Inequalities in birth before arrival at hospital in South West England: a multimethods study of neonatal hypothermia and emergency medical services call-handler advice

OBJECTIVES

To examine inequalities in birth before arrival (BBA) at hospitals in South West England, understand which groups are most likely to experience BBA and how this relates to hypothermia and outcomes (phase A). To investigate opportunities to improve temperature management advice given by emergency medical services (EMS) call-handlers during emergency calls regarding BBA in the UK (phase B).

DESIGN

A two-phase multimethod study. Phase A analysed anonymised data from hospital neonatal records between January 2018 and January 2021. Phase B analysed anonymised EMS call transcripts, followed by focus groups with National Health Service (NHS) staff and patients.

SETTING

Six Hospital Trusts in South West England and two EMS providers (ambulance services) in South West and North East England.

PARTICIPANTS

18 multidisciplinary NHS staff and 22 members of the public who had experienced BBA in the UK.

RESULTS

35% (64/184) of babies conveyed to hospital were hypothermic on arrival. When compared with national data on all births in the South West, we found higher percentages of women with documented safeguarding concerns at booking, previous live births and 'late bookers' (booking their pregnancy >13 weeks gestation). These women may, therefore, be more likely to experience BBA. Preterm babies, babies to first-time mothers and babies born to mothers with disability or safeguarding concerns at booking were more likely to be hypothermic following BBA. Five main themes emerged from qualitative data on call-handler advice: (1) importance placed on neonatal temperature; (2) advice on where the baby should be placed following birth; (3) advice on how to keep the baby warm; (4) timing of temperature management advice and (5) clarity and priority of instructions.

CONCLUSIONS

Findings identified factors associated with BBA and neonatal hypothermia following BBA. Improvements to EMS call-handler advice could reduce the number of babies arriving at hospital hypothermic.

Metabolic Alterations Caused by Simultaneous Loss of HK2 and PKM2 Leads to Photoreceptor Dysfunction and Degeneration

HK2 and PKM2 are two main regulators of aerobic glycolysis. Photoreceptors (PRs) use aerobic glycolysis to produce the biomass necessary for the daily renewal of their outer segments. Previous work has shown that HK2 and PKM2 are important for the normal function and long-term survival of PRs but are dispensable for PR maturation, and their individual loss has opposing effects on PR survival during acute nutrient deprivation. We generated double conditional (dcKO) mice lacking HK2 and PKM2 expression in rod PRs. Western blotting, immunofluorescence, optical coherence tomography, and electroretinography were used to characterize the phenotype of dcKO animals. Targeted and stable isotope tracing metabolomics, qRT-PCR, and retinal oxygen consumption were performed. We show that dcKO animals displayed early shortening of PR inner/outer segments, followed by loss of PRs with aging, much more rapidly than either knockout alone without functional loss as measured by ERG. Significant alterations to central glucose metabolism were observed without any apparent changes to mitochondrial function, prior to PR degeneration. Finally, PR survival following experimental retinal detachment was unchanged in dcKO animals as compared to wild-type animals. These data suggest that HK2 and PKM2 have differing roles in promoting PR neuroprotection and identifying them has important implications for developing therapeutic options for combating PR loss during retinal disease.

A Markov Chain Model for Mental Health Interventions

Poor mental health affects nearly one billion people worldwide and can end in suicide if not treated. Unfortunately, stigma and a lack of mental healthcare providers are barriers to receiving needed care. We developed a Markov chain model to determine whether decreasing stigma or increasing available resources improves mental health outcomes. We mapped potential steps in the mental health care continuum with two discrete outcomes: getting better or committing suicide. Using a Markov chain model, we calculated probabilities of each outcome based on projected increases in seeking help or availability of professional resources. Modeling for a 12% increase in awareness of mental health concerns yielded a 0.39% reduction in suicide. A 12% increase in access to professional help yielded a 0.47% reduction in suicide rate. Our results show that expanding access to professional services has a higher impact on reducing suicide rates than creating awareness. Any intervention towards awareness or access positively impacts reducing suicide rates. However, increased access results in a higher reduction in suicide rates. We have made progress in increasing awareness. Awareness campaigns help to increase recognition of mental health needs. However, focusing efforts on increasing access to care may have a higher impact on reducing suicide rates.

