Healthcare and housing provision for a UK homeless community: a qualitative service evaluation

OBJECTIVES

Homelessness is both a significant determinant and consequence of health and social inequalities. To better meet healthcare needs, dedicated mental health and general nurses were implemented to deliver outreach healthcare to people experiencing homelessness in one United Kingdom (UK) county. During COVID-19, the UK Government also instructed local authorities to accommodate individuals sleeping rough and have a national target to end rough sleeping. This qualitative study explored experiences of this nurse-let outreach service and housing journeys during and beyond COVID-19 among people experiencing homelessness.

STUDY DESIGN

Face-to-face, narrative storytelling interviews were conducted via opportunistic sampling in community settings. Individuals with recent or current experiences of homelessness were eligible.

METHODS

Participants were informed about the study via known professionals and introduced to the researcher. Eighteen narrative interviews were conducted, transcribed, and analysed using reflective thematic analysis.

RESULTS

Individuals described complex journeys in becoming and being homeless. The nurse-led outreach service provided integral support, with reported benefits to person-centred and accessible care and improved outcomes in health and well-being. After being housed, individuals valued housing necessities and described new responsibilities. However, some participants did not accept or stay in housing provisions where they perceived risks.

CONCLUSIONS

Interviewed participants perceived that the dedicated nurse-led outreach service improved their access to care and health outcomes. In the absence of dedicated provisions, mainstream healthcare should ensure flexible processes and collaborative professional working. Local authorities must also be afforded increased resources for housing, as well as integrated support, to reduce social and health inequalities.

Efferent limb stimulation prior to loop ileostomy closure: a systematic review and meta-analysis

BACKGROUND

Postoperative ileus (POI) remains a common phenomenon following loop ileostomy closure. Our aim was to determine whether preoperative physiological stimulation (PPS) of the efferent limb reduced POI incidence.

METHODS

A PRISMA-compliant meta-analysis searching PubMed, EMBASE and CENTRAL databases was performed. The last search was carried out on 30 January 2023. All randomized studies comparing PPS versus no stimulation were included. The primary endpoint was POI incidence. Secondary endpoints included the time to first passage of flatus/stool, time to resume oral diet, need for nasogastric tube (NGT) placement postoperatively, length of stay (LOS) and other complications. Random effects models were used to calculate pooled effect size estimates. Trial sequential analyses (TSA) were also performed.

RESULTS

Three randomized studies capturing 235 patients (116 PPS, 119 no stimulation) were included. On random effects analysis, PPS was associated with a quicker time to resume oral diet (MD - 1.47 days, 95% CI - 2.75 to - 0.19, p = 0.02), shorter LOS (MD - 1.47 days, 95% CI - 2.47 to - 0.46, p = 0.004) (MD - 1.41 days, 95% CI - 2.32 to - 0.50, p = 0.002, I2 = 56%) and fewer other complications (OR 0.42, 95% CI 0.18 to 1.01, p = 0.05). However, there was no difference in POI incidence (OR 0.35, 95% CI 0.10 to 1.21, p = 0.10), the requirement for NGT placement (OR 0.50, 95% CI 0.21 to 1.20, p = 0.12) or time to first passage of flatus/stool (MD - 0.60 days, 95% CI - 1.95 to 0.76, p = 0.39). TSA revealed imprecise estimates for all outcomes (except LOS) and further studies are warranted to meet the required information threshold.

CONCLUSIONS

PPS prior to stoma closure may reduce LOS and postoperative complications albeit without a demonstrable beneficial effect on POI. Further high-powered studies are required to confirm or refute these findings.

Cellular Heterogeneity of Activated Primary Human Macrophages and Associated Drug-Gene Networks: From Biology to Precision Therapeutics

BACKGROUND

Interferon-γ (IFNγ) signaling plays a complex role in atherogenesis. IFNγ stimulation of macrophages permits in vitro exploration of proinflammatory mechanisms and the development of novel immune therapies. We hypothesized that the study of macrophage subpopulations could lead to anti-inflammatory interventions.

METHODS

Primary human macrophages activated by IFNγ (M(IFNγ)) underwent analyses by single-cell RNA sequencing, time-course cell-cluster proteomics, metabolite consumption, immunoassays, and functional tests (phagocytic, efferocytotic, and chemotactic). RNA-sequencing data were analyzed in LINCS (Library of Integrated Network-Based Cellular Signatures) to identify compounds targeting M(IFNγ) subpopulations. The effect of compound BI-2536 was tested in human macrophages in vitro and in a murine model of atherosclerosis.

