Volumetric changes in post hemiglossectomy reconstruction with anterolateral thigh free flap versus radial forearm free flap

The volume of the reconstructed tongue is considered a critical factor for tongue function. Studies investigating the difference in volume loss between the anterolateral thigh free flap (ALTF) and radial forearm free flap (RFFF) used in reconstruction of the tongue after hemiglossectomy are lacking. The aim of this study was to determine whether there is a significant difference in shrinkage between these two flaps. This was a retrospective study of all patients treated for tongue cancer by hemiglossectomy who underwent either ALTF or RFFF reconstruction at the University of Florida College of Medicine between January 2018 and April 2022. Computed tomography scans were used to measure the volumetric changes in the ALTF and RFFF at two time points over a 6-month period. Of the 85 patients assessed, 10 fulfilled the inclusion criteria: five were reconstructed with an ALTF and five with a RFFF. All underwent adjuvant radiotherapy. The mean ALTF percentage shrinkage was 39.6% ± 3.9%, while for the RFFF it was 51.1% ± 6.2% (P = 0.008). Therefore, it is recommended that the difference in volume loss between the two flaps is taken into consideration. It is suggested that in hemiglossectomy cases, the ALTF is made 1.4 times larger than the defect, while the RFFF is made 1.5 times larger.

Identification of candidate novel production variants on the Bos taurus chromosome X

Chromosome X is often excluded from bovine genetic studies due to complications caused by the sex specific nature of the chromosome. As chromosome X is the second largest cattle chromosome and makes up approximately 6% of the female genome, finding ways to include chromosome X in dairy genetic studies is important. Using female animals and treating chromosome X as an autosome, we performed X chromosome inclusive genome-wide association studies in the selective breeding environment of the New Zealand dairy industry, aiming to identify chromosome X variants associated with milk production traits. We report on the findings of these genome-wide association studies and their potential effect within the dairy industry. We identify missense mutations in the MOSPD1 and CCDC160 genes that are associated with decreased milk volume and protein production and increased fat production. Both of these mutations are exonic SNP that are more prevalent in the Jersey breed than in Holstein-Friesians. Of the 2 candidates proposed it is likely that only one is causal, though we have not been able to identify which is more likely.

VSIG4 interaction with heparan sulfates inhibits VSIG4-complement binding

V-set and immunoglobulin domain-containing 4 (VSIG4) is a complement receptor of the immunoglobulin superfamily that is specifically expressed on tissue resident macrophages, and its many reported functions and binding partners suggest a complex role in immune function. VSIG4 is reported to have a role in immune surveillance as well as in modulating diverse disease phenotypes such as infections, autoimmune conditions, and cancer. However, the mechanism(s) governing VSIG4's complex, context-dependent role in immune regulation remains elusive. Here, we identify cell surface and soluble glycosaminoglycans, specifically heparan sulfates, as novel binding partners of VSIG4. We demonstrate that genetic deletion of heparan sulfate synthesis enzymes or cleavage of cell-surface heparan sulfates reduced VSIG4 binding to the cell surface. Furthermore, binding studies demonstrate that VSIG4 interacts directly with heparan sulfates, with a preference for highly sulfated moieties and longer glycosaminoglycan chains. To assess the impact on VSIG4 biology, we show that heparan sulfates compete with known VSIG4 binding partners C3b and iC3b. Furthermore, mutagenesis studies indicate that this competition occurs through overlapping binding epitopes for heparan sulfates and complement on VSIG4. Together these data suggest a novel role for heparan sulfates in VSIG4-dependent immune modulation.

Extended postoperative venous thromboembolism prophylaxis after bariatric surgery: a comparison of existing risk-stratification tools and 5-year MBSAQIP analysis

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of 30-day mortality after metabolic and bariatric surgery (MBS). Multiple predictive tools exist for VTE risk assessment and extended VTE chemoprophylaxis determination.

OBJECTIVE

To review existing risk-stratification tools and compare their predictive abilities.

SETTING

MBSAQIP database.

METHODS

Retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was performed (2015-2019) for primary minimally invasive MBS cases. VTE clinical factors and risk-assessment tools were evaluated: body mass index threshold of 50 kg/m2, Caprini risk-assessment model, and 3 bariatric-specific tools: the Cleveland Clinic VTE risk tool, the Michigan Bariatric Surgery Collaborative tool, and BariClot. MBS patients were deemed high risk based on criteria from each tool and further assessed for sensitivity, specificity, and positive predictive value.

RESULTS

Overall, 709,304 patients were identified with a .37% VTE rate. Bariatric-specific tools included multiple predictors: procedure, age, race, gender, operative time, length of stay, heart failure, and dyspnea at rest; operative time was the only variable common to all. The body mass index cutoff and Caprini risk-assessment model had higher sensitivity but lower specificity when compared with the Michigan Bariatric Surgery Collaborative and BariClot tools. While the sensitivity of the tools varied widely and was overall low, the Cleveland Clinic tool had the highest sensitivity. The bariatric-specific tools would have recommended extended prophylaxis for 1.1%-15.6% of patients.

CONCLUSIONS

Existing MBS VTE risk-assessment tools differ widely for inclusion variables, high-risk definition, and predictive performance. Further research and registry inclusion of all significant risk factors are needed to determine the optimal risk-stratified approach for predicting VTE events and determining the need for extended prophylaxis.

Single-shot 3D photoacoustic computed tomography with a densely packed array for transcranial functional imaging

Photoacoustic computed tomography (PACT) is emerging as a new technique for functional brain imaging, primarily due to its capabilities in label-free hemodynamic imaging. Despite its potential, the transcranial application of PACT has encountered hurdles, such as acoustic attenuations and distortions by the skull and limited light penetration through the skull. To overcome these challenges, we have engineered a PACT system that features a densely packed hemispherical ultrasonic transducer array with 3072 channels, operating at a central frequency of 1 MHz. This system allows for single-shot 3D imaging at a rate equal to the laser repetition rate, such as 20 Hz. We have achieved a single-shot light penetration depth of approximately 9 cm in chicken breast tissue utilizing a 750 nm laser (withstanding 3295-fold light attenuation and still retaining an SNR of 74) and successfully performed transcranial imaging through an ex vivo human skull using a 1064 nm laser. Moreover, we have proven the capacity of our system to perform single-shot 3D PACT imaging in both tissue phantoms and human subjects. These results suggest that our PACT system is poised to unlock potential for real-time, in vivo transcranial functional imaging in humans.