Temperature measurement of babies born in the pre-hospital setting: analysis of ambulance service data and qualitative interviews with paramedics

BACKGROUND

Birth before arrival at hospital (BBA) is associated with unfavourable perinatal outcomes and increased mortality. An important risk factor for mortality following BBA is hypothermia, and emergency medical services (EMS) providers are well placed to provide warming strategies. However, research from the UK suggests that EMS providers (paramedics) do not routinely record neonatal temperature following BBA. This study aimed to determine the proportion of cases in which neonatal temperature is documented by paramedics attending BBAs in the South West of England and to explore the barriers to temperature measurement by paramedics.

METHODS

A two-phase multi-method study. Phase I involved an analysis of anonymised data from electronic patient care records between 1 February 2017 and 31 January 2020 in a single UK ambulance service, to determine 1) the frequency of BBAs attended and 2) the percentage of these births where a neonatal temperature was recorded, and what proportion of these were hypothermic. Phase II involved interviews with 20 operational paramedics from the same ambulance service, to explore their experiences of, and barriers and facilitators to, neonatal temperature measurement and management following BBA.

RESULTS

There were 1582 'normal deliveries' attended by paramedics within the date range. Neonatal temperatures were recorded in 43/1582 (2.7%) instances, of which 72% were below 36.5°C. Data from interviews suggested several barriers and potential facilitators to paramedic measurement of neonatal temperature. Barriers included unavailable or unsuitable equipment, prioritisation of other care activities, lack of exposure to births, and uncertainty regarding responsibilities and roles. Possible facilitators included better equipment, physical prompts, and training and awareness-raising around the importance of temperature measurement.

CONCLUSIONS

This study demonstrates a lack of neonatal temperature measurement by paramedics in the South West following BBA, and highlights barriers and facilitators that could serve as a basis for developing an intervention to improve neonatal temperature measurement.

An app with brief behavioural support to promote physical activity after a cancer diagnosis (APPROACH): study protocol for a pilot randomised controlled trial

Background

There are multiple health benefits from participating in physical activity after a cancer diagnosis, but many people living with and beyond cancer (LWBC) are not meeting physical activity guidelines. App-based interventions offer a promising platform for intervention delivery. This trial aims to pilot a theory-driven, app-based intervention that promotes brisk walking among people living with and beyond cancer. The primary aim is to investigate the feasibility and acceptability of study procedures before conducting a larger randomised controlled trial (RCT).

Methods

This is an individually randomised, two-armed pilot RCT. Patients with localised or metastatic breast, prostate, or colorectal cancer, who are aged 16 years or over, will be recruited from a single hospital site in South Yorkshire in the UK. The intervention includes an app designed to encourage brisk walking (Active 10) supplemented with habit-based behavioural support in the form of two brief telephone/video calls, an information leaflet, and walking planners. The primary outcomes will be feasibility and acceptability of the study procedures. Demographic and medical characteristics will be collected at baseline, through self-report and hospital records. Secondary outcomes for the pilot (assessed at 0 and 3 months) will be accelerometer measured and self-reported physical activity, body mass index (BMI) and waist circumference, and patient-reported outcomes of quality of life, fatigue, sleep, anxiety, depression, self-efficacy, and habit strength for walking. Qualitative interviews will explore experiences of participating or reasons for declining to participate. Parameters for the intended primary outcome measure (accelerometer measured average daily minutes of brisk walking (≥ 100 steps/min)) will inform a sample size calculation for the future RCT and a preliminary economic evaluation will be conducted.

Discussion

This pilot study will inform the design of a larger RCT to investigate the efficacy and cost-effectiveness of this intervention in people LWBC.

