Temporal Patterns in Youth Suicide Deaths Reported in the National Violent Death Reporting System

PURPOSE

Suicide is a leading cause of death in children and adolescents. Prevention efforts may benefit from examining temporal patterns and precipitating circumstances of youth suicide deaths. The purpose of this study was to investigate if there are distinct temporal patterns of suicide death for youth.

METHODS

We examined the distributions of suicide deaths across months of the year and days of the week in youth ages 10-18 using data from the National Violent Death Reporting System.

RESULTS

We found that youth suicides peaked during March, April, and October on Monday, Tuesday, and Wednesday. When disaggregated by separate years of age, we discovered unique patterns in 18-year-olds and 10-year-olds. Suicides peaked during July for 18-year-olds and on Saturday for 10-year-olds.

DISCUSSION

These findings suggest a need to examine temporal patterns by separate years of age, as grouping ages together may mask unique trends.

OP0243 OSTEOPOROSIS CASE-FINDING IN PEOPLE UNDERGOING ROUTINE DIAGNOSTIC CT SCANS ALMOST TRIPLED THE RATE OF OSTEOPOROSIS TREATMENT AT 12 MONTHS. A RANDOMISED, MULTI-CENTRE FEASIBILITY STUDY USING WAITING ROOM FRAX, OPPORTUNISTIC CT BONE DENSITY AND VERTEBRAL FRACTURE ASSESSMENT VERSUS USUAL CARE

Background

Up to 40% of all diagnostic computed tomography (CT) scans include views of the spine or hips. Among older people, osteoporosis or vertebral fractures have been found in 30% of such CT scans. Our ‘PHOENIX’ intervention repurposes CT scans taken for other reasons to identify fractures and measure bone density as an ‘added extra’. Early detection and treatment of osteoporosis in CT-attending patients could improve health outcomes.

Objectives

To determine the feasibility and efficacy of PHOENIX versus usual care in a multi-centre, randomised, pragmatic study conducted in Eastern England involving our Cambridge Specialist Hospital ‘hub’ and four regional General Hospital ‘spokes’.

Methods

Women ≥65 and men ≥75 years attending for routine diagnostic CT scans were invited to participate via a novel consent form incorporating FRAX Fracture Risk Assessment questions. After calculating their FRAX 10-year risk score, higher risk patients were block randomised (1:1:1) to Group 1) PHOENIX intervention, 2) Active Control, where the GP was sent the patients’ FRAX answers only, or 3) Usual Care where data were only analysed after 13 months had elapsed. The CT scans of high FRAX risk patients in Group 1 were retrieved by the Cambridge team using NHS Connecting for Health (Burnbank, UK). The team performed vertebral fracture assessment and measured bone density using QCT Pro (Mindways, USA). They added patient-specific treatment and investigation management advice from ‘drop down’ menus before results were reviewed by a physician, authorised and sent to general practitioners (GPs). Baseline CT scans from groups 2 and 3 were assessed in the same way after 13 months to ensure no patient with osteoporosis/fractures was neglected long term. Assuming 25% attrition, the study was powered to find a superior osteoporosis treatment rate in Group 1 (estimated 20%) versus 16% (Active Control) and 5% (Usual Care). Co-primary feasibility endpoints were the ability to a) randomise 375 patients within 10 months and b) retain 75% of survivors able to complete a 1-year bone health outcome questionnaire. Secondary outcomes included osteoporosis/vertebral fracture identification rates and osteoporosis treatment rates. Stakeholder acceptability and economic aspects will be reported separately.

Results

From 1828 invites, 595 participants consented to participate of whom 213 were excluded due to ‘low’ FRAX score. Mortality at 12 months was 20%. Both feasibility objectives were achieved: 1) 382 people were randomised within 10 months; 2) 84.4% of survivors at 1 year (95%CI: 80.5, 88.3) were successfully followed-up. Groups were well matched at baseline. The average age of 375 patients (334 female, 41 male) was 75.2 years (74.6, 75.9). Osteoporosis of the hip/spine was present in 41% of 362 analysable CT scans. From the 264 spines that were suitable for VFA, 20% (n=53) were found to have vertebral fractures, with 8.3% having multiple vertebral fractures (n=22). Osteoporosis treatment was reported in 8.5% of Usual Care group (2.9, 14.2) and 24.2% (15.4, 33.0) of PHOENIX group participants, while in the Active Control group (FRAX only) it was 18.8% (10.9, 26.6 p=0.021). In the PHOENIX group, a recommendation to treat was sent to 50 patients’ GPs at baseline. Only 18 of the 50 patients (36%) were found to be taking osteoporosis treatment 12 months after this advice was sent.

Conclusion

Osteoporosis treatment rates were almost tripled by screening patients attending for routine diagnostic CT scans with waiting room FRAX, CT-bone densitometry and vertebral fracture analysis.

Acknowledgements

This project is funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0816-20027) and by the Cambridge NIHR Biomedical Research Centre (BRC-1215-20014). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Funding is in place to 31.03.2022. Three individuals, Mr Jeremy Dearling, Mrs Tessa Plume and Dr Ann Frost joined our trial group as PPI representatives; they were specifically involved in patient documentation design (particularly the PHOENIX pack, informed consent form which facilitated consent without having a researcher present) and contributed to suggestions for increasing patient recruitment and follow up.

