Risk Factors and Modifiers for Cardiovascular Disease Assessment of Patients with Heterozygous Familial Hypercholesterolaemia

Background: The assessment of the risk of cardiovascular disease (CVD) in patients with heterozygous familial hypercholesterolemia (HeFH) is determined by conventional risk factors. However, factors modifying CVD, or risk modifiers, beyond conventional risk factors may inform their CVD risk assessment and the subsequent use of new therapies. This work identifies and characterises patients within a lipid clinic cohort with regards to conventional CVD risk factors and risk modifiers with a focus on those with HeFH. Methods: A study of consecutive adult patients attending our specialist lipid clinic was performed over a six-month period. The patient data recorded included demographics, clinical characteristics, risk factors and risk modifiers, biochemical profiles and genetic testing results. Risk modifiers were identified based on ESC/EAS guidance, and those with HeFH were compared to those without. Results: A total of 370 patients were included. Of these, 98 HeFH patients were identified (26%). Then, 52% of HeFH patients were stratified into the very-high risk category due to the presence of CVD risk factors. Risk modifiers were present in 73%. These included a family history of premature CVD (56%), obesity (28%), a sedentary lifestyle (13%) and a major psychiatric disorder (12%). Compared to the rest of the cohort, those with HeFH were less likely to have hypertension and more likely to have a family history of premature CVD. Conclusions: Half of patients with HeFH are categorised as having very high CV risk. Consideration of risk modifiers, particularly a family history of premature CV disease, increases this very-high-risk category further. This may have implications for the clinical application and access to novel treatments.

A hospital to community exercise referral pathway: results of a pilot project

BACKGROUND

People living with chronic disease should ideally engage with community-based exercise services following hospital-based rehabilitation. However, transition from hospital to community exercise settings is extremely challenging and strategies to support this transition are underdeveloped.

AIMS

The aims of this study were to develop and explore the feasibility of a pilot exercise referral pathway between an acute hospital and community gyms for patients with chronic health conditions and to evaluate patient satisfaction with the exercise referral pathway.

METHODS

A stakeholder-informed exercise referral pathway was developed and offered to patients following completion of a hospital-based exercise programme for a chronic health condition. The pathway was evaluated using a mixed-methods approach. Quantitative data examining participant engagement was used to examine feasibility. Quantitative survey data and qualitative data from semi-structured interviews examined satisfaction with the pathway.

RESULTS

Forty-nine people living with chronic conditions (mean age 72 ± 7.8 years) participated (recruitment rate 59%). The average number of community gym visits over 4 months was 17.4 (range 0-51). Twenty-nine (78%) participants reported that they planned to continue their gym membership when the programme ended. Themed responses from participant interviews (n = 12) highlighted the benefits of a supported transition from hospital to gym membership and the need for more structured exercise support in community gyms.

CONCLUSION

A structured exercise referral pathway to support exercise transition between hospital and community settings in populations with chronic health conditions appears feasible. Participants reported high levels of satisfaction with the referral pathway.

Worsening of mental health outcomes in nursing home staff during the COVID-19 pandemic in Ireland

BACKGROUND

Mental health issues in nursing home staff during the COVID-19 pandemic have been significant; however, it is not known if these issues persist following widespread vaccination and easing of restrictions.

OBJECTIVE

To quantify the mental health of nursing home staff at different timepoints during the COVID-19 pandemic in the Republic of Ireland.

DESIGN/METHODS

Two identical, online, cross-sectional, nationwide, anonymous surveys of Republic of Ireland nursing home staff at two timepoints (survey 1 (S1, n = 390): November 2020 to January 2021; survey 2 (S2, N = 229: November 2021 to February 2022) during the COVID-19 pandemic. Convenience sampling was used with staff self-selecting for participation. Methods included the World Health Organisation's Well-Being Index (WHO-5), the Impact of Events Scale-Revised (IES-R), the Moral Injury Events Scale (MIES), two Likert-scale items regarding suicidal ideation and planning, the Work Ability Score (WAS), the Brief Coping Orientation to Problems Experienced (Brief-COPE) Scale, and a 15-item questionnaire assessing perceptions of the outbreak with one additional Likert-scale item on altruism. Descriptive analysis examined differences between staff based on their classification in one of three groups: nurses, healthcare assistants (HCA) and nonclinical staff. Pseudonymous identifiers were used to link responses across surveys.

RESULTS

An insufficient number of participants completed both surveys for linked analyses to be performed; therefore, we performed an ecological comparison between these two independent surveys. More staff reported moderate-severe post-traumatic stress symptoms (S1 45%; S2 65%), depression (S1: 39%; S2 57%), suicidal ideation (S1: 14%; S2 18%) and suicidal planning (S1: 9%; S2 15%) later in the pandemic. There was a higher degree of moral injury at S2 (S1: 20.8 standard deviation (SD) 9.1; S2: 25.7 SD (11.3)) and use of avoidant (maladaptive) coping styles at S2 (S1: 20.8 (6.3); S2 23.0 (6.3)) with no notable differences found in the use of approach (adaptive) coping styles. Staff reported more concerns at S2 regarding contracting COVID-19, social stigma, job stress, doubts about personal protective equipment and systems and processes.

CONCLUSION

In comparison to our previous survey, mental health outcomes appear to have worsened, coping did not improve, and staff concerns, and worries appear to have increased as the pandemic progressed. Follow-up studies could help to clarify is there are any lingering problems and to assess if these issues are related to the pandemic and working conditions in nursing homes.

Microbial composition, rumen fermentation parameters, enteric methane emissions, and lactational performance of phenotypically high and low methane-emitting dairy cows

This experiment was designed to investigate the relation of high and low methane-yield phenotypes with body weight (BW), dry matter intake (DMI), lactation performance, enteric CH4 emissions, and rumen fermentation parameters in lactating dairy cows. A total of 130 multi- and primiparous Holstein cows were screened for enteric CH4 emissions using the GreenFeed system (C-Lock Inc.). Out of these 130 cows, 5 were identified as phenotypically high (HM) and 5 as phenotypically low (LM) CH4 emitters. Cows in the LM group had lower daily enteric CH4 emissions than cows in the HM group (on average 346 vs. 439 g/d, respectively), lower CH4 yield (15.5 vs. 20.4 g of CH4/kg of DMI), and CH4 intensity (13.2 vs. 17.0 g of CH4/ kg of energy-corrected milk yield). Enteric emissions of CO2 and H2 did not differ between HM and LM cows. These 10 cows were blocked by parity, days in milk, and milk production, and were used in a 5-wk randomized complete block design experiment. Milk composition, production, and BW were also not different between LM and HM cows. The concentration of total volatile fatty acids in ruminal contents did not differ between CH4 phenotypes, but LM cows had a lower molar proportion of acetate (57 vs. 62.1%), a higher proportion of propionate (27.5 vs. 21.6%, respectively), and therefore a lower acetate-to-propionate ratio than HM cows. Consistently, the 16S cDNA analysis revealed the abundance of Succinivibrionaceae and unclassified Veillonellaceae to be higher in LM cows compared with HM cows, bacteria that were positively correlated with ruminal propionate concentration. Notably, Succinivibrionaceae trigger the formation of propionate via oxaloacetate pathway from phosphoenolpyruvate via Enzyme Commission: 4.1.1.49, which showed a trend to be higher in LM cows compared with HM cows. Additionally, LM cows possessed fewer transcripts of a gene encoding for methyl-CoM reductase enzyme compared with HM. In this study, low and high CH4-yield cows have similar production performance and milk composition, but total-tract apparent digestibility of organic matter and fiber fractions was lower in the former group of animals.

