Social Isolation and Safety Issues among Rural Older Adults Living Alone: Perspectives of Meals on Wheels Programs

Ensuring the safety and social well-being of rural populations, especially rural older adults living alone with complex medical conditions, is challenging, given large, sparsely populated communities and limited resources. Using qualitative data from surveys with 42 rural Meals on Wheels programs from across the U.S., we highlight particular challenges to meeting the social and safety needs of rural older adults living alone. Respondents described challenges, opportunities, and successes in meeting the needs of their clients. We describe these under four domains: main challenges, what can be done to address social isolation and loneliness, safety issues, improving safety, and current successes. We also identify cross-cutting themes related to programs' rural environment (long distances, inclement weather), infrastructure (housing quality, access to broadband Internet and technological connectivity, road conditions), funding and resource availability, and service provision (availability of health care and partner organizations.) We describe each of these in more detail and also share policy recommendations for improving health and safety of older adults living alone in rural areas, including funding nutrition programs as a health benefit and addressing aging, poor-quality housing stock.

Reaction thermodynamics as a constraint on piscine steroidogenesis flux distributions

While a considerable amount is known of the dynamics of piscine steroidogenesis during reproduction, the influence of thermodynamics constraints on its control has not been studied. In this manuscript, Gibbs free energy change of reactions was calculated for piscine steroidogenesis using the in silico eQuilibrator thermodynamics calculator. The analysis identified cytochrome P450 (cyp450) oxidoreductase reactions to have more negative Gibbs free energy changes relative to hydroxysteroid (HSD) and transferase reactions. In addition, a more favorable Gibbs free energy change was predicted for the Δ5 (cyp450 catalyzed) vs. Δ4 (HSD catalyzed) steroidogenesis branch-point, which converts pregnenolone to 17α-hydroxypregnenolone or progesterone respectively. Comparison of in silico predictions with in vivo experimentally measured flux across the Δ5 vs. Δ4 branch-point showed higher flux through the thermodynamically more favorable Δ5 pathway in reproducing or spawning vs. non-spawning fathead minnows (Pimephales promelas). However, the exposure of fish to endocrine stressors such as hypoxia or the synthetic estrogen 17α-ethinylestradiol (EE2), resulted in increased flux through both Δ5 and Δ4 pathways, indicating an adaptive response to increase steroidogenic redundancy. The correspondence of elevated flux through the Δ5 branch-point in spawning fish indicated the use of a thermodynamically favorable pathway to optimize steroid hormone productions during reproduction. We hypothesize that such selective use of a thermodynamically favorable steroidogenesis pathway may conserve reduced equivalents or transcriptional costs for investment to other biosynthetic or catabolic reactions to support reproduction. If generalizable, such an approach can provide novel insights into the structural principles and regulation of steroidogenesis or other metabolic pathways.

A systematic review and meta-analysis of the clinimetric properties of the core outcome measurement instruments for clinical effectiveness trials of nutritional and metabolic interventions in critical illness (CONCISE)

BACKGROUND

CONCISE is an internationally agreed minimum set of outcomes for use in nutritional and metabolic clinical research in critically ill adults. Clinicians and researchers need to be aware of the clinimetric properties of these instruments and understand any limitations to ensure valid and reliable research. This systematic review and meta-analysis were undertaken to evaluate the clinimetric properties of the measurement instruments identified in CONCISE.

METHODS

Four electronic databases were searched from inception to December 2022 (MEDLINE via Ovid, EMBASE via Ovid, CINAHL via Healthcare Databases Advanced Search, CENTRAL via Cochrane). Studies were included if they examined at least one clinimetric property of a CONCISE measurement instrument or recognised variation in adults ≥ 18 years with critical illness or recovering from critical illness in any language. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist for systematic reviews of Patient-Reported Outcome Measures was used. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in line with COSMIN guidance. The COSMIN checklist was used to evaluate the risk of bias and the quality of clinimetric properties. Overall certainty of the evidence was rated using a modified Grading of Recommendations, Assessment, Development and Evaluation approach. Narrative synthesis was performed and where possible, meta-analysis was conducted.

RESULTS

A total of 4316 studies were screened. Forty-seven were included in the review, reporting data for 12308 participants. The Short Form-36 Questionnaire (Physical Component Score and Physical Functioning), sit-to-stand test, 6-m walk test and Barthel Index had the strongest clinimetric properties and certainty of evidence. The Short Physical Performance Battery, Katz Index and handgrip strength had less favourable results. There was limited data for Lawson Instrumental Activities of Daily Living and the Global Leadership Initiative on Malnutrition criteria. The risk of bias ranged from inadequate to very good. The certainty of the evidence ranged from very low to high.

CONCLUSIONS

Variable evidence exists to support the clinimetric properties of the CONCISE measurement instruments. We suggest using this review alongside CONCISE to guide outcome selection for future trials of nutrition and metabolic interventions in critical illness.

TRIAL REGISTRATION

PROSPERO (CRD42023438187). Registered 21/06/2023.

A285 CHANGE IN ALT DURING MODIFIED OPTIFAST WEIGHT LOSS PROGRAM IN INDIVIDUALS AT RISK FOR NON-ALCOHOLIC FATTY LIVER DISEASE

Background

Obesity is linked to various health complications, including diabetes, metabolic syndrome, cardiovascular disease, and non-alcoholic fatty liver disease (NAFLD). NAFLD is the most frequent cause of abnormally high alanine aminotransferase (ALT) levels. ALT is released at higher levels during hepatocellular injury and represents a simple, low cost and non-invasive method of assessing liver damage. There are conflicting data on ALT response to weight loss between men and women, with some evidence of transient increase in ALT levels in women.

Purpose

The aim of this study was to assess the impact of a dietary weight loss intervention with Optifast on ALT in patients with obesity who have baseline elevated ALT levels.

Method

This was a retrospective cohort study of Ontario adults who participated in a 26 week weight loss program, including 6 or 12 weeks of low-calorie liquid diet meal replacement with Optifast 900^® (Nestlé, Canada), between 1992 and 2015. We included patients with elevated baseline ALT levels, defined by > 40 U/L, who had at least one follow-up ALT between week 15 and 26. We excluded patients with nonadherence to dietary intervention, established liver disease or using hepatotoxic drugs, excessive alcohol intake (>11U/wk for females and >14U/wk for males), and insufficient data to calculate FIB-4. The primary outcome was change in ALT levels, measured by normalization (post-intervention ALT < 40 U/L), percentage decrease and absolute decrease. Multiple linear regressions were obtained for the relationship between ALT changes and age, sex, body mass index (BMI) and FIB-4. All analyses were conducted in SPSS. P value of ≤0.05 was considered statistically significant.