Trial registration

ISRCTN registry, ISRCTN18063498. Registered 16 April 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01028-w.

Management of functional communication, swallowing, cough and related disorders: consensus recommendations for speech and language therapy

Communication problems (eg, dysphonia, dysfluency and language and articulation disorders), swallowing disorders (dysphagia and globus), cough and upper airway symptoms, resulting from functional neurological disorder (FND), are commonly encountered by speech and language professionals. However, there are few descriptions in the literature of the most effective practical management approaches. This consensus document aims to provide recommendations for assessment and intervention that are relevant to both adults and young people. An international panel of speech and language professionals with expertise in FND were approached to take part. Participants responded individually by email to a set of key questions regarding best practice for assessment and interventions. Next, a video conference was held in which participants discussed and debated the answers to these key questions, aiming to achieve consensus on each issue. Drafts of the collated consensus recommendations were circulated until consensus was achieved. FND should be diagnosed on the basis of positive clinical features. Speech and language therapy for FND should address illness beliefs, self-directed attention and abnormal movement patterns through a process of education, symptomatic treatment and cognitive behavioural therapy within a supportive therapeutic environment. We provide specific examples of these strategies for different symptoms. Speech and language professionals have a key role in the management of people with communication and related symptoms of FND. It is intended that these expert recommendations serve as both a practical toolkit and a starting point for further research into evidence-based treatments.

P–640 High physical activity and ovarian reserve: A prospective study of normo-ovulatory professional athletes

Study question

Is high physical activity (HPA) associated with low ovarian reserve in normo-ovulatory, reproductive-age women?

Summary answer

HPA does not affect ovarian reserve negatively.

What is known already

HPA is associated with menstrual irregularities and subsequent potential infertility, probably through hypothalamic neuroendocrine pathways. However, it is not yet known whether HPA influences the ovarian reserves of normo-ovulatory, reproductive-age women.

Study design, size, duration

This observational, cross-sectional study compared 30 professional female athletes who were engaged in HPA for at least 3 years prior to study recruitment, with high International Physical Activity Questionnaire (IPAQ) scores and 30 women who did not engage in physical activity. The study was conducted at a tertiary medical center from 2017–2020.

Participants/materials, setting, methods

Physically active, normo-ovulatory women (n = 30), ages 20–35 years were recruited from The Wingate Institute, the Israeli National Institute for Sport Excellence. Non-physically active women (n = 30), matched by age and BMI to the HPA group, were recruited from the hospital staff. Both groups were evaluated for ovarian reserve markers on day 2–5 of the menstrual cycle, including follicular stimulating hormone (FSH), antral follicle count (AFC), anti-Mullerian hormone (AMH) and Inhibin B.

Main results and the role of chance

The average age of the athletes (HPA group) was 30.1±2.1 years and of the nonactive (control) group 31.6±3.8 years (p = 0.071). BMI of the 2 groups was similar (22.6±2.4 vs. 21.3±2.6; p = 0.075) for the HPA and control groups, respectively. Regarding ovarian reserve, no significant differences were observed between the HPA group and the control group with respect to FSH (p = 0.304), AFC (p = 0.27), AMH (0.507) or Inhibin B (p = 0.074). For the HPA group, older age at menarche was positively associated with AFC (p = 0.008) and AMH (p = 0.009) and not with FSH levels (p = 0.313). For the nonactive group, no significant association between age at menarche and FSH levels, AFC or AMH was found (p = 0.433, p = 0.274 and p = 0.163, respectively). Additionally, for the HPA group, duration of physical activity per week (hours) was not significantly associated with FSH levels, AFC or AMH (p = 0.619, p = 0.608 or p = 0.997, respectively).

Limitations, reasons for caution

Although we investigated the ovarian reserves of 30 women engaged in HPA, a larger cohort would provide more information. Information on diet and sleep habits was not evaluated and may result in some confounding. Moreover, it would be more informative if we also followed these women regarding fecundability and fertility.

