Influences of Software Changes on Oxycodone Prescribing at an Australian Tertiary Emergency Department: A Retrospective Review

Opioid prescribing and dispensing from emergency departments is a noteworthy issue given widespread opioid misuse and diversion in many countries, contributing both physical and economic harm to the population. High patient numbers and the stochastic nature of acute emergency presentations to emergency departments (EDs) introduce challenges for prescribers who are considering opioid stewardship principles. This study investigated the effect of changes to electronic prescribing software on prescriptions with an auto-populated quantity of oxycodone immediate release (IR) from an Australian tertiary emergency department following the implementation of national recommendations for reduced pack sizes. A retrospective review of oxycodone IR prescriptions over two six-month periods between 2019 and 2021 was undertaken, either side of a software adjustment to reduce the default quantities of tablets prescribed from 20 to 10. Patient demographic details were collected, and prescriber years of practice calculated for inclusion in linear mixed effects regression modelling. A reduction in the median number of tablets prescribed per prescription following the software changes (13.5 to 10.0, p < 0.001) with little change in the underlying characteristics of the patient or prescriber populations was observed, as well as an 11.65% reduction in the total number of tablets prescribed. The prescriber's years of practice, patient age and patient sex were found to influence increased prescription sizes. Reduced quantity of oxycodone tablets prescribed was achieved by alteration of prescribing software prefill parameters, providing further evidence to support systems-based policy interventions to influence health care providers behaviour and to act as a forcing function for prescribers to consider opioid stewardship principles.

Spectroscopic Characterization of Mn1+ Low Oxidation State in Prussian Blue-Based Battery Anodes

Stabilization of ions in exotic oxidation states is beneficial for the development of new materials for green energy technologies. Exotic Mn1+ was proposed to play a role in the function of sodium-based Prussian blue analogues (PBA) batteries, a highly sought-out technology for industrial energy storage. Here, we report the detailed electronic structure characterization of uncharged and charged sodium-based manganese hexacyanomanganate anodes via Mn K-edge X-ray absorption spectroscopy (XAS), Kβ nonresonant X-ray emission (XES), and resonant inelastic X-ray scattering (RIXS). The latter allowed us to obtain site-selective XANES information about two distinct Mn centers. The obtained spectroscopic data represent the first electronic structure characterization of low-spin Mn1+ using hard X-ray RIXS and XES and allowed us to confirm its role in anode reduction. Our experimental approach can be expanded to analysis of analogues with other 3d transition metals broadening the application of exotic ionic states in materials engineering.

The Effects of the Paleo Diet on Autoimmune Thyroid Disease: A Mixed Methods Review

The aim of this systematic review was to examine the characteristics of Paleolithic diet (PD) interventions designed for adult patients with autoimmune thyroid disease (AITD) in order to determine if diet elements have the potential to successfully reduce thyroid antibodies (Ab) such as thyroglobulin (Tg), thyroid peroxidase (TPO), and thyroid stimulating hormone receptor (TSHR), and improve thyroid hormones (thyroxine (T4), triiodothyronine (T3) and thyroid stimulating hormone (TSH)) or resolve AITD pathogenesis. Randomized controlled trials (RCTs) with an adult population of 18 years and older, diagnosed with Hashimoto's thyroiditis (HT) or Graves' disease (GD) (Basedow's), who were placed on a diet of Paleolithic or ancestral nature, and achieved reduction of AITD Abs, improvement of thyroid hormones, and, or resolution of AITD were searched. Various electronic databases were used. Bias was assessed using critical appraisal tools from the Scottish Intercollegiate Guidelines Network (SIGN) and Joanna Briggs Institute (JBI). Studies were excluded according to exclusion criteria and results analyzed. One randomized controlled trial (RCT), a pilot study, and six case studies were found. In total, eight AITD studies focusing on Paleolithic or ancestral interventions were located. In highlight, females were the predominant gender. Case studies solely focused on AITD with protocols ranging from 8-60 weeks. All studies showed clinical improvements, one had significant improvement, two showed AITD resolution. After structured evaluation of nutritional interventions utilizing the PD on the effects of AITD, it was concluded foods of ancestral nature along with the addition of specific supplements, food components, exercise and mindfulness meditation, and exclusion of modern day foods have a considerable impact on thyroid Ab and hormones. The relevant studies suggest while this dietary protocol can be useful in clinical practice, larger-scale studies need to be conducted. Key teaching pointsThere are currently no dietary interventions recommended for the treatment of autoimmune thyroid disease. The Paleo diet has been documented to improve AITD antibodies and thyroid hormones in both Hashimoto's thyroiditis and Graves' disease.The Paleo diet can provide a natural source of nutrients similar to supplemental nutrients that have shown positive results on AITD.The paleo diet provides specific macronutrient percentages that may be beneficial in reducing AITD antibodies, while improving thyroid hormones.Methylation supplementation may be useful in AITD cases.

The effect of universal testing and treatment for HIV on health-related quality of life - An analysis of data from the HPTN 071 (PopART) cluster randomised trial

Background

HIV treatment has clear Health-Related Quality-of-Life (HRQoL) benefits. However, little is known about how Universal Testing and Treatment (UTT) for HIV affects HRQoL. This study aimed to examine the effect of a combination prevention intervention, including UTT, on HRQoL among People Living with HIV (PLHIV).