Result(s)

444 patients met study criteria. Mean age was 47.1 years +/- 10.9, 49 % of patients were female, and mean BMI was 43.5 kg/m² +/- 7.9. All patients lost weight, with mean weight loss 27.3 kg +/- 11.5 and a mean 20.7% decrease from baseline weight. Mean ALT at baseline was 58.9 U/L +/- 25.4 and mean ALT post intervention was 32.3 U/L +/- 28.1 (p <0.01). 85.1% of patients had normalization of ALT. Mean % decrease in ALT was 41.9% and mean absolute decrease in ALT was 26.6 U/L +/- 25.4. Younger age and higher baseline FIB-4 were significantly associated with a larger decrease in ALT levels, while sex and initial BMI were not significantly associated with changes in ALT.

Conclusion(s)

In patients with obesity and baseline elevated ALT, dietary weight loss intervention with Optifast leads to ALT normalization in most patients, regardless of sex. Younger age at baseline and higher baseline FIB-4 are significantly associated with greater decrease in ALT.

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Disclosure of Interest

None Declared

A166 RISK STRATIFICATION OF EARLY RE-HOSPITALIZATION IN PERSONS WITH INFLAMMATORY BOWEL DISEASES USING MULTIVARIABLE MODELS

Background

Hospitalization for persons with inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), is a significant contributor to morbidity and health care costs in Canada. Recognition of individuals at high risk of re-hospitalization could help inform targeted outpatient interventions that mitigate this risk.

Purpose

The aim of our study is to derive prediction models of risk of early (90-day) re-hospitalization among persons with IBD.

Method

We conducted a retrospective cohort study of all adult persons with IBD admitted to The Ottawa Hospital, Canada, for an acute IBD-related indication between April 2009 - March 2016. Demographic, clinical, and health services variables were obtained through chart review. Persons were linked to population-based health administrative datasets to identify historical and future IBD-related hospitalizations across the greater Ottawa region. Multivariable logistic regression models of 90-day re-hospitalization in persons with CD and UC were derived, and candidate predictors that demonstrated an independent association with the outcome at a p-value of 0.1 were retained. Bootstrap internal validation (200 iterations) was performed on the final models. Model performance and calibration were evaluated using the optimism-corrected c-statistic value and Hosmer-Lemeshow goodness of fit test, respectively. Adjusted odds ratios are reported with 95% confidence intervals (CI). Optimal probability cut points for re-hospitalization were selected to optimize sensitivity, specificity, and the J (Youden’s) index.

Result(s)

There were 524 CD and 248 UC hospitalizations during the study period. Of these, 57 (10.9%) CD and 27 (10.9%) UC hospitalizations were associated with re-hospitalization within 90 days of discharge. Forty-two candidate predictors were tested among CD hospitalizations, and 35 were tested among UC hospitalizations. Four variables were retained in each of the final models. Model performance and calibration for each variable are described in Table 1. The optimal range of probability cut points allowed for a sensitivity/positive predictive value (PPV)/false positive rate (FPR) of 0.72/0.23/0.29 (maximum J-index of 0.43) in the model for CD, and 0.78/0.33/0.19 (maximum J-index of 0.59) in the model for UC, respectively.

Image

Conclusion(s)

Demographic, clinical, and health services variables at the time of discharge have the potential to help identify persons with IBD at risk of early re-hospitalization, thereby permitting targeted outpatient intervention. Application of the models to our reference cohorts would earmark 1/3 or less of patients for early post-discharge intervention, with the potential to benefit more than 70% of patients destined for early re-hospitalization. Although the PPVs of our models were low, the models incorrectly predicted early re-hospitalization in less than 30% of patients. We are in process of externally validating these models in other jurisdictions across Ontario to test their generalizability.

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Disclosure of Interest

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Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Understanding Causes for Admission in Planned Ambulatory Percutaneous Nephrolithotomy

INTRODUCTION

For treatment of nephrolithiasis, ambulatory percutaneous nephrolithotomy (aPCNL) is growing in popularity for select patients. The aim of this study was to investigate the safety and efficacy of a set of aPCNL selection criteria as well as search for predictors of failed aPCNL resulting in inpatient admission.

METHODS AND MATERIALS

We reviewed all PCNL patients from 2016-2020. A total of 175 met selection criteria for aPCNL and were included. Primary outcome was safety and efficacy, and secondary outcome was to identify predictors of inpatient stay. Demographic and peri-operative data were analyzed with both descriptive and inferential statistics.

RESULTS

In total, between 2016-2020, 552 patients underwent PCNL, with 175 of them meeting criteria for aPCNL. 134/175 (76.6%) of these patients were successfully discharged the same day as the surgery and 41 patients were admitted. On univariate analysis, patients who required upper pole access or multiple accesses, (p=0.038) ASA>2 (p=0.005), or postoperative nephrostomy tube (PCN) (p<0.001) were more likely to be admitted after surgery. On multivariate analysis, only postoperative PCN was significantly associated with admission (p=0.015). Regarding reasons for unsuccessful aPCNL, 19.5% of admissions were attributed to intraoperative complications, 7% to social causes, 12.2% to postoperative complications, 14.6% to uncontrolled pain, and 34.1% to unexpected intraoperative procedures.

CONCLUSIONS

Ambulatory PCNL using selection criteria is safe and effective, with postoperative PCN predicting the possible necessity for conversion to inpatient admission. Furthermore, our study provides a practical algorithm for those opting to provide ambulatory PCNL to patients.

Outcomes of free flap reconstructive surgery in head and neck cancer patients over 80-years old

An increasing elderly population in the United Kingdom has led to an increasing number of older patients with head and neck cancer, resulting in a greater demand for complex head and neck reconstructive surgery in this potentially high-risk age group. A possible perceived poorer tolerance to such major treatment risks under-treating some of these patients. The purpose of this study was to assess the outcomes in the elderly population (older than 80 years) who had undergone free flap reconstruction following head and neck cancer resection. A retrospective review of 127 patients was performed. Eighteen patients were 80 or older (14.2%) and 109 under 80 (85.8%). The elderly group experienced increased number of postoperative medical complications (p=0.01), but the surgical complications were not significantly different in the two groups (p=0.4). The average length of hospital stay was significantly longer in the older group (p=0.01). There was one flap failure during the study period, which belonged to the younger group of patients. Elderly patients undergoing free flap reconstruction experience an increased rate of postoperative medical complications resulting in an increased length of hospital stay. However, good surgical outcomes can still be achieved in this age group, and therefore age alone should not be considered as a primary factor in head and neck cancer management.

