four anatomical sites, head and neck, thorax, abdomen and pelvis, were investigated. The table was evaluated against standard manufacturer pre-sets. Dose was evaluated in terms of system-reported entrance surface air kerma (ESAK). Qualified participants volunteered to perform offline image matching in a further phantom study, recording misalignments detected and providing subjective assessments of image quality using an electronic survey tool. A statistical comparison of matching accuracy was conducted.

RESULTS

Twelve radiation therapists or radiation oncologists completed the image matching task and survey. The low-dose exposure table reduced imaging dose by 20-94% compared to manufacturer pre-sets. No significant difference was observed in the accuracy of image matching (head and neck P = 0.82, thorax P = 0.15, abdomen P = 0.33, pelvis P = 0.59). Participant image exposure preference was largely equivocal.

CONCLUSIONS

Optimising radiographic exposures in paediatric IGRT is feasible, logical and therefore reasonably achievable. Implementation of the low-dose exposure table presented in this study should be considered by paediatric radiotherapy departments wishing to image gently without compromising the potential to detect set up errors. Further study using a contrast detail phantom and contrast to noise image analysis software is recommended.

Determination of Ethoxyquin in Feeds by Liquid Chromatography: Collaborative Study

Ethoxyquin is a chemical antioxidant used in feeds, ingredients, fats, and oils. A liquid chromatographic (LC) method for determination of ethoxyquin was developed. The method involves acetonitrile extraction of the sample and isocratic Cis reversed-phase chromatography with ammonium acetate buffer-acetonitrile as mobile phase and fluorescence detection. A collaborative study of the determination of ethoxyquin in various meals and extruded pet foods was conducted by The lams Company Research Laboratory. Eleven laboratories analyzed 16 samples (including 2 blind duplicates) consisting of 7 meat meals and 9 extruded pet foods. Sample means ranged from 0.25 to 289 ppm. Repeatability standard deviations ranged from 0.08 to 3.2 ppm, and repeatability relative standard deviations ranged from 4.5 to 32%. Reproducibility standard deviations ranged from 0.12 to 13 ppm, and reproducibility relative standard deviations ranged from 4.5 to 55%. The LC method for determination of ethoxyquin in feeds has been adopted first action by AOAC INTERNATIONAL.

Determination of Vitamins A (Retinol) and E (alpha-Tocopherol) in Foods by Liquid Chromatography: Collaborative Study

A collaborative study was conducted for the determination of vitamins A and E. Existing AOAC liquid chromatographic (LC) methods are suited for specific vitamins A and E analytical applications. This method differs from existing methods in that it can be used to assay samples in all 9 sectors of the food matrix. Standards and test samples are saponified in basic ethanol–water solution, neutralized, and diluted, converting fats to fatty acids and retinol esters and tocopherol esters to retinol and tocopherol, respectively. Retinol and alpha-tocopherol are quantitated on separate LC systems, using UV detection at 313 or 328 nm for retinol, and fluorescence detection (excitation 290 nm, emission 330 nm) for alpha-tocopherol. Vitamin concentrations are calculated by comparison of the peak heights or peak areas of vitamins in test samples with those of standards.

Variation in migration pattern, broodstock origin, and family productivity of coho salmon hatchery populations in British Columbia, Canada, derived from parentage-based tagging

In salmonid parentage-based tagging (PBT) applications, entire hatchery broodstocks are genotyped, and subsequently, progeny can be nonlethally sampled and assigned back to their parents using parentage analysis, thus identifying their hatchery of origin and brood year (i.e., age). Inter- and intrapopulation variability in migration patterns, life history traits, and fishery contributions can be determined from PBT analysis of samples derived from both fisheries and escapements (portion of a salmon population that does not get caught in fisheries and returns to its natal river to spawn). In the current study of southern British Columbia coho salmon (Oncorhynchus kisutch) populations, PBT analysis provided novel information on intrapopulation heterogeneity among males in the total number of progeny identified in fisheries and escapements, the proportion of progeny sampled from fisheries versus escapement, the proportion of two-year-old progeny (jacks) produced, and the within-season return time of progeny. Fishery recoveries of coho salmon revealed heterogeneity in migration patterns among and within populations, with recoveries from north and central coast fisheries distinguishing "northern migrating" from "resident" populations. In northern migrating populations, the mean distance between fishery captures of sibs (brothers and sisters) was significantly less than the mean distance between nonsibs, indicating the possible presence of intrapopulation genetic heterogeneity for migration pattern. Variation among populations in productivity and within populations in fish catchability indicated that population selection and broodstock management can be implemented to optimize harvest benefits from hatcheries. Application of PBT provided valuable information for assessment and management of hatchery-origin coho salmon in British Columbia.

