Establishing a neonatology consultation program: extending care beyond the neonatal intensive care unit

Neonates can be cared for in neonatal, pediatric, or cardiac intensive care units, and general and subspecialty pediatric units. Disposition is based on phase of care, gestational and postnatal age, birth weight, specific cardiac or surgical diagnoses, and co-existing medical morbidities. In addition, neonates may transfer between the neonatal intensive care unit (NICU) and other units several times throughout their hospitalization. As such, care for high-risk infants with ongoing neonatal morbidities (often related to prematurity or congenital anomalies) is provided in units with varying neonatal expertise. In this perspective, we provide a framework for the design and implementation of a neonatology consultation service for infants cared for in clinical units outside the NICU. We describe the core principles of effective neonatology consultation and focus on understanding hospital/unit workflow, team composition, patient selection, billing and compliance, and offer suggestions for research initiatives and educational opportunities.

Pediatric Intubations in a Semiurban Helicopter Emergency Medicine Service: A Retrospective Review

OBJECTIVE

Although a small proportion of helicopter emergency medical service (HEMS) missions are for pediatric patients, it is recognized that children do present unique challenges. This case series aims to evaluate the intubation first-pass success rate in HEMS pediatric patients for both medical and trauma patients in a UK semiurban environment.

METHODS

A retrospective review of the computerized records system was performed from January 1, 2015, to July 31, 2022, at 1 UK HEMS. Anonymous data relating to advanced airway interventions in patients < 16 years of age were extracted. Primary analysis related to the first-pass success rate was performed; secondary analysis relating to the initial Glasgow Coma Scale (GCS) of the pediatric patients requiring prehospital anesthesia (rapid sequence induction with drugs) and first-pass success rates by clinician group was also performed.

RESULTS

Of the pediatric patients, 15.8% required intubation. The overall first-pass success rate for intubation (including in cardiac arrest) was 83.5%; for prehospital anesthesia (drugs administered), it was 98.4%. First-pass success rates were lowest for those under 2 years of age (45.2% without drugs and 87.5% with drugs). There was no difference between physician background in the first-pass success rate. The median GCS for pediatric prehospital anesthesia was 7 versus 5 for adults (P = .012). No children with an initial GCS of 15 had prehospital anesthesia.

CONCLUSION

The overall intubation first-pass success rates for pediatric patients is high at 83.5% and higher still for prehospital anesthesia (98.4%). However, it remains a rare intervention for clinicians, and children under 2 years of age require special consideration.

Can the MIRACLE2 Score Be Used in the Prehospital Environment and Is It Useful? An Observational Study

OBJECTIVE

The MIRACLE2 score has been developed for use in a primary percutaneous coronary intervention center. It is unclear if it is feasible in the helicopter emergency medical service (HEMS) setting.

METHODS

The computerized system at 1 UK HEMS was interrogated between December 1, 2020, and May 1, 2022, for the components of the MIRACLE2 score (recorded contemporaneously) plus demographics and outcomes in all post-return of spontaneous circulation patients conveyed to the hospital. pH was excluded because of no point-of-care testing resulting in a modified MIRACLE2 score (maximum score of 9). Data were analyzed using the chi-square test; P < .05 was statistically significant.

RESULTS

Three hundred thirty patients (240 males) with out-of-hospital cardiac arrests were reviewed. Ninety-two adult patients with nontraumatic out-of-hospital cardiac arrests had sustained return of spontaneous circulation and a median MIRACLE2 score of 4 (range, 0-7). Forty-seven patients died before hospital discharge; the median MIRACLE2 score was higher in those who died (4) than those who survived (1.5, P < .01); 90.3% of those with a score ≥ 5 were triaged to an emergency department rather than directly to a catheterization laboratory.

CONCLUSION

A modified MIRACLE2 score can be calculated in the HEMS setting. The benefit of point-of-care testing pH requires investigation. There may be a benefit in predicting outcomes in this nondifferentiated group, but additional research is required.

Genetics and etiology of congenital heart disease

Congenital heart disease (CHD) is the most common severe birth anomaly, affecting almost 1% of infants. Most CHD is genetic, but only 40% of patients have an identifiable genetic risk factor for CHD. Chromosomal variation contributes significantly to CHD but is not readily amenable to biological follow-up due to the number of affected genes and lack of evolutionary synteny. The first CHD genes were implicated in extended families with syndromic CHD based on the segregation of risk alleles in affected family members. These have been complemented by more CHD gene discoveries in large-scale cohort studies. However, fewer than half of the 440 estimated human CHD risk genes have been identified, and the molecular mechanisms underlying CHD genetics remains incompletely understood. Therefore, model organisms and cell-based models are essential tools for improving our understanding of cardiac development and CHD genetic risk. Recent advances in genome editing, cell-specific genetic manipulation of model organisms, and differentiation of human induced pluripotent stem cells have recently enabled the characterization of developmental stages. In this chapter, we will summarize the latest studies in CHD genetics and the strengths of various study methodologies. We identify opportunities for future work that will continue to further CHD knowledge and ultimately enable better diagnosis, prognosis, treatment, and prevention of CHD.

Cardiorespiratory consequences of attenuated fentanyl and augmented rocuronium dosing during protocolised prehospital emergency anaesthesia at a regional air ambulance service: a retrospective study

BACKGROUND

Pre-Hospital Emergency Anaesthesia (PHEA) has undergone significant developments since its inception. However, optimal drug dosing remains a challenge for both medical and trauma patients. Many prehospital teams have adopted a drug regimen of 3 mcg/kg fentanyl, 2 mg/kg ketamine and 1 mg/kg rocuronium ('3:2:1'). At Essex and Herts Air Ambulance Trust (EHAAT) a new standard dosing regimen was introduced in August 2021: 1 mcg/kg fentanyl, 2 mg/kg ketamine and 2 mg/kg rocuronium (up to a maximum dose of 150 mg) ('1:2:2'). The aim of this study was to evaluate the cardiorespiratory consequences of a new attenuated fentanyl and augmented rocuronium dosing regimen.

METHODS

A retrospective study was conducted at EHAAT as a service evaluation. Anonymized records were reviewed from an electronic database to compare the original ('3:2:1') drug dosing regimen (December 2019-July 2021) and the new ('1:2:2') dosing regimen (September 2021-May 2023). The primary outcome was the incidence of absolute hypotension within ten minutes of induction. Secondary outcomes included immediate hypertension, immediate hypoxia and first pass success (FPS) rates.

RESULTS

Following exclusions (n = 121), 720 PHEA cases were analysed (360 new vs. 360 original, no statistically significant difference in demographics). There was no difference in the rate of absolute hypotension (24.4% '1:2:2' v 23.8% '3:2:1', p = 0.93). In trauma patients, there was an increased first pass success (FPS) rate with the new regimen (95.1% v 86.5%, p = 0.01) and a reduced incidence of immediate hypoxia (7.9% v 14.8%, p = 0.05). There was no increase in immediate hypertensive episodes (22.7% vs. 24.2%, p = 0.73). No safety concerns were identified.

CONCLUSION

An attenuated fentanyl and augmented rocuronium dosing regimen showed no difference in absolute hypotensive episodes in a mixed cohort of medical and trauma patients. In trauma patients, the new regimen was associated with an increased FPS rate and reduced episodes of immediate hypoxia. Further research is required to understand the impact of such drug dosing in the most critically ill and injured subpopulation.

Comparative Effectiveness of Alternative Treatment Approaches to Secondary Hyperparathyroidism in Patients Receiving Maintenance Hemodialysis: An Observational Trial Emulation

RATIONALE & OBJECTIVE

Optimal approaches to treat secondary hyperparathyroidism (SHPT) in patients on maintenance hemodialysis (HD) have yet to be established in randomized controlled trials (RCTs).

STUDY DESIGN

Two observational clinical trial emulations.

SETTING & PARTICIPANTS

Both emulations included adults receiving in-center HD from a national dialysis organization. The patients who had SHPT in the period between 2009 and 2014, were insured for≥180 days by Medicare as primary payer, and did not have contraindications or poor health status limiting theoretical trial participation.

EXPOSURE

The parathyroid hormone (PTH) Target Trial emulation included patients with new-onset SHPT (first PTH 300-600pg/mL), with 2 arms defined as up-titration of either vitamin D sterols or cinacalcet within 30 days (lower target) or no up-titration (higher target). The Agent Trial emulation included patients with a PTH≥300 pg/mL while on≥6μg weekly of vitamin D sterol (paricalcitol equivalent dose) and no prior history of cinacalcet. The 2 arms were defined by the first dose or agent change within 30 days (vitamin D-favoring [vitamin-D was up-titrated] vs cinacalcet-favoring [cinacalcet was added] vs nondefined [neither applies]). Multiple trials per patient were allowed in trial 2.

