Healthcare use attributable to COVID-19: a propensity-matched national electronic health records cohort study of 249,390 people in Wales, UK

BACKGROUND

To determine the extent and nature of changes associated with COVID-19 infection in terms of healthcare utilisation, this study observed healthcare contact 1 to 4 and 5 to 24 weeks following a COVID-19 diagnosis compared to propensity-matched controls.

METHODS

Two hundred forty nine thousand three hundred ninety Welsh individuals with a positive reverse transcription-polymerase chain reaction (RT-PCR) test were identified from data from national PCR test results. After elimination criteria, 98,600 positive individuals were matched to test negative and never tested controls using propensity matching. Cohorts were split on test location. Tests could be taken in either the hospital or community. Controls were those who had tested negative in their respective environments. Survival analysis was utilised for first clinical outcomes which are grouped into primary and secondary. Primary outcomes include post-viral-illness and fatigue as an indication of long-COVID. Secondary outcomes include clinical terminology concepts for embolism, respiratory conditions, mental health conditions, fit notes, or hospital attendance. Increased instantaneous risk for positive individuals was quantified using hazard ratios (HR) from Cox regression, while absolute risk (AR) and relative risk were quantified using life table analysis.

RESULTS

Analysis was conducted using all individuals and stratified by test location. Cases are compared to controls from the same test location. Fatigue (HR: 1.77, 95% CI: 1.34-2.25, p =  < 0.001) and embolism (HR: 1.50, 95% CI: 1.15-1.97, p = 0.003) were more likely to occur in all positive individuals in the first 4 weeks; however, anxiety and depression (HR: 0.83, 95% CI: 0.73-0.95, p = 0.007) were less likely. Positive individuals continued to be more at risk of fatigue (HR: 1.47, 95% CI: 1.24-1.75, p =  < 0.001) and embolism (HR: 1.51, 95% CI: 1.13-2.02, p = 0.005) after 4 weeks. All positive individuals are also at greater risk of post-viral illness (HR: 4.57, 95% CI: 1.77-11.80, p = 0.002). Despite statistical association between testing positive and several conditions, life table analysis shows that only a small minority of the study population were affected.

CONCLUSIONS

Community COVID-19 disease is associated with increased risks of post-viral-illness, fatigue, embolism, and respiratory conditions. Despite elevated risks, the absolute healthcare burden is low. Subsequently, either very small proportions of people experience adverse outcomes following COVID-19 or they are not presenting to healthcare.

Factors affecting turnaround time of SARS-CoV-2 sequencing for inpatient infection prevention and control decision making: analysis of data from the COG-UK HOCI study

BACKGROUND

Barriers to rapid return of sequencing results can affect the utility of sequence data for infection prevention and control decisions.

AIM

To undertake a mixed-methods analysis to identify challenges that sites faced in achieving a rapid turnaround time (TAT) in the COVID-19 Genomics UK Hospital-Onset COVID-19 Infection (COG-UK HOCI) study.

METHODS

For the quantitative analysis, timepoints relating to different stages of the sequencing process were extracted from both the COG-UK HOCI study dataset and surveys of study sites. Qualitative data relating to the barriers and facilitators to achieving rapid TATs were included from thematic analysis.

FINDINGS

The overall TAT, from sample collection to receipt of sequence report by infection control teams, varied between sites (median 5.1 days, range 3.0-29.0 days). Most variation was seen between reporting of a positive COVID-19 polymerase chain reaction (PCR) result to sequence report generation (median 4.0 days, range 2.3-27.0 days). On deeper analysis, most of this variability was accounted for by differences in the delay between the COVID-19 PCR result and arrival of the sample at the sequencing laboratory (median 20.8 h, range 16.0-88.7 h). Qualitative analyses suggest that closer proximity of sequencing laboratories to diagnostic laboratories, increased staff flexibility and regular transport times facilitated a shorter TAT.

CONCLUSION

Integration of pathogen sequencing into diagnostic laboratories may help to improve sequencing TAT to allow sequence data to be of tangible value to infection control practice. Adding a quality control step upstream to increase capacity further down the workflow may also optimize TAT if lower quality samples are removed at an earlier stage.

