Children and young people's self-reported experiences of asthma and self-management nursing strategies: An integrative review

AIM

To explore children and young people's (CYP) (5-24 years of age) self-reported experiences of asthma self-management strategies (ASMS) with nursing involvement across various settings.

BACKGROUND

Childhood asthma is an increasingly significant health issue, highlighting the importance of acquiring self-management skills to optimise future health outcomes. Registered nurses play a pivotal role in delivering appropriate, personalized self-management support.

METHODS

This integrative review searched four electronic databases: Cumulated Index to Nursing and Allied Health Literature via Elton B. Stephens Company, Medical Literature Analysis and Retrieval System Online (MEDLINE), Object, View and Interactive Design (OVID), and PubMed, that followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis flowchart. Included studies were critically appraised using the Joanna Briggs Institute critical appraisal tools. Braun and Clarks thematic analysis was used to generate themes, and sub-themes.

FINDINGS

Fifteen studies were included for review. Thematic analysis generated three themes being healthy literacy; health and wellbeing; and tools and working together.

CONCLUSIONS

Asthma continues to have negative physical, psychological, and social implications among CYP. CYP are both willing and capable of engaging in ASMS and learning self-management skills, however, continue to have unmet self-management needs.

IMPLICATIONS TO PRACTICE

Strategies must bolster health literacy, improve physical and psychological health, and harness interactive, youth-centric, and informative tools to facilitate communication and decrease the burden of self-management. Applications pose a promising avenue for self-management support. This age group remains under-explored and future research should enable meaningful engagement with CYP to better understand their perspectives and improve strategy success.

Brain states as wave-like motifs

There is ample evidence of wave-like activity in the brain at multiple scales and levels. This emerging literature supports the broader adoption of a wave perspective of brain activity. Specifically, a brain state can be described as a set of recurring, sequential patterns of propagating brain activity, namely a wave. We examine a collective body of experimental work investigating wave-like properties. Based on these works, we consider brain states as waves using a scale-agnostic framework across time and space. Emphasis is placed on the sequentiality and periodicity associated with brain activity. We conclude by discussing the implications, prospects, and experimental opportunities of this framework.

Survival of pre-formed zirconia crowns in primary teeth: a prospective practice-based cohort study

BACKGROUND

This study aimed to investigate the (1) survival probabilities of prefabricated zirconia crowns (PZCs) placed on primary teeth and (2) identify demographic and tooth-related factors that might affect survival probability.

METHODS

This study prospectively followed children treated under general anaesthesia by a single practitioner between 2012 and 2020. Demographic variables including the age at treatment, gender and tooth-related variables including FDI tooth number, crown size used and any procedural complications at postoperative reviews were collected.

RESULTS

A total of 155 children involving 319 teeth with PZCs were followed up between 12 and 78 months postoperatively with a mean of 38 months. Of the 319 crowns followed, five failures were observed in three patients requiring extraction. Other procedural complications noted included fracture (n = 3), overhangs (n = 3), internal resorption (n = 5) and 24% of crowns showed signs of radiographic changes on postoperative radiographs when these were taken. Age at treatment, tooth type and need for pulp therapy were not statistically associated with clinical success (P > 0.1).

CONCLUSIONS

PZCs provide an aesthetic and durable solution in the management of children with early childhood caries. This study shows very good clinical success and survival extending up to 78 months for PZCs placed on primary teeth under general anaesthesia.

Good manufacturing practice production of CD34+ progenitor-derived NK cells for adoptive immunotherapy in acute myeloid leukemia

Allogeneic natural killer (NK) cell-based immunotherapy is a promising, well-tolerated adjuvant therapeutic approach for acute myeloid leukemia (AML). For reproducible NK cell immunotherapy, a homogenous, pure and scalable NK cell product is preferred. Therefore, we developed a good manufacturing practice (GMP)-compliant, cytokine-based ex vivo manufacturing process for generating NK cells from CD34+ hematopoietic stem and progenitor cells (HSPC). This manufacturing process combines amongst others IL15 and IL12 and the aryl hydrocarbon receptor antagonist StemRegenin-1 (SR1) to generate a consistent and active NK cell product that fits the requirements for NK cell immunotherapy well. The cell culture protocol was first optimized to generate NK cells with required expansion and differentiation capacity in GMP-compliant closed system cell culture bags. In addition, phenotype, antitumor potency, proliferative and metabolic capacity were evaluated to characterize the HSPC-NK product. Subsequently, seven batches were manufactured for qualification of the process. All seven runs demonstrated consistent results for proliferation, differentiation and antitumor potency, and preliminary specifications for the investigational medicinal product for early clinical phase trials were set. This GMP-compliant manufacturing process for HSPC-NK cells (named RNK001 cells) is used to produce NK cell batches applied in the clinical trial 'Infusion of ex vivo-generated allogeneic natural killer cells in combination with subcutaneous IL2 in patients with acute myeloid leukemia' approved by the Dutch Ethics Committee (EudraCT 2019-001929-27).