Screening macroalgae for mitigation of enteric methane in vitro

This study investigated the effects of 67 species of macroalgae on methanogenesis and rumen fermentation in vitro. Specimens were analyzed for their effect on ruminal fermentation and microbial community profiles. Incubations were carried out in an automated gas production system for 24-h and macroalgae were tested at 2% (feed dry matter basis) inclusion rate. Methane yield was decreased 99% by Asparagopsis taxiformis (AT) when compared with the control. Colpomenia peregrina also decreased methane yield 14% compared with control; no other species influenced methane yield. Total gas production was decreased 14 and 10% by AT and Sargassum horneri compared with control, respectively. Total volatile fatty acid (VFA) concentration was decreased between 5 and 8% by 3 macroalgae, whereas AT reduced it by 10%. Molar proportion of acetate was decreased 9% by AT, along with an increase in propionate by 14%. Asparagopsis taxiformis also increased butyrate and valerate molar proportions by 7 and 24%, respectively, whereas 3 macroalgae species decreased molar proportion of butyrate 3 to 5%. Vertebrata lanosa increased ammonia concentration, whereas 3 other species decreased it. Inclusion of AT decreased relative abundance of Prevotella, Bacteroidales, Firmicutes and Methanobacteriaceae, whereas Clostridium, Anaerovibrio and Methanobrevibacter were increased. Specific gene activities for Methanosphaera stadtmane and Methanobrevibacter ruminantium were decreased by AT inclusion. In this in vitro study, Asparagopsis taxiformis was most effective in decreasing methane concentration and yield, but also decreased total gas production and VFA concentration which indicates overall inhibition of ruminal fermentation. No other macroalgae were identified as potential mitigants of enteric methane.

Gender bias in academic medicine: a resumé study

BACKGROUND

Minimising the effects of unconscious bias in selection for clinical academic training is essential to ensure that allocation of training posts is based on merit. We looked at the effect of anonymising applications to a training programme for junior doctors on the scores of the applications and on gender balance; and whether female candidates were more likely to seek gender-concordant mentors.

METHODS

Applications to the training programme were reviewed and scored independently by reviewers who received either an anonymised or named copy. Scores were compared using a paired t-test, and differences in scores compared by gender. The gender of named supervisors for male and female candidates was compared.

RESULTS

Scores of 101 applications were reviewed. When their identity was known, male candidates scored 1.72% higher and female candidates scored 0.74% higher, but these findings were not statistically significant (p value = 0.279 and 0.579). Following introduction of anonymisation, the proportion of successful female candidates increased from 27 to 46%. Female candidates were more likely to name a female supervisor compared to male (41% vs. 25% of supervisors).

CONCLUSIONS

Anonymising applications did not significantly change scores, although gender balance improved. Gender-concordant mentoring initiatives should consider effects on mentors as well as mentees.

The Effect of Semaglutide on Blood Pressure in Patients without Diabetes: A Systematic Review and Meta-Analysis

(1) Background: Recent advances in the pharmacological treatment of obesity with glucagon-like peptide-1 receptor agonists (GLP-1 RA) highlight the potential to target excess body weight to improve blood pressure (BP). This review aimed to determine the BP reduction in trials of semaglutide for weight reduction in patients without diabetes. (2) Methods: Relevant studies were identified via a search of research databases. Studies were screened to include randomized controlled trials (RCTs) of semaglutide versus a placebo in adults. Pooled and sensitivity analyses were performed, and risk of bias was assessed. (3) Results: six RCTs, with 4744 participants, were included in the final analysis. At baseline, the cohorts in these studies had a mean BP in the normotensive range. The mean difference in systolic BP was -4.83 mmHg (95% CI: -5.65 to -4.02), while that for diastolic BP was -2.45 mmHg (95% CI: -3.65 to -1.24). All included studies were of a high methodological quality. (4) Conclusions: A clinically significant reduction in BP was evident following semaglutide treatment in normotensive populations without diabetes. The effect of semaglutide in those with obesity and hypertension is as yet undetermined. Targeting excess body weight may be a novel therapeutic strategy for these patients.

Supratherapeutic dabigatran: a cause of life-threatening haemorrhage

In this case report, we present a rare case of life-threatening gastrointestinal haemorrhage associated with deranged coagulation due to supratherapeutic levels of dabigatran. Dabigatran is a potent, synthetic, reversible non-peptide thrombin inhibitor which is increasingly used for stroke prevention in patients with non-valvular atrial fibrillation. It is generally accepted that dabigatran dosing does not require titration or the monitoring of plasma levels due to its predictable pharmacokinetics and pharmacodynamics. However, this case report challenges this viewpoint while identifying an important knowledge gap in relation to the effect of altered gastrointestinal motility on the absorption of direct oral anticoagulants. Furthermore, it demonstrates the successful use of high-dose idarucizumab in a critical care setting. Idarucizumab is a monoclonal antibody fragment that binds specifically to dabigatran and its metabolites, thereby reversing the anticoagulant effect.

An exploration of the professional identity of clinical academics using repertory grid technique

BACKGROUND

Clinicians who divide their time between clinical work and research have contributed to some of the most fundamental breakthroughs in medicine in recent history, yet their role is not always well-understood or valued. Understanding the factors which contribute to career success for clinical academics is critical for supporting this workforce. Social Cognitive Career Theory (SCCT) provides a conceptual framework for career success, incorporating personal and environmental factors.

PURPOSE

The aim of this study is to explore clinical academics' construal of successful clinical academic practice and to contribute to a holistic view of the professional identity of the clinical academic.

METHODOLOGY

Using a constructivist technique, repertory grid, the authors interviewed ten clinical academics at different career stages in one-to-one structured interviews conducted virtually between November 2020 and April 2021. Data from the interviews were analysed qualitatively and quantitatively. Common themes were identified, analysed, and ranked according to importance with respect to successful clinical academic practice. Using SCCT as a framework, constructs were categorised as personal factors, organisational factors, competencies and person-environment fit. A differential analysis between established/trainee and female/male participants was carried out.

SUMMARY OF RESULTS

One hundred and thirty-three constructs were elicited and categorised into 20 themes (constructs). There was consensus among participants that 6 were of high importance with respect to successful clinical academic practice, 8 of intermediate and 4 of low importance, with no consensus on 2 constructs. Personal factors of high importance include innovation and integrity. Competencies including research and teaching skills are highly important, and ability to collaborate is also considered central to successful clinical academic practice. Female participants expressed greater concerns about the impact of familial responsibilities on career progression.

DISCUSSION AND CONCLUSIONS

This study highlights the importance of interactions between the person and environment, and characterises the important attributes of successful clinical academics including personal factors such as integrity and innovation.

Reproductive Outcomes Following Recurrent First Trimester Miscarriage: A Retrospective Cohort Study

STUDY QUESTION

What are the subsequent reproductive outcomes (livebirths, miscarriages or other adverse pregnancy outcomes or no further pregnancy) of women with recurrent miscarriage (RM) attending a dedicated clinic?

SUMMARY ANSWER

Of women with RM, 77% had a subsequent pregnancy, and among these pregnancies, the livebirth rate was 63%.

WHAT IS KNOWN ALREADY

RM affects ∼1–3% of women of reproductive age. RM has known associations with advanced maternal age, obesity, diabetes, inherited thrombophilias, thyroid dysfunction, endometriosis and parental balanced translocations. However, ∼ 50% of women or couples will be left without an explanation for their pregnancy loss, even after completing investigations. RM is also associated with secondary infertility and adverse pregnancy outcomes including preterm birth and perinatal death.