Optical-resolution photoacoustic microscopy with a needle-shaped beam

Optical-resolution photoacoustic microscopy (OR-PAM) can visualize wavelength-dependent optical absorption at the cellular level. However, OR-PAM suffers from a limited depth of field (DOF) due to the tight focus of the optical excitation beam, making it challenging to acquire high-resolution images of samples with uneven surfaces or high-quality volumetric images without z-scanning. To overcome this limitation, we propose needle-shaped beam photoacoustic microscopy (NB-PAM), which can extend the DOF to up to ~28-fold Rayleigh lengths via customized diffractive optical elements (DOEs). The DOE generate a needle beam with a well-maintained beam diameter, a uniform axial intensity distribution, and negligible sidelobes. The advantage of using NB-PAM is demonstrated by both histology-like imaging of fresh slide-free organs using a 266 nm laser and in vivo mouse brain vasculature imaging using a 532 nm laser. The approach provides new perspectives for slide-free intraoperative pathological imaging and in-vivo organ-level imaging.

Statistical inference for unreliable grading using the maximum entropy principle

Quantitatively assessing the level of confidence on a test score can be a challenging problem, especially when the available information is based on multiple criteria. A concrete example beyond the usual grading of tests occurs with recommendation letters, where a recommender assigns a score to a candidate, but the reliability of the recommender must be assessed as well. Here, we present a statistical procedure, based on Bayesian inference and Jaynes' maximum entropy principle, that can be used to estimate the most probable and expected score given the available information in the form of a credible interval. Our results may provide insights on how to properly state and analyze problems related to the uncertain evaluation of performance in learning applied to several contexts, beyond the case study of the recommendation letters presented here.

A Scoping Review of the Management of Benign Prostate Hyperplasia in Africa

Benign prostatic hyperplasia (BPH) is a non-malignant prostate gland enlargement of unknown cause that affects more than 50% of men over 60 and is the most common cause of bladder outlet obstruction and voiding symptoms. BPH is treated primarily with watchful waiting, phytotherapy (herbs), and medical or surgical options. In this study, we sought to examine the different management practices in African urological centers, outcomes of management, and complications. A literature search was conducted using PubMed, African Journal Online, and Google Scholar regarding the management of BPH from inception till date. Articles were selected based on their relevance to the management of benign prostatic enlargement in Africa. Results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. The studies included were conducted from 1997 to 2022. They were from eight different African countries (Nigeria, Kenya, Togo, Ethiopia, Egypt, South Africa, Ghana, and Congo), with Nigeria contributing the most with 10 studies. Exactly 2999 patients were included in the study. Seventy-three (73.49%) percent of these patients totaling 2204, underwent surgical management of BPH, 124 (4.13%) patients were treated with phytomedicines or herbs, and 684 (22.80%) patients were treated with medical therapy. The complications and outcomes were studied and collated. A total of 808 patients opted for non-surgical treatment for BPH in the included studies. In this group, 124 were treated using phytochemicals or natural herbs, and 648 were treated with standard prescription medications. While surgical treatment for benign prostatic enlargement is shifting towards minimally invasive procedures in the developed world, open prostatectomy is still quite popular in Africa. Further research should focus not only on the reason for these disparities in management but also on the rationale for the selection of medical, surgical, or phytotherapy in African urological centres.

QTc interval in anorexia nervosa: a systematic review and meta-analysis

Background

Patients with anorexia nervosa (AN) are at higher risk of sudden cardiac death. Although the underlying aetiology for this association remains unclear. It may be related to prolongation of the QT interval, which can degenerate into fatal ventricular arrhythmias. However, the presence of prolonged heart rate-corrected QT interval (QTc) in AN remains controversial, and two previous meta-analyses on AN and QTc showed contradictory findings [1,2].

Purpose

In this systematic review and meta-analysis, we aimed to evaluate if AN was associated with changes in the QTc interval and dispersion.

Methods

MEDLINE, EMBASE and COCHRANE databases were systematically searched from inception to January 2021. Random-effects meta-analysis and meta-regression were used. The inclusion criteria were (i) confirmed diagnosis of AN, (ii) measurement of QTc on electrocardiogram and (iii) peer-reviewed articles. The primary endpoint of the study was the duration of the QTc interval calculated using the Bazett (QTcB), Hodges (QTcH), Fridericia (QTcF) and Framingham (QTcFr) formulae. The secondary endpoints were QT dispersion (QTd) and QTc dispersion (QTcd).

Results

The 25 eligible studies included 5687 patients (1862 AN, 3825 control) (Figure 1: PRISMA diagram). The majority of patients were female (96.3%) with a mean age between 14.3 to 31.0 years and mean duration of disease ranging from 9.1 to 129.6 months. The mean BMI ranged from 13.7 to 18.5 kg/m2. Pooled analysis did not show significant prolongation between AN versus control in QTcB (mean difference (MD) MD 4.9ms, 95% CI −3.2, 13.1ms, p=0.23; I2=95%; n=24/25 studies; Figure 2A), QTcH (MD 1.3ms, 95% CI −8.5, 11.2ms, p=0.79; I2=71%; n=3/25 studies), and QTcF (MD 3.1ms, 95% CI −21.6, 27.7ms, p=0.81; I2=97%; n=3/25 studies). Only two studies reporting QTcFr showed a significant prolongation between AN and control (MD 15.9ms, 95% CI 0.0, 31.8ms, p=0.05, I2=65%; n=2/25 studies; Figure 2B). However, QTd and QTcd were significantly greater in AN than control (MD 21.3ms, 95% CI 10.4, 32.3ms, p=0.0001, I2=94%; Figure 2C and MD 16.9ms, 95% CI 4.5, 29.3ms, p=0.007 I2=93%; Figure 2D, respectively).

Conclusion

To the best of our knowledge, this is the largest meta-analysis of QTc in AN and the first meta-analysis exploring the significance of QTd and QTcd in AN. AN was not found to be associated with prolongation of QTc calculated using the Bazett, Fridericia and Hodges formulae. However, an association of AN with prolonged QTc was observed in the studies using the Framingham formula. More pronounced dispersion (QTd and QTcd) was also observed in patients with AN.