Emergency pacemaker implantation in nonagenarians with complete heart block: is single chamber pacing sufficient?

Background

In ambulatory patients with complete heart block and preserved sinus node activity (CHBs), dual chamber pacing confers well-established physiological benefits versus single chamber pacing. There is limited evidence as to whether these benefits extend to very frail patients, especially those over 90 years of age.

Purpose

In nonagenarians presenting with emergent CHBs from 2016–2019, we compared the clinical characteristics of patients selected for single versus dual chamber pacemakers (PPM), and evaluated the symptomatic and prognostic implications of these devices.

Methods

Baseline characteristics were discerned from electronic records, and physiological data extracted from serial PPM interrogations. Frailty was quantified according to the Rockwood clinical frailty scale (1–9). Cause of death was provided by the patients' General Practitioner. Cox proportional hazards analysis (HR, 95% CI) examined associations with all-cause mortality and death from congestive cardiac failure (CCF).

Results

168 consecutive patients were included (44.3% Male, Median age: 91 (2) years) and followed-up for 26.9±14.6 months. 22 patients (13.1%) were implanted with single chamber pacemakers (all programmed VVIR); when compared with patients receiving dual chamber devices, these patients had similar median age (93 (3) versus 91 (2) years, p=0.15) and LV systolic function (LVEF: 49.2% ±9.7 versus 50.7% ±10.1, p=0.71), but were more frail (Rockwood scale: 5.2±1.8 versus 4.3±1.1, p=0.004) and more likely to have severe cognitive impairment (27.3% versus 9.2%, p=0.018). Post implant, patients who received single chamber devices had higher average respiratory rates (21.3±2.4 breaths per minute versus 17.5±2.6 breaths per minute, p=0.002), lower average heart rates (65.5±10.1 bpm versus 71.9±8.6 bpm, p=0.002), and lower daily activity levels (0.57±0.3 hours of activity versus 1.5±1.1 hours of activity, p=0.016) than those with dual chamber devices. Death from CCF was more common in patients receiving single chamber devices (40.9% versus 6.2%, log rank p&lt;0.0001); this association persisted when adjusting for age, frailty and cognitive impairment (adjusted HR: 6.2 (2.2–17.3, p=0.0005). However, in this age group, single chamber pacing was not independently associated with all-cause mortality when compared with dual chamber pacing (adjusted HR: 1.9 (0.95–3.6, p=0.07).

Conclusions

In nonagenarians with CHBs, dual chamber pacing was associated with improved symptomatic outcomes and a reduced risk of death from CCF, but did not affect all-cause mortality when compared with single chamber pacing.

Funding Acknowledgement

Type of funding sources: None.

1051 EMERGENCY PACEMAKER IMPLANTATION IN NONAGENARIANS: IMPACT OF FRAILTY ON OPERATOR DECISION-MAKING AND PATIENT OUTCOMES

Introduction

Complete heart block (CHB) is a time-critical emergency. In frail patients with CHB, the absence of test results or a comprehensive history can challenge operator decision-making; in particular, minimal data exists as to the prognostic impact of single versus dual chamber pacing in this group. In patients over 90 years of age presenting with CHB, we examined the prognostic value of parameters obtained from bedside examination, and analysed the impact of single versus dual chamber pacemakers on mortality.

Method

Data were extracted from 2016–2019. Bedside covariates were age, sex, previous cardiac surgery, atrial rhythm, LV systolic function, syncope at presentation, QRS duration, and Rockwood frailty score. Cox-proportional hazards regression examined associations with all-cause mortality and cardiac death, determined from electronic records and death certificates (adjusted HR, 95% CI).