Methods

Data were from HPTN 071 (PopART), a three-arm cluster randomised controlled trial in 21 communities in Zambia and South Africa (2013-2018). Arm A received the full UTT intervention of door-to-door HIV testing plus access to antiretroviral therapy (ART) regardless of CD4 count, Arm B received the intervention but followed national treatment guidelines (universal ART from 2016), and Arm C received standard care. The intervention effect was measured in a cohort of randomly selected adults, over 36 months. HRQoL scores, and the prevalence of problems in five HRQoL dimensions (mobility, self-care, performing daily activities, pain/discomfort, anxiety/depression) were assessed among all participants using the EuroQol-5-dimensions-5-levels questionnaire (EQ-5D-5L). We compared HRQoL among PLHIV with laboratory confirmed HIV status between arms, using adjusted two-stage cluster-level analyses.

Results

At baseline, 7,856 PLHIV provided HRQoL data. At 36 months, the mean HRQoL score was 0.892 (95% confidence interval: 0.887-0.898) in Arm A, 0.886 (0.877-0.894) in Arm B and 0.888 (0.884-0.892) in Arm C. There was no evidence of a difference in HRQoL scores between arms (A vs C, adjusted mean difference: 0.003, -0.001-0.006; B vs C: -0.004, -0.014-0.005). The prevalence of problems with pain/discomfort was lower in Arm A than C (adjusted prevalence ratio: 0.37, 0.14-0.97). There was no evidence of differences for other HRQoL dimensions.

Conclusions

The intervention did not change overall HRQoL, suggesting that raising HRQoL among PLHIV might require more than improved testing and treatment. However, PLHIV had fewer problems with pain/discomfort under the full intervention; this benefit of UTT should be maximised during roll-out.

The community engagement course and action network: strengthening community and academic research partnerships to advance health equity

Background

Historically Black Colleges and Universities and Minority Serving Institutions are uniquely positioned to implement community-campus research partnerships based on a history of service, the pursuit of community trustworthiness and student demographics often similar to surrounding marginalized communities. The Morehouse School of Medicine Prevention Research Center collaborates with members of Historically Black Colleges and Universities, Minority Serving Institutes, and community organizations on the Community Engaged Course and Action Network. This network is the first of its kind and aims to strengthen members' ability to implement Community-Based Participatory Research (CBPR) principles and partnerships. Projects address public health priorities including mental health among communities of color, zoonotic disease prevention, and urban food deserts.

Materials and methods

To assess the effectiveness of the network, a Participatory Evaluation framework was implemented to conduct process evaluation which included review of partnership structures, operations, project implementation processes, and preliminary outcomes of the research collaborations. A focus group of Community Engagement Course and Action Network members (community and academic) was also conducted to identify benefits and challenges of the network with emphasis on key areas for improvement to further enhance the relationships between partners and to facilitate their subsequent community-campus research.

Results

Network improvements were tied to themes strengthening community-academic partnerships including sharing and fellowship, coalition building and collaboration, and greater connections and awareness of community needs through their current community-academic partnerships. The need to conduct ongoing evaluation during and after implementation, for determining the early adoption of CBPR approaches was also identified.

Conclusion

Evaluation of the network's processes, infrastructure, and operation provides early lessons learned to strengthen the network. Ongoing assessment is also essential for ensuring continuous quality improvement across partnerships such as determining CBPR fidelity, assessing partnership synergy, and dynamics, and for quality improvement of research protocol. The implications and potential for advancing implementation science through this and similar networks are great towards advancing leadership in modeling how foundations in community service can advance to CBPR partnership formation and ultimately, health equity approaches, that are local defined and assessed.

Relationship between psychological distress, health behaviours and future reports of hypertension among adults in East Zimbabwe: a cohort study

INTRODUCTION

Extensive cross-sectional evidence has demonstrated an association between psychological distress (PD) and hypertension. However, evidence on the temporal relationship is limited, especially in low-income and middle-income countries. The role of health risk behaviours including smoking and alcohol consumption in this relationship is also largely unknown. The aim of this study was to investigate the association between PD and later development of hypertension, and how this association may have been influenced by health risk behaviours, among adults in east Zimbabwe.

METHODS

The analysis included 742 adults (aged 15-54 years) recruited by the Manicaland general population cohort study, who did not have hypertension at baseline in 2012-2013, and who were followed until 2018-2019. In 2012-2013, PD was measured using the Shona Symptom Questionnaire, a screening tool validated for use in Shona-speaking countries including Zimbabwe (cut-off point: 7). Smoking, alcohol consumption and use of drugs (health risk behaviours) were also self-reported. In 2018-2019, participants reported if they had diagnosed with hypertension by a doctor or nurse. Logistic regression was used to assess the association between PD and hypertension.

RESULTS

In 2012, 10.4% of the participants had PD. The odds of new reports of hypertension were 2.04 times greater (95% CI 1.16 to 3.59) among those with PD at baseline, after adjusting for sociodemographic and health risk behaviour variables. Female gender (adjusted odds ratio, AOR 6.89, 95% CI 2.71 to 17.53), older age (AOR 2.67, 95% CI 1.63 to 4.42), and greater wealth (AOR 2.10, 95% CI 1.04 to 4.24 more wealthy, 2.88, 95% CI 1.24 to 6.67 most wealthy) were significant risk factors for hypertension. The AOR for the relationship between PD and hypertension did not differ substantially between models with and without health risk behaviours.

CONCLUSION

PD was associated with an increased risk of later reports of hypertension in the Manicaland cohort. Integrating mental health and hypertension services within primary healthcare may reduce the dual burden of these non-communicable diseases.

Delivery of index-linked HIV testing for children: learnings from a qualitative process evaluation of the B-GAP study in Zimbabwe

BACKGROUND

Index-linked HIV testing for children, whereby HIV testing is offered to children of individuals living with HIV, has the potential to identify children living with undiagnosed HIV. The "Bridging the Gap in HIV Testing and Care for Children in Zimbabwe" (B-GAP) study implemented and evaluated the provision of index-linked HIV testing for children aged 2-18 years in Zimbabwe. We conducted a process evaluation to understand the considerations for programmatic delivery and scale-up of this strategy.