Impact of wastewater infrastructure improvements on beach water fecal indicator bacteria levels in Monroe County, Florida

The effects of wastewater infrastructure construction on regional and local environments is unknown. This project evaluated the effects of such projects in Monroe County, Florida, an area that had undergone regional wastewater infrastructure improvements. We used fecal indicator bacteria (FIB) (fecal coliform and enterococci), as a proxy indicator of beach water quality for an 18-year period of record. At the highest level of aggregation, FIBs for all 17 beaches within the county were combined to evaluate trends on a yearly basis. At the lower level, yearly FIB trends were evaluated for each beach separately. FIB data on infrastructure project period (categorical variables: before, during, and after construction), and the influences of environmental conditions (quantitative variables of rainfall and temperature) were also evaluated. In the multiple regression models, enterococci and fecal coliform were significantly associated with rainfall (24 h, p < 0.0001) and water temperature (p < 0.0001) when only the quantitative variables were considered. When both categorical and quantitative variables were considered, project period was significant for enterococci (p < 0.0001) and fecal coliform (p < 0.0001), as was 24 h lagged rainfall. Overall, the most significant factors for both fecal coliform and enterococci were rainfall and project period. Considering all beaches, infrastructure projects seem to have the collective desired effects in the years following construction, as there were decreased FIBs measured at beach sites. Only through the aggregation of all projects and measurements at all beach sites could the decreases in FIB levels be observed. Local analysis is needed to explain anomalies from these general trends for specific beaches. This understanding of FIBs, their responses to environmental and project factors, and the need for aggregated and local site analysis can provide guidance to managers at other locations with similar issues of failing wastewater infrastructure and frequent FIB exceedances.

A100 END-STAGE CIRRHOSIS: EXPLORING THE PERSPECTIVES OF PATIENTS AND THEIR CAREGIVERS

Background

Despite therapy advances for patients with liver disease, readmission rates in patients with decompensated cirrhosis remain high. Studies have evaluated clinical risk factors influencing risk of readmission, but limited data exists on patient related outcome measures. Moreover, scant data exists on the impact of decompensated cirrhosis on caregivers.

Aims

We sought to evaluate and understand the patient experience of hospitalization and post-discharge, including factors perceived to be important by patients and their caregivers.

Methods

We identified patients who were admitted to the Ottawa Hospital for decompensated cirrhosis (October 2018-February 2019). Patients were consented to participate at the time of admission, or at the first clinic appointment with Hepatology post-discharge. Participants were administered a set of validated questionnaires exploring their experiences during their admission, and post-discharge. Questionnaires included the SF-36, Multidimensional Caregiver Strain Index, Social Support Scale, and a sociodemographic sheet. Patients were also asked to identify a caregiver, and if consented, a survey was also administered to their caregiver. Descriptive statistics were performed.

Results

A total of 20 patients and 10 caregivers were captured in the study. Of these, 72% (n=13) self-identified being disabled, retired, or unemployed and not currently looking for work, while 16% (n=3) were working full time. Income wise, 42% (n=8) of patients made between 20–50 thousand dollars, 42% (n=8) made more than fifty thousand, and n=2 had an income less than twenty thousand. With regards to education, 42% (n=8) had some college or technical school training, and 26% (n=5) were college graduates. All patients lived in stable housing, with the majority living alone (n=12, 63%). When assessing health-related quality of life, patients’ general health perception was low (34%), with significant impairment noted in physical role functioning (21%), and vitality (35%). Perceived social support was high, with 78% of patients noting they had a special person they could rely on in need, and someone they could share their feelings with. Our caregiver survey did not reveal any significant burnout trends. Caregivers expressed they were happy to care for their loved one (80%, n=8), and when asked whether they felt resentment or anger towards their spouse or family member, (80%, n=8) said never. Given the exploratory nature and small sample size of the study, we did not run statistical analyses.

Conclusions

Overall, our study revealed that patients with decompensated cirrhosis experience low health-related quality of life, however feel supported by their caregivers. Caregivers did not express significant burnout at first post-discharge visit. Larger studies and longitudinal data would be helpful to better characterize the patient experience in advanced cirrhosis.

Funding Agencies

The Ottawa Hospital Academic Medical Organization (TOHAMO) Quality & Patient Safety Grant

A222 ASSOCIATION BETWEEN PROTON PUMP INHIBITOR USE AND DEVELOPMENT OF HEPATIC ENCEPHALOPATHY AND SPONTANEOUS BACTERIAL PERITONITIS IN HOSPITALIZED PATIENTS WITH CIRRHOSIS

Background

Proton pump inhibitors (PPIs) are commonly prescribed medications which are indicated in various different gastrointestinal (GI) diseases, including peptic ulcer disease, gastroesophageal reflux disorder and upper GI bleeding. There is some evidence to suggest that PPI use in cirrhosis may predispose to the development of hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP), albeit with some controversy.

Aims

We aim to conduct a retrospective epidemiological analysis of the association between PPI use in hospitalized patients with cirrhosis and prevalence of HE and SBP.

Methods

This was a retrospective cohort study of 953 adult patients (mean age 62.3 (SD=12.2)) with cirrhosis admitted to the Ottawa Hospital between January 1, 2011 and December 31, 2015. A chart review was conducted and relevant information extracted.

Results

Average MELD-Na on admission was 17.4 (SD = 7.5) with no significant differences when stratified by in-hospital PPI use (p=0.53). 14.7% of patients had a prior history of HE, 5.4% SBP, 31.6% ascites, 9.3% hepatocellular carcinoma and 1.2% hepatorenal syndrome. 26.4% of patients had a history of varices, of which 34.4% had previous variceal bleeding. 45.4% of patients were on a PPI prior to admission and 69.8% during their hospitalization. Patients with a previous history of HE (16.8% vs. 9.6% p=0.006), varices (31.4% vs. 14.2% p&lt;0.001) and variceal bleed (11.6% vs. 3.1% p&lt;0.001) were more likely to be exposed to a PPI in-hospital. Mortality rate during index admission was 19.4%.