Cross Atlas Remapping via Optimal Transport (CAROT): Creating connectomes for different atlases when raw data is not available

Open-source, publicly available neuroimaging datasets - whether from large-scale data collection efforts or pooled from multiple smaller studies - offer unprecedented sample sizes and promote generalization efforts. Releasing data can democratize science, increase the replicability of findings, and lead to discoveries. Partly due to patient privacy, computational, and data storage concerns, researchers typically release preprocessed data with the voxelwise time series parcellated into a map of predefined regions, known as an atlas. However, releasing preprocessed data also limits the choices available to the end-user. This is especially true for connectomics, as connectomes created from different atlases are not directly comparable. Since there exist several atlases with no gold standards, it is unrealistic to have processed, open-source data available from all atlases. Together, these limitations directly inhibit the potential benefits of open-source neuroimaging data. To address these limitations, we introduce Cross Atlas Remapping via Optimal Transport (CAROT) to find a mapping between two atlases. This approach allows data processed from one atlas to be directly transformed into a connectome based on another atlas without the need for raw data access. To validate CAROT, we compare reconstructed connectomes against their original counterparts (i.e., connectomes generated directly from an atlas), demonstrate the utility of transformed connectomes in downstream analyses, and show how a connectome-based predictive model can generalize to publicly available data that was processed with different atlases. Overall, CAROT can reconstruct connectomes from an extensive set of atlases - without needing the raw data - allowing already processed connectomes to be easily reused in a wide range of analyses while eliminating redundant processing efforts. We share this tool as both source code and as a stand-alone web application (http://carotproject.com/).

Are Training and Experience Adapting Evidence-Based Interventions Associated With Self-Efficacy and Attitudes? A Cross-Sectional Survey of Students and Practitioners With Varying Levels of Adaptation Experience

Increasing use of evidence-based interventions (EBIs) in local settings will help reduce the research-practice gap and improve health equity. Because adaptation to new settings and populations is essential to effective EBI use, frameworks to guide practice are receiving more attention; most, however, only provide broad guidelines without instructions for making adaptations in practice. Therefore, practitioners may need additional training or technical assistance (TA) to implement and adapt EBIs. This study explores whether practitioners' and students' general EBI training or TA and level of adaptation experience are associated with self-efficacy in adapting EBIs and with attitudes toward EBI use. We analyzed baseline survey data of participants in an evaluation of IM-Adapt Online, a newly developed decision support tool. We asked about previous training on EBIs, general and specific adaptation behaviors, and attitudes toward EBIs and found an association between previous training or TA in using EBIs with higher self-efficacy for using and adapting EBIs. Respondents with prior EBI training were significantly more likely to have higher self-efficacy in EBI behaviors across subdomains and in total than those without training. Respondents reported lowest self-efficacy for planning adaptations (M = 3.35) and assessing fit of EBIs to their local context (M = 3.41). This study suggests the importance of EBI adaptation training and TA to increase adoption and adaptation of EBIs, subsequently. More adaptation-specific training is warranted to assist students, practitioners, and researchers undertaking the adaptation process and implement EBIs. Future training on EBI adaptation can help practitioners tailor EBIs to meet the specific needs of their populations.

Evidence-Based Intervention (EBI) Mapping: a systematic approach to understanding the components and logic of EBIs

BACKGROUND

Despite the development of numerous evidence-based interventions (EBIs), many go unused in practice. Hesitations to use existing EBIs may be due to a lack of understanding about EBI components and what it would take to adapt it or implement it as designed. To improve the use of EBIs, program planners need to understand their goals, core components, and mechanisms of action. This paper presents EBI Mapping, a systematic approach based on Intervention Mapping, that can be used to understand and clearly describe EBIs, and help planners put them into practice.

METHODS

We describe EBI Mapping tasks and provide an example of the process. EBI Mapping uses principles from Intervention Mapping, a systematic framework for planning multilevel health promotion interventions. EBI Mapping applies the Intervention Mapping steps retrospectively to help planners understand an existing EBI (rather than plan a new one). We explain each EBI Mapping task and demonstrate the process using the VERB Summer Scorecard (VSS), a multi-level community-based intervention to improve youth physical activity.

RESULTS

EBI Mapping tasks are: 1) document EBI materials and activities, and their audiences, 2) identify the EBI goals, content, and mechanisms of action, 3) identify the theoretical change methods and practical applications of those methods, 4) describe design features and delivery channels, and 5) describe the implementers and their tasks, implementation strategies, and needed resources. By applying the EBI Mapping tasks, we created a logic model for the VSS intervention. The VSS logic model specifies the links between behavior change methods, practical applications, and determinants for both the at-risk population and environmental change agents. The logic model also links the respective determinants to the desired outcomes including the health behavior and environmental conditions to improve the health outcome in the at-risk population.

CONCLUSIONS

EBI Mapping helps program planners understand the components and logic of an EBI. This information is important for selecting, adapting, and scaling-up EBIs. Accelerating and improving the use of existing EBIs can reduce the research-to-practice gap and improve population health.