STUDY DESIGN, SIZE, DURATION

We undertook a retrospective cohort study to identify subsequent pregnancy outcomes in women with RM, defined as three consecutive first-trimester miscarriages. Women attending the RM clinic at a tertiary university hospital in the Republic of Ireland over 12 years (2008–2020) with a confirmed diagnosis of primary or secondary first-trimester RM were eligible for inclusion. In total, 923 charts were identified for review against the eligibility criteria.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with non-consecutive first-trimester miscarriages or ectopic pregnancy were excluded. Epidemiological and clinical information regarding medical history, investigation and management was gathered from paper and electronic medical records. Data were analysed using SPSS (Version 27). Associations between maternal characteristics and outcomes were explored using the χ² test, with significance set at P < 0.05. Multinomial regression analysis was performed using a stepwise approach.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 748 women who were included; 332 (44%) had primary RM and 416 (56%) had secondary RM. The median age was 36 years (range 19–47). Foetal aneuploidy was the most common investigative finding (15%; n = 111/748); 60% had unexplained RM. In addition to supportive care, most women were prescribed aspirin (96%) and folic acid (75%). Of the 748 women, 573 had a subsequent pregnancy (77%) and 359 (48% of all women; 63% of pregnancies) had a livebirth, while 208 had a further pregnancy loss (28% of all women; 36% of pregnancies) and 6 were still pregnant at the end of the study. Women aged 35–39 years were more likely to have a livebirth than no further pregnancy (relative risk ratio (RRR): 2.29 (95% CI: 1.51–5.30)). Women aged 30–34 years were more likely to have a livebirth (RRR: 3.74 (95% CI: 1.80–7.79)) or a miscarriage (RRR: 2.32 (95% CI: 1.07–4.96)) than no further pregnancy. Smokers were less likely to have a livebirth (RRR: 0.37 (95% CI: 0.20–0.69)) or a miscarriage (RRR: 0.45 (95% CI: 0.22–0.90)) than no further pregnancy. Couples with an abnormal parental karyotype were less likely to have a miscarriage than no further pregnancy (RRR: 0.09 (95% CI: 0.01–0.79)). Including successive pregnancies conceived over the study period, the overall livebirth rate was 63% (n = 466/742), but this was reduced to 44% in women aged ≥40 years and 54% in women with infertility.

LIMITATIONS, REASONS FOR CAUTION

This work covers 13 years; however, those included in the later years have a shorter follow-up time. Although electronic health records have improved data availability, data collection in this cohort remains hampered by the absence of a formal booking visit for women presenting with miscarriage and a national miscarriage database or register.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings are largely reassuring as most women with RM and hoping to conceive achieved a livebirth. In addition to older age, smoking and parental balanced translocations were associated with a reduced likelihood of further pregnancy. No investigation or treatment was associated with pregnancy outcome, reiterating the importance of the supportive aspects of care for women and their partners after RM and counselling regarding individual risk factors. This contributes to the limited international data on the investigative findings and treatment of women with RM. The high rate of prescribed medications merits greater scrutiny, in conjunction with other pregnancy outcomes, and reiterates the need for a national guideline on RM.

STUDY FUNDING/COMPETING INTEREST(S)

L.A.L. is a PhD scholar funded through the Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork. M.H. and C.F. are Postdoctoral Researchers on a project funded by the Health Research Board Ireland [ILP-HSR-2019-011] and led by K.O.D., titled: ‘Study of the impact of dedicated recurrent miscarriage clinics in the Republic of Ireland’. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors have no conflicts of interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Training assessment of clinical knowledge and skills in the use of negative pressure wound dressings in cardiac patients

Funding Acknowledgements

Type of funding sources: None.

Objective

An assessment was conducted to analyse the level of improvement impact one can have on clinical knowledge and skills in the use of a novel negative pressure wound dressings in high-risk cardiac patients along with their years of experience following a training program conducted among our cardiac staff.

Methods

In a prospective study involving twenty cardiac nursing staff from December 2020 to June 2021 who voluntarily participated in the study. Their pre and post training assessment of clinical knowledge and skills were assessed using twenty questionnaires. The pre and post training educational knowledge and skills scores were analysed along with their years of clinical experience.

Results

In the six-month period n=20 (100 %) were compliant to the training despite the covid-19 pandemic.

The study group showed an average pre-training score of 10.5% (Knowledge 5.25% and Skills 5.25%)

The average post-training score of84.75% (Knowledge 42.25% and Skills 42.25%)

While comparing the years of clinical experience against the pre and post training scoresSeventeen (n=17/20, 85%) had five to ten years experience compared to three (n-3/20, 15%) with more than 20 years of experience.

Conclusion

Both clinical knowledge and skills can be augmented through regular training members with more than ten years of clinical experience might have an added benefit and their experience could be important to train younger staff members with less clinical experience.

P-427 Pregnancy outcomes following recurrent first-trimester miscarriage: a retrospective cohort study

Study question

What are the subsequent pregnancy outcomes (livebirths, miscarriages or other adverse pregnancy outcomes) in a cohort of women with recurrent miscarriage (RM)?

Summary answer

The overall live birth rate in women with RM was 62% (466/748), falling to 44% in women aged &gt;40 and 54% in women with infertility.

What is known already

RM affects approximately 1% of women of reproductive age. RM is recognized as a prognostic indicator for subsequent pregnancies and adverse pregnancy outcomes including ante-partum hemorrhage, diabetes, preterm birth, small for gestational age and perinatal death. While RM has known associations with advanced maternal age, obesity, diabetes, thyroid dysfunction and endometriosis, approximately 50% of women/couples will be left without an explanation for their pregnancy loss, even after completing investigations.

Study design, size, duration

A retrospective cohort study was undertaken to identify subsequent pregnancy outcomes in women with RM, where RM referral criteria are 3 consecutive first-trimester miscarriages. Women attending the pregnancy loss clinic at a tertiary university hospital in the Republic of Ireland over a 12-year period (2008 - 2020) with a confirmed diagnosis of primary or secondary first-trimester RM were eligible for inclusion. In total, 923 charts were identified for review against the eligibility criteria.

Participants/materials, setting, methods

Women with non-consecutive first trimester miscarriages or ectopic pregnancy were excluded. Epidemiological and clinical information was gathered from paper and electronic medical records. Data were analysed descriptively using SPSS (Version 27).

Main results and the role of chance

Of 748 women identified, 332(44%) had primary RM, 416(56%) had secondary RM. The median age was 36(range 19-47) years with 12% aged under 29 and 64% of women aged ≥35. 142(19%) had a history of infertility with 43(5.7%) attending for ART.

12% of women had anti-nuclear antibodies(89/742), 8% had abnormal thyroid function tests(60/742), 4.7% were heterozygous carriers of the Factor V Leiden gene mutation(35/737), 1.5% had positive anti-cardiolipin antibodies(11/733), 2% were carriers of a Prothrombin gene mutation(7/343) and 1% had elevated HbA1c levels(7/742).

Fetal karyotype was recorded in 141 pregnancies, with 111 abnormal results(78%;111/141). Trisomy(T) 16 was most common(17/111; 15%) followed by T21 and T22(n = 14; 13%). Parental karyotyping of 697 sets of parents identified 28 balanced translocations(4%; 28/697).

Prescribed pharmacological treatments included high dose folic acid(75%; n = 548/728), aspirin(96%; 696/726), progesterone (52%; 389/728), tinzaparin(24%; 175/727), prednisolone(4%; 28/726), metformin(2%; 12/727) and hydroxychloroquine(1%; 7/727).

573 women had a subsequent pregnancy (76.6%); 359(62%; 359/573) had a live birth, 190 had a miscarriage(33%) and 18(3%) had an adverse pregnancy outcome such as ectopic pregnancy, stillbirth or second-trimester miscarriage.

Including successive pregnancies over the study period, the overall live birth rate was 62%(466/748), falling to 44% in women aged &gt;40 and 54% in women with infertility.

Limitations, reasons for caution

This work covers a 12-year period, and while the RM clinic staffing is largely unchanged, some changes in management of RM patients has occurred in this time, reflecting up-to-date evidence and greater public awareness. Furthermore, the adoption of an electronic health chart in 2017 may have affected data availability.

Wider implications of the findings

Our findings confirm RM occurs more frequently in women aged &gt;35. Aneuploidy remains a leading cause of miscarriage. Age is a prognostic indicator for livebirth after RM. These findings will facilitate counselling in this cohort. The substantial rates of prescribed medications and infertility in women with RM merit further exploration.