There was no significant association noted between the incidence of HE (31.2% vs. 25.0% p=0.06) or SBP (10.4% vs. 8.0% p=0.25) and in-hospital PPI use. There was also no significant association between PPI use and infectious complications, including bacteremia (8.6% vs. 7.6% p=0.63), pneumonia (12.7% vs. 12.5% p=0.95), urinary tract infections (9.2% vs. 6.6% p=0.19) and clostridium difficile (3.8% vs. 2.1% p=0.18). Patients on a PPI had greater in-hospital mortality (22.0% vs. 13. 5% p=0.002), although there was no significance between cause of death (p=0.31) nor death from infectious complications (18.5% vs. 23.1% p=0.52) between groups. Length of stay (LOS) was longer in patients exposed to PPI (median (IQR) 7 (4–17) vs 6 (3–13) p=0.03). Similar findings were noted on subgroup analysis of decompensated patients.

Conclusions

We did not observe a significant difference in HE, SBP or infectious complications among this cohort of cirrhotic patients by in-hospital PPI use. However, there was a significantly higher mortality rate noted in hospital and longer LOS, despite similar baseline MELD-Na and causes of death. Further study and judicious PPI prescribing practices in this vulnerable population of patients is warranted.

Funding Agencies

None

Minimally Invasive Percutaneous Nephrolithotomy: Initial North American Experience

Introduction and Objectives: The goal of this study is to evaluate the outcomes in a cohort of patients who underwent minimally invasive percutaneous nephrolithotomy (MIP) at a single institution from 2017 to 2019. Methods: Sixty patients at a single institution with two different surgeons underwent MIP from 2017 to 2019. The MIP technique uses a proprietary nephroscope with a "vacuum" technique for stone evacuation. Patients were identified who had postoperative CT scan imaging available for direct review. A prospectively maintained database was queried along with retrospective chart review to evaluate the stone-free rate defined as no stones on CT imaging. Preoperative, intraoperative, and postoperative variables were analyzed including initial stone size, access type (fluoroscopic vs ultrasonic), access location, operative positioning (supine vs prone), operative time, and 60-day complications. Results: Forty-six of 60 patients had CT imaging postoperatively that were reviewable. Of these, 43% (n = 20) were stone free as defined by no identifiable fragments seen, 11% (n = 5) had residual fragments 0 to 2 mm, 7% (n = 3) had residual fragments 2 to 4 mm, and 39% (n = 18) had residual fragments >4 mm. Mean initial stone size was 21 mm (1.9-84 mm). Sixty percent (n = 28) of the patients were discharged the same day as surgery. Fifty-one percent (n = 24) of access was achieved through ultrasound alone. Seventeen percent of patients (n = 8) had a complication within 30 days of surgery. All complications were Clavien III or lower with unplanned return to operating room rate of 2% (n = 1). Conclusions: We present North America's first single institution analysis of MIP cases with acceptable outcomes comparable with both retrograde intrarenal surgery and standard percutaneous nephrolithotomy. The exact role of MIP in renal stone disease needs to be determined by future studies that critically assess their outcomes.

Establishing nationally representative benchmarks of farm-gate nitrogen and phosphorus balances and use efficiencies on Irish farms to encourage improvements

Agriculture faces considerable challenges of achieving more sustainable production that minimises nitrogen (N) and phosphorus (P) losses and meets international obligations for water quality and greenhouse gas emissions. This must involve reducing nutrient balance (NB) surpluses and increasing nutrient use efficiencies (NUEs), which could also improve farm profitability (a win-win). To set targets and motivate improvements in Ireland, nationally representative benchmarks were established for different farm categories (sector, soil group and production intensity). Annual farm-gate NBs (kg ha^-1) and NUEs (%) for N and P were calculated for 1446 nationally representative farms from 2008 to 2015 using import and export data collected by the Teagasc National Farm Survey (part of the EU Farm Accountancy Data Network). Benchmarks for each category were established using quantile regression analysis and percentile rankings to identify farms with the lowest NB surplus per production intensity and highest gross margins (€ ha^-1). Within all categories, large ranges in NBs and NUEs between benchmark farms and poorer performers show considerable room for nutrient management improvements. Results show that as agriculture intensifies, nutrient surpluses, use efficiencies and gross margins increase, but benchmark farms minimise surpluses to relatively low levels (i.e. are more sustainable). This is due to, per ha, lower fertiliser and feed imports, greater exports of agricultural products, and for dairy, sheep and suckler cattle, relatively high stocking rates. For the ambitious scenario of all non-benchmark farms reaching the optimal benchmark zone, moderate reductions in farm nutrient surpluses were found with great improvements in profitability, leading to a 31% and 9% decrease in N and P surplus nationally, predominantly from dairy and non-suckler cattle. The study also identifies excessive surpluses for each level of production intensity, which could be used by policy in setting upper limits to improve sustainability.

Tibial rotation outcomes following hamstring lengthening as part of single event multilevel surgery in children with cerebral palsy

BACKGROUND

Hamstring lengthening remains the most common surgical procedure in the treatment of crouch gait for children with cerebral palsy (CP). While sagittal plane knee kinematics have been shown to improve post-surgery, the effects on transverse plane kinematics have not been reported. Given the differing actions of the medial and lateral hamstring muscles there is potential for change in tibial rotation post hamstring lengthening.

RESEARCH QUESTION

What is the effect of medial only versus combined medial and lateral hamstring lengthening on tibial rotation during gait in children with CP?

METHODS

A retrospective analysis of children with a diagnosis of CP who underwent a hamstring lengthening procedure. These children were divided into 2 groups: G1 (n = 18) had isolated medial hamstring lengthening while G2 (n = 30) had combined medial and lateral hamstring lengthening. A matched non-surgical control group (n = 15) was also included. Kinematic data were analysed pre and post-operatively. Pre-operative to post-operative outcomes for G1 and G2, a comparison at baseline for both groups and the difference in outcomes between the groups were analysed. Baseline to follow-up outcomes for the control group were also analysed.

RESULTS

External tibial rotation increased significantly within groups (G1: -10°, p < 0.01; G2: -11°, p < 0.001, control: -7.7, p < 0.01), with no significant difference in the change between the intervention groups. Foot progression angles became more external in both intervention groups (G1: -15°, p < 0.001; G2: -15°, p < 0.0001) and did not change in the control group.