OUTCOME

The primary outcome was all-cause death over 24 months; secondary outcomes included cardiovascular (CV) hospitalization or the composite of CV hospitalization or death.

ANALYTICAL APPROACH

Pooled logistic regression.

RESULTS

There were 1,152 patients in the PTH Target Trial (635 lower target and 517 higher target). There were 2,726 unique patients with 6,727 patient trials in the Agent Trial (6,268 vitamin D-favoring trials and 459 cinacalcet-favoring trials). The lower PTH target approach was associated with reduced adjusted hazard of death (HR, 0.71 [95% CI, 0.52-0.93]), CV hospitalization (HR, 0.78 [95% CI, 0.63-0.98]), and their composite (HR, 0.74 [95% CI, 0.61-0.89]). The cinacalcet-favoring approach demonstrated lower adjusted hazard of death compared to the vitamin D-favoring approach (HR, 0.79 [95% CI, 0.62-0.99]), but not of CV hospitalization or the composite outcome.

LIMITATIONS

Potential for residual confounding; low use of cinacalcet with low power.

CONCLUSIONS

SHPT management that is focused on lower PTH targets may lower mortality and CV disease in patients receiving HD. These findings should be confirmed in a pragmatic randomized trial.

PLAIN-LANGUAGE SUMMARY

Optimal approaches to treat secondary hyperparathyroidism (SHPT) have not been established in randomized controlled trials. Data from a national dialysis organization was used to identify patients with SHPT in whom escalated treatment may be indicated. The approach to treatment was defined based on observed upward titration of SHPT-controlling medications: earlier titration (lower target) versus delayed titration (higher target); and the choice of medication (cinacalcet vs vitamin D sterols). In the first trial emulation, we estimated a 29% lower rate of death and 26% lower rate of cardiovascular disease or death for patients managed with a lower versus higher target approach. Cinacalcet versus vitamin D-favoring approaches were not consistently associated with outcomes in the second trial emulation. This observational study suggests the need for additional clinical trials of SHPT treatment intensity.

Prediction of Return of Spontaneous Circulation in a Pediatric Swine Model of Cardiac Arrest Using Low-Resolution Multimodal Physiological Waveforms

Monitoring physiological waveforms, specifically hemodynamic variables (e.g., blood pressure waveforms) and end-tidal CO2 (EtCO2), during pediatric cardiopulmonary resuscitation (CPR) has been demonstrated to improve survival rates and outcomes when compared to standard depth-guided CPR. However, waveform guidance has largely been based on thresholds for single parameters and therefore does not leverage all the information contained in multimodal data. We hypothesize that the combination of multimodal physiological features improves the prediction of the return of spontaneous circulation (ROSC), the clinical indicator of short-term CPR success. We used machine learning algorithms to evaluate features extracted from eight low-resolution (4 samples per minute) physiological waveforms to predict ROSC. The waveforms were acquired from the 2nd to 10th minute of CPR in pediatric swine models of cardiac arrest (N = 89, 8-12 kg). The waveforms were divided into segments with increasing length (both forward and backward) for feature extraction, and machine learning algorithms were trained for ROSC prediction. For the full CPR period (2nd to 10th minute), the area under the receiver operating characteristics curve (AUC) was 0.93 (95% CI: 0.87-0.99) for the multivariate model, 0.70 (0.55-0.85) for EtCO2 and 0.80 (0.67-0.93) for coronary perfusion pressure. The best prediction performances were achieved when the period from the 6th to the 10th minute was included. Poor predictions were observed for some individual waveforms, e.g., right atrial pressure. In conclusion, multimodal waveform features carry relevant information for ROSC prediction. Using multimodal waveform features in CPR guidance has the potential to improve resuscitation success and reduce mortality.

A Hybrid Deep Learning Approach to Identify Preventable Childhood Hearing Loss

OBJECTIVE

Childhood hearing loss has well-known, lifelong consequences. Infection-related hearing loss disproportionately affects underserved communities yet can be prevented with early identification and treatment. This study evaluates the utility of machine learning in automating tympanogram classifications of the middle ear to facilitate layperson-guided tympanometry in resource-constrained communities.

DESIGN

Diagnostic performance of a hybrid deep learning model for classifying narrow-band tympanometry tracings was evaluated. Using 10-fold cross-validation, a machine learning model was trained and evaluated on 4810 pairs of tympanometry tracings acquired by an audiologist and layperson. The model was trained to classify tracings into types A (normal), B (effusion or perforation), and C (retraction), with the audiologist interpretation serving as reference standard. Tympanometry data were collected from 1635 children from October 10, 2017, to March 28, 2019, from two previous cluster-randomized hearing screening trials (NCT03309553, NCT03662256). Participants were school-aged children from an underserved population in rural Alaska with a high prevalence of infection-related hearing loss. Two-level classification performance statistics were calculated by treating type A as pass and types B and C as refer.

RESULTS

For layperson-acquired data, the machine-learning model achieved a sensitivity of 95.2% (93.3, 97.1), specificity of 92.3% (91.5, 93.1), and area under curve of 0.968 (0.955, 0.978). The model's sensitivity was greater than that of the tympanometer's built-in classifier [79.2% (75.5, 82.8)] and a decision tree based on clinically recommended normative values [56.9% (52.4, 61.3)]. For audiologist-acquired data, the model achieved a higher AUC of 0.987 (0.980, 0.993), had an equivalent sensitivity of 95.2 (93.3, 97.1), and a higher specificity of 97.7 (97.3, 98.2).

CONCLUSIONS

Machine learning can detect middle ear disease with comparable performance to an audiologist using tympanograms acquired either by an audiologist or a layperson. Automated classification enables the use of layperson-guided tympanometry in hearing screening programs in rural and underserved communities, where early detection of treatable pathology in children is crucial to prevent the lifelong adverse effects of childhood hearing loss.

Out-of-Hospital Cardiac Arrests during Mass-Participation Endurance Events: A Case Series

INTRODUCTION

Mass-participation endurance events take place throughout the United Kingdom. Although out-of-hospital cardiac arrests (OHCAs) occur during these events, little is known about them. This case series aims to describe the number, type, etiology, and outcome of OHCAs treated by a UK-based specialist sports medicine provider over a period of 8 y.

METHODS

The medical records of a UK-based sports medicine provider were reviewed from 2014 to 2022. Anonymized information from OHCAs during this time was recorded. This included type of event, patient demographics, details of OHCA, and patient outcomes.

RESULTS

Ten OHCAs were identified during the course of 110 sporting events. These included the cases of 9 participants and 1 spectator. Return of spontaneous circulation (ROSC) was achieved on-site in all patients. Eight survived beyond 24 h and achieved a full neurological recovery. Seventy percent of these patients achieved ROSC within 4 min of cardiopulmonary resuscitation being initiated. The 2 patients who died both presented with a nonshockable rhythm.

CONCLUSIONS

OHCAs during mass-participation endurance events are rare. However, medical providers must be prepared to respond promptly. Quick interventions can result in a full neurological recovery.

When can an enhanced critical care team add value to equestrian related incidents? A retrospective observational study

BACKGROUND

Helicopter Emergency Medical Services (HEMS) may be tasked to equestrian related incidents. Previous studies have suggested that majority of patients do not require HEMS specific interventions. No data has been published since 2015 so this article aims to establish the current incidence of equestrian incidents attended by one UK HEMS and identify trends that would aid the dispatch of HEMS to the patients who most need it.

METHODS

A retrospective review of the computerised record system for one UK HEMS was performed between 1st January 2015-30th June 2022. Demographic data, timings, suspected injury pattern and HEMS specific intervention details were extracted. The 20 patients with the highest confirmed injury burden were reviewed in detail.

RESULTS

257 patients (229 female) were treated by HEMS (0.02% of all HEMS dispatches). Of those 124 dispatches were due to interrogation of the 999 calls by a clinician on the dispatch desk. Only 52% were conveyed to hospital by the HEMS team; 51% had no HEMS specific intervention. Of the 20 most severely injured patients their pathology included splenic, liver, spinal cord and traumatic brain injuries.

CONCLUSION

Whilst HEMS dispatches to equestrian incidents remain a small percentage, there are four mechanisms that may benefit due to potential injury burden: fall onto head with suggestion of hyper-extension or hyper-flexion injury; kick to the torso; horse fallen or repetitively rolled onto patient and, no movement of patient since incident. In addition, age >50 years should be considered as higher risk.