Trial registration number

N/A

P-393 The care experiences of women and men who have received recurrent miscarriage care in Ireland: a national survey

Study question

What are the care experiences of women and men who have received recurrent miscarriage (RM) care in the Republic of Ireland?

Summary answer

Of the participants, 24% rated a poor experience of RM care (n = 32), while 36% said the care they received was much worse than expected (n = 48).

What is known already

International guidelines suggest that couples who experience RM should be referred for specialist investigations, support and, if possible, treatment. Providing individualised care, respect for women’s opinions, and appropriate clinical information is imperative to those experiencing RM. However, currently, there is no national standard for the management, investigation, or follow-up of those who experience RM in Ireland. Research on patient-centred early pregnancy care concluded that it is essential for healthcare professionals (HCPs) to realise that women undergoing miscarriage experience a significant life event and recommended that future studies explore potential targets for improving RM care and patients’ perspectives.

Study design, size, duration

A cross-sectional study of women and men who have experienced RM was conducted. An anonymous web-based national survey was used to examine the experience of those who have interacted with the maternity services following RM. The survey was distributed online using Qualtrics between September – November 2021. The survey was shared through emails, websites, newsletters, and social media accounts as well as the Pregnancy Loss Research Group and the Miscarriage Association of Ireland among others.

Participants/materials, setting, methods

Women and men over 18 who have experienced two≥ first trimester miscarriages in the last ten years and who have received care for RM in the Republic of Ireland were invited to participate in the survey. The survey was purposefully designed using relevant literature, including questions on key areas such as sociodemographic information, pregnancy and pregnancy loss history, investigation and treatment for RM. Descriptive statistics and subgroup analysis are ongoing using Stata.

Main results and the role of chance

In total, 213 participants completed the survey (some did not experience a consecutive RM or receive care between 2011-2021 (n = 65)). Therefore, 147 participants were eligible (97% female, n = 135). Of the female participants, 79% were aged 35-44 years (n = 106), 95% were white Irish (n = 128) and 84% were married (n = 114). Women were educated, with 38% having postgraduate degrees (n = 53) or a university degree (27%, n = 36). 57% had experienced two consecutive RM (n = 77) and 25% three consecutive RM (n = 34). Of the 135 women, 53% had investigations for RM (n = 71), with 45% having investigations after two RM (n = 32) or 27% after three RM (26). When asked if their HCP did everything to investigate their RM, 49% said no. Of those who had investigations (n = 71), 83% always had confidence and trust in their HCP (n = 59), and 42% felt treated with dignity and respect (n = 30). However, 44% did not have a HCP to talk to about their worries and fears (n = 31). 24% of women rated a poor experience when receiving RM care (n = 32), 36% said the care they received was much worse than expected (n = 48), with 60% of women saying that HCPs in different places did not work well together during their RM care (n = 81).

Limitations, reasons for caution

Despite an open call to recruit women and men, only four men participated. Therefore, further research needs to include strategies to recruit men to provide a complete picture of RM care experiences. There is also the potential for recall bias as some women received care several years ago.

Wider implications of the findings

This study demonstrates that the overall experience for RM care is poor, providing areas for improvements such as communication and better care coordination between HCPs across hospitals/units. These results provide a better understanding of the drivers shaping care experiences to help inform and improve RM care in Ireland.

Trial registration number

not applicable

Dublin hospital workers' mental health during the peak of Ireland's COVID-19 pandemic

Background

Hospital-based healthcare workers have experienced significant psychological stressors during the COVID-19 pandemic.

Aim

To evaluate the mental health of hospital workers during the third wave of the COVID-19 pandemic in Dublin, Ireland.

Methods

Cross-sectional anonymous online survey of hospital workers (n = 377; 181 doctors (48.0%), 166 nurses (44.0%), 30 radiographers (8.0%)), collecting demographic information, COVID-19 exposure history and mental health measures.

Results

There were significant differences between profession groups in gender, experience, COVID-19 infection history, exposure to COVID-19 positive acquaintances, and work areas. Moderate-severe post-traumatic stress disorder (PTSD) symptoms were found in 45.1% (95% CI 40.1–50.1%) of all participants; significantly fewer doctors reported moderate-severe PTSD symptoms (26%; 95% CI 22–36%). A World Health Organisation-5 Wellbeing Index (WHO-5) score ≤ 32, indicating low mood, was reported by 52% (95% CI 47–57%) of participants; significantly fewer doctors reported low mood (46%; 95% CI 39–53%). One-week suicidal ideation and planning were reported respectively by 13% (95% CI 10–16%) and 5% (95% CI 3–7%) of participants with no between-group differences. Doctors reported significantly less moral injury than other groups. There were no significant between-group differences regarding coping styles. Work ability was insufficient in 39% (95% CI 34–44%) of staff; no between-group differences.

Conclusions

Dublin hospital workers reported high levels of PTSD symptoms, mood disturbance, and moral injury during the COVID-19 pandemic. Concerning levels of suicidal ideation and planning existed in this cohort. Differences in degrees of post-traumatic stress, moral injury, and wellbeing were found between profession groups, which should be considered when planning any supports.

Supplementary information

The online version contains supplementary material available at 10.1007/s11845-022-03056-0.

Exercise and chronic health conditions in the community: A qualitative Study of Patients and Fitness instructors

Further information is needed on how community exercise facilities can be effectively utilised to engage people living with chronic health conditions in exercise. The aim of this study was to identify the exercise barriers, facilitators and needs of patients with chronic disease in the community; and to provide recommendations to support the transition from hospital-based to community-based exercise. Using a qualitative approach, four focus groups were conducted with patients who had completed hospital-based exercise programmes (n = 11) and fitness instructors (n = 10). Data were audio recorded, member checked and transcribed verbatim for thematic analysis using NVivo. The side effects of chronic health conditions, the gym environment and a need for support when joining/attending a gym were perceived as barriers to exercising in the community. In contrast, the presence of supportive staff was perceived by patients as a facilitator to engaging in exercise in the community. A total of three themes emerged from participants views on exercise needs in the community; the referral and induction process in community gyms, fitness instructor training and experience and creating a supportive exercise environment. Themes informed eight key recommendations to support patients to exercise in the community, including supportive gym referral and induction processes for patients with chronic conditions, increased professional training for fitness instructors in the area of chronic disease management and exercise prescription, and exercise support at regular intervals for those with chronic conditions attending community gyms. This study found that there is potential for community gyms to play a key role in promoting health among people with chronic conditions. However, more can be done to foster an inclusive atmosphere in this space. Patients living with chronic conditions need information and advice on exercising in their communities. Community gyms require further support to ensure that facilities meet the exercise needs of people with chronic conditions.

Study protocol for the St James's Hospital, Tallaght University Hospital, Trinity College Dublin Allied Researchers' (STTAR) Bioresource for COVID-19

Background: The current coronavirus disease 2019 (COVID-19) pandemic began in Ireland with the first confirmed positive case in March 2020. In the early stages of the pandemic clinicians and researchers in two affiliated Dublin hospitals identified the need for a COVID-19 biobanking initiative to support and enhance research into the disease. Through large scale analysis of clinical, regional, and genetic characteristics of COVID-19 patients, biobanks have helped identify, and so protect, at risk patient groups The STTAR Bioresource has been created to collect and store data and linked biological samples from patients with SARS-CoV-2 infection and healthy and disease controls. Aim: The primary objective of this study is to build a biobank, to understand the clinical characteristics and natural history of COVID-19 infection with the long-term goal of research into improved disease understanding, diagnostic tests and treatments. Methods: This is a prospective dual-site cohort study across two tertiary acute university teaching hospitals. Patients are recruited from inpatient wards or outpatient clinics. Patients with confirmed COVID-19 infection as well as healthy and specific disease control groups are recruited.  Biological samples are collected and a case report form detailing demographic and medical background is entered into the bespoke secure online Dendrite database. Impact: The results of this study will be used to inform national and international strategy on health service provision and disease management related to COVID-19. In common with other biobanks, study end points  evolve over time as new research questions emerge. They currently include patient survival, occurrence of severe complications of the disease or its therapy, occurrence of persistent symptoms following recovery from the acute illness and vaccine responses.