Wider implications of the findings: This study demonstrated that HPA may not negatively affect ovarian reserve markers. These findings may provide reassurance for women who are engaged in HPA and attempting pregnancy. Further research needs s to be confuted.

Trial registration number

0247–16

Clinicopathological and prognostic significance of programmed cell death ligand 1 expression in patients diagnosed with breast cancer: meta-analysis

BACKGROUND

Uncertainty exists regarding the clinical relevance of programmed cell death ligand 1 (PD-L1) expression in breast cancer.

METHODS

A systematic review was performed in accordance with PRISMA guidelines. Observational studies that compared high versus low expression of PD-L1 on breast cancer cells were identified. Log hazard ratios (HRs) for disease-free and overall survival and their standard errors were calculated from Kaplan-Meier curves or Cox regression analyses, and pooled using the inverse-variance method. Dichotomous variables were pooled as odds ratios (ORs) using the Mantel-Haenszel method.

RESULTS

Sixty-five studies with 19 870 patients were included; 14 404 patients were classified as having low and 4975 high PD-L1 expression. High PD-L1 was associated with achieving a pathological complete response following neoadjuvant chemotherapy (OR 3.30, 95 per cent confidence interval 1.19 to 9.16; P < 0.01; I2 = 85 per cent). Low PD-L1 expression was associated with human epidermal growth factor receptor 2 (OR 3.98, 1.81 to 8.75; P < 0.001; I2 = 96 per cent) and luminal (OR 14.93, 6.46 to 34.51; P < 0.001; I2 = 99 per cent) breast cancer subtypes. Those with low PD-L1 had favourable overall survival rates (HR 1.30, 1.05 to 1.61; P = 0.02; I2 = 85 per cent).

CONCLUSION

Breast cancers with high PD-L1 expression are associated with aggressive clinicopathological and immunohistochemical characteristics and are more likely to achieve a pathological complete response following neoadjuvant chemotherapy. These breast cancers are, however, associated with worse overall survival outcomes.

Whole-genome analysis of extraintestinal Escherichia coli sequence type 73 from a single hospital over a 2 year period identified different circulating clonal groups

Sequence type (ST)73 has emerged as one of the most frequently isolated extraintestinal pathogenic Escherichia coli. To examine the localized diversity of ST73 clonal groups, including their mobile genetic element profile, we sequenced the genomes of 16 multiple-drug resistant ST73 isolates from patients with urinary tract infection from a single hospital in Sydney, Australia, between 2009 and 2011. Genome sequences were used to generate a SNP-based phylogenetic tree to determine the relationship of these isolates in a global context with ST73 sequences (n=210) from public databases. There was no evidence of a dominant outbreak strain of ST73 in patients from this hospital, rather we identified at least eight separate groups, several of which reoccurred, over a 2 year period. The inferred phylogeny of all ST73 strains (n=226) including the ST73 clone D i2 reference genome shows high bootstrap support and clusters into four major groups that correlate with serotype. The Sydney ST73 strains carry a wide variety of virulence-associated genes, but the presence of iss, pic and several iron-acquisition operons was notable.

Offspring polymorphism and bet hedging: a large-scale, phylogenetic analysis

Offspring polymorphism is a reproductive strategy where individual organisms simultaneously produce offspring that differ in morphology and ecology. It occurs across the Tree of Life but is particularly common among plants, where it is termed seed (diaspore) heteromorphism. The prevalence of this strategy in unpredictably varying environments has resulted in the assumption that it serves as a bet-hedging mechanism. We found 101 examples of this strategy in southwestern North America. We provide phylogenetically informed evidence for the hypothesis that the occurrence of seed heteromorphism increases with increasing environmental variability, though this pattern was only significant for aridity, one of our two rainfall variability metrics. We provide a strong test of bet hedging for a large, taxonomically diverse set of seed heteromorphic species, lending support to the hypothesis that bet hedging is an important mechanistic driver for the evolution of seed heteromorphism.