RESULTS

Single-cell RNA sequencing identified 2 major clusters in M(IFNγ): inflammatory (M(IFNγ)i) and phagocytic (M(IFNγ)p). M(IFNγ)i had elevated expression of inflammatory chemokines and higher amino acid consumption compared with M(IFNγ)p. M(IFNγ)p were more phagocytotic and chemotactic with higher Krebs cycle activity and less glycolysis than M(IFNγ)i. Human carotid atherosclerotic plaques contained 2 such macrophage clusters. Bioinformatic LINCS analysis using our RNA-sequencing data identified BI-2536 as a potential compound to decrease the M(IFNγ)i subpopulation. BI-2536 in vitro decreased inflammatory chemokine expression and secretion in M(IFNγ) by shrinking the M(IFNγ)i subpopulation while expanding the M(IFNγ)p subpopulation. BI-2536 in vivo shifted the phenotype of macrophages, modulated inflammation, and decreased atherosclerosis and calcification.

CONCLUSIONS

We characterized 2 clusters of macrophages in atherosclerosis and combined our cellular data with a cell-signature drug library to identify a novel compound that targets a subset of macrophages in atherosclerosis. Our approach is a precision medicine strategy to identify new drugs that target atherosclerosis and other inflammatory diseases.

108 TEIRIPE SA BHAILE TEAM (TSAB): AN EARLY SUPPORTED DISCHARGE SERVICE FOR HIP FRACTURES FROM AN ACUTE HOSPITAL

Background

Due to increasing bed strain in hospitals, Early Supported Discharge (ESD) programmes have helped to reduce length of stay for hip fracture patients. Teiripe sa Bhaile Team (TsaB) provides a multi-disciplinary, patient centred approach to care for patients over 60 with hip fractures, in their own home.

Methods

Patient demographics and data has been collected on all TsaB patients to date with consent from the patients. We measured length of intervention with TsaB, patient directed SMART (Specific, measurable, achievable, relevant, time bound) goals, Functional Independence Measure (FIM) sores. We recorded the number of visits required, medical complications and number of readmissions post discharge from our service.

Results

Since formation in 2018 until April 2022, 33 patients have been treated by TsaB. The average age is 78 years old. The average length of stay prior to discharge was 17 days, compared to 54 days for inpatient hip fracture rehabilitation. Patients received an average of 11 MDT visits during the 6 weeks of rehabilitation. The average improvement in FIM score was 42. All set SMART goals, and only 5 (17%) patients did not achieve these goals.

Only 5 (17%) patients were readmitted within 6 months. No patients required initiation of a home care package for discharge, or after our interventions. No patients developed pressure ulcers while on our service, or other medical complications.

Conclusion

Through TsaB, we are able to offer a rehabilitation service to patients based around their own needs in the home. Patients were able to set and achieve their own SMART goals. Patients were moderately frail on admission to our service, but after intervention were able to improve their FIM scores, marking reduced frailty after intervention. We had low readmission rates, and no patients required a change in home care package.

Abstract 112: Examining The Heterogeneity Of Primary Human Macrophages And Pharmacogenomic Networks To Identify Novel Targets For Precision Medicine For Vascular Inflammation

Background: We hypothesize that macrophage heterogeneity is an unexploited source of therapeutic targets for vascular inflammation. Interferon-gamma (IFNγ) stimulated primary human macrophages M(IFNγ) is a widely used in vitro model for proinflammatory macrophages. However, typical activation-induced transcript profiling assumes a homogenous macrophage population. Our goal is to evaluate the extent of heterogeneity of activated macrophages to devise a strategy for precision medicine for inflammatory vascular disease.

Methods: Using unbiased single-cell RNA sequencing (scRNA-seq), systems biology, and machine learning, we examined inter-subgroup differences of human primary M(IFNγ) (4 donors). Network analysis, kinetic proteomics, and in vitro assays (n=3-6) characterized the clusters, followed by validation in human carotid atherosclerotic plaques (n=13). scRNAseq data analysis in the L1000 CDS 2 drug-gene network computationally identified drugs that may potentiate or suppress each cluster.