Comparison of coded-wire tagging with parentage-based tagging and genetic stock identification in a large-scale coho salmon fisheries application in British Columbia, Canada

Wild Pacific salmon, including Coho salmon Onchorynchus kisutch, have been supplemented with hatchery propagation for over 50 years in support of increased ocean harvest and conservation of threatened populations. In Canada, the Wild Salmon Policy for Pacific salmon was established with the goal of maintaining and restoring healthy and diverse Pacific salmon populations, making conservation of wild salmon and their habitats the highest priority for resource management decision-making. A new approach to the assessment and management of wild coho salmon, and the associated hatchery production and fishery management is needed. Implementation of parentage-based tagging (PBT) may overcome problems associated with coded-wire tag-based (CWT) assessment and management of coho salmon fisheries, providing at a minimum information equivalent to that derived from the CWT program. PBT and genetic stock identification (GSI) were used to identify coho salmon sampled in fisheries (8,006 individuals) and escapements (1,692 individuals) in British Columbia to specific conservation units (CU), populations, and broodyears. Individuals were genotyped at 304 single nucleotide polymorphisms (SNPs) via direct sequencing of amplicons. Very high accuracy of assignment to population (100%) via PBT for 543 jack (age 2) assigned to correct age and collection location and 265 coded-wire tag (CWT, age 3) coho salmon assigned to correct age and release location was observed, with a 40,774-individual, 267-population baseline available for assignment. Coho salmon from un-CWTed enhanced populations contributed 65% of the catch in southern recreational fisheries in 2017. Application of a PBT-GSI system of identification to individuals in 2017 fisheries and escapements provided high-resolution estimates of stock composition, catch, and exploitation rate by CU or population, providing an alternate and more effective method in the assessment and management of Canadian-origin coho salmon relative to CWTs, and an opportunity for a genetic-based system to replace the current CWT system for coho salmon assessment.

Abstract P220: Perception of Blood Pressure Control and Satisfaction with Hypertension Care in the Rural Setting

Background: National Health and Nutrition Examination Survey (NHANES) data indicate only 50% with hypertension (HTN) have controlled blood pressure (BP) yet limited data are available regarding patient’s knowledge of and satisfaction with their BP control.

Methods: We utilized MyHealthStory, an online health information exchange portal to identify a rural, diverse HTN population. Adult patients (≥ 18 yrs) were recruited from existing federally-qualified health center (FQHC) sites. The survey was sent via email to 5000 patients who voluntarily shared email addresses through MyHealthStory. Equal numbers of men and women of any race/ethnicity with a diagnosis of HTN and who consented to receive information about research in MyHealthStory were targeted. We developed the 21 question survey using Qualtrics. The first 300 patients who completed the survey were included. We compared a) patient-reported BP control (BP ≥ 140/90; or <140/90) and patient-reported satisfaction with BP control (yes=happy, no=unhappy) and b) patient reported BP control and perception of BP control (well controlled, uncontrolled); using McNemar’s test for paired nominal data.

Results: Here we report data from the 238 completed surveys received from Caucasians (n=184, 61% female) and African Americans (n=54, 83% female). Among 117 Caucasians reporting BP, 51% (n=60) reported uncontrolled BP, 52% (n=61) reported perception of well controlled BP (p=0.49). A total of 77% (n=46) of patients who had uncontrolled BP reported satisfaction with their HTN care compared to 96% in those who had controlled BP ( P <0.0001). Among 32 African Americans reporting BP, only 13% (n=4) reported controlled BP but 31% (n=10) reported perception of well controlled BP (p=0.034). Among the 4 African Americans whose BP was controlled, all 4 reported satisfaction with their HTN care, while among the 28 patients who reported uncontrolled BP, 23 (82%) reported satisfaction with their HTN care ( P <0.0001).

Conclusions: Among hypertensive individuals, our survey data suggest there is a substantial disconnection between reported BP control, perception of BP control and satisfaction with HTN treatment, suggesting need for improvement in patient education surrounding HTN treatment and BP control.