Funding Acknowledgement

Type of funding sources: None.

Genetic variation within the human papillomavirus type 16 genome is associated with oropharyngeal cancer prognosis

PURPOSE

A significant barrier to adoption of de-escalated treatment protocols for human papillomavirus-driven oropharyngeal cancer (HPV-OPC) is that few predictors of poor prognosis exist. We conducted the first large whole-genome sequencing (WGS) study to characterize the genetic variation of the HPV type 16 (HPV16) genome and to evaluate its association with HPV-OPC patient survival.

PATIENTS AND METHODS

A total of 460 OPC tumor specimens from two large United States medical centers (1980-2017) underwent HPV16 whole-genome sequencing. Site-specific variable positions [single nucleotide polymorphisms (SNPs)] across the HPV16 genome were identified. Cox proportional hazards model estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for overall survival by HPV16 SNPs. Harrell C-index and time-dependent positive predictive value (PPV) curves and areas under the PPV curves were used to evaluate the predictive accuracy of HPV16 SNPs for overall survival.

RESULTS

A total of 384 OPC tumor specimens (83.48%) passed quality control filters with sufficient depth and coverage of HPV16 genome sequencing to be analyzed. Some 284 HPV16 SNPs with a minor allele frequency ≥1% were identified. Eight HPV16 SNPs were significantly associated with worse survival after false discovery rate correction (individual prevalence: 1.0%-5.5%; combined prevalence: 15.10%); E1 gene position 1053 [HR for overall survival (HRos): 3.75, 95% CI 1.77-7.95; Pfdr = 0.0099]; L2 gene positions 4410 (HRos: 5.32, 95% CI 1.91-14.81; Pfdr = 0.0120), 4539 (HRos: 6.54, 95% CI 2.03-21.08; Pfdr = 0.0117); 5050 (HRos: 6.53, 95% CI 2.34-18.24; Pfdr = 0.0030), and 5254 (HRos: 7.76, 95% CI 2.41-24.98; Pfdr = 0.0030); and L1 gene positions 5962 (HRos: 4.40, 95% CI 1.88-10.31; Pfdr = 0.0110) and 6025 (HRos: 5.71, 95% CI 2.43-13.41; Pfdr = 0.0008) and position 7173 within the upstream regulatory region (HRos: 9.90, 95% CI 3.05-32.12; Pfdr = 0.0007). Median survival time for patients with ≥1 high-risk HPV16 SNPs was 3.96 years compared with 18.67 years for patients without a high-risk SNP; log-rank test P < 0.001. HPV16 SNPs significantly improved the predictive accuracy for overall survival above traditional factors (age, smoking, stage, treatment); increase in C-index was 0.069 (95% CI 0.019-0.119, P < 0.001); increase in area under the PPV curve for predicting 5-year survival was 0.068 (95% CI 0.015-0.111, P = 0.008).

CONCLUSIONS

HPV16 genetic variation is associated with HPV-OPC prognosis and can improve prognostic accuracy.

Comparing medication adherence in patients receiving bisphosphonates for preventing fragility fractures: a comprehensive systematic review and network meta-analysis

BACKGROUND

Bisphosphonates are effective in preventing fragility fractures; however, high rates of adherence are needed to preserve clinical benefits.

OBJECTIVE

To investigate persistence and compliance to oral and intravenous bisphosphonates (alendronate, ibandronate, risedronate, and zoledronate).

METHODS

Searches of 12 databases, unpublished sources, and trial registries were conducted, covering the period from 2000 to April 2021. Screening, data extraction, and risk of bias assessment (Cochrane Collaboration risk-of-bias tool 1.0 & ROBINS-I) were independently undertaken by two study authors. Randomised controlled trials (RCTs) and observational studies that used prescription claim databases or hospital medical records to examine patients' adherence were included. Network meta-analyses (NMA) embedded within a Bayesian framework were conducted, investigating users' likelihood in discontinuing bisphosphonate treatment. Where meta-analysis was not possible, data were synthesised using the vote-counting synthesis method.

RESULTS

Fifty-nine RCTs and 43 observational studies were identified, resulting in a total population of 2,656,659 participants. Data from 59 RCTs and 24 observational studies were used to populate NMAs. Zoledronate users were the least likely to discontinue their treatment HR = 0.73 (95%CrI: 0.61, 0.88). Higher rates of compliance were observed in those receiving intravenous treatments. The paucity of data and the heterogeneity in the reported medication possession ratio thresholds precluded a NMA of compliance data.

CONCLUSIONS

Users of intravenously administered bisphosphonates were found to be the most adherent to treatment among bisphosphonates' users. Patterns of adherence will permit the more precise estimation of clinical and cost-effectiveness of bisphosphonates.

TRIAL REGISTRATION

PROSPERO 2020 CRD42020177166.

Utility of PINP to monitor osteoporosis treatment in primary care, the POSE study (PINP and Osteoporosis in Sheffield Evaluation)

PURPOSE

In Sheffield (UK), we introduced the PINP monitoring algorithm for the management of osteoporosis treatment delivered in primary care. Our aims were to evaluate whether this algorithm was associated with better osteoporosis outcomes and was cost-effective compared to standard care.

METHODS

Inclusion criteria were referral from Sheffield GPs, BMD scans performed between 2012 and 2013 and a report advising initiation of oral bisphosphonate and PINP monitoring. 906 patients were identified and retrospectively divided into Group A (intention to monitor, with baseline PINP, n = 588) and Group B (no intention to monitor, without baseline PINP, n = 318). The model described by Davis and colleagues was used to extrapolate life-time costs and quality-adjusted life-years (QALYs).

RESULTS

No differences were found in baseline characteristics between groups (age, gender, BMI, BMD and major risk factors for fractures). More patients in Group A started oral treatment (77.4% vs 49.1%; p < 0.001), but there were no differences between groups in the presence of a gap in treatment >3 months or in treatment duration. Patients in Group A were more likely to have follow-up DXA scan at 4-6 years from baseline (46.9% vs 29.2%; p < 0.000) and had a greater increase in total hip BMD (+2.74% vs + 0.42%; p value = 0.003). Fewer new fractures occurred in Group A but this was not statistically significant, but the numbers of fractures were small. Patients in Group A were more likely to change management (p = 0.005) including switching to zoledronate (p = 0.03). The PINP measurement and increased prescribing in Group A resulted in increases in both costs (£30.19) and QALYs (0.0039) relative to Group B, giving an incremental cost effectiveness ratio (ICER) of £7660 in the probabilistic sensitivity analysis.