METHODS

We used implementation documentation to explore experiences of the field teams and project manager who delivered the index-linked testing program, and to describe barriers and facilitators to index-linked testing from their perspectives. Qualitative data were drawn from weekly logs maintained by the field teams, monthly project meeting minutes, the project coordinator's incident reports and WhatsApp group chats between the study team and the coordinator. Data from each of the sources was analysed thematically and synthesised to inform the scale-up of this intervention.

RESULTS

Five main themes were identified related to the implementation of the intervention: (1) there was reduced clinic attendance of potentially eligible indexes due to community-based differentiated HIV care delivery and collection of HIV treatment by proxy individuals; (2) some indexes reported that they did not live in the same household as their children, reflecting the high levels of community mobility; (3) there were also thought to be some instances of 'soft refusal'; (4) further, delivery of HIV testing was limited by difficulties faced by indexes in attending health facilities with their children for clinic-based testing, stigma around community-based testing, and the lack of familiarity of indexes with caregiver provided oral HIV testing; (5) and finally, test kit stockouts and inadequate staffing also constrained delivery of index-linked HIV testing.

CONCLUSIONS

There was attrition along the index-linked HIV testing cascade of children. While challenges remain at all levels of implementation, programmatic adaptations of index-linked HIV testing approaches to suit patterns of clinic attendance and household structures may strengthen implementation of this strategy. Our findings highlight the need to tailor index-linked HIV testing to subpopulations and contexts to maximise its effectiveness.

Asynchrony in coral community structure contributes to reef-scale community stability

Many aspects of global ecosystem degradation are well known, but the ecological implications of variation in these effects over scales of kilometers and years have not been widely considered. On tropical coral reefs, kilometer-scale variation in environmental conditions promotes a spatial mosaic of coral communities in which spatial insurance effects could enhance community stability. To evaluate whether these effects are important on coral reefs, we explored variation over 2006-2019 in coral community structure and environmental conditions in Moorea, French Polynesia. We studied coral community structure at a single site with fringing, back reef, and fore reef habitats, and used this system to explore associations among community asynchrony, asynchrony of environmental conditions, and community stability. Coral community structure varied asynchronously among habitats, and variation among habitats in the daily range in seawater temperature suggested it could be a factor contributing to the variation in coral community structure. Wave forced seawater flow connected the habitats and facilitated larval exchange among them, but this effect differed in strength among years, and accentuated periodic connectivity among habitats at 1-7 year intervals. At this site, connected habitats harboring taxonomically similar coral assemblages and exhibiting asynchronous population dynamics can provide insurance against extirpation, and may promote community stability. If these effects apply at larger spatial scale, then among-habitat community asynchrony is likely to play an important role in determining reef-wide coral community resilience.

Associations between HIV status and self-reported hypertension in a high HIV prevalence sub-Saharan African population: a cross-sectional study

OBJECTIVES

This study examined whether HIV status and antiretroviral therapy (ART) exposure were associated with self-reported hypertension in Zimbabwe.

DESIGN

Study data were taken from a cross-sectional, general population survey, which included HIV testing (July 2018-December 2019).

SETTING

The data were collected in Manicaland Province, Zimbabwe.

PARTICIPANTS

9780 people aged 15 years and above were included.

OUTCOME MEASURE

Self-reported hypertension was the outcome measure. This was defined as reporting a previous diagnosis of hypertension by a doctor or nurse. After weighting of survey responses by age and sex using household census data, χ² tests and logistic regression were used to explore whether HIV status and ART exposure were associated with self-reported hypertension.

RESULTS

The weighted prevalence of self-reported hypertension was 13.6% (95% CI 12.9% to 14.2%) and the weighted prevalence of HIV was 11.1% (10.4% to 11.7%). In univariable analyses, there was no evidence of a difference in the weighted prevalence of self-reported hypertension between people living with HIV (PLHIV) and HIV-negative people (14.1%, 11.9% to 16.3% vs 13.3%, 12.6% to 14.0%; p=0.503) or between ART-exposed and ART-naive PLHIV (14.8%, 12.0% to 17.7% vs 12.8%, 9.1% to 16.4%,p=0.388). Adjusting for socio-demographic variables in logistic regression did not alter this finding (ORs:HIV status:0.88, 0.70 to 1.10, p=0.261; ART exposure:0.83, 0.53 to 1.30, p=0.411).

CONCLUSIONS

Approximately one in seven PLHIV self-reported having hypertension, highlighting an important burden of disease. However, no associations were found between HIV status or ART exposure and self-reported hypertension, suggesting that it will be valuable to focus on managing other risk factors for hypertension in this population. These findings should be fully accounted for as Zimbabwe reorients its health system towards non-communicable disease control and management.

Rib fracture-related morbidity and mortality for older persons in the era of fascial plane blocks: A cohort study

Introduction

Analgesia is key to successful conservative, nonsurgical management of patients admitted to the hospital with multiple rib fractures. Recently, new fascial plane regional anesthesia techniques have become widely available. We hypothesized that since the introduction of these new regional analgesia techniques, for patients over the age of 65 years, the effect of increasing numbers of rib fractures has been mitigated.

Methods

A retrospective study of patients admitted for the management of rib fractures between 2017 and 2020 was performed. Patients not admitted to the hospital, under the age of 65 years, or with chest trauma other than rib fractures were not eligible for inclusion. The primary outcome of interest was mortality. The secondary outcomes were the incidence of pneumonia and intensive care unit admission. Results were reported as the odds ratio and its 95% confidence interval and associated p-value. Statistical significance was set at [Formula: see text] < 0.05.