Supervision and Care Quality as Perceived by Redeployed Attendings, Fellows, and Residents During a COVID-19 Surge: Lessons for the Future

PURPOSE

To better prepare for potential future large-scale redeployments, this study examines quality of supervision and care as perceived by redeployed residents, fellows, and attendings during a COVID-19 surge.

METHOD

During April and May 2020, attendings, fellows, and residents redeployed at 2 teaching hospitals were invited to participate in a survey, which included questions on respondents' prior experience; redeployed role; amount of supervision needed and received; and perceptions of quality of supervision, patient care, and interprofessional collaboration. Frequencies, means, and P values were calculated to compare perceptions by experience and trainee status. Narrative responses to 2 open-ended questions were independently coded; themes were constructed.

RESULTS

Overall, 152 of 297 (51.2%) individuals responded, including 64 of 142 attendings (45.1%), 40 of 79 fellows (50.6%), and 48 of 76 residents (63.2%). Fellows and attendings, regardless of prior experience, perceived supervision as adequate. In contrast, experienced residents reported receiving more supervision than needed, while inexperienced residents reported receiving less supervision than needed and rated overall supervision as poor. Attendings, fellows, and experienced residents rated the overall quality of care as acceptable to good, whereas inexperienced residents perceived overall quality of care as worse to much worse, particularly when compared with baseline.

CONCLUSIONS

Narrative themes indicated that the quality of supervision and care was buffered by strong camaraderie, a culture of informal consultation, team composition (mixing experienced with inexperienced), and clinical decision aids. The markedly negative view of inexperienced residents suggests a higher risk for disillusionment, perhaps even moral injury, during future redeployments. Implications for planning are explored.

A randomized, double-blind, placebo-controlled trial of intravenous alpha-1 antitrypsin for acute respiratory distress syndrome secondary to COVID-19

Background

Patients with severe coronavirus disease 2019 (COVID-19) develop a febrile pro-inflammatory cytokinemia with accelerated progression to acute respiratory distress syndrome (ARDS). Here we report the results of a phase 2, multicenter, randomized, double-blind, placebo-controlled trial of intravenous (IV) plasma-purified alpha-1 antitrypsin (AAT) for moderate to severe ARDS secondary to COVID-19 (EudraCT 2020-001391-15).

Methods

Patients (n = 36) were randomized to receive weekly placebo, weekly AAT (Prolastin, Grifols, S.A.; 120 mg/kg), or AAT once followed by weekly placebo. The primary endpoint was the change in plasma interleukin (IL)-6 concentration at 1 week. In addition to assessing safety and tolerability, changes in plasma levels of IL-1β, IL-8, IL-10, and soluble tumor necrosis factor receptor 1 (sTNFR1) and clinical outcomes were assessed as secondary endpoints.

Findings

Treatment with IV AAT resulted in decreased inflammation and was safe and well tolerated. The study met its primary endpoint, with decreased circulating IL-6 concentrations at 1 week in the treatment group. This was in contrast to the placebo group, where IL-6 was increased. Similarly, plasma sTNFR1 was substantially decreased in the treatment group while remaining unchanged in patients receiving placebo. IV AAT did not definitively reduce levels of IL-1β, IL-8, and IL-10. No difference in mortality or ventilator-free days was observed between groups, although a trend toward decreased time on ventilator was observed in AAT-treated patients.

Conclusions

In patients with COVID-19 and moderate to severe ARDS, treatment with IV AAT was safe, feasible, and biochemically efficacious. The data support progression to a phase 3 trial and prompt further investigation of AAT as an anti-inflammatory therapeutic.

Funding

ECSA-2020-009; Elaine Galwey Research Bursary.

253 Innovative Teaching Early in Medical Career to Expose Medical Students to Surgery

Aim

At Lancashire Teaching Hospitals medical students begin their clinical career in Year 3 and are posted in General Surgery for 4 weeks, a relatively short period to experience the wide variety of surgical specialities and operative techniques. A surgical skills course - Lancashire Teaching Hospitals Surgical Skills for Medical Students (LTHSSMS) was designed and piloted. The aim was to assess the student experience of the LTHSSMS course conducted for Year 3 students at Lancashire Teaching Hospitals in 2019.

Method

This all-day course was optional, taught in groups of 15 students per course with a minimum of 2 experienced tutors. The LTHSSMS course included practical skills such as scrubbing, gloving, surgical knotting, suturing, excision of skin lesions and local anaesthetic techniques. It also included lectures on suture materials, abdominal incisions, laparoscopic and robotic surgery. There were interactive discussions to include non-technical skills, theatre in brief and WHO checklist.

Results

95% (n- 86) of students posted in surgery attended the course. 86.3% (n-75) felt the course was very relevant for their training. 90.7% (n-78) stated they enjoyed the course and 98.8% (n-85) stated they would recommend the course to fellow third-year students. 97.7% (n-84) stated the tutors delivered the course in an enthusiastic and positive manner. 79.1% (n-68) rated the audio video as excellent.

Conclusions

This course has provided a high impact surgical experience for the medical students at the beginning of their clinical careers. Similar opportunities if made available to students in all medical schools could improve and renew the interest in a surgical career.

Evaluation of an early career clinical academic training programme using the CIPP model

OBJECTIVES

This study describes the successful implementation and outputs of a combined clinical academic training programme for doctors in their first postgraduate year in Ireland, the Academic Internship Track (AIT).

DESIGN

The AIT was evaluated using the Context, Input, Process and Product model. Literature reviews, meetings with key stakeholders, reviews of similar established programmes overseas, a survey of undergraduate medical students, exit survey, scientific outputs and career trajectory monitoring were all implemented in the programme evaluation.

SETTING

The AIT represents collaboration amongst all six intern training networks in Ireland.

RESULTS

Key stakeholders indicated support and significant interest in establishing the AIT. The input evaluation informed programme design which incorporates protected time to carry out a research project, a named supervisor, a bursary and access to dedicated study days. Since the programme's launch in 2017, there has been 100% uptake of posts and 0% attrition. Exiting participants indicate high levels of satisfaction with the programme; 92% reported having benefited from participation. Over 90% intend remaining in Ireland in both the immediate and longer terms. Fifty-seven per cent of participants in the first 3 years of the programme had succeeded in publishing a research article or review paper in a peer-reviewed journal.

CONCLUSIONS

Now in its fourth year, AIT remains a highly sought-after programme and is perceived to be beneficial to one's career. Participants in the programme have contributed significantly to their field of interest despite being in the earliest career stages. The programme has the potential to help retain medical talent in Ireland.

Nursing home staff mental health during the Covid-19 pandemic in the Republic of Ireland

BACKGROUND

Nursing homes for older adults have been disproportionately affected by the Covid-19 pandemic with increased mortality of residents and staff distress.

OBJECTIVE

To quantify the mental health of nursing home staff during the Covid-19 pandemic in the Republic of Ireland.

DESIGN/METHODS

Cross-sectional anonymous study of Republic of Ireland nursing home staff (n = 390) during the third wave of the Covid-19 pandemic. Online survey collecting demographic information, Covid-19 exposure history and mental health measures.

RESULTS

There were significant differences between nurses, healthcare assistants (HCA) and non-clinical staff history in age, ethnicity, years' experience, history of Covid-19 infection and contact with Covid-19 positive acquaintances. Moderate-severe post-traumatic stress disorder symptoms were found in 45.1% (95% confidence interval [CI] 40.2%-50.1%) of all staff. A World Health Organisation-5 (WHO-5) wellbeing index score ≤32, indicating low mood, was reported by 38.7% (95% CI, 33.9%-43.5%) of staff; significantly more nurses reported low mood. Suicidal ideation and suicide planning were reported, respectively, by 13.8% (95% CI, 10.4%-17.3%) and 9.2% (95% CI, 6.4%-12.1%) of participants with no between-group differences. HCAs reported a significantly higher degree of moral injury than non-clinical staff. Nurses were more likely to use approach coping styles than non-clinical staff. Work ability was insufficient in 24.6% (95% CI 20.3%-28.9%) of staff.