Exploring the Therapeutic Potential of Phosphorylated Cis-Tau Antibody in a Pig Model of Traumatic Brain Injury

Traumatic brain injury (TBI) results in the generation of tau. As hyperphosphorylated tau (p-tau) is one of the major consequences of TBI, targeting p-tau in TBI may lead to the development of new therapy. Twenty-five pigs underwent a controlled cortical impact. One hour after TBI, pigs were administered either vehicle (n = 13) or PNT001 (n = 12), a monoclonal antibody for the cis conformer of tau phosphorylated at threonine 231. Plasma biomarkers of neural injury were assessed for 14 days. Diffusion tensor imaging was performed at day 1 and 14 after injury, and these were compared to historical control animals (n = 4). The fractional anisotropy data showed significant white matter injury for groups at 1 day after injury in the corona radiata. At 14 days, the vehicle-treated pigs, but not the PNT001-treated animals, exhibited significant white matter injury compared to sham pigs in the ipsilateral corona radiata. The PNT001-treated pigs had significantly lower levels of plasma glial fibrillary acidic protein (GFAP) at day 2 and day 4. These findings demonstrate a subtle reduction in the areas of white matter injury and biomarkers of neurological injury after treatment with PNT001 following TBI. These findings support additional studies for PNT001 as well as the potential use of this agent in clinical trials in the near future.

Non-invasive diffuse optical monitoring of cerebral physiology in an adult swine-model of impact traumatic brain injury

In this study, we used diffuse optics to address the need for non-invasive, continuous monitoring of cerebral physiology following traumatic brain injury (TBI). We combined frequency-domain and broadband diffuse optical spectroscopy with diffuse correlation spectroscopy to monitor cerebral oxygen metabolism, cerebral blood volume, and cerebral water content in an established adult swine-model of impact TBI. Cerebral physiology was monitored before and after TBI (up to 14 days post injury). Overall, our results suggest that non-invasive optical monitoring can assess cerebral physiologic impairments post-TBI, including an initial reduction in oxygen metabolism, development of cerebral hemorrhage/hematoma, and brain swelling.

Pushing Yourself to the Maximum: What Do Prehospital Interventions Do to the Heart Rates of the Prehospital Team Involved? A Case Report

Little is known about the heart rate changes of prehospital clinicians when performing potentially "stressful" interventions. This case report demonstrates the heart rate changes of two prehospital clinicians when performing a resuscitative thoracotomy. It demonstrates the peak heart rates correlating to the main intervention performed. This highlights areas for future research including the effect heart rate has on optimal performance.

Interrogating assumptions about the relationship between service providers and recipients: Learning from a new service for survivors of In Care Abuse

Understanding the dynamic relationship between service providers and the people who use their services is key to effective evaluation. This paper presents a practical approach to embedded evaluation that can be used by services to interrogate assumptions about relationships. The approach includes a simple framework for developing theories of change that centres relational aspects of the change process. This framework is complemented by a structured approach to surfacing risks and assumptions. Using the example of the evaluation of Future Pathways, a new and ground breaking service provided to people who experienced abuse or neglect as children In Care in Scotland, the paper describes how this approach was used in practice. Focusing in on assumptions identified by the service around trust, the paper describes the process undertaken to interrogate these assumptions through data collection with people using the service and staff. This process led to rich learning to support the development of the service as well as the identification of new elliptical assumptions. The paper concludes by sharing reflections on the learning from this work for the wider evaluation community highlighting the need for evaluators to take a relational approach to interrogating assumptions about relationships.

Success rate of prehospital emergency front-of-neck access (FONA): a systematic review and meta-analysis

BACKGROUND

Front-of-neck access (FONA) is an emergency procedure used as a last resort to achieve a patent airway in the prehospital environment. In this systematic review with meta-analysis, we aimed to evaluate the number and success rate of FONA procedures in the prehospital setting, including changes since 2017, when a surgical technique was outlined as the first-line prehospital method.

METHODS

A systematic literature search (PROSPERO CRD42022348975) was performed from inception of databases to July 2022 to identify studies in patients of any age undergoing prehospital FONA, followed by data extraction. Meta-analysis was used to derive pooled success rates. Methodological quality of included studies was interpreted using the Cochrane risk of bias tool, and rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

From 909 studies, 69 studies were included (33 low quality; 36 very low quality) with 3292 prehospital FONA attempts described (1229 available for analysis). The crude median success rate increased from 99.2% before 2017 to 100.0% after 2017. Meta-analysis revealed a pooled overall FONA success rate of 88.0% (95% confidence interval [CI], 85.0-91.0%). Surgical techniques had the highest success rate at a median of 100.0% (pooled rate=92.0%; 95% CI, 88.0-95.0%) vs 50.0% for needle techniques (pooled rate=52.0%; 95% CI, 28.0-76.0%).

CONCLUSIONS

Despite being a relatively rare procedure in the prehospital setting, the success rate for FONA is high. A surgical technique for FONA appears more successful than needle techniques, and supports existing UK prehospital guidelines.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42022348975.

Experimental testing of a prototype cantilevered liquid-nitrogen-cooled silicon mirror

This report presents testing of a prototype cantilevered liquid-nitrogen-cooled silicon mirror. This mirror was designed to be the first mirror for the new soft X-ray beamlines to be built as part of the Advanced Light Source Upgrade. Test activities focused on fracture, heat transfer, modal response and distortion, and indicated that the mirror functions as intended.

1328. Paenibacillosis: An Emerging Cause of Neonatal Sepsis and Postinfectious Hydrocephalus

Background

The etiology of neonatal sepsis is often not identified. Molecular methods can identify pathogens that culture-based methods miss. Most cases of neonatal sepsis globally are treated empirically per WHO guidelines with intravenous ampicillin and gentamicin, which may not be the best regimen for all pathogens.

Methods

We prospectively enrolled 800 neonates presenting with signs of sepsis to two Ugandan hospitals. Blood and cerebrospinal fluid were subjected to 16S rRNA sequencing, which identified Paenibacillus thiaminolyticus in 33/800 (4%) neonates. We confirmed the presence of P. thiaminolyticus by quantitative polymerase chain reaction (PCR). We describe neonatal and birth characteristics, presenting signs, and 12-month developmental outcomes for neonates with paenibacillosis. We performed antibiotic susceptibility testing and genomic analyses on three clinical isolates successfully grown in the laboratory.

Results

Neonates presented at a median age of 3 (1, 7) days. Fever (86%), irritability (78%) and seizures (52%) were common presenting signs (Figure). Most neonates were born vaginally (73%) at a medical facility (79%). Twelve (36%) had an adverse outcome: 5 (15%) neonates died; 4 (14%) survivors developed postinfectious hydrocephalus and three (9%) additional survivors had neurodevelopmental impairment.

All three isolates were resistant to vancomycin, two were resistant to penicillin and ampicillin and one was unlikely to be sensitive to ceftriaxone; all were susceptible to gentamicin and meropenem. The genomes of all three strains contained multiple beta-lactamase genes and a cluster of genes that encodes a type IV pilus.

Clinical signs at presentation for neonates with good and poor outcomes followng paenibacillosis

Conclusion

Molecular methods such as 16S rRNA sequencing and PCR can be used to improve the identification of pathogens causing neonatal sepsis. Paenibacillosis is an important emerging cause of neonatal sepsis in Uganda and is likely an underrecognized cause of postinfectious hydrocephalus in the region and possibly elsewhere. Antibiotics commonly used for neonatal sepsis may be inadequate for the treatment of paenibacillosis. Additional studies to understand the pathophysiology and optimal treatment of this novel infection are urgently needed to prevent neonatal mortality and morbidity including postinfectious hydrocephalus.

Disclosures

Jessica E. Ericson, MD, MPH, Abbvie: Advisor/Consultant Abhaya Kulkarni, MD, MSc, PhD, Medtronic: Advisor/Consultant.

"Are We Working (Too) Comfortably?": Understanding the Nature of and Factors Associated with Sedentary Behaviour When Working in the Home Environment

Home working has increased due to COVID-19, but little is known about how this change has impacted the health risk behaviour of elevated sedentary time. The aim of this cross-sectional exploratory study was to assess occupational sitting behaviour when working at home, and use the Capability Opportunity Motivation-Behaviour (COM-B) model to identify influences on this behaviour. University staff (n = 267; 69% female; 92% white) who were predominantly working from home completed a questionnaire to assess sitting time, sitting breaks, demographic and occupational characteristics, and a 7-item COM-B questionnaire and open-ended questions to assess influences on time spent sitting whilst working from home. Data were analysed descriptively, a repeated measures ANOVA was used to determine differences in the COM-B items, and binary logistic regression was used to examine predictors of sitting time. Staff spent on average 89.5% (SD = 17.1) of their time sitting whilst working at home, and took an average of 1.36 (1.38) sitting breaks per hour. There were significant and meaningful differences in the influence of the COM factors on ability and willingness to reduce sitting behaviour (p < .0001; η_p ² = .38), and the open-ended responses added further context. The included variables accounted for 20.7% of variance in sitting behaviour, with age, sitting breaks, motivation-automatic, and opportunity-physical contributing significantly. Working from home leads to elevated levels of sitting, and the COM-B provides a useful model to identify key influences on ability and willingness to reduce sitting. Strategies incorporating regular breaks, habit formation/reversal, and restructuring the physical environment may be beneficial.