Results

Overall, 252 patients were included and 142 patients received a regional anesthesia. The mortality rate was 4% (n = 10) with no association between mortality and number of rib fractures ( p = 0.215). Twenty-four patients (9.5%) developed pneumonia during their hospital stay, again with no association with an increasing number of rib fractures. The intensive care unit admission rate was 13.1% (n = 33) and correlated with an increasing number of fractures (odds ratio = 1.15; 95% confidence interval = 1.01 to 1.31; p = 0.038).

Conclusion

Management including liberal utilization of regional anesthesia for at-risk patients appears to mitigate the effect of increasing numbers of rib fractures on the incidence of mortality and pneumonia.

Alternative approaches to identify core bacteria in Fucus distichus microbiome and assess their distribution and host-specificity

BACKGROUND

Identifying meaningful ecological associations between host and components of the microbiome is challenging. This is especially true for hosts such as marine macroalgae where the taxonomic composition of the microbiome is highly diverse and variable in space and time. Identifying core taxa is one way forward but there are many methods and thresholds in use. This study leverages a large dataset of microbial communities associated with the widespread brown macroalga, Fucus distichus, across sites and years on one island in British Columbia, Canada. We compare three different methodological approaches to identify core taxa at the amplicon sequence variant (ASV) level from this dataset: (1) frequency analysis of taxa on F. distichus performed over the whole dataset, (2) indicator species analysis (IndVal) over the whole dataset that identifies frequent taxa that are enriched on F. distichus in comparison to the local environment, and (3) a two-step IndVal method that identifies taxa that are consistently enriched on F. distichus across sites and time points. We then investigated a F. distichus time-series dataset to see if those core taxa are seasonally consistent on another remote island in British Columbia, Canada. We then evaluate host-specificity of the identified F. distichus core ASVs using comparative data from 32 other macroalgal species sampled at one of the sites.

RESULTS

We show that a handful of core ASVs are consistently identified by both frequency analysis and IndVal approaches with alternative definitions, although no ASVs were always present on F. distichus and IndVal identified a diverse array of F. distichus indicator taxa across sites on Calvert Island in multiple years. Frequency analysis captured a broader suit of taxa, while IndVal was better at identifying host-specific microbes. Finally, two-step IndVal identified hundreds of indicator ASVs for particular sites/timepoints but only 12 that were indicators in a majority (> 6 out of 11) of sites/timepoints. Ten of these ASVs were also indicators on Quadra Island, 250 km away. Many F. distichus-core ASVs are generally found on multiple macroalgal species, while a few ASVs are highly specific to F. distichus.

CONCLUSIONS

Different methodological approaches with variable set thresholds influence core identification, but a handful of core taxa are apparently identifiable as they are widespread and temporally associated with F. distichus and enriched in comparison to the environment. Moreover, we show that many of these core ASVs of F. distichus are found on multiple macroalgal hosts, indicating that most occupy a macroalgal generalist niche rather than forming highly specialized associations with F. distichus. Further studies should test whether macroalgal generalists or specialists are more likely to engage in biologically important exchanges with host.

Peptide Enhanced Bone Graft Substitute Presents Improved Short-Term Increase in Bone Volume and Construct Stiffness Compared to Iliac Crest Autologous Bone in an Ovine Lumbar Interbody Fusion Model

STUDY DESIGN

Preclinical ovine model.

OBJECTIVE

To assess the in vivo efficacy and safety of the P-15 L bone graft substitute and compare its performance to autologous iliac crest bone graft (ICBG) for lumbar interbody fusion indications.

METHODS

Thirty skeletally mature sheep underwent lumbar interbody fusion surgery. Half of the sheep received autologous ICBG and the other half the peptide enhanced bone graft substitute (P-15 L). Following termination at 1, 3, and 6 months after surgery, the operated segments were analyzed using micro computed tomography (µCT), histology, and destructive mechanical testing. Additional systemic health monitoring was performed for the P-15 L group.

RESULTS

One month after surgery, there was only minor evidence of bone remodeling and residual graft material could be clearly observed within the cage. There was active bone remodeling between 1 and 3 months after surgery. At 3 months after surgery significantly denser and stiffer bone was found in the P-15 L group, whereas at 6 months, P-15 L and ICBG gave similar fusion results. The P-15 L bone graft substitute did not have any adverse effects on systemic health.

CONCLUSIONS

The drug device combination P-15 L was demonstrated to be effective and save for lumbar interbody fusion as evidenced by this ovine model. Compared to autologous ICBG, P-15 L seems to expedite bone formation and remodeling but in the longer-term fusion results were similar.

Video Analysis of Pectoralis Major Injuries in Professional Australian Football Players

Background:

There is little evidence regarding the mechanisms of pectoralis major (PM) injury and player outcomes in Australian Football League (AFL) players.

Purposes/Hypothesis:

The study aims were to investigate (1) the mechanisms of PM muscle injury in elite AFL players via video analysis and (2) the player profile, method of management, and clinical outcomes of the PM injuries sustained. We hypothesized that the majority of PM tears would occur in outer-range PM positions (hyperextension of the glenohumeral joint).

Study Design:

Case series; Level of evidence, 4.

Methods:

We analyzed video of the precipitating event for traumatic PM injuries during AFL competition or training over a 20-year period (2002-2021). The footage was analyzed by 4 experienced assessors, and the following were evaluated: mechanism of injury, injury variables (arm position, initial contact point, visual awareness, and use of taping), player characteristics (age at the time of injury, hand dominance, and history of injury), injury profile (location and size of tear), method of management (operative vs nonoperative), patient outcomes (time to return to full senior training/match play), and complication rates.