SIGNIFICANCE

Results demonstrated similar increases in external tibial rotation, regardless of whether an isolated medial or combined medial and lateral surgery was performed. The control group demonstrated a similar change in external tibial rotation suggesting that hamstring lengthening surgery does not contribute to increased external tibial rotation in children with CP compared to what would be expected due to natural progression.

Proliferation of microalgae and enterococci in the Lake Okeechobee, St. Lucie, and Loxahatchee watersheds

This study is an analysis of relationships between microalgae (measured as chlorophyll a) and the fecal indicator bacteria enterococci. Microalgae blooms and enterococci exceedances have been occurring in Florida's recreational waterways for years. More recently, this has become a management concern as microalgae blooms have been attributed to potentially toxic cyanobacteria, and enterococci exceedances link to human infection/illness. Since both the microalgal blooms and bacterial exceedances occur in regions that receive managed freshwater releases from Lake Okeechobee, we hypothesized that both the blooms and exceedances are related to excess nutrients from the lake. Two experimental sites, on Lake Okeechobee and the St. Lucie River (downstream of the lake), plus a control site on the Loxahatchee River (which does not receive lake flow) were evaluated. The hypothesis was evaluated through three study components: 1) analysis of available long-term data from local environmental databases, 2) a year-long monthly sampling and analysis of chlorophyll a, enterococci, nutrients, and physical-chemical data, and 3) microcosm experiments with altered water/sediment conditions. Results support the hypothesis that excess nutrients play a role in both chlorophyll a and enterococci levels. For the St. Lucie River, analyses indicate that chlorophyll a correlated significantly with total Kjeldahl nitrogen (TKN) (R² = 0.30, p = 0.008) and the strongest model for enterococci included nitrate-nitrite, TKN, total phosphorus, orthophosphorus, and turbidity in our long-term analysis (n = 39, R² = 0.83, p ≤ 0.001). The microcosm results indicated that chlorophyll a and enterococci only persisted for 36 h in water from all sources, and that sediments from Lake Okeechobee may have allowed for sustained levels of chlorophyll a and enterococci levels. Overall similarities were observed in chlorophyll a and enterococci relationships with nutrient concentrations regardless of a Lake Okeechobee connection, as underscored by a study of flow out of the lake and downstream areas. This suggests that both nutrient-rich lake water and untreated surface water runoff contribute to microalgae blooms and enterococci exceedances in southeast Florida.

Cow-level risk factors for reproductive tract disease diagnosed by 2 methods in pasture-grazed dairy cattle in Ireland

The cow-side diagnosis of reproductive tract disease (RTD) involves identifying the presence of purulent vaginal discharge (PVD) and ultrasonographic endometritis (UE). The objectives of our study were to obtain prevalence estimates for RTD diagnosed by 2 methods (PVD and UE scoring) and to investigate the risk factors for increased probability of RTD if these methods are used in isolation or in combination. Our retrospective observational cohort study tested the hypothesis that RTD assessed by 2 methods would have similar risk factors, and that those would be mainly cow- and calving-related factors. We analyzed data from 5,049 pre-breeding examinations (PBE) from 2,460 spring-calved cows on 8 farms between 2014 and 2018. Cow-related details assessed were days in milk at PBE, breed, lactation number, dry period length, body condition score at calving and PBE, 305-d milk yield, predicted transmitting ability for production and fertility, the presence of a corpus luteum at PBE, and positive diagnosis the previous year. Calving details assessed were type of sire, calf sex, twinning, stillbirth, calving difficulty score, and retained fetal membranes. We conducted statistical analyses using 4 multivariable logistic regression models to identify the risk of RTD diagnosed by (1) PVD in isolation, (2) UE in isolation, (3) the presence of either PVD or UE; and (4) the presence of both PVD and UE. We accounted for herd, cow, and year as random effects in all 4 models. The overall prevalence of RTD in models 1, 2, 3, and 4 were 7.5, 6.7, 11.6, and 2.6%, respectively. Days in milk at PBE, the interaction between days in milk and retained fetal membranes, twinning, and the predicted transmitting ability for calving interval were consistently significant risk factors for positive scores in all 4 models. Considerable calving difficulty [adjusted odds ratio (AOR) = 13.64], Holstein Friesian dam breed (AOR = 2.58), first lactation (AOR = 2.39), and body condition score at PBE (AOR = 1.64) were risk factors for a positive PVD score but not for a positive UE score. Fifth lactation (AOR = 1.69), a beef-sired calf (AOR = 1.46), and the absence of a corpus luteum at PBE (AOR = 1.57) were risk factors for a positive UE score but not for a positive PVD score. These results support the hypothesis that most of the risk factors for PVD and UE are the same but some are distinctly different, implying that in some instances the 2 methods diagnose separate components of the RTD complex.

Hepatitis C virus screening and treatment in Irish prisons from nurse managers' perspectives - a qualitative exploration

Background

Prisoners carry a greater burden of physical, communicable and psychiatric disease compared to the general population. Prison health care structures are complex and provide challenges and opportunities to engage a marginalised and poorly served group with health care including Hepatitis C Virus (HCV) screening, assessment and treatment. Optimising HCV management in prisons is a public health priority. Nurses are the primary healthcare providers in most prisons globally. Understanding the barriers and facilitators to prisoners engaging in HCV care from the perspectives of nurses is the first step in implementing effective strategies to eliminate HCV from prison settings. The aim of this study was to identify the barriers and facilitators to HCV screening and treatment in Irish prisons from a nurse perspective and inform the implementation of a national prison-based HCV screening program.

Methods

A qualitative study using focus group methodology underpinned by grounded theory for analysis in a national group of nurse managers (n = 12).

Results

The following themes emerged from the analysis; security and safety requirements impacting patient access, staffing and rostering issues, prison nurses’ skill set and concerns around phlebotomy, conflict between maintaining confidentiality and concerns for personal safety, peer workers, prisoners’ lack of knowledge, fear of treatment and stigma, inter-prison variations in prisoner health needs and health service delivery and priority, linkage to care, timing of screening and stability of prison life.

Conclusions

Prison nurses are uniquely placed to identify barriers and facilitators to HCV screening and treatment in prisoners and inform changes to health care practice and policy that will optimise the public health opportunity that incarceration provides.