Results

205 patients were included (age 92.3 ± 2.3 years, 45.4% male). Mortality was 13.8% at 90 days and 27.2% at 27.1 ± 16.7 months. The independent predictors of mortality were pre-procedural QRS duration &gt;130 ms (HR 2.4 (1.4–4.1) p = 0.001), age (HR 1.07 (1.02–1.15) p = 0.004), AF (HR 2.0 (1.1–3.6) p = 0.02), and Rockwood score (HR 1.2 (1.02–2.6), p = 0.043). Sex, syncope at presentation, LV function or previous cardiac surgery did not predict mortality (all p &gt; 0.1). In a subset of 168 patients without AF, 30 (17.8%) received single chamber pacemakers. Whilst these patients were more frail than those receiving dual chamber pacemakers (Rockwood scores: 5.2 ± 1.7 vs 4.3 ± 1.1, p = 0.025), implantation of a single chamber pacemaker was independently associated with cardiac death when adjusting for frailty and co-morbidities (HR 6 (1.4–26.4), p = 0.018).

Conclusion

Nonagenarians undergoing emergency pacemaker implantation have a reasonable prognosis. Data ascertained at the bedside can help predict survival, however—when adjusting for frailty and co-morbidities—dual chamber pacing may confer an independent mortality benefit over single chamber pacing in this group.

Electroconvulsive Therapy’s use in Idiopathic Intracranial Hypertension with Mood Disorder: caution, promise, and progress

Introduction

Idiopathic Intracranial Hypertension (IIH) is a condition characterized by an increase of intracranial pressure (ICP) with no identifiable cause to date. One-half of patients who suffer from IIH have co-morbid mood disorders, such as Major Depressive Disorder (MDD), that can be refractory to pharmacologic treatment. Electroconvulsive Therapy (ECT) is a safe and effective treatment for treatment-refractory mood disorder, but possesses a relative contra-indication for IIH due to its theoretical increase in ICP. Can ECT become the gold-standard treatment modality for mood disorder from IIH?

Objectives

We aim to synthesize and summarize the state of the literature surrounding the intersection of ECT and IIH. We will present notable findings and propose avenues for future investigation.

Methods

We conducted a literature review using PubMed’s search function. Key terms that were queried are as follows: Idiopathic Intracranial Hypertension, Pseudotumor Cerebri, Benign Intracranial Hypertension, Mood Disorder, Major Depressive Disorder, ECT, Electroconvulsive Therapy.

Results

The prevailing theory of IIH and mood disorder centers around HPA axis dysfunction, which has been heavily theorized to be positively impacted with ECT. ECT itself may not increase the ICP, but the anesthesia might. The only two case reports in the literature presented safe and successful use of ECT’s in patients with IIH and MDD.

Conclusions

More data is needed to draw conclusions, as the literature surrounding ECT’s use in patients with IIH remains sparse. Further studies must explore whether ECT’s use in IIH remains effective. Through this, we may understand more about both IIH and ECT itself.

Disclosure

No significant relationships.

564 Freedom from Urethral Catherisation – Using QI Methodology to Improve Patient Outcome and Experiences

Aim

To reduce catheter burden on patients who could instead be free of urethral catheter and taught intermittent self-catheterisation (ISC).

Method

2 PDSA (Plan, Do, Study, Act) cycles were performed over a 21-month period from February 2018 to November 2020. Using multiple nurse-led TWOC clinics, data was extracted using nurse-completed proformas and electronic patient records to determine: TWOC rate; urethral catheter-free rate; and ISC rate. Following baseline measurement, interventions were made, such as centralisation of TWOC services, emphasis on ISC teaching and the introduction of industry-nurse led clinics.

Results

At baseline, TWOC rate, urethral catheter-free rate and ISC rate were 55.7%, 68% and 28.2%, respectively. Following centralisation of TWOC services and emphasis on ISC teaching in Cycle 1, urethral catheter-free rate rose to 77.8% whilst ISC rate fell to 25%. Cycle 2 followed the introduction of industry-nurse led clinics. Following this, urethral catheter-free rate rose further to 81.6%, with ISC rate rising dramatically to 56.3%

Conclusions

To those capable, ISC frees patients of catheter burden and its sequalae. Evidently, a greater onus on ISC training will increase the number of patients left catheter-free.

Localising evidence for decision-making: participatory approach to inform schistosomiasis control

Background

The linear theories of change which ground many interventions do not account for the complex processes and systems in which they are implemented. This reductionist approach prioritises statistical methods which do not accommodate the stochastic, non-linear, dynamic interactions between humans and their environment. The inclusion of practitioners in the process of evidence development and utilisation of complex systems methods mitigates these issues and results in locally relevant, timely evidence for decision-making.