Results:

The mean ± standard deviation age of the players was 26.5 ± 3.1 years (range, 21-32 years). Overall, 22 PM injuries were identified in the AFL injury database for a rate of 1.1 per year; 16 of these injuries had accompanying video footage. We identified 3 mechanisms for PM injury: horizontal hyperextension (62.5%), hyperflexion-abduction (25.0%), and horizontal adduction (sustained tackling; 12.5%). The most common site of the tear was the insertion point of the sternocostal head (91.0%). Twenty players (91.0%) required surgical repair, with 75% undergoing surgery within 1 week (range, 0-26 weeks). The mean return to competition for the surgical repair group was 11.1 weeks (range, 8-15 weeks). The rerupture rate was 5.0% (1 repair; <4 weeks postoperatively in 2004).

Conclusion:

PM tears in elite male AFL players were due to 1 of 3 distinct mechanisms: horizontal hyperextension, hyperflexion-abduction, and horizontal adduction (sustained tackling). Players returned to play on average 11 weeks after injury. Knowledge regarding mechanisms of injury, player profile, and return-to-sport timelines is important for appropriate medical management and provides potential areas to target for prevention of PM injuries.

Cereal grain mineral micronutrient and soil chemistry data from GeoNutrition surveys in Ethiopia and Malawi

The dataset comprises primary data for the concentration of 29 mineral micronutrients in cereal grains and up to 84 soil chemistry properties from GeoNutrition project surveys in Ethiopia and Malawi. The work provided insights on geospatial variation in the micronutrient concentration in staple crops, and the potential influencing soil factors. In Ethiopia, sampling was conducted in Amhara, Oromia, and Tigray regions, during the late-2017 and late-2018 harvest seasons. In Malawi, national-scale sampling was conducted during the April–June 2018 harvest season. The concentrations of micronutrients in grain were measured using inductively coupled plasma mass spectrometry (ICP-MS). Soil chemistry properties reported include soil pH; total soil nitrogen; total soil carbon (C); soil organic C; effective cation exchange capacity and exchangeable cations; a three-step sequential extraction scheme for the fractionation of sulfur and selenium; available phosphate; diethylenetriaminepentaacetic acid (DTPA)-extractable trace elements; extractable trace elements using 0.01 M Ca(NO₃)₂ and 0.01 M CaCl₂; and isotopically exchangeable Zn. These data are reported here according to FAIR data principles to enable users to further explore agriculture-nutrition linkages.

Measurement(s)	Trace Element • soil chemical properties
Technology Type(s)	Inductively-Coupled Plasma Mass Spectrometry
Factor Type(s)	Geography • Staple cereal crop
Sample Characteristic - Organism	Staple cereal food crops
Sample Characteristic - Environment	Smallholder farming
Sample Characteristic - Location	Ethiopia • Malawi

996 EFFECT OF COVID-19 ON HIP FRACTURE CARE IN WALES - AN ANALYSIS OF HOW ORGANISATION OF SERVICES AFFECTED HOSPITAL LENGTH OF STAY

Introduction

The National Hip Fracture Database (NHFD) report that length of stay (LOS) fell (from 19.7 to 16.9 days) in the first year of the COVID-19 pandemic, as patients, families, cares, and staff in health and social care responded to this challenge. This analysis examines trends in Wales where LOS can be profiled very completely as it predominantly remains within a single health board.

Method

We used data from the NHFD www.nhfd.co.uk to define pre-pandemic LOS (in the year to 1st March 2020) and compare this with the following 18 months. We set figures for all 12 hospitals in Wales against the changes in service organisation which each reported to the NHFD's 2020 Facilities Survey, and against the local incidence of COVID-19 among their hip fracture patients.

Results

Monthly LOS fell markedly at the pandemic's onset; the national figure falling 8.3 days (from 31.2–22.9 days) between February and June 2020. Overall LOS in Wales fell by 1.6 days across the year as a whole, but this ranged from a fall of 6.3 days in one hospital to a rise of 4.5 days in another. Five hospitals reported a rise in LOS. These hospitals had either never had orthogeriatric support, or lost this to COVID-19 duties, they did not achieve the initial fall in LOS in response to the pandemic, and they reported pressures with ‘outliers’ after the first wave. Unlike other units in Wales they cited problems with workload, particularly in terms of physiotherapy.

Discussion

NHFD data provide a detailed picture of hospitals’ response to the COVID-19 pandemic, and allow us to examine service factors underpinning their resilience in the face of this challenge. More detailed work should be carried out for the 150 hospitals in England using the same sources of data.

Protecting the mental and physical well-being of frontline health care workers during COVID-19: Study protocol of a cluster randomized controlled trial

Introduction

The COVID-19 pandemic has placed health care workers at unprecedented risk of stress, burnout, and moral injury. This paper describes the design of an ongoing cluster randomized controlled trial to compare the effectiveness of Stress First Aid (SFA) to Usual Care (UC) in protecting the well-being of frontline health care workers.

Methods

We plan to recruit a diverse set of hospitals and health centers (eight matched pairs of hospitals and six pairs of centers), with a goal of approximately 50 HCW per health center and 170 per hospital. Participating sites in each pair are randomly assigned to SFA or UC (i.e., whatever psychosocial support is currently being received by HCW). Each site identified a leader to provide organizational support of the study; SFA sites also identified at least one champion to be trained in the intervention. Using a “train the trainer” model, champions in turn trained their peers in selected HCW teams or units to implement SFA over an eight-week period. We surveyed HCW before and after the implementation period. The primary outcomes are posttraumatic stress disorder and general psychological distress; secondary outcomes include depression and anxiety symptoms, sleep problems, social functioning problems, burnout, moral distress, and resilience. In addition, through in-depth qualitative interviews with leaders, champions, and HCW, we assessed the implementation of SFA, including acceptability, feasibility, and uptake.