CONCLUSIONS

Patients monitored with PINP are more likely to start oral bisphosphonate treatment, switch to zoledronate, have follow-up DXA scans and a greater increase of hip BMD. PINP monitoring has the potential to be cost-effective in a UK NHS setting given that interventions with an ICER under £20,000 are generally considered to be cost-effective.

Latent profiles of autism symptoms in children and adolescents with Down syndrome

BACKGROUND

Down syndrome (DS) is associated with elevated rates of autism spectrum disorder (ASD) and autism symptomatology. To better characterise heterogeneity in ASD symptomatology in DS, profiles of caregiver-reported ASD symptoms were modelled for children and adolescents with DS.

METHODS

Participants (n = 125) were recruited through several multi-site research studies on cognition and language in DS. Using the Social Responsiveness Scale-2 (SRS-2; Constantino and Gruber 2012), two latent profile analyses (LPA) were performed, one on the broad composite scores of social communication and interaction and restricted interests and repetitive behaviour, and a second on the four social dimensions of social communication, social motivation, social awareness, and social cognition.

RESULTS

A three-profile model was the best fit for both analyses, with each analysis yielding a low ASD symptom profile, an elevated or mixed ASD symptom profile and a high ASD symptom profile. Associations were observed between profile probability scores and IQ, the number of co-occurring biomedical conditions reported, sex, and SRS-2 form.

CONCLUSIONS

Characterising heterogeneity in ASD symptom profiles can inform more personalised supports in this population, and implications for potential therapeutic approaches for individuals with DS are discussed.

Interactions between 2′-fluoro-(carbamoylpyridinyl)deschloroepibatidine analogues and acetylcholine-binding protein inform on potent antagonist activity against nicotinic receptors

The binding of a series of epibatidine derivatives to acetylcholine-binding protein was investigated using biolayer interferometry. The structures of three complexes inform discussion on the biological implications for interactions with nicotinic acetylcholine receptor subtypes, which are important targets for control of pain.

Low-nanomolar binding constants were recorded for a series of six 2′-fluoro-(carbamoylpyridinyl)deschloroepibatidine analogues with acetylcholine-binding protein (AChBP). The crystal structures of three complexes with AChBP reveal details of molecular recognition in the orthosteric binding site and imply how the other three ligands bind. Comparisons exploiting AChBP as a surrogate for α4β2 and α7 nicotinic acetylcholine receptors (nAChRs) suggest that the key interactions are conserved. The ligands interact with the same residues as the archetypal nAChR agonist nicotine yet display greater affinity, thereby rationalizing their in vivo activity as potent antagonists of nicotine-induced antinociception. An oxyanion-binding site is formed on the periphery of the AChBP orthosteric site by Lys42, Asp94, Glu170 and Glu210. These residues are highly conserved in the human α4, β2 and α7 nAChR sequences. However, specific sequence differences are discussed that could contribute to nAChR subtype selectivity and in addition may represent a point of allosteric modulation. The ability to engage with this peripheral site may explain, in part, the function of a subset of ligands to act as agonists of α7 nAChR.

Acute respiratory infection symptoms and COVID-19 testing behaviour: results based on South Australian health surveys

Background

Effective syndromic surveillance alongside COVID-19 testing behaviours in the population including in higher risk and hard to reach subgroups is vital to detect re-emergence of COVID-19 transmission in the community. The aim of this paper was to identify the prevalence of acute respiratory infection symptoms and coronavirus testing behaviour among South Australians using data from a population based survey.

Methods

We used cross-sectional data from the 2020 state-wide population level health survey on 6857 respondents aged 18 years and above. Descriptive statistics were used to explore the risk factors and multivariable logistic regression models were used to assess the factors associated with the acute respiratory infection symptoms and coronavirus testing behaviour after adjusting for gender, age, household size, household income, Aboriginal and/or Torres Strait Islander status, SEIFA, Country of birth, number of chronic diseases, wellbeing, psychological distress, and mental health.

Results

We found that 19.3% of respondents reported having symptoms of acute respiratory infection and the most commonly reported symptoms were a runny nose (11.2%), coughing (9.9%) and sore throat (6.2%). Fever and cough were reported by 0.8% of participants. Of the symptomatic respondents, 32.6% reported seeking health advice from a nurse, doctor or healthcare provider. Around 18% (n = 130) of symptomatic respondents had sought testing and a further 4.3% (n = 31) reported they intended to get tested. The regression results suggest that older age, larger household size, a higher number of chronic disease, mental health condition, poor wellbeing, and psychological distress were associated with higher odds of ARI symptoms. Higher household income was associated with lower odds of being tested or intending to be tested for coronavirus after adjusting for other explanatory variables.

Conclusions

There were relatively high rates of self-reported acute respiratory infection during a period of very low COVID-19 prevalence and low rate of coronavirus testing among symptomatic respondents. Ongoing monitoring of testing uptake, including in higher-risk groups, and possible interventions to improve testing uptake is key to early detection of disease.

1087 Establishing Guidelines for VTE Prophylaxis for Acute ENT Admissions

Aim

VTE prophylaxis is a vital aspect of patient safety. The decision whether to offer pharmacological thromboprophylaxis is a balance of risk versus benefit. There is a low incidence of VTE in ENT patients, admissions are often short and active bleeding on admission is not uncommon (epistaxis patients, already on anticoagulation are particularly difficult to manage}. There are no clear, specialty specific guidelines to assist in these frequently encountered endeavours.

Method

The number of emergency ENT admissions who had a documented VTE during admission or in the 28 days following was used to calculate the incidence of VTE in acute admissions. An audit of VTE prophylaxis and documentation was also conducted using 20 admissions over 24 hours.

Results

Incidence was 0.12%. 75% had a documented VTE risk assessment. Only 50% patients were prescribed chemical and mechanical thromboprophylaxis. 0% had appropriately documented that the patient did not require thromboprophylaxis on the drug chart (as per trust guidelines).