Results: The scRNA-seq demonstrated 3 distinct subpopulations: Clusters 1, 2, and 3 (C1, 2, and 3). C3 showed increased proinflammatory chemokine production, protein synthesis, and glycolysis. C1 was more efferocytotic/phagocytic, chemotactic, and less inflammatory. C2 is intermediate between C1 and C3. Histological analysis localized C1 and C3-like macrophages in different areas of the plaques ( Fig. 1A ). In addition, we used targeted scRNAseq (n=4) to analyze M(IFNγ) treated with an L1000-derived drug BI-2536 (Polo-like kinase inhibitor). As predicted, BI-2536 shifted the phenotypic heterogeneity of M(IFNγ) towards less inflammatory characteristics ( Fig. 1B ) which were further validated with bulk qPCR & ELISA (n=8).

Conclusion: Our study presents a novel strategy for precision medicine that leverages single-cell data and gene interaction networks to identify modulators of macrophage heterogeneity as new anti-inflammatory therapies.

Carcinogenicity assessment: technical and political challenges

The rising rates of cancer incidence and prevalence identified by the WHO are of serious concern. The scientific advances of the past twenty years have helped to describe major properties of the cancer disease, enabling therapies that are more sophisticated. It has become clear that the management of relevant risk factors can also significantly reduce cancer occurrence worldwide. Public health policy actions cannot be decoupled from environmental policy actions, since exposure to chemicals through air, soil, water and food can contribute to cancer as well as other chronic diseases. Furthermore, due to the increasing global trend of chemical production including novel compounds, chemical exposure patterns are foreseen to change, posing high demands on chemical safety assessment, and creating potential protection gaps. The safety assessment of carcinogenicity needs to evolve to keep pace with changes in the chemical environment and cancer epidemiology. The presentation focusses on EC-JRC recommendations and future strategies for carcinogenicity safety assessment. This also includes discussion on how the traditional data streams of regulatory toxicology, together with new available assessment methods can inform, along with indicators of public health status based on biomonitoring and clinical data, a more holistic human-relevant and impactful approach to carcinogenicity assessment and overall prevention of cancer disease.

The need for integrated public health surveillance to address sexually transmitted and blood-borne syndemics

A national approach to addressing sexually transmitted and blood-borne infections (STBBIs) was recently articulated in the Public Health Agency of Canada's new A Pan-Canadian Framework for Action: Reducing the health impact of sexually transmitted and blood-borne infections in Canada by 2030. This Framework promotes an integrated approach, with a focus on the key populations that are affected by overlapping epidemics (i.e., syndemics). We advance the idea that integrating surveillance would be helpful in characterizing and understanding the populations, locations, risk behaviours and other drivers that contribute to STBBI syndemics. The creation of matched or linked data systems that would allow routine reporting of integrated data is challenged by the technical barriers of integrating data silos as well as by the privacy and ethical considerations of merging sensitive individual-level data. Lessons can be learned from jurisdictions where an improved understanding of syndemics, through integrated STBBI surveillance, has led to more efficient and effective operational, program and policy decisions. Emerging enablers include the development of data standards and guidelines, investment in resources to overcome technical challenges and community engagement to support the ethical and non-stigmatizing use of integrated data. The Framework's call to action offers an opportunity for national discussion on priorities and resources needed to advance STBBI syndemic surveillance for local, regional and national reporting in Canada.

Soil exchange rates of COS and CO18O differ with the diversity of microbial communities and their carbonic anhydrase enzymes

Differentiating the contributions of photosynthesis and respiration to the global carbon cycle is critical for improving predictive climate models. Carbonic anhydrase (CA) activity in leaves is responsible for the largest biosphere-atmosphere trace gas fluxes of carbonyl sulfide (COS) and the oxygen-18 isotopologue of carbon dioxide (CO¹⁸O) that both reflect gross photosynthetic rates. However, CA activity also occurs in soils and will be a source of uncertainty in the use of COS and CO¹⁸O as carbon cycle tracers until process-based constraints are improved. In this study, we measured COS and CO¹⁸O exchange rates and estimated the corresponding CA activity in soils from a range of biomes and land use types. Soil CA activity was not uniform for COS and CO₂, and patterns of divergence were related to microbial community composition and CA gene expression patterns. In some cases, the same microbial taxa and CA classes catalyzed both COS and CO₂ reactions in soil, but in other cases the specificity towards the two substrates differed markedly. CA activity for COS was related to fungal taxa and β-D-CA expression, whereas CA activity for CO₂ was related to algal and bacterial taxa and α-CA expression. This study integrates gas exchange measurements, enzyme activity models, and characterization of soil taxonomic and genetic diversity to build connections between CA activity and the soil microbiome. Importantly, our results identify kinetic parameters to represent soil CA activity during application of COS and CO¹⁸O as carbon cycle tracers.