CONCLUSION

Nursing home staff report high levels of post-traumatic stress, mood disturbance and moral injury during the Covid-19 pandemic. Differences in degree of moral injury, wellbeing and coping styles were found between staff groups, which need to be incorporated into planning supports for this neglected workforce.

Comparing noninvasive sampling techniques with standard cannula sampling method for ruminal microbial analysis

•

Ruminal cannula is the gold standard for sampling rumen contents but is limited to few animals.

•

Noninvasive methods are needed as proxy for cannula to enable sampling larger numbers of cows.

•

Saliva, rumination bolus, tube-derived rumen samples, and feces were compared with cannula samples.

•

Microbial community in the solid fraction of tube samples mirrored that of cannula samples.

•

Rumination bolus may serve as a proxy for cannula samples under certain conditions.

Rumen microbes play an important role in the conversion of indigestible plant material to energy and protein in dairy cows. Sampling for ruminal contents via cannula is considered the gold standard technique for microbial analysis, but the technique requires ruminally cannulated animals and specialized animal facilities. The purpose of this study was to determine whether other sampling methods and locations along the digestive tract may serve as noninvasive proxies to the cannula method for microbial analysis. Six ruminally cannulated lactating Holstein dairy cows were adapted to a standard total mixed ration for 2 wk and sampled during the third week. Sampling locations and methods included salivary content, rumination bolus (regurgitated digesta collected from the cow's mouth), feces, and rumen contents via stomach tube and cannula. Stomach tube and cannula samples differ in proportions of solid and liquid material and were therefore separated into whole (as collected), liquid, and solid fractions. Samples were collected at 0 (before feeding), 2, 4, 6, 8, and 12 h after feeding over 2 d. All samples were extracted for total genomic DNA and selected samples for metabolically active DNA (RNA), PCR-amplified for the V1-V2 region of the 16S rRNA bacterial gene, and analyzed for bacterial diversity using the QIIME2 pipeline followed by statistical analysis in R (https://www.R-project.org/). In DNA-based analysis, at the community level, saliva, rumination bolus, and fecal samples clustered in separate groups, whereas all fractions of stomach tube and cannula samples clustered together, indicating that microbial communities of stomach tube and cannula samples were homogeneous. Rumination bolus samples at 6, 8, and 12 h after feeding clustered with stomach tube and cannula samples, indicating that rumination bolus samples may be an alternative for cannula samples; however, time of sampling is critical for sampling of bolus digesta. Results of the RNA-based analysis of rumination bolus samples and solid samples from cannula and stomach tube at 0 and 6 h after feeding were similar. We concluded that the solid fraction of samples obtained via the stomach tube method may serve as a proxy for the solid fraction of whole ruminal contents obtained via cannula for DNA-based microbial investigations. Both rumination bolus and stomach tube solid samples may serve as proxies for cannula solid samples for RNA-based microbial analysis.

Collaboration, supervision and patient safety in the era of COVID-19: an analysis of medical wards and ICU

AIMS

COVID-19 resulted in significant changes across medical wards and ICU in St James's Hospital Dublin. This included the implementation of ward-based medical teams (WBMT). The purpose of this study was to identify how these structural changes affected inter-professional collaboration, supervision and patient safety.

METHODS

Questionnaires were distributed to doctors working on medical wards and ICU at the height of the first wave of COVID-19. The sense of collaboration, patient safety and supervision were assessed.

RESULTS

Fifty-three doctors took part in the study. Thirty-three (62%) felt that collaboration was better than normal. Forty-six (87%) of participants described supervision as "good" or "excellent". Thirty-one out of 40 participants (77%) felt that patient safety was better than normal.

DISCUSSION

Implementation of WBMT may result in improved sense of collaboration, supervision and patient safety during COVID-19; however, the increased sense of solidarity and comradery felt during the initial surge make drawing these conclusions challenging.

Assessment of an electronic patient record system on discharge prescribing errors in a Tertiary University Hospital

Background

Prescribing error represent a significant source of preventable harm to patients. Prescribing errors at discharge, including omission of pre-admission medications (PAM), are particularly harmful as they frequently propagate following discharge. This study assesses the impact of an educational intervention and introduction of an electronic patient record (EPR) in the same centre on omission of PAM at discharge using a pragmatic design. A survey of newly qualified doctors is used to contextualise findings.

Methods

Discharge prescriptions and discharge summaries were reviewed at discharge, and compared to admission medicine lists, using a paper-based chart system. Discrepancies were noted, using Health Information and Quality Authority guidelines for discharge prescribing. An educational intervention was conducted. Further review of discharge prescriptions and discharge summaries took place. Following introduction of an EPR, review of discharge summaries and discharge prescriptions was repeated. A survey was administered to recently qualified doctors (interns), and analysed using descriptive statistics and thematic analysis.

Results

Omission of PAM as prescribed or discontinued items at discharge occurs frequently. An educational intervention did not significantly change prescribing error rates (U = 1255.5, p = 0.206). EPR introduction did significantly reduce omission of PAM on discharge prescribing (U = 694, p < 0.001), however there was also a reduction in the rate of deliberate discontinuation of PAM at discharge (U = 1237.5, p = 0.007). Survey results demonstrated that multiple sources are required to develop a discharge prescription. Time pressure, access to documentation and lack of admission medicine reconciliation are frequently cited causes of discharge prescribing error.

Conclusion

This study verified passive educational interventions alone do not improve discharge prescribing. Introduction of EPR improved discharge prescribing, but negatively impacted deliberate discontinuation of PAM at discharge. This is attributable to reduced access to key sources of information used in formulating discharge prescriptions, and separation of the discontinuation function from the prescribing function on the EPR discharge application.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01551-5.

Local NO2 concentrations and asthma among over-50s in Ireland: A microdata analysis

BACKGROUND

Links between air pollution and asthma are less well established for older adults than some younger groups. Nitrogen dioxide (NO2) concentrations are widely used as an indicator of transport-related air pollution, and some literature suggests NO2 may directly affect asthma.

METHODS

This study used data on 8162 adults >50 years old in the Republic of Ireland to model associations between estimated annual outdoor concentration of NO2 and the probability of having asthma. Individual-level geo-coded survey data from The Irish Longitudinal Study on Ageing (TILDA) were linked to model-based estimates of annual average NO2 at 50 m resolution. Asthma was identified using two methods: self-reported diagnoses and respondents' use of medications related to obstructive airway diseases. Logistic regressions were used to model the relationships.

RESULTS

NO2 concentrations were positively associated with the probability of asthma [marginal effect (ME) per 1 ppb of airborne NO2 = 0.24 percentage points asthma self-report, 95% confidence interval (CI) 0.06-0.42, mean asthma prevalence 0.09; for use of relevant medications ME = 0.21 percentage points, 95% CI 0.049-0.37, mean prevalence 0.069]. Results were robust to varying model specification and time period. Respondents in the top fifth percentile of NO2 exposure had a larger effect size but also greater standard error (ME = 2.4 percentage points asthma self-report, 95% CI -0. 49 to 5.3).

CONCLUSIONS

Associations between local air pollution and asthma among older adults were found at relatively low concentrations. To illustrate this, the marginal effect of an increase in annual average NO2 concentration from sample minimum to median (2.5 ppb) represented about 7-8% of the sample average prevalence of asthma.

Feasibility assessment of an 8-week attention-based training programme in the management of chronic spontaneous urticaria

BACKGROUND

Chronic spontaneous urticaria is a common disorder that is poorly understood and frequently misdiagnosed. Psychological difficulties are a significant factor in dermatological diseases and may also aggravate symptom burden. Mind-body interventions are used as a complementary approach to alleviate symptoms in chronic diseases and may represent a valuable non-pharmacological approach in CSU.