Conclusions

The results showed that both documentation and prescribing related to VTE prevention were poor. By highlighting the low incidence amongst this patient group, we were able to establish clearer guidance for VTE prophylaxis in acute ENT admissions and a protocol to standardise the management of anticoagulation in actively bleeding epistaxis patients.

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

BACKGROUND

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes.

OBJECTIVE

The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change.

STUDY DESIGN

This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis.

CONCLUSION

Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

Are Smaller Emergency Departments More Prone to Volume Variability?

Introduction: Daily patient volume in emergency departments (ED) varies considerably between days and sites. Although studies have attempted to define “high-volume” days, no standard definition exists. Furthermore, it is not clear whether the frequency of high-volume days, by any definition, is related to the size of an ED. We aimed to determine the correlation between ED size and the frequency of high-volume days for various volume thresholds, and to develop a measure to identify high-volume days. Methods: We queried retrospective patient arrival data including 1,682,374 patient visits from 32 EDs in 12 states between July 1, 2018–June 30, 2019 and developed linear regression models to determine the correlation between ED size and volume variability. In addition, we performed a regression analysis and applied the Pearson correlation test to investigate the significance of median daily volumes with respect to the percent of days that crossed four volume thresholds ranging from 5–20% (in 5% increments) greater than each site’s median daily volume. Results: We found a strong negative correlation between ED median daily volume and volume variability (R2 = 81.0%; P < 0.0001). In addition, the four regression models for the percent of days exceeding specified thresholds greater than their daily median volumes had R2 values of 49.4%, 61.2%, 70.0%, and 71.8%, respectively, all with P < 0.0001. Conclusion: We sought to determine whether smaller EDs experience high-volume days more frequently than larger EDs. We found that high-volume days, when defined as days with a count of arrivals at or above certain median-based thresholds, are significantly more likely to occur in lower-volume EDs than in higher-volume EDs. To the extent that EDs allocate resources and plan to staff based on median volumes, these results suggest that smaller EDs are more likely to experience unpredictable, volume-based staffing challenges and operational costs. Given the lack of a standard measure to define a high-volume day in an ED, we recommend 10% above the median daily volume as a metric, for its relevance, generalizability across a broad range of EDs, and computational simplicity.

Predicting a Need for Financial Assistance in Emergency Department Care

Identifying patients with a low likelihood of paying their bill serves the needs of patients and providers alike: aligning government programs with their target beneficiaries while minimizing patient frustration and reducing waste among emergency physicians by streamlining the billing process. The goal of this study was to predict the likelihood of patients paying the balance of their emergency department visit bill within 90 days of receipt. Three machine learning methodologies were applied to predict payment: logistic regression, decision tree, and random forest. Models were trained and performance was measured using 1,055,941 patients with non-zero balances across 27 EDs from 1 August 2015 to 31 July 2017. The decision tree accurately predicted 87% of unsuccessful payments, providing significant opportunities to identify patients in need of financial assistance.

Aquatic contaminants in Solomon Islands and Vanuatu: Evidence from passive samplers and Microtox toxicity assessment

Water Quality issues in many Pacific countries are rising, with the increase in coastal populations and associated urban runoff but management requires contamination issues in the aquatic environment to be identified and prioritised. In Vanuatu and Solomon Islands there are few laboratories and resources to assess for the presence or impact of complex chemical contaminants. The extent and impact of chemical contamination of the marine and coastal environment is poorly described. Passive chemical samplers were used to measure a range of aquatic pollutants around the capital cities, Honiara (Solomon Islands) and Port Vila (Vanuatu). We detected a range of chemicals indicative of agricultural and industrial contamination and a few sites had concerning concentrations of specific hydrocarbons and pesticides. The rapid ecotoxicology test, Microtox, indicated toxic impacts in rivers, coastal sites and urban drains This work provides new data on chemical contamination and possible impacts of that contamination for both countries. The techniques could be applied widely across the region to generate critical data for environmental management, guide monitoring efforts and measure the impact of policy or land-use changes.

Examining online postings on a russian internet self-harm message board: Further evidence of addiction to self-harm?

Introduction

There has been an increasing amount of research examining the addictive nature of self-harm (non-suicidal self-injury). One such area of research has examined if themes related to addiction are present in self-harm board postings on imessages. Recent research from the UK suggests that such themes are evident.

Objectives

The present aim was to build on previous research to examine if themes of addiction are present in other cultural contexts.

Methods

A sample of 254 online postings from a self-harm discussion forum on a Russian Internet message board were translated, extracted, read, and re-read before being coded using inductive content analysis to identify themes.

Results

Five themes were extracted and labelled: “Relationships with Family and Friends”, “Self-Blame and Hatred”, “Ongoing Battle”, “Positive affect”, “Other Mental Health Problems Difficulties”. These themes are somewhat similar to those found within messages in a UK based self-harm forum.

Conclusions

The present findings, obtained from Russian respondents, provide further evidence demonstrating that repetitive self-harming seems to have addictive aspects.

Exit strategies: optimising feasible surveillance for detection, elimination, and ongoing prevention of COVID-19 community transmission

BACKGROUND

Following implementation of strong containment measures, several countries and regions have low detectable community transmission of COVID-19. We developed an efficient, rapid, and scalable surveillance strategy to detect remaining COVID-19 community cases through exhaustive identification of every active transmission chain. We identified measures to enable early detection and effective management of any reintroduction of transmission once containment measures are lifted to ensure strong containment measures do not require reinstatement.

METHODS

We compared efficiency and sensitivity to detect community transmission chains through testing of the following: hospital cases; fever, cough and/or ARI testing at community/primary care; and asymptomatic testing; using surveillance evaluation methods and mathematical modelling, varying testing capacities, reproductive number (R) and weekly cumulative incidence of COVID-19 and non-COVID-19 respiratory symptoms using data from Australia. We assessed system requirements to identify all transmission chains and follow up all cases and primary contacts within each chain, per million population.