The impact of the COVID-19 lockdown restrictions on orthopaedic trauma admissions in a central academic hospital in Johannesburg

BACKGROUND: The novel coronavirus (SARS-CoV-2), commonly known as Covid-19, has caused a global economic and healthcare crisis. Many countries tried to curb the spread of the virus by implementing various lockdown restrictions to reduce transmission. The Republic of South Africa (RSA) implemented an alcohol ban as one of the lockdown restrictions. The objectives were to describe the effect of the lockdown alert levels and alcohol availability on orthopaedic trauma admissions, compared to the preceding two years. METHODS: A retrospective review of clinical records was conducted. Data included orthopaedic trauma admissions for the five-month period in a facility in Johannesburg from 27 March to 31 August in the years 2018, 2019 and 2020. Lockdown alert levels were categorised according to the Department of Health which included the ban, reintroduction and re-banning of alcohol consumption. Data collected for 2018, 2019 and 2020 included demographics of sex and age, as well as fracture location, open or closed injuries, polytrauma patients and gunshot injuries. RESULTS: Overall, 672, 621 and 465 patients were admitted in 2018, 2019 and 2020, respectively. There was a decrease of 25% of orthopaedic trauma admissions during the five-month lockdown period in 2020 compared to 2019 (p-value = 0.020) and 30% from 2020 compared to 2018 (p-value = 0.010). In 2020, admissions increased by 112% (n = 82) from alert level 4, when alcohol was banned, to alert level 3 (3a), when alcohol was reintroduced. Admissions decreased by 33% (n = 51) from alert level 3 (3a) to alert level 3 (3b), when alcohol was re-banned. Motor vehicle accidents (MVAs) were the commonest cause of admissions in alert level 3 (3a), accounting for 41% (n = 56). Covid-19 tests were positive in 10% (n = 34) of the 346 tests performed on orthopaedic trauma admissions CONCLUSION: Our study showed the decrease in orthopaedic trauma admissions due to the Covid-19 lockdown regulations. Furthermore, our study demonstrated the impact of alcohol availability on orthopaedic trauma admissions in a central academic hospital in Johannesburg. Level of evidence: Level 4.

Applying evidence-based intervention (EBI) mapping to identify the components and logic of colorectal cancer screening interventions

Implementation of evidence-based interventions (EBIs) can help to increase colorectal cancer screening (CRCS). Potential users of CRCS EBIs are often unclear about the specific features, logic, and core elements of existing EBIs, making it challenging to use or adapt them. We used EBI Mapping, a systematic process developed from Intervention Mapping that identifies an EBI's components and logic, to characterize existing CRCS EBIs from the National Cancer Institute's Evidence-Based Cancer Control Programs website. The resulting information can facilitate intervention adoption, adaptation, and/or implementation. Two trained coders independently coded intervention materials to describe intervention components and logic (n = 20). We display CRCS EBI components (potential mechanism of change) using evidence tables and heat maps. All EBIs addressed completion of at least one CRCS behavior (stool-based test, n = 9; stool-based test or another CRCS test, n = 8; colonoscopy, n = 3; colonoscopy or sigmoidoscopy, n = 1). The psychosocial determinants most frequently addressed by these interventions were knowledge (n = 19), attitudes (n = 17), risk perception/perceived susceptibility (n = 16), skills (n = 15), and overcoming barriers (n = 15). Multi-level EBIs (n = 9) attempted to change an average of 2.1 ± 1.1 conditions in the patients' environment (e.g., accessibility of CRCS); only four EBIs used environmental change agents (e.g., providers, nurses). From the heat maps of EBIs, we describe common theoretical change methods' (e.g., facilitation) used for addressing determinants (e.g., overcoming barriers). EBI Mapping can help users identify important components of a CRCS EBI's logic; these proposed mechanisms of action can inform adoption, adaptation, and implementation in new settings, and facilitate scale up of EBIs.

Bariatric Surgery for Congestive Heart Failure Patients Improves Access to Transplantation and Long-term Survival

INTRODUCTION

Obese patients with congestive heart failure (CHF) are often denied access to heart transplantation until they obtain significant weight loss to achieve a certain BMI threshold, often less than 35 kg/m². It is unknown whether the rapid weight loss associated with bariatric surgery leads to improved waitlist placement, and as such improved survival for morbidly obese patients with CHF.

METHODS

A decision analytic Markov state transition model was created to simulate the life of morbidly obese patients with CHF who were deemed ineligible to be waitlisted for heart transplantation unless they achieved a BMI less than 35 kg/m². Life expectancy following medical weight management (MWM), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) was estimated. Base case patients were defined as having a pre-intervention BMI of 45 kg/m². Sensitivity analysis of initial BMI was performed. Markov parameters were extracted from literature review.

RESULTS

RYGB improved survival compared with both SG and MWM. RYGB patients had higher rates of transplantation, leading to improved mean long-term survival. Base case patients who underwent RYGB gained 2.1 additional years of life compared with patient's who underwent SG and 7.4 additional years of life compared with MWM. SG patients gained 5.3 years of life compared with MWM.

CONCLUSIONS

When strict waitlist criteria were applied, bariatric surgery improved access to heart transplantation and thereby increased long-term survival compared with MWM. Morbidly obese CHF patients who anticipate need for heart transplantation should be encouraged to pursue surgical weight management strategies, necessitating discussion between bariatric surgeons, cardiologists, and cardiac surgeons for appropriate perioperative risk management.