Discussion

Results from this study will provide initial evidence for the application of SFA to support HCW well-being during a pandemic.

Trial registration: (Clinicaltrials.govNCT04723576).

Inter-Domain Fusion for Enhanced Intrusion Detection in Power Systems: An Evidence Theoretic and Meta-Heuristic Approach

False alerts due to misconfigured or compromised intrusion detection systems (IDS) in industrial control system (ICS) networks can lead to severe economic and operational damage. However, research using deep learning to reduce false alerts often requires the physical and cyber sensor data to be trustworthy. Implicit trust is a major problem for artificial intelligence or machine learning (AI/ML) in cyber-physical system (CPS) security, because when these solutions are most urgently needed is also when they are most at risk (e.g., during an attack). To address this, the Inter-Domain Evidence theoretic Approach for Inference (IDEA-I) is proposed that reframes the detection problem as how to make good decisions given uncertainty. Specifically, an evidence theoretic approach leveraging Dempster-Shafer (DS) combination rules and their variants is proposed for reducing false alerts. A multi-hypothesis mass function model is designed that leverages probability scores obtained from supervised-learning classifiers. Using this model, a location-cum-domain-based fusion framework is proposed to evaluate the detector's performance using disjunctive, conjunctive, and cautious conjunctive rules. The approach is demonstrated in a cyber-physical power system testbed, and the classifiers are trained with datasets from Man-In-The-Middle attack emulation in a large-scale synthetic electric grid. For evaluating the performance, we consider plausibility, belief, pignistic, and general Bayesian theorem-based metrics as decision functions. To improve the performance, a multi-objective-based genetic algorithm is proposed for feature selection considering the decision metrics as the fitness function. Finally, we present a software application to evaluate the DS fusion approaches with different parameters and architectures.

Erector spinae plane block vs. peri-articular injection for pain control after arthroscopic shoulder surgery: a randomised controlled trial

Interscalene brachial plexus block is the standard regional analgesic technique for shoulder surgery. Given its adverse effects, alternative techniques have been explored. Reports suggest that the erector spinae plane block may potentially provide effective analgesia following shoulder surgery. However, its analgesic efficacy for shoulder surgery compared with placebo or local anaesthetic infiltration has never been established. We conducted a randomised controlled trial to compare the analgesic efficacy of pre-operative T2 erector spinae plane block with peri-articular infiltration at the end of surgery. Sixty-two patients undergoing arthroscopic shoulder repair were randomly assigned to receive active erector spinae plane block with saline peri-articular injection (n = 31) or active peri-articular injection with saline erector spinae plane block (n = 31) in a blinded double-dummy design. Primary outcome was resting pain score in recovery. Secondary outcomes included pain scores with movement; opioid use; patient satisfaction; adverse effects in hospital; and outcomes at 24 h and 1 month. There was no difference in pain scores in recovery, with a median difference (95%CI) of 0.6 (-1.9-3.1), p = 0.65. Median postoperative oral morphine equivalent utilisation was significantly higher in the erector spinae plane group (21 mg vs. 12 mg; p = 0.028). Itching was observed in 10% of patients who received erector spinae plane block and there was no difference in the incidence of significant nausea and vomiting. Patient satisfaction scores, and pain scores and opioid use at 24 h were similar. At 1 month, six (peri-articular injection) and eight (erector spinae plane block) patients reported persistent pain. Erector spinae plane block was not superior to peri-articular injection for arthroscopic shoulder surgery.

What can Europe learn from HCP knowledge and attitudes towards hepatitis A vaccination in the US?

Background

An estimated &gt;100 million new hepatitis A (hepA) infections occur annually worldwide. Centres for disease control and prevention reported 38795 hepA cases in the US since 2016, and 4475 outbreak-confirmed cases in Europe between 2016-2018. HepA outbreaks resulted mainly from person-to-person contact, especially among homeless, illegal drug users (IDU) and men who have sex with men (MSM). In 2020, we surveyed US health care providers (HCPs) to understand their knowledge and attitudes towards hepA vaccination in these populations at higher risk of infection and complications.

Methods

This was a cross-sectional, web-based survey of 400 HCPs (primary care providers, nurse practitioners, gastroenterologists, internal medicine and infectious disease specialists [IDs], emergency room physicians [ERs]) who had recommended and/or administered hepA vaccines to ≥ 19-year-olds.

Results

85% of 371 HCPs reported recommending hepA vaccine to homeless, 87% of 393 to IDU and 83% of 397 to MSM, although vaccination may not actually occur after recommendation. Results varied by specialty, 16% fewer ERs than IDs reported recommending the vaccine in these at-risk populations. Moreover, 64%, 75% and 71% of all (400) HCPs reported extremely important that homeless, IDU and MSM, respectively, get vaccinated for hepA, while 6%, 7% and 8% of all HCPs reported this as slightly, or not important. Reasons for not recommending hepA vaccine to homeless, IDU and MSM included uncertainty on guidelines (reported by 22/56, 24/50 and 29/66 HCPs, respectively) and low risk of infection (reported by 20/56, 30/50 and 27/66 HCPs, respectively).

Conclusions

Despite recent hepA outbreaks and strengthened recommendations for vaccination in at-risk populations, knowledge gaps persist among US HCPs. This survey may motivate European countries to reinforce national hepA vaccination recommendations and, in parallel, consider efforts to raise vaccination awareness.