Methods

The aim of this work was to develop localised evidence for decision-making for schistosomiasis control in Uganda, Malawi, and Tanzania. Workshops were conducted with practitioners from the Ministries of Health at various levels and partner organisations to identify evidence needs for their decision-making processes and perceptions of disease transmission and control activities. Participatory systems mapping was used to identify factors directly and indirectly related to transmission. The maps were synthesised to a master complex systems map, which served as the blueprint for a generalised spatial agent-based model and specific ABMs tailored to the evidence needs of decision-makers.

Results

There was a gap in available evidence for practitioners to advocate for resources within the MoH and government budgets, as well as intervention efficacy and resource allocation. The adaptable and data-inclusive characteristics of the AMBs made them well-suited to produce localised outputs. Converted to NetLogo with a tailored user interface, these models were appropriate and responsive to the needs of decision-makers from village to national levels and across country contexts.

Conclusions

Used together, participatory and agent-based modelling resulted in the development of responsive and relevant evidence for practitioner decision-making. This process is generalisable and transferable to other diseases and locations outside of those in this study.

Key messages

The use of participatory systems mapping to develop agent-based models resulted in relevant and timely evidence for practitioner decision-making. The approach used here is transferable and generalisable outside schistosomiasis control and the contexts in this study.

Participatory systems mapping for localised evidence and decision-making: helminth control, SSA

Background

Evidence-informed decision-making to assist public health practitioners in local-level programme implementation requires adaptive approaches to research, policy and practice. To address these needs there is focus on using participatory methods. Adopting such methods, this research asks: what are the evidence needs of local public health practitioners? How do evidence and decision-making processes interact? We reflect on the process of using Participatory Systems Mapping (PSM) and implications for localising evidence-informed decision-making.

Methods

We conducted workshops with district and national-level MoH personnel in Uganda and Malawi using PSM to elicit insights into local modes of schistosomiasis transmission and control, and group discussions on evidence needs and use in implementing control programmes. PSM maps are analysed, triangulated with thematic analysis of group discussion transcripts.

Results

Analysing PSM outputs alongside discussions on evidence provides critical methodological and policy insights with implications for localised evidence and decision-making. Further insights into the local dynamics of public health decision-making are gained by triangulating PSM with discussions on the meanings and importance of 'factors' identified. Information which is accessible and useful for local practitioner's decision-making in implementing disease control measures does not always align with academic production and dissemination of evidence, nor across levels where policy is produced or implemented.

Conclusions

An array of factors influence local decision-making with implications for global health policies and practices such as for schistosomiasis control. Processes of decision-making and evidence needs of local practitioners need to be better understood within broader context. Evidence and knowledge production on health interventions rarely feedback or respond to local implementation needs, decision-making practices and public health practitioners.

Key messages

Processes of decision-making and evidence needs of local practitioners need to be better understood within broader context. Evidence and knowledge production on health interventions rarely feedback or respond to local implementation needs, decision-making practices and public health practitioners.

Investigating physiotherapy stakeholders' preferences for the development of performance-based assessment in practice education

OBJECTIVES

Discrete choice experiments (DCEs) are used in healthcare to measure the relative importance that stakeholders give to different features (or attributes) of medical treatments or services. They may also help to address research questions in health professional education. Several challenges exist regarding the performance-based assessment process (PBA) employed in physiotherapy practice-based education, a process which determines students' readiness for independent practice. Evidence highlights many commonalities among these challenges, but it is unknown which factors are the most important to stakeholders. The use of DCE methodology may provide answers and help to prioritise areas for development. Thus, this study employed DCE to identify clinical educators', practice tutors and physiotherapy students' preferences for developing the PBA process in physiotherapy.

DESIGN

Attributes (aspects of the PBA process known to be important to stakeholders) were derived from focus group interviews conducted with three groups; physiotherapy students, clinical educators (practising clinicians) and practice tutors (dedicated educational roles in the workplace). These attributes included the PBA tool, grading mechanisms, assessors involved, and, feedback mechanisms. Preferences for each group were calculated using a logistic regression model.