METHODS

We sought to develop and evaluate the feasibility of an 8-week attention-based training (ABT) programme, coupled to biofeedback technology for CSU. Through convergent interviews, we gathered information from individuals with urticaria about possible links between stress, mood and skin symptoms. Using these data, we recruited 12 participants to engage in an amended ABT programme for patients with CSU, comprising eight 90-min sessions held weekly. Participants completed psychometric measures and measures of urticaria symptomatology as assessed by the urticaria control test, prior to and after the intervention. Adherence to ABT practice was measured using individual inner balance devices which tracked heart rate variability. We completed qualitative interviews after the intervention to obtain feedback on participant experience of the programme.

RESULTS

Participants with CSU described how their psychological wellbeing can be linked to skin symptoms, poor sleep and difficulty concentrating. An amended ABT programme was found to be an acceptable component of care in the management of CSU. Retention of participants in the programme was challenging with 33% participants dropping out of the programme. For those who did complete the programme, three participants exceeded weekly practice at week 8. A decrease in severity of urticaria symptomatology as measured by the urticaria control test was observed upon completion of the intervention. The most commonly cited barrier to implementation of the programme was the time commitment required.

CONCLUSIONS

Integrating an ABT programme into routine clinical care for CSU patients is feasible and was deemed acceptable and valuable by individuals who took part. Further formal evaluation of ABT for CSU including the analysis of biochemical parameters is required to determine its role in the management of this distressing condition.

TRIAL REGISTRATION

This trial is registered with ISRCTN with study ID ISRCTN13672947 . Registration took place on 22/09/2020 (retrospectively registered).

A randomised, double-blind, placebo-controlled, pilot trial of intravenous plasma purified alpha-1 antitrypsin for SARS-CoV-2-induced Acute Respiratory Distress Syndrome: a structured summary of a study protocol for a randomised, controlled trial

OBJECTIVES

The primary objective is to demonstrate that, in patients with PCR-confirmed SARS-CoV-2 resulting in Acute Respiratory Distress Syndrome (ARDS), administration of 120mg/kg of body weight of intravenous Prolastin®(plasma-purified alpha-1 antitrypsin) reduces circulating plasma levels of interleukin-6 (IL-6). Secondary objectives are to determine the effects of intravenous Prolastin® on important clinical outcomes including the incidence of adverse events (AEs) and serious adverse events (SAEs).

TRIAL DESIGN

Phase 2, randomised, double-blind, placebo-controlled, pilot trial.

PARTICIPANTS

The study will be conducted in Intensive Care Units in hospitals across Ireland. Patients with a laboratory-confirmed diagnosis of SARS-CoV-2-infection, moderate to severe ARDS (meeting Berlin criteria for a diagnosis of ARDS with a PaO₂/FiO₂ ratio <200 mmHg), >18 years of age and requiring invasive or non-invasive mechanical ventilation. All individuals meeting any of the following exclusion criteria at baseline or during screening will be excluded from study participation: more than 96 hours has elapsed from onset of ARDS; age < 18 years; known to be pregnant or breastfeeding; participation in a clinical trial of an investigational medicinal product (other than antibiotics or antivirals) within 30 days; major trauma in the prior 5 days; presence of any active malignancy (other than nonmelanoma skin cancer) which required treatment within the last year; WHO Class III or IV pulmonary hypertension; pulmonary embolism prior to hospital admission within past 3 months; currently receiving extracorporeal life support (ECLS); chronic kidney disease receiving dialysis; severe chronic liver disease with Child-Pugh score > 12; DNAR (Do Not Attempt Resuscitation) order in place; treatment withdrawal imminent within 24 hours; Prisoners; non-English speaking patients or those who do not adequately understand verbal or written information unless an interpreter is available; IgA deficiency.

INTERVENTION AND COMPARATOR

Intervention: Either a once weekly intravenous infusion of Prolastin® at 120mg/kg of body weight for 4 weeks or a single dose of Prolastin® at 120mg/kg of body weight intravenously followed by once weekly intravenous infusion of an equal volume of 0.9% sodium chloride for a further 3 weeks. Comparator (placebo): An equal volume of 0.9% sodium chloride intravenously once per week for four weeks.

MAIN OUTCOMES

The primary effectiveness outcome measure is the change in plasma concentration of IL-6 at 7 days as measured by ELISA. Secondary outcomes include: safety and tolerability of Prolastin® in the respective groups (as defined by the number of SAEs and AEs); PaO₂/FiO₂ ratio; respiratory compliance; sequential organ failure assessment (SOFA) score; mortality; time on ventilator in days; plasma concentration of alpha-1 antitrypsin (AAT) as measured by nephelometry; plasma concentrations of interleukin-1β (IL-1β), interleukin-8 (IL-8), interleukin-10 (IL-10), soluble TNF receptor 1 (sTNFR1, a surrogate marker for TNF-α) as measured by ELISA; development of shock; acute kidney injury; need for renal replacement therapy; clinical relapse, as defined by the need for readmission to the ICU or a marked decline in PaO₂/FiO₂ or development of shock or mortality following a period of sustained clinical improvement; secondary bacterial pneumonia as defined by the combination of radiographic findings and sputum/airway secretion microscopy and culture.

RANDOMISATION

Following informed consent/assent patients will be randomised. The randomisation lists will be prepared by the study statistician and given to the unblinded trial personnel. However, the statistician will not be exposed to how the planned treatment will be allocated to the treatment codes. Randomisation will be conducted in a 1:1:1 ratio, stratified by site and age.

BLINDING (MASKING)

The investigator, treating physician, other members of the site research team and patients will be blinded to treatment allocation. The clinical trial pharmacy personnel and research nurses will be unblinded to facilitate intervention and placebo preparation. The unblinded individuals will keep the treatment information confidential. The infusion bag will be masked at the time of preparation and will be administered via a masked infusion set to maintain blinding.

NUMBERS TO BE RANDOMISED (SAMPLE SIZE)

A total of 36 patients will be recruited and randomised in a 1:1:1 ratio to each of the trial arms.

TRIAL STATUS

In March 2020, version 1.0 of the trial protocol was submitted to the local research ethics committee (REC), Health Research Consent Declaration Committee (HRCDC) and the Health Products regulatory Authority (HPRA). REC approval was granted on April 1^st 2020, HPRA approval was granted on April 24^th 2020 and the HRCDC provided a conditional declaration on April 17^th 2020. In July 2020 a substantial amendment (version 2.0) was submitted to the REC, HRCDC and HPRA. Protocol changes in this amendment included: the addition of trial sites; extending the duration of the trial to 12 months from 3 months; removal of inclusion criteria requiring the need for vasopressors; amendment of randomisation schedule to stratify by age only and not BMI and sex; correction of grammatical error in relation to infusion duration; to allow for inclusion of subjects who may have been enrolled in a clinical trial involving either antibiotics or anti-virals in the past 30 days; to allow for inclusion of subjects who may be currently enrolled in a clinical trial involving either antibiotics or anti-virals; to remove the need for exclusion based on alpha-1 antitrypsin phenotype; removal of mandatory isoelectric focusing of plasma to confirm Pi*MM status at screening; removal of need for mandatory echocardiogram at screening; amendment on procedures around plasma analysis to reflect that this will be conducted at the central site laboratory (as trial is multi-site and no longer single site); wording amended to reflect that interim analysis of cytokine levels taken at 7 days may be conducted. HRCDC approved version 2.0 on September 14th 2020, and HPRA approved on October 22nd 2020. REC approved the substantial amendment on November 23^rd. In November 2020, version 3.0 of the trial protocol was submitted to the REC and HPRA. The rationale for this amendment was to allow for patients with moderate to severe ARDS from SARS-CoV-2 with non-invasive ventilation. HPRA approved this amendment on December 1st 2020 and the REC approved the amendment on December 8th 2020. Patient recruitment commenced in April 2020 and the last patient will be recruited to the trial in April 2021. The last visit of the last patient is anticipated to occur in April 2021. At time of writing, patient recruitment is now complete, however follow-up patient visits and data collection are ongoing.