Deliberative Dialogues Between Policy Makers and Researchers in Canada and Australia

Knowledge translation (KT) and implementation science are growing fields in Canada, Australia, and worldwide. Many audiences are targeted as KT knowledge users—policy makers represent one key knowledge user in the health care field. The need for policy makers to understand research and for researchers to understand policy processes is commonly recognized. There is also increasing interest in health policy that focuses on KT as a framework for understanding the use of evidence and, in particular, describing the influence of research on policy along with concepts of coproduction and user involvement. With relationship building central to successful evidence-informed policy, this article explores deliberative dialogue as a potential approach to enhancing KT. It describes two examples of researcher efforts to cultivate relationships and contacts with policy and decision makers via such dialogues and illustrates the inherent opportunities and challenges of doing so.

TOPGEAR: A Randomized, Phase III Trial of Perioperative ECF Chemotherapy with or Without Preoperative Chemoradiation for Resectable Gastric Cancer: Interim Results from an International, Intergroup Trial of the AGITG, TROG, EORTC and CCTG

BACKGROUND

Postoperative chemoradiation and perioperative chemotherapy using epirubicin/cisplatin/5-fluorouracil (ECF) represent two standards of care for resectable gastric cancer. In the TOPGEAR (Trial Of Preoperative therapy for Gastric and Esophagogastric junction AdenocaRcinoma) trial, we hypothesized that adding preoperative chemoradiation to perioperative ECF will improve survival; however, the safety and feasibility of preoperative chemoradiation have yet to be determined.

METHODS

TOPGEAR is an international phase III trial in which patients with adenocarcinoma of the stomach were randomized to perioperative ECF alone or with preoperative chemoradiation. The ECF-alone group received three preoperative cycles of ECF, while the chemoradiation group received two cycles of preoperative ECF followed by chemoradiation. Both groups received three postoperative cycles of ECF. A planned interim analysis of the first 120 patients was conducted, and was reviewed by the Independent Data Safety Monitoring Committee to assess treatment compliance, toxicity/safety, and response rates.

RESULTS

The proportion of patients who received all cycles of preoperative chemotherapy was 93% (ECF group) and 98% (chemoradiation group), while 65 and 53%, respectively, received all cycles of postoperative chemotherapy. Overall, 92% of patients allocated to preoperative chemoradiation received this treatment. The proportion of patients proceeding to surgery was 90% (ECF group) and 85% (chemoradiation group). Grade 3 or higher surgical complications occurred in 22% of patients in both groups. Furthermore, grade 3 or higher gastrointestinal toxicity occurred in 32% (ECF group) and 30% (chemoradiation group) of patients, while hematologic toxicity occurred in 50 and 52% of patients.

CONCLUSIONS

These results demonstrate that preoperative chemoradiation can be safely delivered to the vast majority of patients without a significant increase in treatment toxicity or surgical morbidity.

Meeting radiation therapy patients informational needs through educational videos augmented by 3D visualisation software

Introduction

Misconceptions and uncertainties about radiotherapy compound the anxiety patients experience at the commencement of treatment. This project investigated the utility of locally produced treatment process videos in meeting patients’ informational needs.

Methods

In‐house video production was conducted on a voluntary basis by staff and patients at a regional Australian radiotherapy centre. Videos included real footage and animated sections created with PEARL^TM 3D visualisation software (Vertual Ltd, UK) to meet specific key content objectives. Quantitative cross sectional analysis was conducted. Patients attending for simulation watched a relevant video. After their first fraction of radiotherapy they were asked to complete an ethics‐reviewed questionnaire about how well the video addressed their information needs.

Results

The survey completion rate was 29% (n = 61/212). Surveys were collected over 9 months from August 2014 to April 2015. Statistical analysis found 98% of patients reported that the video was useful in meeting one or more of the learning objectives. Forty‐nine percent of patients also reported a reduction in fear and anxiety as a result of watching the video. Patients reported subsequent review of videos at home (39%), primarily to explain treatment processes to loved ones (46%).

Conclusion

The combination of real footage and 3D visualisation software assisted in meeting learning objectives regarding the treatment process. Standardised videos provided consistency of information provision to patients and facilitated multiple viewings of the video if desired.

The Rey Figure Copy as a Screening Instrument for Perceptual Deficits after Stroke

The aim of the study was to investigate the use of the Rey figure for screening patients for perceptual impairment following stroke. Stroke patients in a trial of a stroke unit were assessed using the Rey figure copy at entry to the study. Those admitted to the stroke unit were also assessed on the Rivermead Perceptual Assessment Battery (RPAB). In 61 patients assessed consecutively on both tests, using conventional clinical cut-off points the Rey figure copy was impaired in 31 out of 32 patients who were impaired on the RPAB. Fifteen patients who failed the Rey figure did not have perceptual problems on the RPAB, indicating that deficits on the Rey figure are not only due to perceptual problems. A receiver operating characteristic curve was plotted to compare different cut-off points. The Rey figure may be used as a brief screening assessment for perceptual deficits following stroke.