Hepatitis C virus screening and treatment in Irish prisons from a governor and prison officer perspective - a qualitative exploration

BACKGROUND

Prisons are a key location to access Hepatitis C Virus (HCV) infected people who inject drugs (PWID). Prison health care structures are complex and optimising health care delivery to this high need, marginalised and underserved population remains challenging. Despite international guidelines recommending that prisons are a priority location for HCV screening and treatment levels of prisoner engagement in HCV care remain low. Competing priorities between security and healthcare is a key feature of prison health care. A collaborative approach to health care delivery in prisons can maximise the benefits for prisoners, staff and the wider community.

AIM

To identify the barriers and enablers to HCV screening and treatment in Irish prisons and inform the implementation of a HCV screening program within the Irish Prison Services (IPS).

METHODS

Qualitative study using focus group methodology underpinned by grounded theory.

RESULTS

The following themes emerged from the analysis: priority of safety and security, staffing and resources, concerns about personal risk, lack of knowledge, concerns around confidentiality, prisoners' fear of treatment and stigma, timing of screening, use of peer workers, in-reach hepatology and fibroscanning services. The primary role of prison security is to ensure the safety of staff and prisoners with a secondary but important supporting role in health care delivery. Maintaining adequate staffing levels and the provision of training and education were seen as priorities and impacted on prison officers' fear for personal safety and risk of HCV transmission. Opt-out screening and peer support workers had high levels of support among participants.

CONCLUSION

Upscaling HCV management in prisons requires an in-depth understanding of all barriers and facilitators to HCV screening and treatment. Engaging prison officers in the planning and delivery of health care initiatives is a key strategy to optimising the public health opportunity that prisons provides.

First detection of Edwardsiella ictaluri (Proteobacteria: Enterobacteriaceae) in wild Australian catfish

The bacterium Edwardsiella ictaluri is considered to be one of the most significant pathogens of farmed catfish in the United States of America and has also caused mortalities in farmed and wild fishes in many other parts of the world. E. ictaluri is not believed to be present in wild fish populations in Australia, although it has previously been detected in imported ornamental fishes held in quarantine facilities. In an attempt to confirm freedom from the bacterium in Australian native fishes, we undertook a risk-based survey of wild catfishes from 15 sites across northern Australia. E. ictaluri was detected by selective culturing, followed by DNA testing, in Wet Tropics tandan (Tandanus tropicanus) from the Tully River, at a prevalence of 0.40 (95% CI 0.21-0.61). The bacterium was not found in fishes sampled from any of the other 14 sites. This is the first report of E. ictaluri in wild fishes in Australia.

Renal mucous production in Australian freshwater plotosid and ariid catfishes

This study reports the presence of large mucous cells lining the large renal collecting ducts and opisthonephric ducts of the Australian freshwater catfishes Tandanus tandanus and Tandanus tropicanus. Histologic examination of the renal tissue from four other species of Australian freshwater catfishes suggests that this feature is unique to the two species of Tandanus studied. The potential functions of renal mucous secretion in T. tandanus and T. tropicanus are discussed.

Modelling random antibody adsorption and immunoassay activity

One of the primary considerations in immunoassay design is optimizing the concentration of capture antibody in order to achieve maximal antigen binding and, subsequently, improved sensitivity and limit of detection. Many immunoassay technologies involve immobilization of the antibody to solid surfaces. Antibodies are large molecules in which the position and accessibility of the antigen-binding site depend on their orientation and packing density. In this paper we propose a simple mathematical model, based on the theory known as random sequential adsorption (RSA), in order to calculate how the concentration of correctly oriented antibodies (active site exposed for subsequent reactions) evolves during the deposition process. It has been suggested by experimental studies that high concentrations will decrease assay performance, due to molecule denaturation and obstruction of active binding sites. However, crowding of antibodies can also have the opposite effect by favouring upright orientations. A specific aim of our model is to predict which of these competing effects prevails under different experimental conditions and study the existence of an optimal coverage, which yields the maximum expected concentration of active particles (and hence the highest signal).

Can We Predict Post-Hemorrhagic Ventricular Dilatation in Preterm Infants with Severe Intraventricular Hemorrhage?

BACKGROUND: The incidence of post-hemorrhagic ventricular dilatation (PHVD) remains high in preterm infants. Little is known about the risk factors for PHVD in infants with severe intraventricular hemorrhage (IVH).

OBJECTIVES: To determine the predictors of PHVD among preterm infants with severe IVH.

DESIGN/METHODS: We conducted a retrospective review of all pre-term infants (22+0 - 32+6 weeks) who were admitted to NICUs participating in the Canadian Neonatal Network between 2010 and 2014. Infants with severe IVH (IVH with ventricular dilatation or parenchymal bleeding) who survived ≥ 72 hours were included. Perinatal and neonatal risk factors were compared between infants with and without PHVD (lateral ventricles &gt;10 mm).

RESULTS: Of 16600 eligible infants, 1964 (11.8%) developed severe IVH. Of 1815 infants with severe IVH who survived ≥72 hours, 616 (34%) developed PHVD. Factors associated with occurrence of PHVD include: lower gestational age, small for gestational age, low 5 minute Apgar score, SNAPII score&gt;20, surfactant therapy, high frequency oscillatory ventilation (HFOV), inotropes and occurrence of pneumothorax. [table 1]. There were no differences between both groups in relation to antenatal steroids, multiple pregnancy, mode of delivery, birth weight, gender or the proportion received prophylactic indomethacin. Multivariate analysis showed low five-minute Apgar score and HFOV to be independent predictors of PHVD while maternal magnesium sulfate and small for gestation (SGA) to be protective against PHVD.[table 2].

CONCLUSION: Our study identified factors involved in the prediction of PHVD in a national cohort of preterm infants. The mechanisms by which these factors may impact PHVD need further investigation.

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Epidemiology of Posthemorrhagic Ventricular Dilatation in Canadian Neonatal Intensive Care Units

BACKGROUND: Severe intraventricular hemorrhage (IVH) is a common cause of neonatal morbidity and mortality .The incidence and management of post-hemorrhagic ventricular dilatation (PHVD) vary among different centres.

OBJECTIVES: To assess the incidence, temporal trend, management and associated outcomes of PHVD in Canadian NICUs.