Funding

GlaxoSmithKline Biologicals SA

Key messages

Education on hepatitis A vaccination recommendations in at-risk populations is needed. Health care providers’ vaccination knowledge plays a critical role to control the hepatitis A outbreak in the US and preventing hepatitis A in Europe.

Seeking Approval: International Higher Education Students' Experiences of Applying for Human Research Ethics Clearance in Australia

University human research ethics application procedures can be complicated and daunting, especially for international students unfamiliar with the process and the language. We conducted focus groups and interviews with four research higher degree and 21 Master’s coursework international students at an Australian university to gain their views on the human ethics application process. We found the most important influences on their experience were: the time it took to do an application; support from supervisors, peers and others; their own language skills; and their lack of familiarity with research ethics procedures. To improve the experience of international students undertaking research involving human research ethics applications, we recommend universities provide guidance on institutional ethics review processes, concepts and terminology, with translations in a range of languages, together with guidance on how to conduct research ethically within and outside the students’ own countries. We also recommend curricula be developed to further students’ understanding of the importance of ethical research practice, and that these curricula be embedded in undergraduate and postgraduate degree programs and reflected in course learning outcomes.

Reducing clinical review burden for insertable cardiac monitors

Funding Acknowledgements

Type of funding sources: None.

Background

The insertable cardiac monitor (ICM) is an essential tool for the ambulatory diagnosis of arrhythmias. However, definitive diagnoses still rely on time-consuming, manual adjudication of electrograms (EGMs) transmitted to the patient care network. This EGM review burden may be minimized by automatically selecting a subset of EGMs for fast review without delaying the diagnosis.

Purpose

Develop EGM selection strategies to reduce the EGM review burden without delaying diagnoses.

Methods

A retrospective analysis of 1,000 randomly selected Abbott Confirm Rx devices with 90+ days of remote transmission history was performed, regardless of transmission frequency, and all EGMs were adjudicated as either true or false positive (TP, FP). Up to 3 EGMs per day per arrhythmia type were prioritized for review based on ventricular rate and episode duration, with rules specific to each arrhythmia type: atrial fibrillation (AF), tachycardia, bradycardia, and pause. The resulting reduction in EGM review burden and TP days (patient-days with at least 1 TP EGM), as well as any diagnostic delay from the first transmitted TP, were calculated relative to reviewing all transmitted EGMs.

Results

In this population and transmission period, at least one AF, tachycardia, bradycardia, and pause EGM was transmitted by 424, 343, 190, and 325 unique devices, respectively, with a total of 35,723, 12,239, 19,752, and 28,002 EGMs, and a total of 6,163, 1,572, 1,438, and 646 TP days. For these patients with ≥1 EGM, the median [IQR] EGM transmission rate was 2.6 [0.7, 11.6], 1.1 [0.4, 4.7], 2.1 [0.6, 10.7], and 3.4 [0.6, 29.9] EGMs/patient/month, respectively. The optimal EGM selection strategy reduced this EGM review burden by 43%, 67%, 76%, and 50%, while only missing 3.4%, 2.2%, 0.3%, and 0.2% of TP days, respectively. Ultimately, 97%, 99%, 99%, and 99% of devices with a TP AF, tachycardia, bradycardia, or pause EGM exhibited no diagnostic delay vs. reviewing all transmitted EGMs.

Conclusion

EGM prioritization rules for selecting up to 3 episodes/day significantly reduced EGM burden across all patients, not just "frequent fliers," with no delay-to-diagnosis in &gt;97% of patients who exhibited a true arrhythmia. Implementing these rules on the patient care network may improve clinical workflow and ICM patient management. Abstract Figure.

Association between HIV infection and hypertension: a global systematic review and meta-analysis of cross-sectional studies

BACKGROUND

Improved access to effective antiretroviral therapy has meant that people living with HIV (PLHIV) are surviving to older ages. However, PLHIV may be ageing differently to HIV-negative individuals, with dissimilar burdens of non-communicable diseases, such as hypertension. While some observational studies have reported a higher risk of prevalent hypertension among PLHIV compared to HIV-negative individuals, others have found a reduced burden. To clarify the relationship between HIV and hypertension, we identified observational studies and pooled their results to assess whether there is a difference in hypertension risk by HIV status.

METHODS

We performed a global systematic review and meta-analysis of published cross-sectional studies that examined hypertension risk by HIV status among adults aged > 15 (PROSPERO: CRD42019151359). We searched MEDLINE, EMBASE, Global Health and Cochrane CENTRAL to August 23, 2020, and checked reference lists of included articles. Our main outcome was the risk ratio for prevalent hypertension in PLHIV compared to HIV-negative individuals. Summary estimates were pooled with a random effects model and meta-regression explored whether any difference was associated with study-level factors.

RESULTS

Of 21,527 identified studies, 59 were eligible (11,101,581 participants). Crude global hypertension risk was lower among PLHIV than HIV-negative individuals (risk ratio 0.90, 95% CI 0.85-0.96), although heterogeneity between studies was high (I² = 97%, p < 0.0001). The relationship varied by continent, with risk higher among PLHIV in North America (1.12, 1.02-1.23) and lower among PLHIV in Africa (0.75, 0.68-0.83) and Asia (0.77, 0.63-0.95). Meta-regression revealed strong evidence of a difference in risk ratios when comparing North American and European studies to African ones (North America 1.45, 1.21-1.74; Europe 1.20, 1.03-1.40).

CONCLUSIONS

Our findings suggest that the relationship between HIV status and prevalent hypertension differs by region. The results highlight the need to tailor hypertension prevention and care to local contexts and underscore the importance of rapidly optimising integration of services for HIV and hypertension in the worst affected regions. The role of different risk factors for hypertension in driving context-specific trends remains unclear, so development of further cohorts of PLHIV and HIV-negative controls focused on this would also be valuable.