Injury patterns of patients with upper limb and hand trauma sustained during the COVID-19 pandemic lockdown in the UK: a retrospective cohort study

This work aimed to identify the lead causes of upper limb injury presenting to a busy hand and major trauma unit during the UK COVID-19 domestic lockdown period, in comparison to a cohort from the same period one year previously. Hand and upper limb injuries presenting to the host organization during a pre-lockdown period (23rd March 2019–11th May 2019) and the formal UK lockdown period (23rd March 2020–11th May 2020) were compared, using data collated from the host institution’s hand surgery database. The UK lockdown period was associated with a 52% fall in the number of patients presenting to the service with hand and upper limb injuries (589 pre-lockdown vs. 284 during lockdown). There was a significant increase in the proportion of injuries due to machinery use during lockdown (38, 6.5% pre-lockdown vs. 33, 11.6% during lockdown, P = 0.009), other etiologies were consistent. The proportion requiring surgical management were similar (n = 272, 46.2% pre-lockdown vs. n = 138, 48.6% during lockdown, P = 0.50). The proportion requiring overnight admission fell (n = 94, 16.0% pre-lockdown vs. 29, 10.2% during lockdown, P = 0.022). COVID-19 related lockdown in the UK resulted in a reduction in the presenting numbers of hand related injuries; however almost half of these patients still required surgery. These data may be of use to other hand surgery centers for resource planning during future lockdown periods, and for injury prevention strategies in the post-COVID-19 world.

Loneliness and Facebook use: the role of social comparison and rumination

There is conflicting evidence as to whether Facebook, one of the most popular social networking sites, either promotes social connectedness or contributes to the rising prevalence of loneliness. This study aimed to understand the association between Facebook use and loneliness. Two hundred and fourteen active Facebook users (M_age = 35.65; 80.8% female) completed a cross-sectional questionnaire measuring the nature of their Facebook use, how frequently they ruminate, the tendency to compare themselves to their Facebook friends, and upward and downward social comparison. The results showed that rumination and upward social comparison on Facebook were significantly associated with loneliness. The type of activity users engaged in when using Facebook was not significant. The study therefore demonstrates that Facebook users who ruminate and compare themselves to their perceived superiors on Facebook are more likely to experience loneliness. Suggested solutions include raising awareness and using algorithms on Facebook to deliver targeted interventions.

Reflecting on success in trauma research: experiences from the SGCNS and SIR studies

The inclusion of British Service Personnel (SP) lacking capacity into research studies from the point of injury through to medium-term rehabilitation had not previously been undertaken until work to support operations in Afghanistan (2001-2014). The Surgeon General's Casualty Nutrition Study and the Steroids and Immunity from Injury through to Rehabilitation Study sought to address the nutrition, endocrine and immune responses in a military patient cohort. A fundamental part of research is to feedback to patients, their relatives and ward staff on data collection and outcomes, and how future research may be improved to better support both injured SP and trauma patients in the UK. This paper will provide an experiential view on the delivery, operations and infrastructure requirements that should be considered when developing military research at a role-3 facility, before, during and after a study.

OP0234 MBS2320, A NOVEL SELECTIVE MODULATOR OF IMMUNE METABOLISM, IN PATIENTS WITH SEVERE RHEUMATOID ARTHRITIS: SAFETY, TOLERABILITY AND EFFICACY RESULTS OF A PHASE 2 STUDY

Background:

Despite the availability of several treatment options for Rheumatoid Arthritis (RA), many patients are classed as ‘non-responders’ who show little or no improvement. Hence, there remains a need for new therapies with a differentiated mechanism of action, to be used alone or in combination. MBS2320 is a selective modulator of immune metabolism displaying distinctive dual pharmacology: strong anti-inflammatory activity as well as a broader spectrum of osteoprotection than TNFα inhibition in preclinical models1.

Objectives:

To evaluate the safety, tolerability and efficacy of MBS2320 in patients receiving a stable dose of methotrexate (MTX).

Methods:

Patients with active RA on a stable dose of MTX were randomised 2:1 to receive MBS2320 (80mg) or matching placebo once daily for 4 weeks. Subject to a satisfactory safety and tolerability assessment, patients were escalated to a dose of 120 mg qd or remained on 80 mg qd for a further 8 weeks. Safety, efficacy, pharmacokinetics and pharmacodynamics were evaluated.

Results:

121 patients were randomised (Safety analysis set) to MBS2320 or matching placebo and 96 completed the study. Sixteen subjects were excluded from the efficacy analysis set due to evidence of poor compliance or absence of efficacy evaluations. Enrolled patients were mostly female (86.8%), white and with a mean (range) age at baseline (BL) of 52 (19-69) years.

The study population had hard-to-treat, severe, active and erosive disease as indicated by high BL DAS28-CRP and DAS28-ESR, low Week-12 placebo ACR50 and DAS28-CRP responder rates (2.5% and 5% respectively) and a low ratio of synovitis-to-erosion volume despite treatment with DMARD(s).

There were no serious treatment emergent adverse events (TEAEs). 15 patients (19%) randomised to MBS2320 withdrew due to TEAEs, predominantly of nausea. TEAEs were typically reported soon after dosing, were mostly mild in severity and resolved without treatment. Onset of TEAEs reduced as the study proceeded.