Evaluation of multiplex polymerase chain reaction utilising multiple targets in Mycobacterium tuberculosis direct test negative but culture positive cases: a potential method for enhancing the diagnosis of tuberculosis

PURPOSE

To evaluate multiplex Polymerase Chain Reaction (MPCR) utilising multiple targets (IS6110, Protein b [Pab] and MPB64 genes) in Mycobacterium tuberculosis Direct Test (MTD) negative but culture positive cases and comparison of MPCR with Real-Time polymerase chain reaction (RT-PCR) for diagnosis of tuberculosis.

MATERIALS AND METHODS

MPCR was carried out on 28 culture positive sputum samples. Out of 28 culture positive samples, 17 were originally reported, as MTD test negative and 11 were MTD test positive, respectively. The results of MPCR were compared with RT-PCR. To check the specificity of the tests, MPCR and RT-PCR were also evaluated with 16 non-tuberculous mycobacterial (NTM) isolates.

RESULTS

Out of 28 culture positive sputum samples, MPCR was positive in all 28/28 samples, whereas RT-PCR was positive in 27/28 samples and MTD test was originally tested positive in six sputum samples and on repeating MTD testing, five more sputum samples were positive and thus total number of MTD positive were 11/28 sputum samples, respectively. All the tests were negative on evaluation with all the 16 NTMs, thus giving specificity of 100% to all the tests; sensitivity of MPCR, RT-PCR and MTD tests were 100%, 96.42% and 39.28%, respectively, in these specifically selected samples.

CONCLUSIONS

MPCR may be an important tool in the rapid diagnosis of tuberculosis especially in disease endemic, resource limited countries.

Detecting initiation or risk for initiation of substance use before high school during pediatric well-child check-ups

BACKGROUND

Youth substance use (SU) is prevalent and costly, affecting mental and physical health. American Academy of Pediatrics and Affordable Care Act call for SU screening and prevention. The Youth Risk Index(©) (YRI) was tested as a screening tool for having initiated and propensity to initiate SU before high school (which forecasts SU disorder). YRI was hypothesized to have good to excellent psychometrics, feasibility and stakeholder acceptability for use during well-child check-ups.

DESIGN

A high-risk longitudinal design with two cross-sectional replication samples, ages 9-13 was used. Analyses included receiver operating characteristics and regression analyses.

PARTICIPANTS

A one-year longitudinal sample (N=640) was used for YRI derivation. Replication samples were a cross-sectional sample (N=345) and well-child check-up patients (N=105) for testing feasibility, validity and acceptability as a screening tool.

RESULTS

YRI has excellent test-retest reliability and good sensitivity and specificity for concurrent and one-year-later SU (odds ratios=7.44, CI=4.3-13.0) and conduct problems (odds ratios=7.33, CI=3.9-13.7). Results were replicated in both cross-sectional samples. Well-child patients, parents and pediatric staff rated YRI screening as important, acceptable, and a needed service.

CONCLUSIONS

Identifying at-risk youth prior to age 13 could reap years of opportunity to intervene before onset of SU disorder. Most results pertained to YRI's association with concurrent or recent past risky behaviors; further replication ought to specify its predictive validity, especially adolescent-onset risky behaviors. YRI well identifies youth at risk for SU and conduct problems prior to high school, is feasible and valid for screening during well-child check-ups, and is acceptable to stakeholders.

Using technology to deliver mental health services to children and youth: a scoping review

OBJECTIVE

To conduct a scoping review on the use of technology to deliver mental health services to children and youth in order to identify the breadth of peer-reviewed literature, summarize findings and identify gaps.

METHOD

A literature database search identified 126 original studies meeting criteria for review. Descriptive numerical summary and thematic analyses were conducted. Two reviewers independently extracted data.

RESULTS

Studies were characterized by diverse technologies including videoconferencing, telephone and mobile phone applications and Internet-based applications such as email, web sites and CD-ROMs.

CONCLUSION

The use of technologies plays a major role in the delivery of mental health services and supports to children and youth in providing prevention, assessment, diagnosis, counseling and treatment programs. Strategies are growing exponentially on a global basis, thus it is critical to study the impact of these technologies on child and youth mental health service delivery. An in-depth review and synthesis of the quality of findings of studies on effectiveness of the use of technologies in service delivery are also warranted. A full systematic review would provide that opportunity.