DESIGN/METHODS: We conducted a retrospective review of all pre-term infants (22+0 -32+6 weeks) who were admitted to NICUs participating in the Canadian Neonatal Network between 2010 and 2014. Infants with severe IVH (IVH with ventricular dilatation or parenchymal bleeding) who survived ≥ 72 hours were included. We compared the rates of severe IVH, PHVD and VP shunting between the 5 Canadian regions. Short-term outcomes of infants who developed PHVD (ventricles size ≥10 mm) were compared with those who did not.

RESULTS: Of 16600 eligible infants, 1964 (11.8%) developed severe IVH. Of 1815 infants with severe IVH who survived ≥72 hours, 616 (34%) developed PHVD and 91 (5%) treated with VP shunt. No significant difference in the incidence of severe IVH, PHVD or VP shunting over the last five years was noted. There was a statistically significant difference in the rates of severe IVH (p&lt;0.0001) and PHVD (p=0.02) among the 5 Canadian regions. VP shunts rates were variable with some Canadian regions with higher rates of PHVD had low rates of VP shunts. [figure 1]. Infants with PHVD had significantly higher mortality and short term morbidities. [table 1]. On regression analysis, PHVD is an independent predictor of death in infants with severe IVH [adjusted OR 1.55, 95% CI (1.18, 2.04)]. Infants with VP shunt had significantly higher rates of severe ROP (p&lt;0.0001), meningitis (p&lt;0.0001), and hospitalization (89 vs 41 days, p&lt;0.0001).

CONCLUSION: PHVD is an independent predictor of death and is associated with adverse short- term outcomes. Variability exists between different regions in managing PHVD. Further studies are needed to investigate the impact of this variability on long-term outcomes.

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Neurodevelopmental Outcomes in Preterm Infants with Intraventricular Hemorrhage in Canada

BACKGROUND: Conflicting evidence exists in regards to outcomes of infants with mild IVH [subependymal hemorrhage (SEH) and IVH without ventricular dilatation (VD)] with recent reports suggesting poor outcomes.

OBJECTIVES: To compare 1) neurodevelopmental (ND) outcomes of infants &lt; 29 wks GA with normal head ultrasound scan findings (Group 1: no IVH/PVL/VD to those with a) Group 2: SEH or IVH without VD, b) Group 3: IVH with VD (ventricle size &gt; 10 mm) and c) Group 4: persistent intraparenchymal echogenicity (IPE) or lucency with or without IVH and 2) composite outcome of death or ND impairment (NDI)/severe NDI (SNDI) at 18-24 months in these groups.

DESIGN/METHODS: Retrospective cohort study of data from Canadian Neonatal Network (CNN)and Canadian Neonatal Follow-up Network (CNFUN) from April 2010 to September 2011. NDI was defined as any one of Bayley III score &lt; 85 (cognition, language or motor), cerebral palsy (CP) or visual/hearing impairment. SNDI was defined as Bayley III score &lt; 70 for any of the 3 components, CP with GMFCS &gt; 3, severe visual impairment &lt;20/200 or hearing impairment needing aids/cochlear implants. Data for the 4 groups were compared using Chi-squared test or ANOVA as appropriate. Multivariable regression was conducted to obtain adusted OR (95% CI).

RESULTS: See tables on page e51.

Sulfasalazine: A rare cause of acute eosinophilic pneumonia

Sulfasalazine is a compound of 5-aminosalicylic acid (5-ASA) and sulfapyridine joined by an azo bond. It is a widely used drug in the treatment of chronic inflammatory bowel disease. Fatal toxicity of sulfasalazine arises from its effects on the bone marrow and the resulting blood dyscrasias. Pulmonary toxicity from sulfasalazine is a rather rare finding. Here, we present the case of a patient who developed acute eosinophilic pneumonia with sulfasalazine use.

Spiritual well-being and quality of life among Icelanders receiving palliative care: data from Icelandic pilot-testing of a provisional measure of spiritual well-being from the European Organisation for Research and Treatment of Cancer

Palliative care focuses on improving quality of life (QoL). This study examined the feasibility of the Icelandic version of a provisional European Organisation for Research and Treatment of Cancer (EORTC) measure of spiritual well-being (SWB), and explored the relationship between SWB and QoL for palliative care patients in Iceland. Instruments from the EORTC were used: the provisional measure of SWB, which was undergoing pilot-testing in Iceland, and the EORTC QLQ C15-PAL. The correlation between scores was examined and descriptive statistics were used. Structured interviews explored feasibility. Thirty persons participated with average age 72 years. Belief in God or a higher power had the mean 3.33 on a 1-4 scale and the mean for overall SWB was 5.73 on a 1-7 scale. The mean score for global health/QoL was 59.4, physical functioning 48.5 and emotional functioning 78.9 on a 0-100 scale. Overall QoL was positively correlated with SWB showing r(30) = 0.386, P = 0.035. The participants found that answering the provisional EORTC QLQ-SWB prompted an emotional response and took the opportunity to discuss the subject. The provisional SWB measure was found relevant for the Icelandic context, and the study indicates that SWB and QoL are closely connected.

Patients Hospitalised with an Acute Exacerbation of COPD: Is There a Need for a Discharge Bundle of Care?

Acute Exacerbations of COPD (AECOPD) are the commonest cause of hospitalisation for patients with COPD. A number of interventions are known to improve care for such patients. Internationally and in Ireland, there is significant variation in care delivered to such patients. We reviewed admissions with AECOPD (n = 174) to an Irish teaching hospital during one year, to determine if recommended interventions had been delivered to patients prior to discharge. The most frequently delivered of such interventions were: assessment of oxygen requirements 151 (87%) and arrangements for follow-up 135 (78%). The least frequently delivered were: referral for pulmonary rehabilitation 19 (11%) and advice given regarding influenza vaccination 27 (17%). Patients who received care from a respiratory physician or respiratory clinical nurse specialist (RCNS) received more interventions than those cared for by other specialties. This study demonstrates poor compliance with internationally agreed interventions. The introduction of a discharge bundle of care for use in Irish hospitals should be considered.

Disordered breathing during sleep and exercise in idiopathic pulmonary fibrosis and the role of biomarkers

BACKGROUND AND OBJECTIVE

Idiopathic pulmonary fibrosis (IPF) patients report fatigue, possibly reflecting sleep disturbance, but little is known about sleep-related changes. We compared ventilation and gas exchange during sleep and exercise in a cohort of IPF patients, and evaluated associations with selected biological markers.