Disclosure of Interests

None declared

POS1514-HPR UNDERSTANDING AND CHARACTERISING PATIENT PATHWAYS TO TREATMENT FOR VERTEBRAL FRACTURES: A QUALITATIVE STUDY

Background

Osteoporosis involves thinning of the bones, making them more prone to break. The most common osteoporotic fracture is a vertebral fracture (OVF). People with OVFs are at high risk of further fractures. To reduce this risk, guidelines recommend prescription of bone protection therapies to people who have experienced a fracture. However, many patients do not receive diagnosis. Understanding patient pathways to treatment for OVFs will provide information to improve practice and aid in effective identification and management.

Objectives

To understand and characterise patient pathways to treatment for OVFs.

Methods

Twenty-three semi-structured qualitative interviews were conducted with patients aged ≥50 years with diagnosis of OVF. Patients were recruited through two hospitals in England and were purposively sampled to capture variation in pathways to diagnosis, sex, age, comorbidities and other relevant characteristics. Interviews were audio-recorded, transcribed and analysed thematically, with themes transposed onto key stages of the patient pathway.

Results

Several factors influenced patient pathways to treatment:

Patient appraisal and self-management: Characteristics and attitudes towards back pain impacted treatment-seeking behaviour. Patients who appraised their pain as ‘different’, severe or disruptive, or associated with an injury such as a fall, were more likely to seek help. Limited availability of information about OVFs and risk factors meant most patients did not associate symptoms with a potential OVF. Factors contributing to delayed consultation included the normalisation of back pain and prioritisation of comorbid conditions. Several misappraised their symptoms as a “pulled muscle” or other minor injury. Many adopted strategies to manage pain, including use of painkillers, lying flat or resting. For some, a lack of improvement in symptoms over time, combined with worsening pain, created a ‘tipping point’ in seeking care. There was a moral dimension for some patients who did not want to “bother” healthcare professionals.

Healthcare professional appraisal: Differential diagnosis was a barrier to treatment and healthcare professionals interpreted OVF pain as broken ribs, muscular pain, kidney pain or sciatica. GPs tended to instigate watchful waiting, in which patients were asked to re-consult if pain did not improve. Feeling disbelieved caused some patients to become disillusioned and reluctant to re-consult and a small number of patients presented at Accident and Emergency. Those already having treatment for musculoskeletal conditions with access to specialist care, were more likely to receive timely diagnosis.

Communication of diagnosis: Patients discussed multiple methods of communication, including written communication and clinical conversations. Several expressed confusion around the use of unfamiliar medical terminology, the implications of OVFs, how many OVFs they had experienced and how they had been identified.

Treatment initiation: Bone protection therapies were not consistently prescribed after diagnosis. Patients who were familiar with these therapies were unsure whether treatment should be initiated in primary or secondary care. Patients described how they felt a need to be proactive by arranging appointments and asking for treatment.

Conclusion

The study provides novel findings about patient pathways to treatment and will be used to identify targeted solutions to improve management of OVFs. This work addresses stages of the Model of Pathways to Treatment[1] and provides detailed understanding of patients’ experiences of these stages. Further work with healthcare professionals in primary care is underway to identify additional system-level factors that may impact patients’ journeys to treatment.

References

[1]Scott, S.E., et al., The model of pathways to treatment: conceptualization and integration with existing theory. Br J Health Psychol, 2013. 18(1): p. 45-65.

Acknowledgements

This study is funded by the National Institute for Health Research (NIHR) Research for Patient Benefit (RfPB) programme NIHR201523. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Disclosure of Interests

None declared

Duodenal volvulus: a rare cause of small bowel obstruction

Small bowel volvulus is a rare but life-threatening emergency. Volvulus of the duodenum is even rarer without the presence of predisposing factors. The clinical presentation is vague, including abdominal pain, nausea and vomiting, prompt diagnosis of volvulus therefore relies heavily on radiographs. The treatment options lie between conservative or surgical management, where the decision is influenced by the patient and their presentation. This case is of a 100-year-old female with an extensive surgical and medical background presenting with signs of small bowel obstruction. With the help of imaging, a rare case of duodenal volvulus was diagnosed but managed conservatively due to the patient's background, age and personal wishes.

Informing policy on school and daycare operations during COVID-19 with a living rapid evidence review

Background

To support evidence-informed decision making (EIDM) for safe re-opening and operation of schools and daycares, the National Collaborating Centre for Methods and Tools (NCCMT) has maintained since May 2020 a living rapid review answering the following question: “What is the role of schools and daycares in COVID-19 transmission”. Traditional rapid review methodology was modified for the COVID-19 context. This presentation will describe the global reach and usefulness of this living rapid review.

Methods

Following completion of each update of the living rapid review, findings were disseminated broadly with the aim of informing policy and public health practice. Key dissemination strategies include e-mails to key contacts and a subscriber list; highlight in a monthly newsletter; media outreach; and social media. The review's reach was analyzed using Google Analytics, citation tracking, and qualitative feedback.