Gastrointestinal disorders were the most frequently reported TEAEs (all causalities) with a higher incidence in patients receiving MBS2320 (68.8%) than placebo (14.6%). Nausea was most frequently reported during Week 1 (27.3% patients). Asthenia and/or fatigue was reported more frequently in the MBS2320 treatment group (23.8% patients) than with placebo (7.3% patients), with the majority being considered related to study drug. Infections were more frequently reported by patients receiving placebo (22.0%) than those receiving MBS2320 (12.5%). There were no clinically relevant treatment-related trends in the biochemistry, haematology, urinalysis, vital signs or ECG data.

Higher ACR20 response rates were observed in patients receiving MBS2320 versus those receiving placebo at all time points and increased with time. At Week 12, ACR50 response rates with MBS2320 treatment were increased by >4-fold compared with placebo (11.6% vs 2.5%). Greater mean reductions from baseline in DAS28-CRP were also observed in patients receiving MBS2320 versus those receiving placebo at Week 12 (-18.6% vs -8.4%). DAS28-CRP responder rates were more than doubled with MBS2320 treatment compared to placebo (5% vs 14%). These changes were mirrored by improvements in tender joint counts, reduced hsCRP and improvements in Patient Reported Outcomes of pain VAS, Patients’ and Clinicians‘ Global Assessments of Disease Activity and Patients‘ Global Impression of Change.

Conclusion:

MBS2320 was generally well tolerated for up to 12 weeks in this RA study population. Nausea was the most common TEAE, was generally mild in severity and resolved without treatment. In this population of patients with hard-to-treat, severe, active, erosive disease MBS2320 showed evidence of a clinical benefit on both ACR20 responses and DAS28-CRP.

References:

[1]Patel et al, Ann Rheum Dis, 78, S2, 2019, A228

Acknowledgments:

Louise Jopling, Ian Anderson, Ian Gourley, Devenini Damayanthi,

Disclosure of Interests:

Lisa Patel Shareholder of: Istesso Ltd, Employee of: Istesso Ltd, Laurence Skillern Consultant of: Istesso Ltd, Martyn Foster Shareholder of: Istesso Ltd, Consultant of: Istesso Ltd, Andy Gray Shareholder of: Istesso Ltd, Consultant of: Istesso Ltd, Richard Leff Consultant of: Istesso Ltd, Sam Williams Shareholder of: Istesso Ltd, Employee of: Istesso Ltd

Dysregulation of the actin scavenging system and inhibition of DNase activity following severe thermal injury

Background

Circulating cell‐free DNA (cfDNA) is not found in healthy subjects, but is readily detected after thermal injury and may contribute to the risk of multiple organ failure. The hypothesis was that a postburn reduction in DNase protein/enzyme activity could contribute to the increase in cfDNA following thermal injury.

Methods

Patients with severe burns covering at least 15 per cent of total body surface area were recruited to a prospective cohort study within 24 h of injury. Blood samples were collected from the day of injury for 12 months.

Results

Analysis of blood samples from 64 patients revealed a significant reduction in DNase activity on days 1–28 after injury, compared with healthy controls. DNase protein levels were not affected, suggesting the presence of an enzyme inhibitor. Further analysis revealed that actin (an inhibitor of DNase) was present in serum samples from patients but not those from controls, and concentrations of the actin scavenging proteins gelsolin and vitamin D‐binding protein were significantly reduced after burn injury. In a pilot study of ten military patients with polytrauma, administration of blood products resulted in an increase in DNase activity and gelsolin levels.

Conclusion

The results of this study suggest a novel biological mechanism for the accumulation of cfDNA following thermal injury by which high levels of actin released by damaged tissue cause a reduction in DNase activity. Restoration of the actin scavenging system could therefore restore DNase activity, and reduce the risk of cfDNA‐induced host tissue damage and thrombosis.

P96 Screening for cerebrovascular pathology on the basis of positive family history in the paediatric population

Objectives

Neurovascular disorders are uncommon, complex conditions in children. We reviewed the screening practice and outcome of children referred to the neurovascular service on the basis of positive family history.

Design

Retrospective review of prospectively maintained database.

Subjects

Children referred to the neurovascular service on the basis of family history, for screening at our hospital.

Methods

We retrospectively examined our database between July 2008 and April 2018 for the reasons for referral, family history, investigations performed, and the outcome of the screening process.

Results

44 children were reviewed (23 male, median age 10). Thirty-one children had an MRI/MRA brain. One child subsequently had uncomplicated digital subtraction angiography. Thirty children were referred due to a family history of subarachnoid haemorrhage, of which 17 had a single first-degree relative, and two had two first-degree relatives. Nine children were referred with a family history of arteriovenous malformation, (2 were associated with hereditary haemorrhagic telangiectasia). Five children were discussed due to a family history of non-specific haemorrhagic stroke. Seven children had a history of headache, (4 were prescribed Pizotifen for migraine). No neurovascular pathology was detected following screening within our cohort.

Conclusions

A consensus screening policy does not exist but is required both to guide clinical practice and to assuage parental or patient concerns. We will survey UK paediatric centres to commence this process.

TP1-10 Non tumour brain biopsies in alder hey paediatric neurosurgery

Objectives

To review the utility of non-tumour brain biopsies in Alder Hey Children’s NHS Foundation Trust Paediatric Neurosurgery Department.

Methods

Operative records were searched for ‘biopsy’. Case notes were reviewed for referral source, histology, surgical complication and outcome. Tumour, epilepsy and non-brain biopsy cases were excluded.