The Prehospital Emergency Anaesthetic in 2022

Prehospital emergency anesthesia (PHEA) is a commonly performed prehospital procedure with inherent risks. The processes and drug regimens behind PHEA are continually updated by prehospital teams across the country as part of their governance structure. Essex & Herts Air Ambulance has recently updated this practice by reviewing the entire process of performing PHEA. Through experiential learning in a high-volume service, audit, and a contemporary literature review, a new standard operating procedure has been developed to combat common problems, such as hypotension, associated with the more traditional methods of performing PHEA. The aim of this article was to summarize the literature behind this new standard operating procedure, systematically breaking down the core components of performing a PHEA and the rationale behind them. The key components identified in the review are indications for PHEA, airway assessment, peri-intubation oxygenation, preparation for PHEA, drug dosing, special circumstances, and failed intubation. One significant change is the drug dosage regimen; 1 μg/kg fentanyl, 2 mg/kg ketamine, and 2 mg/kg rocuronium is recommended as the main drug dosing regimen for both medical and trauma patients. Other changes include preoxygenation with a nasal cannula in addition to the nonrebreather mask, optimizing patients in the preparation phase by considering inopressors or fluid bolus and ensuring a "sterile cockpit" to control the surrounding environment to ensure the first intubation attempt is the best attempt.

Development of an Administrative Data-Based Frailty Index for Older Adults Receiving Dialysis

Background

Frailty is present in ≥50% of older adults receiving dialysis. Our objective was to a develop an administrative data–based frailty index and assess the frailty index’s predictive validity for mortality and future hospitalizations.

Methods

We used United States Renal Data System data to establish two cohorts of adults aged ≥65 years, initiating dialysis in 2013 and in 2017. Using the 2013 cohort (development dataset), we applied the deficit accumulation index approach to develop a frailty index. Adjusting for age and sex, we assessed the extent to which the frailty index predicts the hazard of time until death and time until first hospitalization over 12 months. We assessed the Harrell’s C-statistic of the frailty index, a comorbidity index, and jointly. The 2017 cohort was used as a validation dataset.

Results

Using the 2013 cohort (n=20,974), we identified 53 deficits for the frailty index across seven domains: disabilities, diseases, equipment, procedures, signs, tests, and unclassified. Among those with ≥1 deficit, the mean (SD) frailty index was 0.30 (0.13), range 0.02–0.72. Over 12 months, 18% (n=3842) died, and 55% (n=11,493) experienced a hospitalization. Adjusted hazard ratios for each 0.1-point increase in frailty index in models of time to death and time to first hospitalization were 1.41 (95% confidence interval, 1.37 to 1.44) and 1.33 (95% confidence interval, 1.31 to 1.35), respectively. For mortality, C-statistics for frailty index, comorbidity index, and both indices were 0.65, 0.65, and 0.66, respectively. For hospitalization, C-statistics for frailty index, comorbidity index, and both indices were 0.61, 0.60, and 0.61, respectively. Data from the 2017 cohort were similar.

Conclusions

We developed a novel frailty index for older adults receiving dialysis. Further studies are needed to improve on this frailty index and validate its use for clinical and research applications.

Decisional Conflict About Kidney Failure Treatment Modalities Among Adults With Advanced CKD

Rationale & Objective

Choosing from multiple kidney failure treatment modalities can create decisional conflict, but little is known about this experience before decision implementation. We explored decisional conflict about treatment for kidney failure and its associated patient characteristics in the context of advanced chronic kidney disease (CKD).

Study Design

Cross-sectional study.

Setting & Participants

Adults (N = 427) who had advanced CKD, received nephrology care in Pennsylvania-based clinics, and had no history of dialysis or transplantation.

Predictors

Participants' sociodemographic, physical health, nephrology care/knowledge, and psychosocial characteristics.

Outcomes

Participants' results on the Sure of myself; Understand information; Risk-benefit ratio; Encouragement (SURE) screening test for decisional conflict (no decisional conflict vs decisional conflict).

Analytical Approach

We used multivariable logistic regression to quantify associations between aforementioned participant characteristics and decisional conflict. We repeated analyses among a subgroup of participants at highest risk of kidney failure within 2 years.

Results

Most (76%) participants reported treatment-related decisional conflict. Participant characteristics associated with lower odds of decisional conflict included complete satisfaction with patient-kidney team treatment discussions (OR, 0.16; 95% CI, 0.03-0.88; P = 0.04), attendance of treatment education classes (OR, 0.38; 95% CI, 0.16-0.90; P = 0.03), and greater treatment-related decision self-efficacy (OR, 0.97; 95% CI, 0.94-0.99; P < 0.01). Sensitivity analyses showed a similarly high prevalence of decisional conflict (73%) and again demonstrated associations of class attendance (OR, 0.26; 95% CI, 0.07-0.96; P = 0.04) and decision self-efficacy (OR, 0.95; 95% CI, 0.91-0.99; P = 0.03) with decisional conflict.

Limitations

Single-health system study.

Conclusions

Decisional conflict was highly prevalent regardless of CKD progression risk. Findings suggest efforts to reduce decisional conflict should focus on minimizing the mismatch between clinical practice guidelines and patient-reported engagement in treatment preparation, facilitating patient-kidney team treatment discussions, and developing treatment education programs and decision support interventions that incorporate decision self-efficacy-enhancing strategies.

Low frequency power in cerebral blood flow is a biomarker of neurologic injury in the acute period after cardiac arrest

AIM

Cardiac arrest often results in severe neurologic injury. Improving care for these patients is difficult as few noninvasive biomarkers exist that allow physicians to monitor neurologic health. The amount of low-frequency power (LFP, 0.01-0.1 Hz) in cerebral haemodynamics has been used in functional magnetic resonance imaging as a marker of neuronal activity. Our hypothesis was that increased LFP in cerebral blood flow (CBF) would be correlated with improvements in invasive measures of neurologic health.

METHODS

We adapted the use of LFP for to monitoring of CBF with diffuse correlation spectroscopy. We asked whether LFP (or other optical biomarkers) correlated with invasive microdialysis biomarkers (lactate-pyruvate ratio - LPR - and glycerol concentration) of neuronal injury in the 4 h after return of spontaneous circulation in a swine model of paediatric cardiac arrest (Sus scrofa domestica, 8-11 kg, 51% female). Associations were tested using a mixed linear effects model.

RESULTS

We found that higher LFP was associated with higher LPR and higher glycerol concentration. No other biomarkers were associated with LPR; cerebral haemoglobin concentration, oxygen extraction fraction, and one EEG metric were associated with glycerol concentration.

CONCLUSION

Contrary to expectations, higher LFP in CBF was correlated with worse invasive biomarkers. Higher LFP may represent higher neurologic activity, or disruptions in neurovascular coupling. Either effect may be harmful in the acute period after cardiac arrest. Thus, these results suggest our methodology holds promise for development of new, clinically relevant biomarkers than can guide resuscitation and post-resuscitation care. Institutional protocol number: 19-001327.

What works to reduce sedentary behavior in the office, and could these intervention components transfer to the home working environment?: A rapid review and transferability appraisal

Background

Working patterns have changed dramatically due to COVID-19, with many workers now spending at least a portion of their working week at home. The office environment was already associated with high levels of sedentary behavior, and there is emerging evidence that working at home further elevates these levels. The aim of this rapid review (PROSPERO CRD42021278539) was to build on existing evidence to identify what works to reduce sedentary behavior in an office environment, and consider whether these could be transferable to support those working at home.

Methods

The results of a systematic search of databases CENTRAL, MEDLINE, Embase, PsycInfo, CINHAL, and SportDiscus from 10 August 2017 to 6 September 2021 were added to the references included in a 2018 Cochrane review of office based sedentary interventions. These references were screened and controlled peer-reviewed English language studies demonstrating a beneficial direction of effect for office-based interventions on sedentary behavior outcomes in healthy adults were included. For each study, two of five authors screened the title and abstract, the full-texts, undertook data extraction, and assessed risk of bias on the included studies. Informed by the Behavior Change Wheel, the most commonly used intervention functions and behavior change techniques were identified from the extracted data. Finally, a sample of common intervention strategies were evaluated by the researchers and stakeholders for potential transferability to the working at home environment.