Results

Between May 2020 and April 2021, the living review has been updated 14 times. The posted review has been viewed over 5000 times across 46 countries. The review has been cited and indexed in over 40 sources, including key governmental and non-governmental reports and guidelines. The NCCMT has received positive qualitative feedback on the review's value in informing the public health response related to schools and daycares in various jurisdictions across Canada. Key stakeholders have expanded the review's reach organically as they use the evidence in practice and share the review with their networks.

Lessons

Using a living rapid review to continuously provide high-quality synthesized evidence amidst the evolving COVID-19 research literature demonstrates a responsive approach to decision makers' requests for evidence. An emerging challenge is reaching the proper stakeholders responsible for EIDM, particularly during public health emergencies with many competing high-priority questions and decisions to be made.

Key messages

As the evidence landscape changes due to a surge in literature, evidence-informed decision making can be supported by rapid but rigorous syntheses that evaluate quality and emerging recommendations. A long-standing, trusting relationship with decision makers is key to optimizing living rapid review methodology to meet the evidence needs of decision makers despite the changing literature.

Pathogenic NR2F1 variants cause a developmental ocular phenotype recapitulated in a mutant mouse model

Pathogenic NR2F1 variants cause a rare autosomal dominant neurodevelopmental disorder referred to as the Bosch-Boonstra-Schaaf Optic Atrophy Syndrome. Although visual loss is a prominent feature seen in affected individuals, the molecular and cellular mechanisms contributing to visual impairment are still poorly characterized. We conducted a deep phenotyping study on a cohort of 22 individuals carrying pathogenic NR2F1 variants to document the neurodevelopmental and ophthalmological manifestations, in particular the structural and functional changes within the retina and the optic nerve, which have not been detailed previously. The visual impairment became apparent in early childhood with small and/or tilted hypoplastic optic nerves observed in 10 cases. High-resolution optical coherence tomography imaging confirmed significant loss of retinal ganglion cells with thinning of the ganglion cell layer, consistent with electrophysiological evidence of retinal ganglion cells dysfunction. Interestingly, for those individuals with available longitudinal ophthalmological data, there was no significant deterioration in visual function during the period of follow-up. Diffusion tensor imaging tractography studies showed defective connections and disorganization of the extracortical visual pathways. To further investigate how pathogenic NR2F1 variants impact on retinal and optic nerve development, we took advantage of an Nr2f1 mutant mouse disease model. Abnormal retinogenesis in early stages of development was observed in Nr2f1 mutant mice with decreased retinal ganglion cell density and disruption of retinal ganglion cell axonal guidance from the neural retina into the optic stalk, accounting for the development of optic nerve hypoplasia. The mutant mice showed significantly reduced visual acuity based on electrophysiological parameters with marked conduction delay and decreased amplitude of the recordings in the superficial layers of the visual cortex. The clinical observations in our study cohort, supported by the mouse data, suggest an early neurodevelopmental origin for the retinal and optic nerve head defects caused by NR2F1 pathogenic variants, resulting in congenital vision loss that seems to be non-progressive. We propose NR2F1 as a major gene that orchestrates early retinal and optic nerve head development, playing a key role in the maturation of the visual system.

The effect of intestinal microbiota dysbiosis on growth and detection of carbapenemase-producing Enterobacterales within an in vitro gut model

BACKGROUND

Carbapenemase-producing Enterobacterales (CPE) can colonize the gut and are of major clinical concern. Identification of CPE colonization is problematic; there is no gold-standard detection method, and the effects of antibiotic exposure and microbiota dysbiosis on detection are unknown.

AIM

Based on a national survey we selected four CPE screening assays in common use. We used a clinically reflective in vitro model of human gut microbiota to investigate the performance of each test to detect three different CPE strains under different, clinically relevant antibiotic exposures.

METHODS

Twelve gut models were seeded with a pooled faecal slurry and exposed to CPE either before, after, concomitant with, or in the absence of piperacillin-tazobactam (358 mg/L, 3 × daily, seven days). Total Enterobacterales and CPE populations were enumerated daily. Regular screening for CPE was performed using Cepheid Xpert® Carba-R molecular test, and with Brilliance™ CRE, Colorex™ mSuperCARBA and CHROMID® CARBA SMART agars.

FINDINGS

Detection of CPE when the microbiota are intact is problematic. Antibiotic exposure disrupts microbiota populations and allows CPE proliferation, increasing detection. The performances of assays varied, particularly with respect to different CPE strains. The Cepheid assay performed better than the three agar methods for detecting a low level of CPE within an intact microbiota, although performance of all screening methods was comparable when CPE populations increased in a disrupted microbiota.

CONCLUSION

CPE strains differed in their dynamics of colonization in an in vitro gut model and in their subsequent response to antibiotic exposure. This affected detection by molecular and screening methods, which has implications for the sensitivity of CPE screening in healthcare settings.

Perceptual reasoning skills mediate the relationship between attention and math proficiency in individuals with a neurodevelopmental condition

BACKGROUND

An important component of academic success in typically developing students is the development of math skills, which is associated with attention and perceptual reasoning (PR) skills. For children with a neurodevelopmental condition (NDC), the relationship is confounded by diagnostic-specific cognitive characteristics. Specifically, enhanced PR is specific to individuals with Autism Spectrum Disorder (ASD).

AIMS

The purpose of this study was to test: (i) a mediation model where PR skills would mediate the relationship between attention and math proficiency for students with an NCD, and (ii) whether this mediation model is moderated by a diagnostic profile.