Results

83 ‘biopsy’ cases were identified between 2008 and 2017. 31 tumour, 5 epilepsy, 2 infections and 28 non brain/other biopsies were excluded. 17 brain biopsies for non-tumour causes were seen. 15 patients were referred by neurology, 2 by rheumatology. 14 underwent a craniotomy/mini-craniotomy, 3 had burrholes.4 biopsies were non diagnostic, 2 were abnormal but inconclusive for diagnosis. Diagnoses included: 3 demyelinating lesions, 2 normal brain tissue, 1 neurosarcoidosis, 1 autoimmune encephalitis, 1 definite Rasmussen’s Encephalitis, 1 possible Rasmussen’s Encephalitis, 1 systemic lupus erythematosus associated CNS vasculitis, 1 inflammatory infiltrate (secondary to hydrocephalus/ventriculitis), 1 patient developed a late wound infection. No other surgical morbidities/mortalities were recorded. 11 of these cases had a change in management or the treating team were reassured due to the result of the biopsy (i.e. were able to start immunomodulatory drugs in the absence of infection).

Conclusions

65% of brain biopsies were diagnostic. 71% of biopsies either changed management or reassured the treating team about a line of management. The procedure is low risk with 0.06% morbidity and 0% mortality.

P98 A decade of primary tumours of the spine in the paediatric population

Objectives

Primary spinal tumours in children are rare and poorly understood; we review 10 years of surgical experience.

Design

Retrospective review of prospectively maintained database.

Subjects

Children receiving surgical management of primary spinal tumours in a single, tertiary paediatric neurosurgery centre.

Methods

Operations for primary spinal tumours were abstracted from our prospectively maintained surgical database and supplemented with data from case notes, operative records, and imaging studies.

Results

Between 2008 and 2017, 37 procedures were performed on 29 patients (19 male; Median age 7.5 years, IQR 2–11.25). 28 had their primary procedure in our unit: 21 excisions, and 7 biopsies (of which 5 proceeded to further surgery). Tumours were classified as extradural (10), intradural extramedullary (3), intradural intramedullary (11) or bony (4). Tumours were found at the following levels: Cervical (8; 29%), Cervicothoracic (2; 7.1%), Thoracic (10; 36%), Thoracolumbar (3; 11%), Lumbar (2; 7.1%), Lumbosacral (2; 7.1%) and Sacral (1; 3.6%). Histology comprised: Pilocytic Astrocytoma (6), Other Astrocytoma (4), Schwannoma (3), Ewing Sarcoma (2), Langerhans cell histiocytosis (2), Lymphoma (2), Neurofibroma (2), and others (7) including one Myxopapillary Ependymoma.

Conclusions

The rarity and heterogeneity of paediatric spinal tumours makes treatment challenging. We propose a national online registry including a tissue bank, and invite collaboration with other units.

Use of intravenous immunoglobulin for the treatment of autoimmune encephalitis: audit of the NHS experience

Objectives

The treatments of limbic and other autoimmune encephalitis include immunosuppression, symptomatic treatment, and in the case of paraneoplastic syndromes, appropriate therapy for underlying neoplasms. When immunotherapy is considered, intravenous immunoglobulin is one option for treatment, either alone or in combination with corticosteroids. To date, however, evidence for the use of intravenous immunoglobulin in this context comes from case series/expert reviews as no controlled trials have been performed. We aimed to analyse the NHS England Database of intravenous immunoglobulin usage, which was designed to log use and guide procurement, to explore usage and therapeutic effect of intravenous immunoglobulin in autoimmune encephalitis in England.

Design

We conducted a retrospective audit and review of the NHS England Database on intravenous immunoglobulin use.

Setting

NHS England Database of intravenous immunoglobulin use which covers secondary and tertiary care prescribing and use of intravenous immunoglobulin for all patients in hospitals in England.

Participants

Hospital in-patients with confirmed or suspected autoimmune/limbic encephalitis between September 2010 and January 2017.

Results

A total of 625 patients who were 18 years of age or older were treated with intravenous immunoglobulin for autoimmune encephalitis, of whom 398 were determined as having 'highly likely' or 'definite' autoimmune/limbic encephalitis. Ninety-six percent were treated with a single course of intravenous immunoglobulin. The availability and accuracy of reporting of outcomes was very poor, with complete data only available in 27% of all cases.

Conclusions

This is the first review of data from this unique national database. Whilst there was evidence for clinical improvement in many cases of patients treated with intravenous immunoglobulin, the quality of outcome data was generally inadequate. Methods to improve quality, accuracy and completeness of reporting are crucial to maximise the potential value of this resource as an auditing tool.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Time from Screening Mammography to Biopsy and from Biopsy to Breast Cancer Treatment among Black and White, Women Medicare Beneficiaries Not Participating in a Health Maintenance Organization

PURPOSE

There is a breast cancer mortality gap adversely affecting Black women in the United States. This study assessed the relationship between number of days between abnormal mammogram, biopsy, and treatment among Medicare (Part B) beneficiaries ages 65 to 74 and 75 to 84 years, accounting for race and comorbidity.