Co-Infection with SARS-COV-2 and Parainfluenza in a young adult patient with pneumonia: Case Report

Coronavirus 2 (SARS-CoV-2) is now considered a pandemic causing Coronavirus disease (COVID-19), multiple fatalities and morbidities which have been associated with it worldwide. We report a severe pneumonia causing acute respiratory distress syndrome due to a coinfection with SARS-COV-2 and Parainfluenza 4 virus in a Hispanic 21 year old male in Florida, USA. The case represents the importance of prompt diagnosis and awareness of the potential co-infection with other respiratory viruses and this novel deadly virus.

Understanding foreign accent syndrome

OBJECTIVE

Foreign accent syndrome (FAS) is widely understood as an unusual consequence of structural neurological damage, but may sometimes represent a functional neurological disorder. This observational study aimed to assess the prevalence and utility of positive features of functional FAS in a large group of individuals reporting FAS.

METHODS

Participants self-reporting FAS recruited from informal unmoderated online support forums and via professional networks completed an online survey. Speech samples were analysed in a subgroup.

RESULTS

Forty-nine respondents (24 UK, 23 North America, 2 Australia) reported FAS of mean duration 3 years (range 2 months to 18 years). Common triggers were: migraine/severe headache (15), stroke (12), surgery or injury to mouth or face (6) and seizure (5, including 3 non-epileptic). High levels of comorbidity included migraine (33), irritable bowel syndrome (17), functional neurological disorder (12) and chronic pain (12). Five reported structural lesions on imaging. Author consensus on aetiology divided into, 'probably functional (n=35.71%), 'possibly structural' (n=4.8%) and 'probably structural' (n=10.20%), but positive features of functional FAS were present in all groups. Blinded analysis of speech recordings supplied by 13 respondents correctly categorised 11 (85%) on the basis of probable aetiology (functional vs structural) in agreement with case history assignment.

CONCLUSIONS

This largest case series to date details the experience of individuals with self-reported FAS. Although conclusions are limited by the recruitment methods, high levels of functional disorder comorbidity, symptom variability and additional linguistic and behavioural features suggest that chronic FAS may in some cases represent a functional neurological disorder, even when a structural lesion is present.

The feasibility and acceptability of using a novel wrist worn cueing device to self-manage drooling problems in people with Parkinson's disease: A pilot study

Introduction

Daytime drooling is experienced by around 50% of Parkinson’s patients, who fail to swallow saliva in sufficient volume or regularity, despite normal production. This research explored the feasibility and acceptability of using a cueing device, to improve drooling.

Methods

During a four-week intervention, 28 participants were asked to use a cueing device for 1 h per day. During this time, the device vibrated once-per-minute, reminding the participant to swallow their saliva. A daily diary was used to collect self-report around swallowing severity, frequency, and duration. This was filled out by participants for one week before, four weeks during and for one week immediately after intervention. Diaries were also collected for one week during a follow up, carried out four weeks after intervention finished.

Results

Participants self-reported benefits in drooling severity (p = 0.031), frequency (p ≤ 0.001), and duration (p = 0.001) after using the device. Improvements were maintained at follow up. Twenty-two participants explicitly reported a positive benefit to their drooling during exit interview. All felt the intervention and device were acceptable and usable.

Conclusions

Using a cueing device for one month had perceived benefit to drooling severity, frequency and duration in patients with Parkinson’s. Participants accepted the device and treatment protocol.

Abstract P6-20-06: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Dann S, Chionis J, Eisele K, Zhang Q, Liu C, Yuan J, Miller N, Murray B, Xu M, Solowiej J, Wei P, Weinrich S, Sutton S, Behenna D, Ninkovic S, Hoffman R, Freeman-Cook K, Jessen B, Huser N, Zhang C, Visswanathan R, Boras B, VanArsdale T, White MA. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-20-06.