RESULTS

Assuming 20% of cases are asymptomatic and 30% of symptomatic COVID-19 cases present for testing, with R = 2.2, a median of 14 unrecognised community cases (8 infectious) occur when a transmission chain is identified through hospital surveillance versus 7 unrecognised cases (4 infectious) through community-based surveillance. The 7 unrecognised community upstream cases are estimated to generate a further 55-77 primary contacts requiring follow-up. The unrecognised community cases rise to 10 if 50% of cases are asymptomatic. Screening asymptomatic community members cannot exhaustively identify all cases under any of the scenarios assessed. The most important determinant of testing requirements for symptomatic screening is levels of non-COVID-19 respiratory illness. If 4% of the community have respiratory symptoms, and 1% of those with symptoms have COVID-19, exhaustive symptomatic screening requires approximately 11,600 tests/million population using 1/4 pooling, with 98% of cases detected (2% missed), given 99.9% sensitivity. Even with a drop in sensitivity to 70%, pooling was more effective at detecting cases than individual testing under all scenarios examined.

CONCLUSIONS

Screening all acute respiratory disease in the community, in combination with exhaustive and meticulous case and contact identification and management, enables appropriate early detection and elimination of COVID-19 community transmission. An important component is identification, testing, and management of all contacts, including upstream contacts (i.e. potential sources of infection for identified cases, and their related transmission chains). Pooling allows increased case detection when testing capacity is limited, even given reduced test sensitivity. Critical to the effectiveness of all aspects of surveillance is appropriate community engagement, messaging to optimise testing uptake and compliance with other measures.

Exit strategies: optimising feasible surveillance for detection, elimination, and ongoing prevention of COVID-19 community transmission

BACKGROUND

Following implementation of strong containment measures, several countries and regions have low detectable community transmission of COVID-19. We developed an efficient, rapid, and scalable surveillance strategy to detect remaining COVID-19 community cases through exhaustive identification of every active transmission chain. We identified measures to enable early detection and effective management of any reintroduction of transmission once containment measures are lifted to ensure strong containment measures do not require reinstatement.

METHODS

We compared efficiency and sensitivity to detect community transmission chains through testing of the following: hospital cases; fever, cough and/or ARI testing at community/primary care; and asymptomatic testing; using surveillance evaluation methods and mathematical modelling, varying testing capacities, reproductive number (R) and weekly cumulative incidence of COVID-19 and non-COVID-19 respiratory symptoms using data from Australia. We assessed system requirements to identify all transmission chains and follow up all cases and primary contacts within each chain, per million population.

RESULTS

Assuming 20% of cases are asymptomatic and 30% of symptomatic COVID-19 cases present for testing, with R = 2.2, a median of 14 unrecognised community cases (8 infectious) occur when a transmission chain is identified through hospital surveillance versus 7 unrecognised cases (4 infectious) through community-based surveillance. The 7 unrecognised community upstream cases are estimated to generate a further 55-77 primary contacts requiring follow-up. The unrecognised community cases rise to 10 if 50% of cases are asymptomatic. Screening asymptomatic community members cannot exhaustively identify all cases under any of the scenarios assessed. The most important determinant of testing requirements for symptomatic screening is levels of non-COVID-19 respiratory illness. If 4% of the community have respiratory symptoms, and 1% of those with symptoms have COVID-19, exhaustive symptomatic screening requires approximately 11,600 tests/million population using 1/4 pooling, with 98% of cases detected (2% missed), given 99.9% sensitivity. Even with a drop in sensitivity to 70%, pooling was more effective at detecting cases than individual testing under all scenarios examined.

CONCLUSIONS

Screening all acute respiratory disease in the community, in combination with exhaustive and meticulous case and contact identification and management, enables appropriate early detection and elimination of COVID-19 community transmission. An important component is identification, testing, and management of all contacts, including upstream contacts (i.e. potential sources of infection for identified cases, and their related transmission chains). Pooling allows increased case detection when testing capacity is limited, even given reduced test sensitivity. Critical to the effectiveness of all aspects of surveillance is appropriate community engagement, messaging to optimise testing uptake and compliance with other measures.

Leveraging nurse practitioner capacities to achieve global health for all: COVID-19 and beyond

Aim

To argue that nurse practitioners have been under‐utilized generally in the current global health environment, creating barriers to achieving universal health coverage and the Sustainable Development Goals.

Background

Nurse practitioners are advanced practice nurses possessing expert knowledge and leadership skills that can be optimized to narrow disparities and ensure access to high‐quality health care globally. Nurses worldwide have been challenged to meet global public health needs in the context of COVID‐19 (SARS‐CoV‐2 virus), and there are early indications that nurse practitioners are being called upon to the full extent of their capabilities in the current pandemic.

Sources of evidence

PubMed; Google Scholar; the International Council of Nurses; World Health Organization; United Nations; and the experiences of the authors.

Discussion

Several international reports, nursing and health organizations have called for continued investment in and development of nursing to improve mechanisms that promote cost‐effective and universally accessible care. Expanding nurse practitioner scopes of practice across nations will leverage their clinical capacities, policy and advocacy skills, and talents to lead at all levels.

Conclusion

Ongoing empirical data and policy change is needed to enable the full scope and strategic utilization of nurse practitioners across healthcare systems and contexts.

Implications for nursing practice, and nursing and health policy

Widespread education regarding nurse practitioner capacities for interdisciplinary partners, policymakers and the public is needed. Policies that safely expand their roles are critical. Role titles and remuneration reflective of their scope and service are required to lead, sustain and grow the workforce internationally.

Droplet factories: Synthesis and assembly of metal nanoparticles on magnetic supports

The interface between two immiscible liquids represent an ideal substrate for the assembly of nanomaterials. The defect free surface provides a reproducible support for creating densely packed ordered materials. Here a droplet flow reactor is presented for the synthesis and/or assembly of nanomaterials at the interface of the emulsion. Each droplet acts as a microreactor for a reaction between decamethylferrocene (DmFc) within the hexane and metal salts (Ag⁺/Pd²⁺) in the aqueous phase. The hypothesis was that a spontaneous, interfacial reaction would lead to the assembly of nanomaterials creating a Pickering emulsion. The subsequent removal of the solvents showed how the Ag nanoparticles remain trapped at the interface and retain the shape of the droplet, however the Pd nanoparticles were dispersed with no tertiary structure. To further exploit this, a one-step process where the particles are synthesised and then assembled into core-shell materials was proposed. The same reactions were performed in the presence of oleic acid stabilised iron oxide nanoparticles dispersed within the hexane. It was shown that by changing the reaction rate and ratio between metal and iron oxide a continuous coating of metal nanoparticles can be formed on top of an iron oxide microsphere, or form a uniform composite. These insights offer a new method and chemistry within flow reactors for the creation of palladium and silver nanoparticles. We use the technique to create metal coated iron oxide nanomaterials but the methodology could be easily transferred to the assembly of other materials.