RESULTS

Seventy-two students, 124 clinical educators and 49 practice tutors (n=245) participated. Priorities identified centred primarily on the mandatory inclusion of two assessors in the PBA process and on refinement of the PBA tool.

CONCLUSION

Employment of DCE enabled the prioritisation of stakeholder-informed challenges related to PBA in physiotherapy practice-based education. This corroborates findings from previous qualitative work and facilitates a prioritised pathway for development of this process.

When genomic medicine reveals misattributed genetic relationships-the debate about disclosure revisited

PURPOSE

Accidental discovery of misattributed parentage is an age-old problem in clinical medicine, but the ability to detect it routinely has increased recently as a result of high-throughput DNA sequencing technologies coupled with family sequencing studies. Problems arise at the clinical-research boundary, where policies and consent forms guaranteeing nondisclosure may conflict with standard clinical care.

METHODS

To examine the challenges of managing misattributed parentage within hybrid translational research studies, we used a case study of a developmentally delayed child with a candidate variant found through a large-scale trio genome sequencing study in which data from unrelated samples were routinely excluded.

RESULTS

We discuss whether genetic parentage should be explicitly confirmed during clinical validation, thus giving greater weight to the diagnosis according to American College of Medical Genetics and Genomics variant interpretation guidelines, and what tensions this approach would create.

CONCLUSION

We recommend that the possibility of finding and disclosing misattributed parentage should be addressed during the consent or pretest counseling process, and that clinical relevance should determine whether or not to disclose results in the clinic. This proposition has implications for research governance, and implies that it may not always be possible to uphold nondisclosure commitments as investigations move from research to clinical care.

Nodal disease predicts recurrence whereas other traditional factors affect survival in a cohort of South African patients with differentiated thyroid carcinoma

Background and aim

Information on patients with differentiated thyroid carcinoma in South Africa is limited. The objective of this study was to review demographics and tumour characteristics in a cohort of patients with differentiated thyroid carcinoma, presenting to Groote Schuur Hospital and evaluate risk factors for recurrence and survival.

Patients and methodology

Retrospective demographic and clinical data were collected on all patients referred between January 2003 and December 2013. Prognostic factors for recurrence free survival and cancer specific survival were assessed using univariate and multivariate analyses.

Results

The total number of patients was 231.The median age at presentation was 44 years and 82% were female patients. The pathological sub-types were papillary (60.6%), follicular (38.9%) and poorly differentiated (0.5%). Total thyroidectomy was performed in 191 patients and 30 patients required neck dissections. A total of 171 (74%) patients received ¹³¹Iodine. The recurrence free and cause specific survival rates at 10 years were 83 and 91%, respectively. Nodal disease at presentation was the only significant risk factor for recurrence (p <  0.001) on multivariate analysis. Significant risk factors for cause specific mortality were age ≥ 45 years (p = 0.006), follicular pathology (p = 0.004), extra-thyroid extension (p = 0.013) and residual tumour (p = 0.004).

Conclusions

Consistent with international trends, patients with differentiated thyroid carcinoma treated at Groote Schuur Hospital had a favourable prognosis. The known risk factors associated with recurrence and survival in this South African cohort were consistent with those reported in developed countries.

Juggling roles and generating solutions; practice-based educators' perceptions of performance-based assessment of physiotherapy students

OBJECTIVES

Physiotherapy lacks the significant body of evidence that underpins performance-based assessments in disciplines such as medicine and nursing. In particular, very few studies have examined stakeholder perspectives of the process. This study set out to explore the perceptions of clinicians who undertake student assessment in the workplace in order to inform further development of performance-based assessment in physiotherapy.

DESIGN

A qualitative, descriptive design was employed where focus group interviews were utilised for data collection. Inductive thematic analysis was used to analyse the data.

PARTICIPANTS

Clinical educator and practice tutor volunteers affiliated with three Irish universities participated in one of seven focus groups (n=46).