Standardisation of defined approaches for skin sensitisation testing to support regulatory use and international adoption: position of the International Cooperation on Alternative Test Methods

Skin sensitisation is the regulatory endpoint that has been at the centre of concerted efforts to replace animal testing in recent years, as demonstrated by the Organisation for Economic Co-operation and Development (OECD) adoption of five non-animal methods addressing mechanisms under the first three key events of the skin sensitisation adverse outcome pathway. Nevertheless, the currently adopted methods, when used in isolation, are not sufficient to fulfil regulatory requirements on the skin sensitisation potential and potency of chemicals comparable to that provided by the regulatory animal tests. For this reason, a number of defined approaches integrating data from these methods with other relevant information have been proposed and documented by the OECD. With the aim to further enhance regulatory consideration and adoption of defined approaches, the European Union Reference Laboratory for Alternatives to Animal testing in collaboration with the International Cooperation on Alternative Test Methods hosted, on 4-5 October 2016, a workshop on the international regulatory applicability and acceptance of alternative non-animal approaches, i.e., defined approaches, to skin sensitisation assessment of chemicals used in a variety of sectors. The workshop convened representatives from more than 20 regulatory authorities from the European Union, United States, Canada, Japan, South Korea, Brazil and China. There was a general consensus among the workshop participants that to maximise global regulatory acceptance of data generated with defined approaches, international harmonisation and standardisation are needed. Potential assessment criteria were defined for a systematic evaluation of existing defined approaches that would facilitate their translation into international standards, e.g., into a performance-based Test Guideline. Informed by the discussions at the workshop, the ICATM members propose practical ways to further promote the regulatory use and facilitate adoption of defined approaches for skin sensitisation assessments.

Assessing a New Clue to How Much Carbon Plants Take Up

Current climate models disagree on how much carbon dioxide land ecosystems take up for photosynthesis. Tracking the stronger carbonyl sulfide signal could help.

Sensitivity of predicted bioaerosol exposure from open windrow composting facilities to ADMS dispersion model parameters

Bioaerosols are released in elevated quantities from composting facilities and are associated with negative health effects, although dose-response relationships are not well understood, and require improved exposure classification. Dispersion modelling has great potential to improve exposure classification, but has not yet been extensively used or validated in this context. We present a sensitivity analysis of the ADMS dispersion model specific to input parameter ranges relevant to bioaerosol emissions from open windrow composting. This analysis provides an aid for model calibration by prioritising parameter adjustment and targeting independent parameter estimation. Results showed that predicted exposure was most sensitive to the wet and dry deposition modules and the majority of parameters relating to emission source characteristics, including pollutant emission velocity, source geometry and source height. This research improves understanding of the accuracy of model input data required to provide more reliable exposure predictions.

Endoscopic tattooing to aid tumour localisation in colon cancer: the need for standardisation

BACKGROUND/AIMS

An increasing number of colon and rectal tumours are being resected using laparoscopic techniques. Identifying these tumours intraoperatively can be difficult. The use of tattooing can facilitate an easier resection; however, the lack of standardised guidelines can potentially lead to errors intraoperatively and potentially result in worse outcomes for patients. The aim of this study was to identify the most reliable method of preoperative tumour localisation from the available literature to date.

METHODS

A literature review was undertaken to identify any articles related to endoscopic tattooing and tumour localisation during colorectal surgery.

RESULTS

To date there is still mixed evidence regarding tattooing techniques and the choice of ink that should be used. There are numerous studies demonstrating safe tattooing techniques and highlighting the risks and benefits of different types of ink available.

CONCLUSION

Based on the available studies we have recommended a standardised approach to endoscopic tattooing of colorectal tumours prior to laparoscopic resection.

Towards an alternative testing strategy for nanomaterials used in nanomedicine: lessons from NanoTEST

In spite of recent advances in describing the health outcomes of exposure to nanoparticles (NPs), it still remains unclear how exactly NPs interact with their cellular targets. Size, surface, mass, geometry, and composition may all play a beneficial role as well as causing toxicity. Concerns of scientists, politicians and the public about potential health hazards associated with NPs need to be answered. With the variety of exposure routes available, there is potential for NPs to reach every organ in the body but we know little about the impact this might have. The main objective of the FP7 NanoTEST project ( www.nanotest-fp7.eu ) was a better understanding of mechanisms of interactions of NPs employed in nanomedicine with cells, tissues and organs and to address critical issues relating to toxicity testing especially with respect to alternatives to tests on animals. Here we describe an approach towards alternative testing strategies for hazard and risk assessment of nanomaterials, highlighting the adaptation of standard methods demanded by the special physicochemical features of nanomaterials and bioavailability studies. The work has assessed a broad range of toxicity tests, cell models and NP types and concentrations taking into account the inherent impact of NP properties and the effects of changes in experimental conditions using well-characterized NPs. The results of the studies have been used to generate recommendations for a suitable and robust testing strategy which can be applied to new medical NPs as they are developed.