Results

Twenty-two studies including 29 interventions showing a beneficial direction of effect on sedentary outcomes were included. The most commonly used intervention functions were training (n = 21), environmental restructuring (n = 21), education (n = 15), and enablement (n = 15). Within these the commonly used behavior change techniques were instructions on how to perform the behavior (n = 21), adding objects to the environment (n = 20), and restructuring the physical environment (n = 19). Those strategies with the most promise for transferring to the home environment included education materials, use of role models, incentives, and prompts.

Conclusions

This review has characterized interventions that show a beneficial direction of effect to reduce office sedentary behavior, and identified promising strategies to support workers in the home environment as the world adapts to a new working landscape.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021278539, identifier CRD42021278539.

Arterial Blood Gases and Arterial Lines in the Prehospital Setting: A Systematic Literature Review and Survey of Current United Kingdom Helicopter Emergency Medical Services

OBJECTIVE

Prehospital guidelines state that monitoring should match in-hospital standards, but consensus on the use of arterial blood gases (ABGs) and arterial lines remains unclear. The aim was to perform a systematic literature review and survey of UK helicopter emergency medical services (HEMS) use and perceptions of ABGs and arterial lines.

METHODS

A systematic literature review was conducted for arterial lines and ABGs and prehospital care. Additionally, two questionnaires were distributed to all UK HEMS (questionnaire 1: current clinical practice and questionnaire 2: clinicians' opinions).

RESULTS

From 1,028 results, 13 studies (10 ABGs and 3 arterial lines) were included, demonstrating it is feasible to obtain ABGs and place arterial lines in the prehospital setting. There were concerns about practical difficulties for ABGs and the time taken for arterial lines. Survey responses were obtained from all UK HEMS (N = 22). Six services carry equipment for performing ABGs and nine services for arterial lines. Clinicians expressed concerns relating to the time taken to perform both procedures, but most believed it would allow better monitoring and more targeted treatment.

CONCLUSION

The evidence of benefit for both procedures remains poor. Overall, there may be clinical benefits, but these are likely to be patient specific and require further investigation.

Systematic review of process evaluations of interventions in trials investigating sedentary behaviour in adults

OBJECTIVES

To systematically review and synthesise findings from process evaluations of interventions in trials which measured sedentary behaviour as an outcome in adults to explore: (1) how intervention content, implementation, mechanisms of impact and context influence outcomes and (2) how these interventions are experienced from different perspectives (participants, carers, staff).

DESIGN

Systematic review and narrative synthesis underpinned by the Medical Research Council process evaluation framework.

DATA SOURCES

Databases searches were conducted in March 2019 then updated in May 2020 and October 2021 in: CINAHL, SPORTDiscus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, AMED; EMBASE, PsycINFO, MEDLINE, Web of Science and ProQuest Dissertations & Theses.

ELIGIBILITY CRITERIA

We included: Process evaluations of trials including interventions where sedentary behaviour was measured as an outcome in adults aged 16 or over from clinical or non-clinical populations. We excluded studies if interventions were delivered in educational or workplace settings, or if they were laboratory studies focused on immediate effects of breaking sitting.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted and coded data into a framework and assessed the quality of studies using the Mixed Methods Appraisal Tool. We synthesised findings using a narrative approach.

RESULTS

17 process evaluations were included. Five interventions focused on reducing sedentary behaviour or sitting time, 12 aimed to increase physical activity or promote healthier lifestyles. Process evaluations indicated changes in sedentary behaviour outcomes were shaped by numerous factors including: barriers (eg, staffing difficulties and scheduling problems) and facilitators (eg, allowing for flexibility) to intervention delivery; contextual factors (eg, usual lifestyle and religious events) and individual factors (eg, pain, tiredness, illness, age and individual preferences).

DISCUSSION

Intervention requires careful consideration of different factors that could influence changes in sedentary behaviour outcomes to ensure that interventions can be tailored to suit different individuals and groups.

PROSPERO REGISTRATION NUMBER

CRD42018087403.

A 6-year case series of resuscitative thoracotomies performed by a helicopter emergency medical service in a mixed urban and rural area with a comparison of blunt versus penetrating trauma

Background

Resuscitative thoracotomy (RT) is an intervention that can be performed in the prehospital setting for relieving cardiac tamponade and/or obtaining vascular control of suspected sub-diaphragmatic haemorrhage in patients in traumatic cardiac arrest. The aim of this retrospective case study is to compare the rates of return of spontaneous circulation (ROSC) in RTs performed for both penetrating and blunt trauma over 6 years in a mixed urban and rural environment.

Methods

The electronic records of a single helicopter emergency medical service were reviewed between 1st June 2015 and 31st May 2021 for RTs. Anonymised data including demographics were extracted for relevant cases. Data were analysed with independent t-tests and Χ² tests. A p value < 0.05 was considered statistically significant.

Results

Forty-four RTs were preformed within the 6 years (26 for blunt trauma). Eleven ROSCs were achieved (nine blunt, two penetrating) but no patient survived to discharge. In contrast to RTs for penetrating trauma, twelve of the RTs for blunt trauma had a cardiac output present on arrival of the prehospital team (p = 0.01). Two patients had an RT performed in a helicopter (one ROSC) and two on a helipad (both achieving ROSC), likely due to the longer transfer times seen in a more rural setting. Four of the RTs for blunt trauma (15%) were found to have a cardiac tamponade versus seven (39%) of the penetrating trauma RTs.

Conclusion

Prehospital RT remains a procedure with low rates of survival but may facilitate a ROSC to allow patients to reach hospital and surgery, particularly when distances to hospitals are greater. A higher-than-expected rate of cardiac tamponade was seen in RTs for blunt trauma, although not caused by a right ventricular wound but instead due to underlying vessel damage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-00997-4.

Adverse Childhood Experiences, Domestic Violence and Substance Misuse: An Action Research Study on Routine Enquiry and Practice Responses

The long-term impacts of Adverse Childhood Experiences (ACEs) are of increasing interest to researchers and practitioners, including the effectiveness of screening for ACEs to improve health and social outcomes. Despite a focus on implementing such practices, there has been little focus on ACEs experiences for women experiencing domestic violence and substance use, or consideration of practice responses around ACEs routine enquiry for domestic violence and related services. The Irish study discussed in this paper used an action research approach to implement ACEs routine enquiry within a domestic violence service for women accessing the service (n = 60), while also utilizing co-operative inquiry groups for practitioners both within the organization (n = 10) and with those working in associated fields of infant mental health, child protection, substance misuse and welfare and community support (n = 7). Of the 60 women who completed the ACEs routine enquiry in the study, over one-half (58 per cent) reported experiencing at least two ACEs in their childhood, including one-third of all respondents reporting experiencing four or more; service users reported significant levels of overlap between direct child maltreatment and adverse home environments. Reported parental substance misuse with the home environment was substantially higher than in general population studies. These findings offered early indications of both ACEs prevalence as well the types of ACEs that most define the experiences of the women presenting to a domestic violence service that supports women with substance misuse and other related issues. This paper discusses the ways in which the co-operative inquiry groups used this information and other processes to enhance practitioner, organizational, and inter-agency understanding and service responses. The practitioners felt that this form of ACEs routine enquiry, while not an end in itself, was a useful tool to engage women in conversations about trauma and intergenerational patterns and a basis for developing trauma-informed interventions. We conclude with discussion about: considerations of the risks of "individualizing" women's traumatic experiences; skills and supports for practitioners; and resource implications.

Adult intensive care unit admissions with severe COVID-19 infection following emergency Caesarean section deliveries: A case series

BACKGROUND

UK data suggest 6% of COVID-19 hospital admissions are either currently pregnant or immediately post-partum. However, the current literature suggests that if COVID-19 occurs in pregnancy, or post-partum, symptoms are mostly mild.

METHODS

All COVID-19 admissions to one acute London National Health Service Foundation trust were reviewed since the beginning of the COVID-19 pandemic to 1 May 2020 to establish whether there were any pregnant or immediately post-partum admissions. Data were extracted from hospital electronic records and anonymised. Any patients admitted to adult intensive care unit had their case notes reviewed in detail and comparison made to a local risk-assessment guideline identifying patients at-risk of thromboembolic events or cytokine storms. Local hospital guidelines were followed. Patients admitted to adult intensive care unit gave written consent.