225 Rheumatic heart disease in Timor Leste school students (RHD-TL) follow-up study: assessment of secondary prophylaxis and outcomes in Timor Leste

Background

The Rheumatic Heart disease in Timor Leste school students (RHD-TL) study identified Timor Leste as having some of the highest rates of definite rheumatic heart disease (RHD) in the world. The RHD-TL follow-up study aimed to assess the delivery and outcomes of the secondary prophylaxis program in known patients with echocardiographic screen detected definite and borderline RHD.

Methods

School-students in Timor Leste where reassessed over a 3-year period since the initial study in 2016. Prospective assessments included adherence to secondary prophylaxis, complications of prophylaxis, follow-up clinical assessment and serial echocardiography. Of the 48 patients, 25 Definite and 23 Borderline, 38 (79%) of all patients, and 92% of definite RHD cases have had one or more follow-up assessments including full datasets for adherence, recurrence rates and progression of disease. Follow-up is provided by the volunteer paediatric cardiology team and rheumatic heart disease team of two NGOs in collaboration with local clinics.

Results

The median duration of follow-up of the 38 patients was of 1.6 years. The median age was 13 years (range 8-22) and 75% were female. Adherence rates in patients with definite RHD was on average greater than 95% during the follow-up period. Of the 23 patients with mild or moderate RHD one case with documented acute rheumatic fever (ARF) recurrence progressed whilst 8 cases improved on benzathine-penicillin G (BPG) therapy. There was no progression of the 6 borderline cases who were not prescribed BPG. Out of the 9 borderline cases in whom BPG was prescribed, one, with 67% adherence, had a documented episode of ARF leading to echocardiographic progression and moderate definite RHD.

Conclusion

This was the first follow-up study to look at disease natural history, both in treated and untreated groups, in Timor-Leste and brought practical insights into the efficacy of the Timor Leste RHD monitoring and prophylaxis programs. Its ongoing project will enable advocacy and quality assessment for the program as it expands.

Abstract 225 Figure 1.

Can we rely on non-randomised studies? Findings from a meta-epidemiological review

Background

Increasingly, health technology assessment (HTA) agencies must decide whether new medicines should be used routinely in the absence of randomised controlled trial (RCT) data, relying solely on non-randomised studies (NRS), which are at high risk of bias due to confounding. Against the background of increased availability and improved methods to analyse non-randomised data (e.g., propensity score methods and instrumental variables), it is important for decision-makers to have guidance on the analysis and interpretation of NRS to inform health economic evaluation. We therefore aimed to systematically and empirically assess the performance of NRS using different analytical methods as compared to RCTs and develop recommendations on the basis of our findings.

Methods

We conducted a large-scale meta-epidemiological review to obtain estimates of the discrepancy in treatment effects in matched RCTs and NRS of pharmacologic interventions from published meta-analyses indexed in MEDLINE and the Cochrane Database of Systematic Reviews. We also consulted with HTA bodies, regulators and academics from five European countries to learn from their experience with using non-randomised evidence.

Results

We compiled the largest dataset of clinical topics with matching RCTs and NRS using various analytical methods to date, covering &gt;100 unique clinical questions. Incorporating information on direction of effect and effect size from &gt;700 unique studies, the dataset can be used to evaluate discrepancies in treatment effects between study designs across a wide range of therapeutic areas.

Conclusions

An empirically based understanding of the risk of bias in NRS is required in order to promote the adequate use of non-randomised evidence as input for health economic decision-making.

P3133Single parasternal long axis echocardiography by briefly trained health workers using handheld devices for detection of rheumatic heart disease: a prospective study of diagnostic accuracy

Introduction

Echocardiographic screening can detect rheumatic heart disease (RHD) in high-risk populations,but is limited by reliance on highly-trained experts and equipment. We sought to determine the diagnostic utility of an ultra-abbreviated single parasternal-long-axis-sweep of the heart (SPLASH) echocardiography protocol to detect RHD, performed by briefly-trained health workers.

Methods

In Timor-Leste and Northern Australia, individuals aged 5–20y were offered school-based echocardiographic screening. Health workers completed online modules followed by one-week of practical training, logging 50 echocardiograms prior to study. The index test was SPLASH, performed and reported by health workers using handheld GE V-scan devices. The index test was abnormal if any mitral or aortic regurgitation was detected. The reference test was a comprehensive echocardiogram, performed by an echocardiographers or cardiologist on a GE Vivid-Q, reported according to World Heart Federation criteria. The diagnostic accuracy of the index test was determined.

Results

2590 subjects underwent index and reference tests. Prevalence of definite RHD was 3.2% (83/2590). Sensitivity and specificity of index test were 0.75 (95% CI 0.64–0.83) and 0.77 (95% CI 0.75–0.78) respectively for detection of any definite RHD, and 0.91 (95% CI 0.74–0.98) and 0.76 (95% CI 0.74–0.78) respectively for detection of moderate or severe RHD.

Conclusion

Health workers using SPLASH detected the vast majority of moderate and severe RHD cases, but lacked sensitivity for detection of mild RHD. Further analysis is underway to evaluate the learning curve and other performance indicators of health workers performing and interpreting echocardiograms. This will allow refinement of SPLASH protocol and augmentation of health worker training to increase detection rates and accuracy for future population screening initiatives.

Acknowledgement/Funding

Heart Foundation Australia Vanguard Grant, Menzies HOT-NORTH pilot project grant, Snow Foundation, Rotary, Bawinanga Aboriginal Corporation, Mala'la