RESULTS

Two themes were identified; 1) Tensions in the clinical learning environment, 2) An optimal PBA process. The first theme describes clinical educators' struggle with juggling multiple roles and highlights the challenges of sustaining a balance between student mentoring and patient care. The second theme outlines factors perceived to contribute to an optimal performance-based assessment process; these include maintaining aspects of the current process and expanding the employment of dedicated educational roles in the workplace.

CONCLUSION

Our findings illustrate a complex working environment for clinicians involved in student supervision and assessment. A dedicated educational role was perceived to provide a more standardised and rigorous approach to performance-based assessment. These findings provide critical stakeholder-centred insights, which may inform development of this process by addressing critical aspects deemed to facilitate and challenge clinical educator's roles as assessors.

Diagnostic accuracy of a prototype rapid chlamydia and gonorrhoea recombinase polymerase amplification assay: a multicentre cross-sectional preclinical evaluation

Objectives

Rapid and accurate sexually transmitted infection diagnosis can reduce onward transmission and improve treatment efficacy. We evaluated the accuracy of a 15-minute run-time recombinase polymerase amplification–based prototype point-of-care test (TwistDx) for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG).

Methods

Prospective, multicentre study of symptomatic and asymptomatic patients attending three English sexual health clinics. Research samples provided were additional self-collected vulvovaginal swab (SCVS) (female participants) and first-catch urine (FCU) aliquot (female and male participants). Samples were processed blind to the comparator (routine clinic CT/NG nucleic acid amplification test (NAAT)) results. Discrepancies were resolved using Cepheid CT/NG GeneXpert.

Results

Both recombinase polymerase amplification and routine clinic NAAT results were available for 392 male and 395 female participants. CT positivity was 8.9% (35/392) (male FCU), 7.3% (29/395) (female FCU) and 7.1% (28/395) (SCVS). Corresponding NG positivity was 3.1% (12/392), 0.8% (3/395) and 0.8% (3/395). Specificity and positive predictive values were 100% for all sample types and both organisms, except male CT FCU (99.7% specificity (95% confidence interval (CI) 98.4–100.0; 356/357), 97.1% positive predictive value (95% CI 84.7–99.9; 33/34)). For CT, sensitivity was ≥94.3% for FCU and SCVS. CT sensitivity for female FCU was higher (100%; 95% CI, 88.1–100; 29/29) than for SCVS (96.4%; 95% CI, 81.7–99.9; 27/28). NG sensitivity and negative predictive values were 100% in FCU (male and female).

Conclusions

This prototype test has excellent performance characteristics, comparable to currently used NAATs, and fulfils several World Health Organization ASSURED criteria. Its rapidity without loss of performance suggests that once further developed and commercialized, this test could positively affect clinical practice and public health.

A culturally tailored research ethics training curriculum for American Indian and Alaska Native communities: a randomized comparison trial

The primary aim of this study was to develop an American Indian and Alaska Native (AIAN) tailored research with human subjects curriculum that would increase the participation of AIAN members in research affecting their communities. We used a community-engaged research approach to co-design and evaluate a culturally tailored online human subjects curriculum among a national sample of AIAN community members (n = 244) with a standard nationally used online curriculum (n = 246). We evaluated pre-and post-test measures to assess group differences in ethics knowledge, perceived self-efficacy to apply such knowledge to protocol review, and trust in research. Analysis of regional tribal differences assessed curriculum generalizability. Using an 80% correct item cut-off at first attempt as passing criterion, the tailored curriculum achieved a 59.3% passing rate versus 28.1% in the standard curriculum (p < .001). For both arms, participants reported a significant increase in trust in research and in research review efficacy. Participants took less time to complete the training and reported significantly higher acceptability, satisfaction, and understandability of the curriculum for the tailored curriculum. This culturally tailored research ethics curriculum has the potential to increase participation in AIAN communities in research affecting tribal members. The AIAN curriculum achieved significantly higher levels of participants' research ethics knowledge, self-efficacy in reviewing research protocols, trust in research, and completion of the training requirements. Culturally grounded training curricula may help remedy the impact of historical research ethics abuses involving AIAN communities that have contributed to mistrust of research and lack of community engagement in research.