Radiotherapy of abdomen with precise renal assessment with SPECT/CT imaging (RAPRASI): design and methodology of a prospective trial to improve the understanding of kidney radiation dose response

Background

The kidneys are a principal dose-limiting organ in radiotherapy for upper abdominal cancers. The current understanding of kidney radiation dose response is rudimentary. More precise dose-volume response models that allow direct correlation of delivered radiation dose with spatio-temporal changes in kidney function may improve radiotherapy treatment planning for upper-abdominal tumours.

Our current understanding of kidney dose response and tolerance is limited and this is hindering efforts to introduce advanced radiotherapy techniques for upper-abdominal cancers, such as intensity-modulated radiotherapy (IMRT). The aim of this study is to utilise radiotherapy and combined anatomical/functional imaging data to allow direct correlation of radiation dose with spatio-temporal changes in kidney function. The data can then be used to develop a more precise dose-volume response model which has the potential to optimise and individualise upper abdominal radiotherapy plans.

Methods/design

The Radiotherapy of Abdomen with Precise Renal Assessment with SPECT/CT Imaging (RAPRASI) is an observational clinical research study with participating sites at Sir Charles Gairdner Hospital (SCGH) in Perth, Australia and the Peter MacCallum Cancer Centre (PMCC) in Melbourne, Australia. Eligible patients are those with upper gastrointestinal cancer, without metastatic disease, undergoing conformal radiotherapy that will involve incidental radiation to one or both kidneys. For each patient, total kidney function is being assessed before commencement of radiotherapy treatment and then at 4, 12, 26, 52 and 78 weeks after the first radiotherapy fraction, using two procedures: a Glomerular Filtration Rate (GFR) measurement using the ⁵¹Cr-ethylenediamine tetra-acetic acid (EDTA) clearance; and a regional kidney perfusion measurement assessing renal uptake of ^99mTc-dimercaptosuccinic acid (DMSA), imaged with a Single Photon Emission Computed Tomography / Computed Tomography (SPECT/CT) system. The CT component of the SPECT/CT provides the anatomical reference of the kidney’s position. The data is intended to reveal changes in regional kidney function over the study period after the radiotherapy. These SPECT/CT scans, co-registered with the radiotherapy treatment plan, will provide spatial correlation between the radiation dose and regional renal function as assessed by SPECT/CT. From this correlation, renal response patterns will likely be identified with the purpose of developing a predictive model.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12609000322235

Target localisation for tumour bed radiotherapy in early breast cancer

INTRODUCTION

To compare clinical and CT techniques in localisation of the tumour bed in patients undergoing adjuvant breast radiotherapy for breast cancer.

METHODS

Patients were CT scanned in the treatment position following clinical delineation of the whole breast, surgical scar and boost volume. Computed tomography boost volumes were contoured in three dimensions. A definitive treatment plan was generated to encompass the CT-localised planning target volume (PTV) with ≥90% isodose using electrons. A hypothetical plan was also generated to cover the clinically determined boost field for comparison. The primary end point was the difference in PTV coverage by the 90% isodose between the plans based on clinically and CT localised boost volumes.

RESULTS

The plans for 50 patients were evaluated. The median percentage of PTV encompassed by the 90% isodose using the clinical and CT techniques was 29% (range 5-90%) and 83% (range 25-100%), respectively. PTV coverage by the 90% isodose using the clinical technique was at least 10% less than that using CT technique in 88% of patients (95% confidence interval 77-95%; P < 0.0001).

CONCLUSION

Tumour bed boost PTV coverage was insufficient using clinical determination as compared with CT localisation. This study supports CT planning for target volume localisation of the tumour bed boost in patients treated with breast-conserving therapy for breast cancer.

Out-of-hospital cardiac arrest in Cork, Ireland

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) in Ireland accounts for approximately 5000 deaths annually. Little published evidence exists on survival from OHCA in this country to date. We aimed to characterise and describe 'presumed cardiac' OHCA in Cork City and County attended by the Ambulance Service.

METHODS

Dispatch records, ambulance patient records and hospital records for a 1-year period were examined for patient demographics, OHCA characteristics, interventions and patient outcomes.