METHODS AND PROCEDURES

One hundred and thirty-seven students with an NDC participated in a school-based study examining the effectiveness of using a standardized measure of attention in predicting math capabilities.

OUTCOMES AND RESULTS

PR mediated the relationship between attention and math proficiency for students diagnosed with an NDC. However, the model was not moderated by diagnostic profile.

CONCLUSIONS AND IMPLICATIONS

The results of this study provide a better understanding of the roles of higher-level cognitive ability specific to students with NDCs. Additionally, the superior PR skills demonstrated by the ASD sample further supports the research suggesting this population possesses cognitive strengths in this domain.

A non-randomised pilot study of the Solutions for Medication Adherence Problems (S-MAP) intervention in community pharmacies to support older adults adhere to multiple medications

BACKGROUND

Older patients prescribed multiple medications commonly experience difficulties with adherence. High-quality evidence on interventions targeting older patients is lacking. Theory is rarely used to tailor adherence solutions. This study aimed to pilot test a novel intervention, developed using the Theoretical Domains Framework, which guides community pharmacists in identifying adherence barriers and delivering tailored solutions (behaviour change techniques). Key study procedures (e.g. recruitment, data collection) for a future randomised controlled trial (cRCT) were also assessed.

METHODS

Using purposive sampling, this non-randomised pilot study aimed to recruit 12 community pharmacies (six in Northern Ireland; six in London, England). Pharmacists were trained to deliver the intervention to non-adherent older patients (maximum 10 per pharmacy; target n = 60-120) aged ≥ 65 years (reduced to 50 years due to recruitment challenges) and prescribed ≥ 4 regular medicines. The intervention, guided by an iPad web-application, was delivered over 3-4 face-to-face or telephone sessions, tailored to specific barriers to adherence. We assessed the feasibility of collecting adherence data (primary outcome: self-report and dispensing records), health-related quality of life (HRQOL) and unplanned hospitalisations (secondary outcomes) at baseline and 6-months. The final decision on progressing to a cRCT, using pre-defined 'stop-amend-go' criteria, is presented.

RESULTS

Fifteen pharmacists from 12 pharmacies were recruited and trained. One pharmacy subsequently dropped out. Sixty patients were recruited (meeting the 'Amend' progression criteria), with 56 receiving the intervention. Adherence barriers were identified for 55 patients (98%) and a wide range of behaviour change solutions delivered (median: 5 per patient). Self-report and dispensing adherence data were available for 37 (61.7%) and 44 (73.3%) patients, respectively. HRQOL data were available for 35 (58.3%) patients. GP-reported and self-reported hospitalisations data were available for 47 (78.3%) and 23 (38.3%) patients, respectively. All progression concepts were met (nine 'Go' and three 'Amend' criteria).

CONCLUSION

This study demonstrates the feasibility of key study procedures (e.g. pharmacy recruitment) and delivery of a tailored adherence intervention in community pharmacies. However, modifications are required to enhance issues identified with patient recruitment, retention and missing data. A future definitive cRCT will explore the effectiveness of the intervention.

TRIAL REGISTRATION

ISRCTN, ISRCTN73831533 , Registered 12 January 2018.

How the history of American Psychological Association Division 16 can shape the future of school psychology: Demonstrating organizational transformation

Over the past 75 years, the history of Division 16 (School Psychology) has been integral to the science and practice of school psychology. As a constituent body of the American Psychological Association (APA), the division has advocated for role definitions and professional boundaries within APA and has represented the specialty of school psychology within the larger community of psychology. Since the convening of school psychology's Thayer Conference in 1955, the division has remained steadfastly committed to promoting the well-being of children. Toward this end, Division 16 has negotiated entry level debates between APA and the broad specialty of school psychology, sustained partnerships within and among APA and other organizations representing school mental health, elevated the place of technology in the profession of school psychology, and promoted the central importance of cultural competence and diversity within the discipline. The past contributions of Division 16 shape the future of the profession and the division in ways that are consistent with and add to Conoley, Power, and Gutkin's (2020) recommendations for strengthening school psychology's contributions to psychological health promotion and risk reduction in schools. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A new tool to assess community-level evidence to inform public health decision making

Background

As public health responds to evolving challenges around the globe, it is critical to draw on community-level evidence to inform decisions on emerging needs. There are existing tools for assessing the quality of research evidence, but none that explicitly focus on quality assessment of evidence from community sources, including local health status and ever-changing community and political preferences and actions.

Methods

The National Collaborating Centre for Methods and Tools (NCCMT) in Canada has developed new tools, called Quality Assessment of Community Evidence (QACE), to help public health decision makers assess the quality of community evidence. The QACE tools were drafted through extensive review of existing frameworks, tools and measures for appraising population health and community evidence, and diverse key informants. We identified three consistent themes that became the core dimensions in these tools. By using the QACE tools, practitioners can answer the question: “Is the quality of this evidence about local context, community needs and political preferences good enough to influence decision making?”

Results

The QACE tools provide probing questions for each of three dimensions: relevant, trustworthy and equity-informed. Supplementary resources help users delve more deeply into different aspects of quality assessment. The QACE tools are intended for public health practitioners who provide and use evidence to support or make decisions about public health practice and policy, including public health practitioners, senior leaders, policy makers and funders.