METHODS

A cohort of non-Hispanic Black and non-Hispanic White women residing in the continental United States and receiving no services from a health maintenance organization was randomly selected from the Center for Medicare and Medicaid Services denominator file. The cohort was followed from 2005 to 2008 using Center for Medicare and Medicaid Services claims data. The sample included 4,476 women (weighted n = 70,731) with a diagnosis of breast cancer. Cox proportional hazard modeling was used to identify predictors of waiting times.

FINDINGS

Black women had a mean of 16.7 more days between biopsy and treatment (p < .001) and 15.7 more days from mammogram to treatment (p = .003) than White women. Median duration from abnormal mammogram to treatment exceeded National Quality Measures for Breast Centers medians regardless of race, age, or number of comorbidities (overall 43 days vs. the National Quality Measures for Breast Centers value of 28 days).

CONCLUSIONS

Medical care delays may contribute, in part, to the widening breast cancer mortality gap between Black women and White women. Further study, with additional clinical and social information, is needed to broaden scientific understanding of racial determinants and assess the clinical significance of mammogram to treatment times among Medicare beneficiaries.

Abstract A63: Time course from screening mammography to biopsy to treatment among black and white, non-HMO Medicare beneficiaries in 2005-2008

Background: While breast cancer incidence is higher among whites, breast cancer mortality is higher among blacks. Delays in diagnosis and treatment could contribute.

Objective: Describe the time course of screening, diagnosis and treatment among non-Hispanic black and white non-HMO Medicare beneficiaries ages &gt; 65 years.

Data and Methods: We selected a 2005-2008 sub-sample of Medicare beneficiaries, restricted to non-Hispanic black women and white women ages 65 years and older who were: alive from at least 2005 to 2007; had out-patient (Part B) Medicare insurance; and were not enrolled in HMO's for any part of the observation period. For each continental US county or county equivalent we selected a random sample of 250 beneficiaries from each racial/ethnic group, based on analyses showing that n=250 would yield sufficient power to detect differences by race. When counties had &lt;250 beneficiaries, all women from the deficient group(s) were selected. Race/ethnicity-specific sampling weights were obtained by dividing the number of women from a specific county who appeared in the Medicare Denominator file by the race-age-specific number of women residing in that county in excess of 250 who appeared in the sample. The final data set included 11,558 women who received a biopsy between 2005 and 2008, equivalent to a weighted population of 185,153. Claims were identified for diagnostic and screening mammography in 2005-08 as well as a diagnosis of a lump or breast mass at the time of mammography. Algorithms from Smith-Bindman et al. and Fenton et al. were used to distinguish screening from diagnostic mammograms. Positive screens were defined by finding subsequent billing for breast biopsy. Multivariable analysis was used to estimate associations between delays (defined as &gt;21 days from screening to biopsy and &gt;60 days from biopsy to surgery, radiation, or chemotherapy) and age in 2005, race, depression, Charlson co-morbidity scores and US Census region of residence.

Results: Among women receiving biopsies, 7703 or 66.7% had 21 or more days between their most recent mammogram and biopsy. After accounting for co-variables, the delay was 20% (OR 1.20, 95% CI 1.09-1.32) more likely among black beneficiaries than whites and 15% (OR 1.15, 95% CI 1.06-1.25) more likely among beneficiaries with at least one co-morbid condition relative to those with none. The number of days waiting for biopsy were inversely associated with yearly increases in age (OR 0.97, 95% CI 0.97-0.98) and diagnosed depression (OR 0.87, 95% CI 0.77-0.97). Overall, 5236 of the women receiving biopsies were diagnosed with breast cancer (weighted population n=84,837). Among these women, 359 (6.9%) did not start treatment within sixty days and an additional 228 (4.4%) did not start treatment within 60 days or before the end study period. Black women were 2.16 times more likely (95% CI 1.72-2.71) to experience &gt; 60 days post-diagnosis before treatment initiation than white women. Also, yearly increases in age were associated with a 3% (OR 1.03, 95% CI 1.01-1.04, p&lt;0.0001) increase in time until treatment regardless of race. Neither co-morbidity nor depression were significantly associated with longer times between biopsy and treatment. Significant geographic differences (p&lt;0.001) were found for both longer times between mammogram and biopsy, and biopsy and treatment initiation.

Conclusions: These descriptive data are consistent with the hypotheses that black race, age, and geographic region of residence are independent predictors of longer waits for biopsy and treatment among non-HMO black and white Medicare elderly. Relationship of depression to delays between screening and biopsy warrants further study. Analytic epidemiologic study is needed to test these hypotheses and determine whether they contribute to disparities in breast cancer mortality.

Citation Format: Rebecca Selove, Barbara Kilbourne, Maureen Sanderson, Maya Foster, Mary Kay Fadden, Regina Offodile, Baqar Husaini. Time course from screening mammography to biopsy to treatment among black and white, non-HMO Medicare beneficiaries in 2005-2008. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr A63.

Medium-term outcomes following limb salvage for severe open tibia fracture are similar to trans-tibial amputation

Extremity injuries define the surgical burden of recent conflicts. Current literature is inconclusive when assessing the merits of limb salvage over amputation. The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to equivalent outcomes for unilateral trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 and 2010, as described in a previously published series, were contacted. Consenting individuals conducted a brief telephone interview and were asked to complete a SF-36 questionnaire. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation between 2004 and 2010. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria. Telephone follow-up and SF-36 questionnaire data was available for 30 patients (61%). The median follow-up was 4 years (49 months, IQR 39-63). Ten of the 30 patients required revision surgery, three of which involved conversion from initial fixation to a circular frame for non- or mal-union. Twenty-two of the 30 patients (73%) recovered sufficiently to complete an age-standardised basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35-54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores between the limb salvage and amputation groups (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma.