RESULTS

There were 231 'presumed cardiac' OHCAs attended over the study period; 130 (56%) were in urban locations and 101 (44%) in rural. OHCAs were lay-witnessed in 20% (n=46), and 22% (n=50) received bystander CPR. Shockable rhythm was present in 36 cases (16%) on initial assessment, and there was no difference in presence of shockable rhythm between urban and rural OHCAs (18% vs 13%, p=0.31). Resuscitation was attempted in 176 cases (77.5%), of whom 27 (15%) achieved return of spontaneous circulation and 13 (7.4%) survived to leave hospital. Survival when the initial rhythm was shockable was 16.7% (6 of 36 patients). Despite longer response times for rural compared with urban OHCAs (median (IQR) 16.5 (11.0-23.5) vs 9 (7-12) min, p<0.001), survival to leave hospital alive where resuscitation was attempted was similar (7.4% vs 7.4%, p=0.99, respectively).

CONCLUSION

A survival rate of 16.7% in shockable rhythms indicates scope for improvement which would influence the overall survival rate which was found to be 7.4%. Real-time feedback of performance and quality of the continuum of patient care through a clinical-quality cardiac arrest registry would monitor and incentivise such initiatives.

Adjuvant chemoradiation for gastric cancer using epirubicin, cisplatin, and 5-fluorouracil before and after three-dimensional conformal radiotherapy with concurrent infusional 5-fluorouracil: a multicenter study of the Trans-Tasman Radiation Oncology Group

PURPOSE

The INT0116 study has established postoperative chemoradiotherapy as the standard of care for completely resected gastric adenocarcinoma. However, the optimal chemoradiation regimen remains to be defined. We conducted a prospective, multicenter study to evaluate an alternative chemoradiation regimen that combines more current systemic treatment with modern techniques of radiotherapy delivery.

METHODS AND MATERIALS

Patients with adenocarcinoma of the stomach who had undergone an R0 resection were eligible. Adjuvant therapy consisted of one cycle of epirubicin, cisplatin, and 5-FU (ECF), followed by radiotherapy with concurrent infusional 5-FU, and then two additional cycles of ECF. Radiotherapy was delivered using precisely defined, multiple-field, three-dimensional conformal techniques.

RESULTS

A total of 54 assessable patients were enrolled from 19 institutions. The proportion of patients commencing Cycles 1, 2, and 3 of ECF chemotherapy were 100%, 81%, and 67% respectively. In all, 94% of patients who received radiotherapy completed treatment as planned. Grade 3/4 neutropenia occurred in 66% of patients with 7.4% developing febrile neutropenia. Most neutropenic episodes (83%) occurred in the post-radiotherapy period during cycles 2 and 3 of ECF. Grade 3/4 gastrointestinal toxicity occurred in 28% of patients. In all, 35% of radiotherapy treatment plans contained protocol deviations that were satisfactorily amended before commencement of treatment. At median follow-up of 36 months, the 3-year overall survival rate was estimated at 61.6%.

CONCLUSIONS

This adjuvant regimen using ECF before and after three-dimensional conformal chemoradiation is feasible and can be safely delivered in a cooperative group setting. A regimen similar to this is currently being compared with the INT0116 regimen in a National Cancer Institute-sponsored, randomized Phase III trial.

3D conformal radiotherapy for gastric cancer--results of a comparative planning study

BACKGROUND AND PURPOSE

Many radiation oncologists are reluctant to use anteroposterior-posteroanterior (AP-PA) field arrangements when treating gastric cancer with adjuvant postoperative radiotherapy due to concerns about normal tissue toxicity, particularly in relation to the kidneys and spinal cord. In this report, we describe a multiple-field conformal radiotherapy technique, and compare this technique to the more commonly used AP-PA technique that was used in the recently reported Intergroup study (INT0116).

MATERIALS AND METHODS

Fifteen patients with stages II-IV adenocarcinoma of the stomach were treated with adjuvant postoperative chemoradiotherapy using a standardised 3D conformal radiotherapy technique that consisted of a 'split-field', mono-isocentric arrangement employing 6 radiation fields. For each patient, a second radiotherapy treatment plan was generated utilising AP-PA fields. The two techniques were then compared for target volume coverage and dose to normal tissues using dose volume histogram (DVH) analysis.

RESULTS

The conformal technique provides more adequate coverage of the target volume with 99% of the planning target volume (PTV) receiving 95% of the prescribed dose, compared to 93% using AP-PA fields. Comparative DVHs for the right kidney, left kidney and spinal cord demonstrate lower radiation doses using the conformal technique, and although the liver dose is higher, it is still well below liver tolerance.

CONCLUSIONS

3D conformal radiotherapy produces superior dose distributions and reduced radiation doses to the kidneys and spinal cord compared to AP-PA techniques, with the potential to reduce treatment toxicity.