NLRC3 Localizes to the Endoplasmic Reticulum via Interactions with a Novel ER-Resident Protein

Sensing of cytosolic nucleotides is a critical initial step in the elaboration of type I interferon. One of several upstream receptor cGAS (cyclic-GMP-AMP synthase) binds to cytosolic DNA and generates di-cyclic nucleotides that act as secondary messengers. These secondary messengers bind directly to Stimulator of Interferon Genes (STING). STING recruits TANK binding kinase 1 (TBK1) which acts as a critical node that allows for efficient activation of interferon regulatory factors (IRFs) to drive the anti-viral transcriptome. NLRC3 is a recently characterized nucleotide-binding domain, leucine rich repeat containing protein (NLR) that negatively regulates the type I interferon pathway by inhibiting subcellular redistribution and effective signaling of STING, thus blunting the transcription of type I interferons. NLRC3 is predominantly expressed in lymphoid and myeloid cells. IQGAP1 was identified as a putative interacting partner of NLRC3 through yeast two hybrid screening. Here we show that a novel ER-resident protein associates with NLRC3 in human cells. This interaction occurs at the ER. This data provides a mechanism by which NLRC3 localizes to the ER to affect STING signaling in response to cytosolic nucleotides.

Computed tomography imaging in ventral hernia repair: can we predict the need for myofascial release?

INTRODUCTION

Currently, the need for additional myofascial release (AMR) in addition to retromuscular dissection during open Rives-Stoppa hernia repair is determined intraoperatively based on the discretion of the surgeon. We developed a novel method to objectively predict the need for AMR preoperatively using computed tomography (CT)-measured rectus width to hernia width ratio (RDR).

METHODS

A retrospective chart review of all patients who underwent open retro-muscular mesh repair of midline ventral hernia between August 1, 2007 and February 1, 2018, who had a preoperative CT scan within 1 year prior to their operation. The primary endpoint was the ability of the defect ratio to predict the need for AMR in pursuit of fascial closure. The secondary endpoint was the ability of Component Separation Index (CSI) to predict the need for AMR to obtain fascial closure.

RESULTS

Of 342 patients, 208 repaired with rectus abdominis release alone (RM group), while 134 required AMR (RM + group). An RDR of > 1.34 on area under the curve analysis predicted the need for AMR with 77.6% accuracy. There was a linear decrease in the need for AMR with increasing RDR: RDR < 1 required AMR in 78.8% of cases, RDR 1.1-1.49 in 52%, RDR 1.5-1.99 in 32.1%, and RDR > 2 in just 10.8%. Similarly, CSI > 0.146 predicted the need for AMR with 76.3% accuracy on area under the curve analysis.

CONCLUSION

The RDR is a practical and reliable tool to predict the ability to close the defect during open Rives-Stoppa ventral hernia repair without AMR. An RDR of > 2 portends fascial closure with rectus abdominis myofascial release alone in 90% of cases.

The thermodynamic profile and molecular interactions of a C(9)-cytisine derivative-binding acetylcholine-binding protein from Aplysia californica

Cytisine, a natural product with high affinity for clinically relevant nicotinic acetylcholine receptors (nAChRs), is used as a smoking-cessation agent. The compound displays an excellent clinical profile and hence there is an interest in derivatives that may be further improved or find use in the treatment of other conditions. Here, the binding of a cytisine derivative modified by the addition of a 3-(hydroxypropyl) moiety (ligand 4) to Aplysia californica acetylcholine-binding protein (AcAChBP), a surrogate for nAChR orthosteric binding sites, was investigated. Isothermal titration calorimetry revealed that the favorable binding of cytisine and its derivative to AcAChBP is driven by the enthalpic contribution, which dominates an unfavorable entropic component. Although ligand 4 had a less unfavorable entropic contribution compared with cytisine, the affinity for AcAChBP was significantly diminished owing to the magnitude of the reduction in the enthalpic component. The high-resolution crystal structure of the AcAChBP-4 complex indicated close similarities in the protein-ligand interactions involving the parts of 4 common to cytisine. The point of difference, the 3-(hydroxypropyl) substituent, appears to influence the conformation of the Met133 side chain and helps to form an ordered solvent structure at the edge of the orthosteric binding site.

P6546Canadian Registry of Electronic Device Outcomes (CREDO): remote monitoring outcomes in the abbott battery performance alert, a multicentre cohort

Background

Cardiac implantable electronic devices have been known to have lead and device malfunctions leading to advisories. Increased use of remote monitoring of devices has been suggested to allow the identification of abnormal device performance and allow early intervention. We sought to describe the outcomes of patients with and without remote monitoring of in devices in the Abbott Premature Battery Depletion advisory with data from a Canadian registry

Methods

Patients with an Abbott device subject to the Battery Performance Alert Advisory from nine ICD implanting centres in Canada were included in the registry. The use of remote monitoring was identified from baseline and followup data in the registry. The primary outcome was detection of premature battery depletion and all cause mortality.

Results

2679 patents were identified with a device subject to the advisory. Devices were implanted between 2010 and 2017. 1716 patients (64%) had remote monitoring at baseline with this increasing to 83.7% at followup at 12 months. Premature battery depletion occurred in 43 patients (1.6%). Discovery of premature battery depletion was detected by remote monitoring in 70% of patients. There were 492 deaths during the follow up. Mortality was higher in those without a remote monitor compared to those with a remote monitor at follow-up and remote monitor at baseline and follow-up (11.3%, 2.6% versus 6.1% respectively; p=0.0186). There were no deaths attributed to premature battery depletion

Conclusion

The use of remote monitoring in patients with ICD and CRT under advisory reliably detected device failure and was associated with a reduction in all-cause mortality.

Abstract P3-08-07: Distinct biological signatures describe differences in BRCA mutated subgroups

Background: BRCA mutated (BRCA+) breast cancers are expected to have increased activation of Homologous Recombination Deficiency (HRD) and altered DNA damage repair pathways when compared to BRCA wildtype (BRCA-). To better understand differences in these populations, biological patterns and immune responses to BRCA+ breast cancers were evaluated. The primary aim of our study was to use novel gene expression tools to assess early stage breast cancers with and without germline BRCA mutations, and within distinct BRCA+ subgroups.