Conclusions

The QACE tool is a new addition to the public health toolbox for evidence-informed decision making, providing questions to ask about evidence from community sources. By using the tool as part of a decision-making process, public health practitioners can be assured that their decisions are based on the best-available evidence for their communities.

Key messages

The new Quality Assessment of Community Evidence (QACE) tools fill the gap in assessing quality of community-level evidence for public health decision-makers. Community evidence, including local health status and needs and community and political preferences and actions, should be assessed for quality in three critical domains.

Enhancing partnerships and collaboration in times of change

Issue

In 2019, the government of the Canadian province of Ontario announced major changes to the structure, governance and funding of public health services. Throughout these changes, publicly funded local and regional public health organizations are still expected to provide effective, evidence-informed programming to their communities. The National Collaborating Centre for Methods and Tools (NCCMT) has facilitated collaborations to support Ontario public health through this transition.

Description of the problem

In order to support evidence-informed public health in Ontario during this transition, the NCCMT reached out to current and potential partners, within and beyond the public health sector for a multidisciplinary approach. We conducted a needs assessment for an evidence review repository, which would allow public health practitioners to share and build upon each other's work. Finally, demonstrating the value of public health to policymakers can be inherently challenging as the return on investment in public health is often very long term. We partnered with health units in varying capacities to find and synthesize evidence to advocate for continued investment in public health.

Results

This initiative has provided important lessons in developing and maintaining strong partnerships. Looking beyond the public health sector can establish mutually beneficial partners and allies in other disciplines. A key finding was the need to establish infrastructure to support collaboration and resource sharing. Finally, we learned that big picture questions like demonstrating the value of public health require many different perspectives, inputs and areas of expertise.

Lessons

Through this initiative, we have developed a multidisciplinary, collaborative approach to supporting evidence-informed public health through times of major restructuring. This approach can be applied to future changes to public health on smaller or larger scales, or within other geographic regions.

Key messages

Multidisciplinary approaches can support collaboration, unity and advocacy in times of change. Establishing infrastructure to support collaboration and sharing of resources is valuable.

The NCCMT’s dynamic model for evidence-informed public health

Issue

It is well accepted that public health decision makers should use the best available research evidence in their decision-making process. However, research evidence alone is insufficient to inform public health decision making.

Description of the problem

As new challenges to public health emerge, there can be a paucity of high quality research evidence to inform decisions on new topics. Public health decision makers must combine various sources of evidence with their public health expertise to make evidence-informed decisions. The National Collaborating Centre for Methods and Tools (NCCMT) has developed a model which combines research evidence with other critical sources of evidence that can help guide decision makers in evidence-informed decision making.

Results

The NCCMT's model for evidence-informed public health combines findings from research evidence with local data and context, community and political preferences and actions and evidence on available resources. The model has been widely used across Canada and worldwide, and has been integrated into many public health organizations' decision-making processes. The model is also used for teaching an evidence-informed public health approach in Masters of Public Health programs around the globe. The model provides a structured approach to integrating evidence from several critical sources into public health decision making. Use of the model helps ensure that important research, contextual and preference information is sought and incorporated.

Lessons

Next steps for the model include development of a tool to facilitate synthesis of evidence across all four domains. Although Indigenous knowledges are relevant for public health decision making and should be considered as part of a complete assessment the current model does not capture Indigenous knowledges.

Key messages

Decision making in public health requires integrating the best available evidence, including research findings, local data and context, community and political preferences and available resources. The NCCMT’s model for evidence-informed public health provides a structured approach to integrating evidence from several critical sources into public health decision making.

A pilot study of the S-MAP (Solutions for Medications Adherence Problems) intervention for older adults prescribed polypharmacy in primary care: study protocol

Background

Adhering to multiple medications as prescribed is challenging for older patients (aged ≥ 65 years) and a difficult behaviour to improve. Previous interventions designed to address this have been largely complex in nature but have shown limited effectiveness and have rarely used theory in their design. It has been recognised that theory (‘a systematic way of understanding events or situations’) can guide intervention development and help researchers better understand how complex adherence interventions work. This pilot study aims to test a novel community pharmacy-based intervention that has been systematically developed using the Theoretical Domains Framework (12-domain version) of behaviour change.

Methods

As part of a non-randomised pilot study, pharmacists in 12 community pharmacies across Northern Ireland (n = 6) and London, England (n = 6), will be trained to deliver the intervention to older patients who are prescribed ≥ 4 regular medicines and are non-adherent (self-reported). Ten patients will be recruited per pharmacy (n = 120) and offered up to four tailored one-to-one sessions, in the pharmacy or via telephone depending on their adherence, over a 3–4-month period. Guided by an electronic application (app) on iPads, the intervention content will be tailored to each patient’s underlying reasons for non-adherence and mapped to the most appropriate solutions using established behaviour change techniques. This study will assess the feasibility of collecting data on the primary outcome of medication adherence (self-report and dispensing data) and secondary outcomes (health-related quality of life and unplanned hospitalisations). An embedded process evaluation will assess training fidelity for pharmacy staff, intervention fidelity, acceptability to patients and pharmacists and the intervention’s mechanism of action. Process evaluation data will include audio-recordings of training workshops, intervention sessions, feedback interviews and patient surveys. Analysis will be largely descriptive.