RESULTS

A total of 24 pregnant or immediately post-partum patients with COVID-19 were admitted. Three patients required long adult intensive care unit admissions for severe single-organ respiratory failure after emergency C-sections. Two of these patients required proning (three times and eight times, respectively). All were considered medium risk for thromboembolic events but had rising D-dimers following adult intensive care unit admission, resulting in increased dosing of pharmacological thromboprophylaxis throughout their admission. All were considered low risk for a cytokine storm, and none had any significant cardiovascular or renal involvement. One patient developed a super-imposed fungal lung infection. All three patients developed delirium following cessation of sedation.

CONCLUSION

Pregnant or immediately post-partum women can develop severe COVID-19 symptoms requiring prolonged adult intensive care unit admission. It is likely to be single-organ failure, but patients are at a high risk of a thromboembolic event and delirium.

“We don’t have any answers within the current framework”: tensions within cannabis policy change in Ireland

Purpose

International policy approaches to cannabis production and use are changing rapidly, and within the Irish context, alternatives to prohibition are being considered. This study aims to explore policymaker’s attitudes towards the decriminalisation and legal regulation of cannabis for recreational use in the midst of an unfolding policy process, examining the degree which a “policy window” might be open for the implementation of cannabis policy change.

Design/methodology/approach

Semi-structured interviews were held with eight key informants within the policy field in Dublin, Ireland. Kingdon’s (2014) Multiple Streams framework was used to consider whether the problems, policy and political streams were aligning to support progressive policy change.

Findings

Irish policymakers indicated broad support for the decriminalisation of cannabis. The legal regulation of cannabis received more qualified support. Existing policy was heavily criticised with criminalisation identified as a clear failure. Of particular interest was the willingness of policymakers to offer opinions which contrasted with the policy positions of their organisations. While a policy window did open – and close – subsequent governmental commitments to examine the issue of drugs policy in a more deliberative process in the near future highlight the incremental nature of policy change.

Originality/value

This study provides unique insight into the opinions of policymakers in the midst of a prolonged period of policy evolution. A latent aspiration for historical policy change was situated within the realpolitik of more traditional approaches to policy development, demonstrating that the alignment of Kingdon’s (2014) problem, policy and political streams are essential for change in cannabis policy.

Non-nutritive suck and airborne metal exposures among Puerto Rican infants

Air pollution has been shown to impact multiple measures of neurodevelopment in young children. Its effects on particularly vulnerable populations, such as ethnic minorities, however, is less studied. To address this gap in the literature, we assess the associations between infant non-nutritive suck (NNS), an early indicator of central nervous system integrity, and air pollution exposures in Puerto Rico. Among infants aged 0-3 months enrolled in the Center for Research on Early Childhood Exposure and Development (CRECE) cohort from 2017 to 2019, we examined associations between exposure to fine particulate matter (PM_2.5) and its components on infant NNS in Puerto Rico. NNS was assessed using a pacifier attached to a pressure transducer, allowing for real-time visualization of NNS amplitude, frequency, duration, cycles/burst, cycles/min and bursts/min. These data were linked to 9-month average prenatal concentrations of PM_2.5 and components, measured at three community monitoring sites. We used linear regression to examine the PM_2.5-NNS association in single pollutant models, controlling for infant sex, maternal age, gestational age, and season of birth in base and additionally for household smoke exposure, age at testing, and NNS duration in full models. Among 198 infants, the average NNS amplitude and burst duration was 17.1 cmH₂O and 6.1 s, respectively. Decreased NNS amplitude was consistently and significantly associated with 9-month average exposure to sulfur (-1.026 ± 0.507), zinc (-1.091 ± 0.503), copper (-1.096 ± 0.535) vanadium (-1.157 ± 0.537), and nickel (-1.530 ± 0.501). Decrements in NNS frequency were associated with sulfur exposure (0.036 ± 0.018), but not other examined PM components. Our findings provide new evidence that prenatal maternal exposure to specific PM components are associated with impaired neurodevelopment in Puerto Rican infants soon after birth.

Helicopter Emergency Medical Services Out-of-Hospital Cardiac Arrests During the Initial COVID-19 Lockdown Versus Nonpandemic: A Comparison

Objective

COVID-19 may have contributed to an excess of out-of-hospital cardiac arrests (OOHCAs). This observational study identified changes in OOHCA epidemiology pre– and post–COVID-19 lockdown in a single UK helicopter emergency medical service (HEMS).

Methods

A retrospective, single-center (Essex & Herts Air Ambulance), observational study was undertaken with anonymized OOHCA data (demographics, etiology, and outcomes) from March 23, 2020, to June 23, 2020, and comparative data from March 23, 2019, to June 23, 2019. Supplementary data (total OOHCAs and patient outcomes) were provided by the East of England Ambulance Service National Health Service Trust. Data were analyzed using the Mann-Whitney U test and chi-square test; P < .05 was statistically significant.

Results: Of the HEMS activations during national lockdown, 33.6% were for OOHCAs compared with 25.8% during the reference time frame. The frequency of young and female OOHCAs demonstrated a statistically significant increase. Statistically significant variations in medical etiology and initial cardiac rhythm were identified.

Conclusion

During the initial UK-wide lockdown, the OOHCA characteristics attended by 1 HEMS team were altered. The changes seen may be due to the pathophysiology of COVID-19 or an alteration in dispatch due to the demand placed on the wider ambulance service; this may require further consideration for any future lockdowns or pandemics.

A qualitative study of sedentary behaviours in stroke survivors: non-participant observations and interviews with stroke service staff in stroke units and community services

PURPOSE

Sedentary behaviour (SB) is associated with negative health outcomes and is prevalent post-stroke. This study explored SB after stroke from the perspective of stroke service staff.

METHODS

Qualitative mixed-methods study. Non-participant observations in two stroke services (England/Scotland) and semi-structured interviews with staff underpinned by the COM-B model of behaviour change. Observations were analysed thematically; interviews were analysed using the Framework approach.

RESULTS

One hundred and thirty-two observation hours (October - December 2017), and 31 staff interviewed (January -June 2018). Four themes were identified: (1) Opportunities for staff to support stroke survivors to reduce SB; (2) Physical and psychological capability of staff to support stroke survivors to reduce SB; (3) Motivating factors influencing staff behaviour to support stroke survivors to reduce SB; (4) Staff suggestions for a future intervention to support stroke survivors to reduce SB.

CONCLUSIONS

Staff are aware of the consequences of prolonged sitting but did not relate to SB. Explicit knowledge of SB was limited. Staff need training to support stroke survivors to reduce SB. Sedentary behaviour in the community was not reported to change markedly, highlighting the need to engage stroke survivors in movement from when capable in hospital, following through to home.Implications for rehabilitationStroke survivor sedentary behaviour is influenced, directly and indirectly, by the actions and instructions of stroke service staff in the inpatient and community setting.The built and social environment, both in the inpatient and community settings, may limit opportunities for safe movement and can result in stroke survivors spending more time sedentary.Stroke service staff appreciate the benefit of encouraging stroke survivors to stand and move more, if it is safe for them to do so.Staff would be amenable to encourage stroke survivors to reduce sedentary behaviour, provided they have the knowledge and resources to equip them to support this.

Core Outcome Measures for Palliative and End-of-Life Research After Severe Stroke: Mixed-Method Delphi Study

Supplemental Digital Content is available in the text.

Background and Purpose:

Stroke is the second commonest cause of death worldwide and a leading cause of severe disability, yet there are no published trials of palliative care in stroke. To design and evaluate palliative care interventions for people with stroke, researchers need to know what measurable outcomes matter most to patients and families, stroke professionals, and other service providers.

Methods:

A multidisciplinary steering group of professionals and laypeople managed the study. We synthesized recommendations from respected United Kingdom and international consensus documents to generate a list of outcome domains and then performed a rapid scoping literature review to identify potential outcome measures for use in future trials of palliative care after stroke. We then completed a 3-round, online Delphi survey of professionals, and service users to build consensus about outcome domains and outcome measures. Finally, we held a stakeholder workshop to review and finalize this consensus.

Results:

We generated a list of 36 different outcome domains from 4 key policy documents. The rapid scoping review identified 43 potential outcome measures that were used to create a shortlist of 16 measures. The 36 outcome domains and 16 measures were presented to a Delphi panel of diverse healthcare professionals and lay service users. Of 48 panelists invited to take part, 28 completed all 3 rounds. Shared decision-making and quality of life were selected as the most important outcome domains for future trials of palliative care in stroke. Additional comments highlighted the need for outcomes to be feasible, measurable, and relevant beyond the initial, acute phase of stroke. The stakeholder workshop endorsed these results.

Conclusions:

Future trials of palliative care after stroke should include pragmatic outcome measures, applicable to the evolving patient and family experiences after stroke and be inclusive of shared decision-making and quality of life.