Methods: We identified 124 early stage untreated breast cancers with and without BRCA mutations (n = 62 and 62, respectively). Our BRCA- group was matched by hormone receptor (HR) status, age, and stage to the BRCA+ group. The NanoString Breast Cancer 360 panel was applied to RNA isolated from 80 breast tumors (BRCA+ = 39; BRCA- = 41). The BRCA+ group had a BRCA1+ subgroup (n=17) and a BRCA2+ subgroup (n=22).

Results: There was a significant increase in two BC360 signatures in both the BRCA1+ and BRCA2+ tumors compared with the BRCA- population: Prosigna™Risk of Recurrence (ROR) score [BRCA1+: HR: 1.142 (95% CI 1.019, 1.279), p=0.02; BRCA2+: HR: 1.321 (95% CI 1.190, 1.466), p&lt;0.001] and HRD [BRCA1+: HR: 3.576 (95% CI 2.174, 5.880), p=0.02; BRCA2+: HR: 1.801 (95% CI 1.142, 2.840), p&lt;0.001]. BRCA1+ tumors had lower expression of ESR1 [p=0.03], PGR [p=0.02], ER signaling [p&lt;0.001], and differentiation [p=0.005]; while BRCA2+ tumors had lower expression of stroma markers [p=0.02] and inflammatory chemokines [p=0.001]. The two BRCA+ subgroups had distinct molecular subtype correlation trends that were highly significant. BRCA1+ tumors were positively associated with a basal subtype [p&lt;0.001], whereas this association was not significant for BRCA2+ tumors. BRCA2+ tumors were associated with an increase in luminal B subtype [p=0.05]. All BRCA+ tumors had a decrease in luminal A subtype correlation [BRCA1+: p&lt;0.001; BRCA2+: p=0.002]. In addition to the BC360 signatures, a differential analysis of all genes in the BC360 panel revealed more single gene differences in BRCA2+ than BRCA1+ tumors when compared to BRCA- tumors.

Conclusions: In early stage BRCA+ breast cancer, tumors have higher ROR and increased HRD signature scores compared to BRCA- tumors. Furthermore, BRCA1+ and BRCA2+ tumors have both signature and single gene expression differences when compared to BRCA- tumors, indicating distinct subgroup-related biology. The greater correlation of BRCA1+ tumors with basal-like biology and BRCA2+ tumors with aggressive hormonal biology confirms these trends. Distinctions in hormone receptor signaling, DNA-damage pathways, and microenvironment/inflammatory features between BRCA1 and BRCA2 associated cancers suggest a need for different prevention and therapeutic strategies for each of these breast cancer subtypes. The unique biological patterns identified here should be further evaluated as predictive or prognostic tools that could be translated into clinical care for early stage BRCA+ patients.

Citation Format: Force J, Plichta J, Stashko I, Kimmick G, Westbrook K, Sammons S, Hwang S, Hyslop T, Kauff N, Castellar E, Nair S, Weinhold K, Davis S, Mashadi-Hossein A, Brauer HA, Marcom PK. Distinct biological signatures describe differences in BRCA mutated subgroups [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 P3-08-07.

An observational cohort study to produce and evaluate an improved tool to screen older women with back pain for osteoporotic vertebral fractures (Vfrac): study protocol

The aim of this study is to produce an easy to use checklist for general practitioners to complete whenever a woman aged over 65 years with back pain seeks healthcare. This checklist will produce a binary output to determine if the patient should have a radiograph to diagnose vertebral fracture.

PURPOSE

People with osteoporotic vertebral fractures are important to be identified as they are at relatively high risk of further fractures. Despite this, less than a third of people with osteoporotic vertebral fractures come to clinical attention due to various reasons including lack of clear triggers to identify who should have diagnostic spinal radiographs. This study aims to produce and evaluate a novel screening tool (Vfrac) for use in older women presenting with back pain in primary care based on clinical triggers and predictors identified previously. This tool will generate a binary output to determine if a radiograph is required.

METHODS

The Vfrac study is a two-site, pragmatic, observational cohort study recruiting 1633 women aged over 65 years with self-reported back pain. Participants will be recruited from primary care in two sites. The Vfrac study will use data from two self-completed questionnaires, a simple physical examination, a lateral thoracic and lateral lumbar radiograph and information contained in medical records.

RESULTS

The primary objective is to develop an easy-to-use clinical screening tool for identifying older women who are likely to have vertebral fractures.

CONCLUSIONS

This article describes the protocol of the Vfrac study; ISRCTN16550671.

The Impact of Hospital and Patient Factors on the Emergency Department Decision to Admit

BACKGROUND

Substantial variation exists in rates of emergency department (ED) admission. We examine this variation after accounting for local and community characteristics.

OBJECTIVES

Elucidate the factors that contribute to admission variation that are amenable to intervention with the goal of reducing variation and health care costs.

METHODS

We conducted a retrospective cross-sectional study of 1,412,340 patient encounters across 18 sites from 2012-2013. We calculated the adjusted hospital-level admission rates using multivariate logistic regression. We adjusted for patient, provider, hospital, and community factors to compare admission rate variation and determine the influence of these characteristics on admission rates.

RESULTS

The average adjusted admission rate was 22.9%, ranging from 16.1% (95% confidence interval [CI] 11.5-22%) to 32% (95% CI 26.0-38.8). There were higher odds of hospital admission with advancing age, male sex (odds ratio [OR] 1.20, 95% CI 1.91-1.21), and patients seen by a physician vs. mid-level provider (OR 2.26, 95% CI 2.23-2.30). There were increased odds of admission with rising ED volume, at academic institutions (OR 2.23, 95% CI 2.20-2.26) and at for-profit hospitals (OR 1.15, 95% CI 1.12-1.18). Admission rates were lower in communities with a higher per capita income, a higher rate of uninsured patients, and in more urban hospitals. In communities with the most primary providers, there were lower odds of admission (OR 0.60, 95% CI 0.57-0.68).

CONCLUSION

Variation in hospital-level admission rates is associated with a number of local and community characteristics. However, the presence of persistent variation after adjustment suggests there are other unmeasured variables that also affect admission rates that deserve further study, particularly in an era of cost containment.