Discussion

Using pre-defined progression criteria, the findings from this pilot study will guide the decision whether to proceed to a cluster randomised controlled trial to test the effectiveness of the S-MAP intervention in comparison to usual care in community pharmacies. The study will also explore how the intervention components may work to bring about change in older patients’ adherence behaviour and guide further refinement of the intervention and study procedures.

Trial registration

This study is registered at ISRCTN: 10.1186/ISRCTN73831533

Caries-preventive efficacy of a supervised school toothbrushing programme in Northland, New Zealand

BACKGROUND

Toothbrushing with fluoride toothpaste reduces the incidence of dental caries.

OBJECTIVE

To evaluate a supervised school toothbrushing programme to reduce dental caries experience in children.

BASIC RESEARCH DESIGN

Quasi-experimental study. All children had routine dental examinations at baseline using the ICDAS to record dental caries, along with bitewing radiographs. Half of the children were involved in a supervised toothbrushing programme. Examinations were repeated at the end of the school year.

CLINICAL SETTING

Northland, New Zealand.

PARTICIPANTS

335 10-13-year-old New Zealand children with high caries experience.

INTERVENTIONS

Half of the children participated in the supervised toothbrushing session each school day; the other half had no intervention.

MAIN OUTCOME MEASURES

Caries increment, determined by comparing the baseline and follow-up status of each tooth surface.

RESULTS

At baseline, there were 335 children, of whom 240 (71.6%) were followed up. The ICDAS net caries increment for those in the toothbrushing group was a mean of 11.7 surfaces improved; the control group had a mean of 8.6 surfaces which had deteriorated. Caries incidence for those in the toothbrushing group was 7.3%; that for the control group was 71.5%. Multivariate analysis showed that membership of the brushing group was the only statistically significant predictor of a lower net caries increment.

CONCLUSION

A supervised school toothbrushing programme can reduce caries increment in a population experiencing high levels of dental disease.

Abstract P1-13-07: Incidence and management of diarrhea with adjuvant pertuzumab and trastuzumab in HER2-Positive breast cancer

Background

Diarrhea is the most commonly reported adverse event (AE) on pertuzumab (Ptz) in both early and metastatic breast cancer (BC) settings. We report safety analyses of diarrhea from the large adjuvant APHINTY study in HER2 positive early breast cancer (EBC).

Patients and methods

In this exploratory analysis, the safety population included 2364 patients in the Ptz arm and 2405 in the placebo (Pla) arm. No specific prophylaxis was mandated by the protocol, however early intervention with loperamide as well as fluid and electrolyte replacement was recommended. Diarrhea incidence, severity (NCI-CTCAE v4.0), onset and management were analyzed.

Results

Diarrhea was the most common AE in the Ptz arm (71.3% vs. 45.2% in the Pla arm) and the events were mostly G1. Diarrhea ≥G3 was observed in 9.8% and 3.7% in Ptz and Pla arms, respectively. The highest incidence was reported during administration of HER2 targeted therapy and taxane (61.4% vs. 33.8% with Ptz and Pla, respectively) with a marked decrease observed upon chemotherapy cessation (18.1% vs. 9.2% with Ptz and Pla, respectively). The median time from first targeted treatment to onset of diarrhea during the chemotherapy phase was 7 and 10 days (Ptz/Pla). On average, diarrhea events lasted longer in the Ptz than in the Pla arm (median 8 vs. 6 days). Diarrhea events were more frequent with the administration of docetaxel + carboplatin and targeted agents, irrespective of the severity. Detailed results are reported in Table 1.

Conclusions

In the curative setting, diarrhea due to Ptz was mild, generally manageable with common antidiarrheals and did not affect patients' ability to receive treatment. The APHINITY findings are consistent with the well-characterized pattern of pertuzumab-related diarrhea across the HER2 BC spectrum.

Diarrhea incidence, severity (NCI-CTCAE v4.0), onset and management Ptz, n=2364Pla, n=2405Incidence and severityTotal number of patients with at least one adverse event$1685 (71.3%)1086 (45.2%)Total number of events$34151792NCI CTC AE Grade (highest grade per patient)!n1683 (71.2%)1085 (45.1%)Grade 1829 (35.1%)690 (28.7%)Grade 2622 (26.3%)305 (12.7%)Grade 3229 (9.7%)90 (3.7%)Grade 43 (0.1%)0Onset and duration$Median time (days) from 1st HER2 targeted treatment to onset (min-max)7 (1 – 358)10 (1 - 384)Median Duration (days) of each event (min-max)8 (1 - 811)6 (1 - 1022)ManagementAntidiarrheals$898 (38.0%)386 (16.0%)Dose modification* of any study drug!210 (8.9%)74 (3.1%)Dose modification* of HER2 targeted treatment!69 (2.9%)18 (0.7%)Discontinuation of any study drug!38 (1.6%)7 (0.3%)Discontinuation of HER2 Targeted treatment!20 (0.8%)2 (<0.1%)$ Based on a basket of preferred terms for diarrhea ! Based only on the preferred term diarrhea * Includes dose reductions (chemotherapy only), delays or interruptions during infusion

Citation Format: Bines J, de Azambuja E, Zardavas D, Procter M, Restuccia E, Viale G, Suter T, Arahmani A, van Dooren V, Clark E, Eng-Wong J, Gelber R, Piccart M, von Minckwitz G, Baselga J. Incidence and management of diarrhea with adjuvant pertuzumab and trastuzumab in HER2-Positive breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-13-07.