Risks associated with continuation of potentially inappropriate antihypertensive medications in older adults receiving hemodialysis

Background and objectives

After dialysis initiation, older adults may experience orthostatic or post-dialysis hypotension. Some orthostasis-causing antihypertensives (i.e., central alpha agonists and alpha blockers), are considered potentially inappropriate medications (PIMs) for older adults because they carry more risk than benefit. We sought to (1) describe antihypertensive PIM prescribing patterns before and after dialysis initiation and (2) ascertain the potential risk of adverse outcomes when these medications are continued after dialysis initiation.

Design, setting, participants, and measurements

Using United States Renal Data System data, we evaluated monthly prevalence of antihypertensive PIM claims in the period before and after dialysis initiation among older adults aged ≥66 years initiating in-center hemodialysis in the US between 2013 and 2014. Patients with an antihypertensive PIM prescription at hemodialysis initiation and who survived for 120 days were classified as ‘continuers’ or ‘discontinuers’ based on presence or absence of a refill within the 120 days after initiation. We compared rates of hospitalization and risk of death across these groups from day 121 through 24 months after dialysis initiation.

Results

Our study included 30,760 total patients, of whom 5981 (19%) patients had an antihypertensive PIM claim at dialysis initiation and survived ≥120 days. Most [65% (n = 3920)] were continuers. Those who continued (versus discontinued) were more likely to be black race (26% versus 21%), have dual Medicare-Medicaid coverage (31% versus 27%), have more medications on average (12 versus 9) and have no functional limitations (84% versus 80%). Continuers experienced fewer all-cause hospitalizations and deaths, but neither were statistically significant after adjustment (Hospitalization: RR 0.93, 95% CI 0.86, 1.00; Death: HR 0.89, 95% CI: 0.78–1.02).

Conclusions

Nearly one in five older adults had an antihypertensive PIM at dialysis initiation. Among those who survived ≥120 days, continuation of an antihypertensive PIM was not associated with increased risk of all-cause hospitalization or mortality.

REPORT-PFP: a consensus from the International Patellofemoral Research Network to improve REPORTing of quantitative PatelloFemoral Pain studies

Patellofemoral pain is a common and often debilitating musculoskeletal condition. Clinical translation and evidence synthesis of patellofemoral pain research are compromised by heterogenous and often inadequately reported study details. This consensus statement and associated checklist provides standards for REPORTing of quantitative PatelloFemoral Pain (REPORT-PFP) research to enhance clinical translation and evidence synthesis, and support clinician engagement with research and data collection. A three-stage Delphi process was initiated at the 2015 International Patellofemoral Research Network (iPFRN) retreat. An initial e-Delphi activity (n=24) generated topics and items, which were refined at the 2017 iPFRN retreat, and voted on prior to and following the 2019 iPFRN retreat (n=51 current and past retreat participants). Voting criteria included 'strongly recommended' (essential), 'recommended' (encouraged) and uncertain/unsure. An item was included in the checklist if ≥70% respondents voted 'recommended'. Items receiving ≥70% votes for 'strongly recommended' were labelled as such. The final REPORT-PFP checklist includes 31 items (11 strongly recommended, 20 recommended), covering (i) demographics (n=2,4); (ii) baseline symptoms and previous treatments (n=3,7); (iii) outcome measures (2,4); (iv) outcomes measure description (n=1,2); (v) clinical trial methodology (0,3) and (vi) reporting study results (n=3,0). The REPORT-PFP checklist is ready to be used by researchers and clinicians. Strong stakeholder engagement from clinical academics during development means consistent application by the international patellofemoral pain research community is likely. Checklist adherence will improve research accessibility for clinicians and enhance future evidence synthesis.

POS1189 THE IMPACT OF TELEMEDICINE AND COVID-19 ON A TERTIARY RHEUMATOLOGY SERVICE: A RETROSPECTIVE AUDIT

Background:

Telemedicine was widely utilised to complement face-to-face (F2F) care in 2020 during the COVID-19 pandemic, but the impact of this on patient care is poorly understood.

Objectives:

To investigate the impact of telemedicine during COVID-19 on outpatient rheumatology services.

Methods:

We retrospectively audited patient electronic medical records from rheumatology outpatient clinics in an urban tertiary rheumatology centre between April-May 2020 (telemedicine cohort) and April-May 2019 (comparator cohort). Differences in age, sex, primary diagnosis, medications, and proportion of new/review appointments were assessed using Mann-Whitney U and Chi-square tests. Univariate analysis was used to estimate associations between telemedicine usage and the ability to assign a diagnosis in patients without a prior rheumatological diagnosis, the frequency of changes to immunosuppression, subsequent F2F review, planned admissions or procedures, follow-up phone calls, and time to next appointment.

Results:

3,040 outpatient appointments were audited: 1,443 from 2019 and 1,597 from 2020. There was no statistically significant difference in the age, sex, proportion of new/review appointments, or frequency of immunosuppression use between the cohorts. Inflammatory arthritis (IA) was a more common diagnosis in the 2020 cohort (35.1% vs 31%, p=0.024). 96.7% (n=1,444) of patients seen in the 2020 cohort were reviewed via telemedicine. In patients without an existing rheumatological diagnosis, the odds of making a diagnosis at the appointment were significantly lower in 2020 (28.6% vs 57.4%; OR 0.30 [95% CI 0.16-0.53]; p<0.001). Clinicians were also less likely to change immunosuppressive therapy in 2020 (22.6% vs 27.4%; OR 0.78 [95% CI 0.65-0.92]; p=0.004). This was mostly driven by less de-escalation in therapy (10% vs 12.6%; OR 0.75 [95% CI 0.59-0.95]; p=0.019) as there was no statistically significant difference in the escalation or switching of immunosuppressive therapies. There was no significant difference in frequency of follow-up phone calls, however, patients seen in 2020 required earlier follow-up appointments (p<0.001). There was also no difference in unplanned rheumatological presentations but significantly fewer planned admissions and procedures in 2020 (1% vs 2.6%, p=0.002). Appointment non-attendance reduced in 2020 to 6.5% from 10.9% in 2019 (OR 0.57 [95% CI 0.44-0.74]; p<0.001), however the odds of discharging a patient from care were significantly lower in 2020 (3.9% vs 6%; OR 0.64 [95% CI 0.46-0.89]; p=0.008), although there was no significance when patients who failed to attend were excluded. Amongst patients seen via telemedicine in 2020, a subsequent F2F appointment was required in 9.4%. The predictors of needing a F2F review were being a new patient (OR 6.28 [95% CI 4.10-9.64]; p<0.001), not having a prior rheumatological diagnosis (OR 18.43 [95% CI: 2.35-144.63]; p=0.006), or having a diagnosis of IA (OR 2.85 [95% CI: 1.40-5.80]; p=0.004) or connective tissue disease (OR 3.22 [95% CI: 1.11-9.32]; p=0.031).

Conclusion:

Most patients in the 2020 cohort were seen via telemedicine. Telemedicine use during the COVID-19 pandemic was associated with reduced clinic non-attendance, but with diagnostic delay, reduced likelihood of changing existing immunosuppressive therapy, earlier requirement for review, and lower likelihood of discharge. While the effects of telemedicine cannot be differentiated from changes in practice related to other aspects of the pandemic, they suggest that telemedicine may have a negative impact on the timeliness of management of rheumatology patients.

Disclosure of Interests:

None declared.

Rapid sequence induction: where did the consensus go?

Background

Rapid Sequence Induction (RSI) was introduced to minimise the risk of aspiration of gastric contents during emergency tracheal intubation. It consisted of induction with the use of thiopentone and suxamethonium with the application of cricoid pressure.

This narrative review describes how traditional RSI has been modified in the UK and elsewhere, aiming to deliver safe and effective emergency anaesthesia outside the operating room environment. Most of the key aspects of traditional RSI – training, technique, drugs and equipment have been challenged and often significantly changed since the procedure was first described. Alterations have been made to improve the safety and quality of the intervention while retaining the principles of rapidly securing a definitive airway and avoiding gastric aspiration. RSI is no longer achieved by an anaesthetist alone and can be delivered safely in a variety of settings, including in the pre-hospital environment.

Conclusion

The conduct of RSI in current emergency practice is far removed from the original descriptions of the procedure. Despite this, the principles – rapid delivery of a definitive airway and avoiding aspiration, are still highly relevant and the indications for RSI remain relatively unchanged.

124 Skeletal muscle RNA and insulin sensitivity during insufficient sleep

Introduction

Insufficient sleep is associated with a down-regulation of genes involved in glycolysis, in conjunction with an upregulation of genes involved in lipid metabolism in skeletal muscle. However, whether changes in RNA are associated with impairments in insulin sensitivity is unclear. We therefore tested the hypothesis that insufficient sleep will induce alterations in skeletal muscle RNA that correlate with changes in insulin sensitivity.