Engaging 'communities': anthropological insights from the West African Ebola epidemic

The recent Ebola epidemic in West Africa highlights how engaging with the sociocultural dimensions of epidemics is critical to mounting an effective outbreak response. Community engagement was pivotal to ending the epidemic and will be to post-Ebola recovery, health system strengthening and future epidemic preparedness and response. Extensive literatures in the social sciences have emphasized how simple notions of community, which project solidarity onto complex hierarchies and politics, can lead to ineffective policies and unintended consequences at the local level, including doing harm to vulnerable populations. This article reflects on the nature of community engagement during the Ebola epidemic and demonstrates a disjuncture between local realities and what is being imagined in post-Ebola reports about the lessons that need to be learned for the future. We argue that to achieve stated aims of building trust and strengthening outbreak response and health systems, public health institutions need to reorientate their conceptualization of 'the community' and develop ways of working which take complex social and political relationships into account.This article is part of the themed issue 'The 2013-2016 West African Ebola epidemic: data, decision-making and disease control'.

Hepatitis C Seroprevalence Among HIV-Infected Childbearing Women in New York State in 2006

OBJECTIVE

To identify factors associated with maternal hepatitis C virus (HCV) seroprevalence and transmission of HCV as identified by qualitative HCV ribonucleic acid (RNA) in the infants of human immunodeficiency virus (HIV) infected women delivering in New York State (NYS) in 2006.

STUDY DESIGN

In this retrospective cohort study of HIV-exposed infants born in NYS, leftover infant plasma from HIV diagnostic testing was de-identified and tested for HCV. If HCV antibodies were detected, a second specimen collected when the infant was >2 months old was tested for HCV qualitative RNA. Multivariate logistic regression was used to identify factors associated with HCV seropositivity.

RESULTS

In a final sample of 553 live birth events with perinatal HIV exposure, 21 (3.8 %) of tested infant specimens had HCV antibodies indicative of maternal HCV seropositivity. Maternal age at delivery of >35 years, Hispanic ethnicity, white race and injection drug use (IDU) were significantly associated with HCV seropositivity in multivariate analysis. No cases of HCV vertical transmission were identified among HCV exposed infant specimens.

CONCLUSIONS

This statewide population-based study of HIV-infected childbearing women shows HCV seroprevalence of 3.8 %. Maternal age of >35 years and IDU are the strongest predictors of HCV seropositivity. Although no viral transmission was documented, more comprehensive longitudinal testing would be required to conclude that HCV transmission did not occur.

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

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

Promoting health and reducing costs: a role for reform of self-monitoring of blood glucose provision within the National Health Service

AIM

To determine the cost-effectiveness of all options for the self-monitoring of blood glucose funded by the National Health Service, providing guidance for disinvestment and testing the hypothesis that advanced meter features may justify higher prices.

METHODS

Using data from the Health and Social Care Information Centre concerning all 8 340 700 self-monitoring of blood glucose-related prescriptions during 2013/2014, we conducted a cost-minimization analysis, considering both strip and lancet costs, including all clinically equivalent technologies for self-monitoring of blood glucose, as determined by the ability to meet ISO-15197:2013 guidelines for meter accuracy.

RESULTS

A total of 56 glucose monitor, test strip and lancet combinations were identified, of which 38 met the required accuracy standards. Of these, the mean (range) net ingredient costs for test strips and lancets were £0.27 (£0.14-£0.32) and £0.04 (£0.02-£0.05), respectively, resulting in a weighted average of £0.28 (£0.18-£0.37) per test. Systems providing four or more advanced features were priced equal to those providing just one feature. A total of £12 m was invested in providing 42 million self-monitoring of blood glucose tests with systems that fail to meet acceptable accuracy standards, and efficiency savings of £23.2 m per annum are achievable if the National Health Service were to disinvest from technologies providing lesser functionality than available alternatives, but at a much higher price.

CONCLUSION

The study uncovered considerable variation in the price paid by the National Health Service for self-monitoring of blood glucose, which could not be explained by the availability of advanced meter features. A standardized approach to self-monitoring of blood glucose prescribing could achieve significant efficiency savings for the National Health Service, whilst increasing overall utilisation and improving safety for those currently using systems that fail to meet acceptable standards for measurement accuracy.