Relationship of executive functioning deficits to N-acetyl aspartate (NAA) and gamma-aminobutyric acid (GABA) in youth with bipolar disorder

BACKGROUND

Although cognitive deficits in bipolar disorder (BD) have been repeatedly observed, our understanding of these impairments at a mechanistic level remains limited. Few studies that investigated cognitive impairments in bipolar illness have examined the association with brain biochemistry. This pilot study utilized proton magnetic resonance spectroscopy (¹H-MRS) to evaluate the relationship between neurocognitive performance and brain metabolites in youth with BD.

METHODS

Thirty participants, twenty depressed BD participants and ten healthy comparison participants, ages 13-21, completed mood and executive function measures. ¹H-MRS data were also acquired from the anterior cingulate cortex (ACC) using two-dimensional (2D) J-resolved ¹H-MRS sequence. Proton metabolites including N-acetyl aspartate (NAA) and gamma-aminobutyric acid (GABA) were quantified for both groups.

RESULTS

Participants with BD performed significantly lower on executive functioning measures than comparison participants. There were significant positive correlations between Wisconsin Card Sorting Test (WCST) performance and NAA (p < .001) and GABA (p < .01) in the ACC in bipolar youth, such that as WCST performance increased, both NAA and GABA levels increased.

LIMITATIONS

Small sample size and lack of control for medications.

CONCLUSIONS

These findings build on previous observations of biochemical alterations associated with BD and indicate that executive functioning deficits in bipolar youth are correlated with NAA and GABA. These results suggest that cognitive deficits occur early in the course of illness and may reflect risk factors associated with altered neurochemistry. Further investigation of the relationship between brain metabolites and cognition in BD may lead to important information for developing novel, targeted interventions.

Effect of powder oxidation on the impact toughness of electron beam melt Ti-6Al-4V

Powder quality in additive manufacturing (AM) electron beam melt (EBM) of Ti-6Al-4V components is crucial in determining the critical material properties of the end item. In this study, we report on the effect of powder oxidation on the Charpy impact energy of Ti-6Al-4V parts manufactured using EBM. In addition to oxidation, the effects on impact energy due to hot isostatic pressing (HIP), specimen orientation, and EBM process defects were also investigated. This research has shown that excessive powder oxidation (oxygen mass fraction above 0.25 % and up to 0.46 %) dramatically decreases the impact energy. It was determined that the room temperature impact energy of the parts after excessive oxidation was reduced by about seven times. We also report that HIP post-processing significantly increases the impact toughness, especially for specimens with lower or normal oxygen content. The specimen orientation effect was found to be more significant for low oxidation levels.

Translational Modeling of Drug-Induced Myelosuppression and Effect of Pretreatment Myelosuppression for AZD5153, a Selective BRD4 Inhibitor

In this work, we evaluate the potential risk of thrombocytopenia in man for a BRD4 inhibitor, AZD5153, based on the platelet count decreases from a Han Wistar rat study. The effects in rat were modeled and used to make clinical predictions for human populations with healthy baseline blood counts. At doses >10 mg, a dose-dependent effect on circulating platelets is expected, with similar predicted changes for both q.d. and b.i.d. dose schedules. These results suggest that at predicted efficacious doses, AZD5153 is likely to have some reductions in the clinical platelet counts, but within the normal range at projected efficacious doses. The model was then extended to incorporate preexisting myelosuppression where bone marrow function is inhibited by acute myeloid leukemia. Under these conditions, duration of platelet count recovery has the potential to be prolonged due to drug-induced myelosuppression.

Building confidence in quantitative systems pharmacology models: An engineer's guide to exploring the rationale in model design and development

This tutorial promotes good practice for exploring the rationale of systems pharmacology models. A safety systems engineering inspired notation approach provides much needed rigor and transparency in development and application of models for therapeutic discovery and design of intervention strategies. Structured arguments over a model's development, underpinning biological knowledge, and analyses of model behaviors are constructed to determine the confidence that a model is fit for the purpose for which it will be applied.

Dental clearance unsuccesful: cleidocranial dysplasia diagnosed at a relief of pain clinic

A 55-year-old woman presented to Whangarei Base Hospital Emergency Department with a mandibular swelling adjacent to her unerupted tooth 48. She had never had dental radiographs taken, having had a dental clearance 20 years earlier. She wore full dentures. A panoramic dental radiograph revealed 44 unerupted teeth. Based on the clinical, oral and radiographic examinations a diagnosis of cleidocranial dysplasia (CCD) was confirmed. The patient had not been diagnosed with CCD prior to her hospital visit. Treatment included staged extractions of superficial mandibular supernumeraries and enucleation of the mandibular cyst, attempting to avoid pathological fracture. This would be followed by a six-month review and then annually as required. The case outlines the value of dental radiography in dental practice. Little is known about the prevalence of CCD in New Zealand and this is an area where future research could be conducted.