Abstract B64: Using the Consolidated Framework for Implementation Research (CFIR) to identify potential facilitators and barriers of an intervention to increase HPV vaccine uptake

Background: African American and Hispanic women have substantially higher rates of cervical cancer incidence and mortality than White women.

Methods: A community-based participatory research (CBPR) project was undertaken to develop, implement and evaluate a culturally-tailored provider intervention to increase uptake of the Human Papilloma Virus (HPV) vaccine among African American and Hispanic adolescents aged 9-18 years and appropriate cervical cancer screening in their mothers. This CBPR is a collaboration between Meharry Medical College, Tennessee State University (TSU), three community health centers in Nashville, Memphis and Chattanooga, and a Community Advisory Board. The current project re-examined provider interview data obtained for developing the intervention to seek information about potential facilitators and barriers to implementation. The study was also undertaken to inform development of follow-up provider interview questions to assess organizational, provider, and intervention characteristics that might enhance or impede implementation with the aim of improving implementation outcomes.

Investigators conducted 20-30 minute interviews in-person or via telephone with 38 providers from four project sites. Three were community health centers located in Memphis, Chattanooga, and Nashville TN, and one was at a historically Black medical school in Nashville. Individuals in the convenience sample were interviewed between August 2009 and July 2001.

Narrative analysis of transcribed interviews was used to identify (a) provider attitudes, beliefs, and practices related to HPV vaccine, and (b) provider perceptions of organizational or cultural factors that might affect implementation outcomes of acceptability, adoption, and sustainability of the intervention. The approach was primarily holistic (as contrasted with a categorical) approach in that provider remarks were interpreted in the overall context of the project. A coding framework based on the Consolidated Framework for Implementation Research (CFIR) was developed in Excel. Two investigators completed the coding of all interviews and generated composite analyses of each interview and of each coding category. The results of all 38 interviews were summarized as responses to the research objectives.

Results: While initial interview questions were developed to inform design of the intervention, this study determined that narrative analysis of interview transcriptions yielded information about all five CFIR domains that may be related to facilitators and barriers of implementation: (1) Intervention: Provider support for HPV vaccine and engaging educational material was strong. (2) Outer setting: Providers described a variety of their patient population's needs, preferences, and cultural/social contexts that may impact implementation. (3) Inner setting: The intervention takes into account provider workflow needs. However, there are likely to be implementation challenges associated with clinic structures and procedures. (4) Provider characteristics: Some provider beliefs and provider-patient communication strategies may facilitate implementation more than others. (5) Process: The CBPR approach may enhance the adoption of the intervention.

Conclusion: Narrative analysis of provider interviews yields rich information regarding facilitators and barriers to implementing a comprehensive provider intervention to facilitate receipt of the HPV vaccine in project sites. Additional provider training in strategic listening and motivational interviewing may improve individual and organizational capacity to increase HPV vaccine uptake in African American and Hispanic adolescents in settings in which the intervention is offered.

Citation Format: Rebecca Selove, Maya Foster, Maureen Sanderson, Pamela Hull. Using the Consolidated Framework for Implementation Research (CFIR) to identify potential facilitators and barriers of an intervention to increase HPV vaccine uptake. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B64. doi:10.1158/1538-7755.DISP13-B64

The effects and effectiveness of electromotive drug administration and chemohyperthermia for treating non-muscle invasive bladder cancer

INTRODUCTION

Preliminary studies show that device assisted intravesical therapies appear more effective than passive diffusion intravesical therapy for the treatment of non-muscle invasive bladder cancer (NMIBC) in specific settings, and phase III studies are now being conducted. Consequently, we have undertaken a non-systematic review with the objective of describing the scientific basis and mechanisms of action of electromotive drug administration (EMDA) and chemohyperthermia (CHT).

METHODS

PubMed, ClinicalTrials.gov and the Cochrane Library were searched to source evidence for this non-systematic review. Randomised controlled trials, systematic reviews and meta-analyses were evaluated. Publications regarding the scientific basis and mechanisms of action of EMDA and CHT were identified, as well as clinical studies to date.

RESULTS

EMDA takes advantage of three phenomena: iontophoresis, electro-osmosis and electroporation. It has been found to reduce recurrence rates in NMIBC patients and has been proposed as an addition or alternative to bacillus Calmette-Guérin (BCG) therapy in the treatment of high risk NMIBC. CHT improves the efficacy of mitomycin C by three mechanisms: tumour cell cytotoxicity, altered tumour blood flow and localised immune responses. Fewer studies have been conducted with CHT than with EMDA but they have demonstrated utility for increasing disease-free survival, especially in patients who have previously failed BCG therapy.

CONCLUSIONS

It is anticipated that EMDA and CHT will play important roles in the management of NMIBC in the future. Techniques of delivery should be standardised, and there is a need for more randomised controlled trials to evaluate the benefits of the treatments alongside quality of life and cost-effectiveness.