METHODS

Twenty stable IPF patients (aged 67.9 ± 12.3 [SD]) underwent overnight polysomnography following an acclimatization night. Cardiopulmonary exercise testing was performed and inflammatory markers measured including TNF-α, IL-6, CXCL8, C-C motif ligand 18 (CCL-18) and C-reactive protein (CRP) RESULTS: Nine patients had sleep-disordered breathing (SDB) with an apnea-hypopnea frequency (AHI) ≥ 5/h, but only two had Epworth sleepiness score ≥ 10, thus having an obstructive sleep apnea syndrome. Sleep quality was poor. Transcutaneous carbon dioxide tension (PtcCO2) rose by 2.56 ± 1.59 kPa overnight (P = 0.001), suggesting hypoventilation. Oxygen saturation (SaO2) was lower during sleep than exercise (P < 0.01), and exercise variables correlated with resting pulmonary function. CCL-18 and CRP levels were elevated and correlated with PtcCO2 rise during sleep (P < 0.05). CCL-18 negatively correlated with diffusion capacity of carbon monoxide (DLCO), arterial oxygen (PaO2) and mean arterial carbon dioxide (PaCO2) (P < 0.05) and CRP negatively correlated with DLCO, PaO2, sleep SaO2 and oxygen uptake (VO2) during exercise (P < 0.05).

CONCLUSIONS

IPF patients desaturate more during sleep than exercise; thus, nocturnal pulse oxymetry could be included in clinical assessment. CCL-18 and CRP levels correlate with physiological markers of fibrosis.

The haematology of six species of native catfish from northern Australia

Haematology has the potential to be a valuable tool in determining the health status of wild fish populations and wider ecosystem health. However, limited haematological data are available for wild Australian fish species, and the interpretation and nomenclature of leukocytes is variable and inconsistent in fish. The morphology and cytochemical reactions of erythrocytes, thrombocytes and leukocytes of 189 wild eel-tailed catfish (Tandanus tandanus), Wet Tropics tandan (Tandanus tropicanus), Hyrtyl’s tandan (Neosilurus hyrtlii), black catfish (Neosilurus ater), lesser salmon catfish (Neoarius graeffei), and silver cobbler (Neoarius midgleyi) are described. Erythrocytes, thrombocytes, lymphocytes, monocytes and heterophils in all six species are morphologically similar to those reported in other Siluriformes. Basophils and eosinophils are rarely reported in fish; however basophils were observed in peripheral blood smears of T. tropicanus and N. ater, and eosinophils were observed in N. graeffei. Periodic acid Schiff positive granular leukocytes were observed in N. graeffei, N. midgleyi, N. ater and T. tandanus. This is the first report on the leukocyte morphology and cytochemistry of any native Australian catfish species, and provides useful baseline data for future assessments of fish health and ecosystem integrity in Australia.

Oxygen saturation profile in late-preterm and term infants: a prospective cohort study

OBJECTIVE

To determine oxygen saturation profile over 6 h monitoring period in healthy late-preterm and term neonates during the first 48 h of age, and to assess the impact of gestational age, birth weight and method of delivery on this profile.

STUDY DESIGN

Prospective cohort study of measurement of SpO2 over 6 h in 20 late-preterm (35 to 36 weeks gestation) and 40 term infants within 12 to 48 h of birth was conducted. Infants with cardiorespiratory symptoms or need for cardiorespiratory support at birth were excluded. Percentage time spent at SpO2 >90% and ⩽90% was calculated by gestational age and birth weight.

RESULT

Late-preterm infants and infants born weighing <2.5 kg spent approximately 7% of the time at SpO2 ⩽90%; this time decreased as gestational age and birth weight increased. Time at SpO2 >90% was significantly different between late-preterm and term infants (93% (5%) vs 96% (3%); P =0.002). Time at SpO2 >90% was not significantly different between males and females (95% (5%) vs 95% (4%), both n=30; P =0.72) or between vaginal births and cesarean births (95% (4%), n=32, vs 95% (4%), n=28; P =0.39). Cumulative time with SpO2 <90 was mean (s.d.) of 25 (18) in preterm vs 13 (10) min in term infants.

CONCLUSION

Over a 6-h period healthy late-preterm and term infants spent significant time at SpO2 ⩽90%. Lower gestation and lower birth weight were associated with higher time at SpO2 ⩽90%.

Longitudinal trends in utilization of endocrine therapies for breast cancer: an international comparison

WHAT IS KNOWN AND OBJECTIVE

Endocrine therapy is an effective treatment for post-menopausal women with 'oestrogen receptor-positive' invasive breast cancers. There are two main types of endocrine therapies: selective oestrogen receptor modulators (tamoxifen) and aromatase inhibitors (anastrozole, letrozole and exemestane). The aim of this study was to compare the patterns of use of endocrine therapies for breast cancer in women between nine developed countries.

METHODS

A longitudinal, cross-national drug utilization study was conducted. The endocrine therapies included were tamoxifen and the aromatase inhibitors: anastrozole, letrozole and exemestane. Annual drug utilization data were collected from Australia, Denmark, England, Finland, France, Iceland, the Netherlands, Norway and Sweden over the period 2001-2012. Utilization was measured in DDD/1000 inhabitants/day and was also adjusted for breast cancer incidence and female population statistics.

RESULTS AND DISCUSSION

Total use of endocrine therapies either increased or remained steady in all countries. Total endocrine therapy usage was consistently highest in England and France. Norway showed the lowest usage of endocrine therapies overall, using only 1.80 DDD/1000 inhabitants/day in 2012. Downward trends in tamoxifen use and upward trends in aromatase inhibitors were seen across all countries over the study period. By 2012, aromatase inhibitors represented over half of total endocrine therapy use in all countries, and as high as 74% and 80% in France and Denmark, respectively.

WHAT IS NEW AND CONCLUSION

Our analysis found a shift in use of endocrine therapy from tamoxifen to aromatase inhibitors. This trend is consistent with major clinical guidelines endorsing preferential use of aromatase inhibitors in post-menopausal women. Stabilization or small increase in tamoxifen use in the recent years may reflect the recognition of tamoxifen as still an appropriate first-line treatment. The similarity in utilization patterns may be due to the relatively comparable healthcare systems in the countries, namely universal health insurance and pharmaceutical coverage. Differences in utilization observed could be due to differences in breast cancer incidence, prescribing behaviours, interpretation of new trial evidence, and timing of drug marketing approval and reimbursement between countries.