A systematic review of presacral extramedullary haematopoiesis: a diagnosis to be considered for presacral masses

AIM

Presacral masses are uncommon and have malignant potential; treatment typically includes surgical excision. However, there are conditions such as extramedullary haematopoiesis (EMH) which are benign. The present study aimed to summarize the presentation of presacral EMH in our institution, to review the literature and to offer management strategies for this rare condition.

METHOD

The literature was searched for articles related to presacral EMH, and case reports were collected from articles meeting the inclusion criteria. We collected data on patient demographics, diagnostic investigation, management and the results of treatment.

RESULTS

Thirty-nine patients were included in the systematic review. Initial imaging included computed tomography (CT), magnetic resonance imaging (MRI) or ultrasound (US) suggestive of EMH. Some patients then underwent a technetium scan (n = 7, 18%), biopsy of the presacral lesion (n = 27, 69%) or excision of the entire mass (n = 3, 8%). All patients who underwent technetium scan were confirmed to have EMH, demonstrating enhancement similar to bone marrow. Patients who underwent technetium scan and presacral mass biopsy had concordant results confirming presacral EMH (n = 5, 13%). Data on management were available for 35/39 (90%) with most patients followed by clinical observation (n = 20, 51%). Symptomatic patients were treated with radiotherapy (15%), surgical excision (15%) or hydroxyurea (5%) and blood transfusions (10%). Most (81%, n = 17/21) patients whose outcome was reported remained asymptomatic or experienced pain relief.

CONCLUSION

Although uncommon, EMH should be considered in the differential diagnosis of a presacral mass. Presacral EMH is a benign condition that can be suspected on CT or MRI and confirmed with technetium scan. Patients may not necessarily need to undergo biopsy to confirm haematopoietic elements. Unlike other presacral masses, patients diagnosed with presacral EMH can be managed by observation. If symptomatic, radiotherapy or surgical excision may be offered.

Health-related quality of life in older people with osteoporotic vertebral fractures: a systematic review and meta-analysis

Health-related quality of life in osteoporotic patients with vertebral fracture is of increasing interest, but relevant studies have yielded debatable results. This systematic review and meta-analysis of 16 observational studies demonstrate a clear association between physical health status and presence of vertebral fracture after accounting for age. This meta-analysis was conducted to identify if there are any differences between physical and/or mental health-related quality of life (HRQoL) in older people with osteoporosis based on conventional T-score definitions and the presence or absence of vertebral fracture. A comprehensive search was undertaken using the databases of PubMed, Embase, Medline, Web of Science, and the "grey" literature from 1950 to the end of April 2015. Search terms for vertebral fracture (VF) included VF, osteoporotic fracture, fragility fracture, and spinal fracture. Quality of life was searched using the following terms: quality of life, health-related quality of life, HRQoL, and QoL. Strict inclusion and exclusion criteria were used. The standardized mean difference (SMD) was calculated for each HRQoL domain by the difference in means between case and control groups divided by the pooled SD of participants. Sixteen eligible studies were identified involving 3131 men and women. There was evidence of publication bias and heterogeneity. The meta-analysis showed worse physical (SMD = 0.53, 95 % confidence interval (CI) 0.38 to 0.68; P < 0.001) and mental (SMD = 0.19, 95 % CI 0.05 to 0.33; P = 0.009) HRQoL in osteoporotic older people with vertebral fracture compared to those without fracture. Similar differences were observed for physical HRQoL in further analyses accounting for possible confounding effects of age. Sub-analysis to assess associations between number/severity of fractures and time since fracture was not possible due to small numbers of studies that accounted for age. Osteoporotic older people with vertebral fracture have worse physical HRQoL than osteoporotic older people without vertebral fracture, even after accounting for age differences.

Regression, Practice, and Expectation Effects on the Revised Conners Teacher Rating Scale

This study investigated the influence of practice effects, regression toward the mean, teachers' expectations, and warm-up procedures on the Revised Conners Teacher Rating Scale. Sixty elementary school teachers viewed videotapes of 3 Attention Deficit Hyperactivity Disordered children on two or three occasions. The teachers rated each child on the Revised Conners directly after watching that child's videotaped classroom observation. The teachers were divided randomly into three groups: expectation, control, and warm-up.

The data were analyzed by a “doubly” repeated measures multivariate analysis of variance (MANOVA). Results indicated that practice effects, regression, teachers' expectations, and warm-up procedures did not play a significant role in influencing teachers' repeated ratings of the 3 children. There were significant effects for the order of presentation of the children on the tapes at the time of the first rating. On the whole, findings lend support for the validity of the Revised Conners.

Responses of Mothers and Fathers on the Personality Inventory for Children: Are they Significantly Different?

The ability of fathers to identify salient cognitive and personality characteristics of their handicapped children using the Personality Inventory for Children (PIC) was compared to that of mothers. Furthermore, the relationship between each of their PIC responses and independently derived measures of classroom behavior (i.e., WPBIC) and cognitive functioning (i.e., WISC-R) was studied. Even though the results showed high interparent agreement across all 16 PIC profile scales for 30 learning disabled and 15 emotionally disturbed children, mothers consistently rated their children as having greater difficulty. Scale to criterion correlations, nonetheless, indicate that PICs completed by either the mother or father can be interpreted similarly.