[Not Available]

OBJECTIVES

Database review to analyse age and sex differences in complication and conversion rates and influence on return to normal daily activities and work after laparoscopic cholecystectomy (LC).

METHODS

658 patients had a laparoscopic cholecystectomy for proven gallstones between 9/4/2001 and 15/2/2006 under the care of one surgeon (F. H.) at Benenden hospital, Kent, UK.

RESULTS

We had a 65.5% response rate with 431 replies at a mean follow up of 22.4 months (2.3-52.8). There was a male to female ratio of 5:23 with a mean age of 54.2 years (22-83). Using linear regression we found no significant correlation with operative time and variables of age and sex (df = 2, 251, R (2) = 0.03, F = 0.574, p < 0.564). No significant correlation with number of complications and age or sex (df = 2, 334, R (2) = 0.004, F = 1.615, p < 0.200). Age (Exp(B) = 1.040, p < 0.51) and sex (Exp(B) = 0.863, p < 0.855) had no effect on conversion. No difference was found in relation to age and sex with return to normal daily activities (df = 2, 307, F = 0.904, p < 0.406). Age was a non-significant predictor of return to work (Beta = 0.040, p < 0.572) however men return to work significantly sooner (Beta = 0.191, p < 0.007).

CONCLUSIONS

Operative time, number of complications, conversion to open and return to normal daily activities may not be affected by age or sex of patients. Hospital stay may be longer in older patients. Men appear to return to work sooner. Further analysis with validated questionnaires are required.

Medical education and law: withholding/withdrawing treatment from adults without capacity

BACKGROUND

Law is increasingly involved in clinical practice, particularly at the end of life, but undergraduate and postgraduate education in this area remains unsystematic. We hypothesised that attitudes to and knowledge of the law governing withholding/withdrawing life-sustaining treatment from adults without capacity (the WWLST law) would vary and demonstrate deficiencies among medical specialists.

AIMS

We investigated perspectives, knowledge and training of medical specialists in the three largest (populations and medical workforces) Australian states, concerning the WWLST law.

METHODS

Following expert legal review, specialist focus groups, pre-testing and piloting in each state, seven specialties involved with end-of-life care were surveyed, with a variety of statistical analyses applied to the responses.

RESULTS

Respondents supported the need to know and follow the law. There were mixed views about its helpfulness in medical decision-making. Over half the respondents conceded poor knowledge of the law; this was mirrored by critical gaps in knowledge that varied by specialty. There were relatively low but increasing rates of education from the undergraduate to continuing professional development (CPD) stages. Mean knowledge score did not vary significantly according to undergraduate or immediate postgraduate training, but CPD training, particularly if recent, resulted in greater knowledge. Case-based workshops were the preferred CPD instruction method.

CONCLUSIONS

Teaching of current and evolving law should be strengthened across all stages of medical education. This should improve understanding of the role of law, ameliorate ambivalence towards the law and contribute to more informed deliberation about end-of-life issues with patients and families.

Confirmatory factorial analysis of the children´s attraction to physical activity scale (capa)

AIM

Attraction to physical activity (PA) is an important contributor to children´s intrinsic motivation to engage in games, and sports. Previous studies have supported the utility of the children´s attraction to PA scale (CAPA) (Brustad, 1996) but the validity of this measure for use in Portugal has not been established. The purpose of this study was to cross-validate the shorter version of the CAPA scale in the Portuguese cultural context.

METHODS

A sample of 342 children (8--10 years of age) was used. Confirmatory factor analyses using EQS software ( version 6.1) tested t hree competing measurement models: a single--factor model, a five factor model, and a second order factor model.

RESULTS

The single--factor model and the second order model showed a poor fit to the data. It was found that a five-factor model similar to the original one revealed good fit to the data (S--B χ 2 (67) =94.27,p=0.02; NNFI=0.93; CFI=0.95; RMSEA=0.04; 90%CI=0.02;0.05).

CONCLUSIONS

The results indicated that the CAPA scale is valid and appropriate for use in the Portuguese cultural context. The availability of a valid scale to evaluate attraction to PA at schools should provide improved opportunities for better assessment and understanding of children´s involvement in PA.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.