TRIAL REGISTRATION

EudraCT 2020-001391-15 (Registered 31 Mar 2020).

FULL PROTOCOL

The full protocol (version 3.0 23.11.2020) is attached as an additional file accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).

COVID-19, when fourteen days are not enough-A case series of affected healthcare workers

We highlight the need for planning for mass workforce absentees as we prepare for subsequent surges. We suggest a multicomponent intervention including guiding return dates more by symptomatology and fitness for work rather than infectivity status.

Effects of the macroalga Asparagopsis taxiformis and oregano leaves on methane emission, rumen fermentation, and lactational performance of dairy cows

Asparagopsis taxiformis (AT) is a source of multiple halogenated compounds and, in a limited number of studies, has been shown to decrease enteric CH₄ emission in vitro and in vivo. Similarly, oregano has been suggested as a potential CH₄ mitigating agent. This study consisted of 2 in vitro and 2 in vivo experiments. Experiment (Exp.) 1 was aimed at establishing the effect of AT on CH₄ emission in vitro. Two experiments (Exp. 2 and 3) with lactating dairy cows were conducted to determine the antimethanogenic effect of AT and oregano (Exp. 3) in vivo. Another experiment (Exp. 4) was designed to investigate stability of bromoform (CHBr₃) in AT over time. In Exp. 3, 20 Holstein cows were used in a replicated 4 × 4 Latin square design with four 28-d periods. Treatments were basal diet (control) or basal diet supplemented with (dry matter basis) 0.25% AT (LowAT), 0.50% AT (HighAT), or 1.77% oregano (Origanum vulgare L.) leaves. Enteric gas emissions were measured using the GreenFeed system (C-Lock Inc., Rapid City, SD), and rumen samples were collected for fermentation analysis using the ororuminal technique. In Exp.1 (in vitro), relative to the control, AT (at 1% dry matter basis, inclusion rate) decreased CH₄ yield by 98%. In Exp. 3, HighAT decreased average daily CH₄ emission and CH₄ yield by 65% and 55%, respectively, in experimental periods 1 and 2, but had no effect in periods 3 and 4. The differential response to AT among experimental periods was likely a result of a decrease in CHBr₃ concentration in AT over time, as observed in Exp. 4 (up to 84% decrease in 4 mo of storage). In Exp. 3, H₂ emission was increased by AT and, as expected, the proportion of acetate in the total volatile fatty acids in the rumen was decreased and those of propionate and butyrate were increased by HighAT compared with the control. Compared with the control, HighAT decreased dry matter intake, milk yield, and energy-corrected milk yield in Exp. 3. Milk composition was not affected by treatment, except lactose percentage and yield were decreased by HighAT. Concentrations of iodine and bromide in milk were increased by HighAT compared with the control. Milk CHBr₃ concentration and its organoleptic characteristics were not different between control and HighAT. Oregano had no effect on CH₄ emission or lactational performance of the cows in Exp. 3. Overall, AT included at 0.50% in the ration of dairy cows can have a large mitigation effect on enteric CH₄ emission, but dry matter intake and milk production may also decrease. There was a marked decrease in the CH₄ mitigation potential of AT in the second half of Exp. 3, likely resulting from CHBr₃ decay over time.

Optimal Timing of CT Scanning in the Rapid Access Lung Cancer Clinic

Aims To investigate whether a ‘CT first’ approach to Rapid Access Lung Cancer Clinic (RALC) review could be feasible in an Irish context. Methods A retrospective review of our institution’s Lung Cancer Database was performed. All RALC first attendances from 2012-2018 were identified. Timing of CT was assessed as well as CT imaging findings. Results Total first attendances in this period were 2372, of whom 91% had CT thorax as part of their evaluation. 866 patients (37%) were diagnosed with lung cancer, all had an abnormal CT. 1290 patients (54%) underwent CT but did not have lung cancer after clinical work up. 34% of patients diagnosed with Lung Cancer had their CT scan post RALC. Time to diagnosis was longer in those who had post RALC CT (34.5 versus 21 days) Conclusion CT scanning plays a vital role in the RALC pathway. Initial delays in obtaining CT can result in delayed time to diagnosis. These findings warrant close consideration when devising future national lung cancer policy.

Effect of 2-hydroxy-4-(methylthio) butanoate (HMTBa) supplementation on rumen bacterial populations in dairy cows when exposed to diets with risk for milk fat depression

Diet-induced milk fat depression (MFD) is a condition marked by a reduction in milk fat yield experimentally achieved by increasing dietary unsaturated fatty acids and fermentable carbohydrates. 2-Hydroxy-4-(methylthio) butanoate (HMTBa) is a methionine analog observed to reduce diet-induced MFD in dairy cows. We hypothesize that the reduction in diet-induced MFD by HMTBa is due to changes in the rumen microbiota. To test this, 22 high-producing cannulated Holstein dairy cows were placed into 2 groups using a randomized block design and assigned to either control or HMTBa supplementation (0.1% of diet dry matter). All cows were then exposed to 3 different diets with a low risk (32% neutral detergent fiber, no added oil; fed d 1 to 7), a moderate risk (29% neutral detergent fiber and 0.75% soybean oil; fed d 8 to 24), or a high risk (29% neutral detergent fiber and 1.5% soybean oil; fed d 25 to 28) for diet-induced MFD. Rumen samples were collected on d 0, 14, 24, and 28, extracted for DNA, PCR-amplified for the V1-V2 region of the 16S rRNA gene, sequenced on an Illumina MiSeq (Illumina, San Diego, CA), and subjected to bacterial diversity analysis using the QIIME pipeline. The α diversity estimates (species richness and Shannon diversity) were decreased in the control group compared with the HMTBa group. Bacterial community composition also differed between control and HMTBa groups based on both weighted UniFrac (relative abundance of commonly detected bacteria) and unweighted UniFrac (presence/absence) distances. Within the HMTBa group, no differences were observed in bacterial community composition between d 0 and d 14, 24, and 28; however, in the control group, d 0 samples were different from d 14, 24, and 28. Certain bacterial genera including Dialister, Megasphaera, Lachnospira, and Sharpea were increased in the control group compared with the HMTBa group. Interestingly, these genera were positively correlated with milk fat trans-10,cis-12 conjugated linoleic acid and trans-10 C18:1, fatty acid isomers associated with biohydrogenation-induced MFD. It can be concluded that diet-induced MFD is accompanied by significant alterations in the rumen bacterial community and that HMTBa supplementation reduces these microbial perturbations.

Introduction of an academic internship in Ireland: views of undergraduate medical students

INTRODUCTION

A combined academic and clinical training programme for junior doctors in Ireland, the academic track for internship, has recently been launched. The academic track offers newly graduated doctors protected time within the working week to undertake a research project in addition to funding, an academic supervisor, and additional training in research skills. This study seeks to investigate the views of undergraduate medical students.

METHODS

The study population was undergraduate medical students at Trinity College Dublin in their penultimate year of study. An online questionnaire was designed and disseminated via a gatekeeper. Descriptive statistics were used to carry out data analysis on students' responses.

RESULTS

The response rate was 50/203 (24.6%). All respondents indicated that protected time would be 'very important' or 'important'. The most frequently cited reason for participating in the academic track was 'To progress my career in a particular specialty' (28/42). The most frequently cited anticipated achievement was research publication (39/42). The most common response when asked what concerns (if any) students had about participating in the programme was 'I am not sure I could achieve all the clinical competencies of an intern in addition to research' (58%).

DISCUSSION

There was a significant interest in the academic track for internship, and it is perceived by students as being of benefit to their careers. The value of protected time and an academic supervisor were recognised, and a research publication was the most frequently cited anticipated outcome. The data gathered in this questionnaire will help inform curriculum development and the identification of suitable learning outcomes.