A multi disciplinary obstetric emergency training programme

The Rotunda Hospital (Dublin) obstetric emergency training programme (RHOET) was designed, in 2008, to meet the ongoing education and training needs of the local multidisciplinary team. Prior to its implementation, senior midwives attended the advanced life support in obstetrics (ALSO) course, and many of the obstetricians attended the Management of obstetric emergencies and trauma (MOET) and/or ALSO courses. Attendance at these off site courses meant that the only opportunity for team training was the informal and ad hoc 'drills and skills' that took place in the birthing suite. This paper documents our journey since RHOET was implemented.

Inter- and intra-laboratory study to determine the reproducibility of toxicogenomics datasets

The application of toxicogenomics as a predictive tool for chemical risk assessment has been under evaluation by the toxicology community for more than a decade. However, it predominately remains a tool for investigative research rather than for regulatory risk assessment. In this study, we assessed whether the current generation of microarray technology in combination with an in vitro experimental design was capable of generating robust, reproducible data of sufficient quality to show promise as a tool for regulatory risk assessment. To this end, we designed a prospective collaborative study to determine the level of inter- and intra-laboratory reproducibility between three independent laboratories. All test centres (TCs) adopted the same protocols for all aspects of the toxicogenomic experiment including cell culture, chemical exposure, RNA extraction, microarray data generation and analysis. As a case study, the genotoxic carcinogen benzo[a]pyrene (B[a]P) and the human hepatoma cell line HepG2 were used to generate three comparable toxicogenomic data sets. High levels of technical reproducibility were demonstrated using a widely employed gene expression microarray platform. While differences at the global transcriptome level were observed between the TCs, a common subset of B[a]P responsive genes (n=400 gene probes) was identified at all TCs which included many genes previously reported in the literature as B[a]P responsive. These data show promise that the current generation of microarray technology, in combination with a standard in vitro experimental design, can produce robust data that can be generated reproducibly in independent laboratories. Future work will need to determine whether such reproducible in vitro model(s) can be predictive for a range of toxic chemicals with different mechanisms of action and thus be considered as part of future testing regimes for regulatory risk assessment.

Development of micro-electrode array based tests for neurotoxicity: assessment of interlaboratory reproducibility with neuroactive chemicals

Neuronal assemblies within the nervous system produce electrical activity that can be recorded in terms of action potential patterns. Such patterns provide a sensitive endpoint to detect effects of a variety of chemical and physical perturbations. They are a function of synaptic changes and do not necessarily involve structural alterations. In vitro neuronal networks (NNs) grown on micro-electrode arrays (MEAs) respond to neuroactive substances as well as the in vivo brain. As such, they constitute a valuable tool for investigating changes in the electrophysiological activity of the neurons in response to chemical exposures. However, the reproducibility of NN responses to chemical exposure has not been systematically documented. To this purpose six independent laboratories (in Europe and in USA) evaluated the response to the same pharmacological compounds (Fluoxetine, Muscimol, and Verapamil) in primary neuronal cultures. Common standardization principles and acceptance criteria for the quality of the cultures have been established to compare the obtained results. These studies involved more than 100 experiments before the final conclusions have been drawn that MEA technology has a potential for standard in vitro neurotoxicity/neuropharmacology evaluation. The obtained results show good intra- and inter-laboratory reproducibility of the responses. The consistent inhibitory effects of the compounds were observed in all the laboratories with the 50% Inhibiting Concentrations (IC(50)s) ranging from: (mean ± SEM, in μM) 1.53 ± 0.17 to 5.4 ± 0.7 (n = 35) for Fluoxetine, 0.16 ± 0.03 to 0.38 ± 0.16 μM (n = 35) for Muscimol, and 2.68 ± 0.32 to 5.23 ± 1.7 (n = 32) for Verapamil. The outcome of this study indicates that the MEA approach is a robust tool leading to reproducible results. The future direction will be to extend the set of testing compounds and to propose the MEA approach as a standard screen for identification and prioritization of chemicals with neurotoxicity potential.