Methods

As part of an ongoing study, sixteen sedentary, healthy, lean adults (24.9±3.4y; 22.6±1.7kg/m2; 6F; mean±SD) participated in a controlled 6-day in-laboratory protocol with 9h in bed (habitual sleep) followed by 4 nights of 5h in bed (insufficient sleep), achieved by delaying bedtime by 4 hours. For one week prior to the study, participants maintained a 9h sleep schedule based on their habitual bed and wake times. Participants consumed energy-balanced diets 3 days prior to and throughout the laboratory protocol. Whole body insulin sensitivity was assessed using glucose infusion rate from a hyperinsulinemic euglycemic clamp before and after 4 nights of insufficient sleep. Skeletal muscle biopsies of the vastus lateralis were taken immediately before each clamp. In a subset of subjects (n=12), RNA sequencing was performed (Novogene Co., Ltd). Generalized linear model likelihood ratio tests were completed using the DESeq2/EdgeR R packages with a false discovery rate (FDR) cut-off of 5%. P-values were adjusted for multiple comparisons using the Benjamini-Hochberg method and a corrected p-value of 0.05 and log2 fold-change of 0 were set as the threshold for statistical significance.

Results

Insulin sensitivity was impaired by 6% following insufficient sleep (10.1±1.4 vs 9.1±1.1mg/kg/min, p&lt;0.05, mean±SEM). Preliminary results from skeletal muscle RNAseq analyses suggest approximately 25 genes were down-regulated and 60 genes were up-regulated. Down-regulated genes were involved in insulin-like growth factor binding and signal transduction (p=8.4e-11), while up-regulated genes were involved in glycolysis and ATP binding (p=1.1e-9). While there were trends for associations between changes in gene expression and insulin sensitivity, these relationships did not reach statistical significance.

Conclusion

Preliminary findings suggest insufficient sleep alters skeletal muscle RNA. Changes in these aforementioned pathways may contribute to metabolic dysregulation during insufficient sleep.

Support (if any)

NIH K01DK110138, R03 DK118309, UL1 TR002535, and GCRC RR-00036

Mechanisms of Congenital Heart Disease Caused by NAA15 Haploinsufficiency

[Figure: see text].

Early detection of melanoma in specialised primary care practice in Australia

BACKGROUND

Primary care skin cancer clinics facilitate early treatment of melanoma in Australia. We investigated the clinical and histopathological features of melanomas diagnosed and treated in an established clinic in Brisbane.

METHODS

Retrospective audit of medical records of patients diagnosed with in situ or invasive primary cutaneous melanoma in a primary care clinic specializing in skin cancer, 2000-2017. Demographic and clinical data were standardly extracted by a medically-trained investigator. We used descriptive analyses to assess characteristics of patients and melanomas, and examine surgical management according to tumour thickness.

RESULTS

Of 380 patients (median age 57 years; 57 % male) newly diagnosed with 497 histologically-confirmed primary cutaneous melanomas, 369 were in situ and 128 invasive. Of the 369 in situ melanomas, 143 (39 %) were on the trunk and 87 (24 %) on the head and neck; 247 (67 %) were diagnosed by shave biopsy; and 141 (38 %) referred for wide local excision (WLE). Of the 128 invasive melanomas, only 21 (16 %) had thickness ≥ 0.8 mm and these occurred more often on head and neck than thin invasive melanomas (p = 0.02). The majority of invasive melanomas were diagnosed by excision biopsy, and WLE was carried out in a median of 3 days (melanomas ≥ 0.8 mm) and 2 days (<0.8 mm). The doctor detected the majority of in situ (83 %) and thin invasive (73 %) melanomas during surveillance, compared with 48 % of thicker invasive melanomas ≥ 0.8 mm (p < 0.001).

CONCLUSION

In Australia, specialised primary care practice plays a major role in detection and treatment of early primary melanoma.

Properties of Pain Assessment Tools for Use in People Living With Stroke: Systematic Review

Background: Pain is a common problem after stroke and is associated with poor outcomes. There is no consensus on the optimal method of pain assessment in stroke. A review of the properties of tools should allow an evidence based approach to assessment.

Objectives: We aimed to systematically review published data on pain assessment tools used in stroke, with particular focus on classical test properties of: validity, reliability, feasibility, responsiveness.

Methods: We searched multiple, cross-disciplinary databases for studies evaluating properties of pain assessment tools used in stroke. We assessed risk of bias using the Quality Assessment of Diagnostic Accuracy Studies tool. We used a modified harvest plot to visually represent psychometric properties across tests.

Results: The search yielded 12 relevant articles, describing 10 different tools (n = 1,106 participants). There was substantial heterogeneity and an overall high risk of bias. The most commonly assessed property was validity (eight studies) and responsiveness the least (one study). There were no studies with a neuropathic or headache focus. Included tools were either scales or questionnaires. The most commonly assessed tool was the Faces Pain Scale (FPS) (6 studies). The limited number of papers precluded meaningful meta-analysis at level of pain assessment tool or pain syndrome. Even where common data were available across papers, results were conflicting e.g., two papers described FPS as feasible and two described the scale as having feasibility issues.

Conclusion: Robust data on the properties of pain assessment tools for stroke are limited. Our review highlights specific areas where evidence is lacking and could guide further research to identify the best tool(s) for assessing post-stroke pain. Improving feasibility of assessment in stroke survivors should be a future research target.

Systematic Review Registration Number: PROSPERO CRD42019160679

Available online at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019160679.

A co-production approach guided by the behaviour change wheel to develop an intervention for reducing sedentary behaviour after stroke

Background

Stroke survivors are highly sedentary; thus, breaking up long uninterrupted bouts of sedentary behaviour could have substantial health benefit. However, there are no intervention strategies specifically aimed at reducing sedentary behaviour tailored for stroke survivors. The purpose of this study was to use co-production approaches to develop an intervention to reduce sedentary behaviour after stroke.

Methods

A series of five co-production workshops with stroke survivors, their caregivers, stroke service staff, exercise professionals, and researchers were conducted in parallel in two-stroke services (England and Scotland). Workshop format was informed by the behaviour change wheel (BCW) framework for developing interventions and incorporated systematic review and empirical evidence. Taking an iterative approach, data from activities and audio recordings were analysed following each workshop and findings used to inform subsequent workshops, to inform both the activities of the next workshop and ongoing intervention development.

Findings

Co-production workshop participants (n = 43) included 17 staff, 14 stroke survivors, six caregivers and six researchers. The target behaviour for stroke survivors is to increase standing and moving, and the target behaviour for caregivers and staff is to support and encourage stroke survivors to increase standing and moving. The developed intervention is primarily based on co-produced solutions to barriers to achieving the target behaviour. The developed intervention includes 34 behaviour change techniques. The intervention is to be delivered through stroke services, commencing in the inpatient setting and following through discharge into the community. Participants reported that taking part in intervention development was a positive experience.

Conclusions

To our knowledge, this is the first study that has combined the use of co-production and the BCW to develop an intervention for use in stroke care. In-depth reporting of how a co-production approach was combined with the BCW framework, including the design of bespoke materials for workshop activities, should prove useful to other researchers and practitioners involved in intervention development in stroke.

De Novo Damaging Variants, Clinical Phenotypes, and Post-Operative Outcomes in Congenital Heart Disease

Supplemental Digital Content is available in the text.

Background:

De novo genic and copy number variants are enriched in patients with congenital heart disease, particularly those with extra-cardiac anomalies. The impact of de novo damaging variants on outcomes following cardiac repair is unknown.

Methods:

We studied 2517 patients with congenital heart disease who had undergone whole-exome sequencing as part of the CHD GENES study (Congenital Heart Disease Genetic Network).

Results:

Two hundred ninety-four patients (11.7%) had clinically significant de novo variants. Patients with de novo damaging variants were 2.4 times more likely to have extra-cardiac anomalies (P=5.63×10⁻¹²). In 1268 patients (50.4%) who had surgical data available and underwent open-heart surgery exclusive of heart transplantation as their first operation, we analyzed transplant-free survival following the first operation. Median follow-up was 2.65 years. De novo variants were associated with worse transplant-free survival (hazard ratio, 3.51; P=5.33×10⁻⁰⁴) and longer times to final extubation (hazard ratio, 0.74; P=0.005). As de novo variants had a significant interaction with extra-cardiac anomalies for transplant-free survival (P=0.003), de novo variants conveyed no additional risk for transplant-free survival for patients with these anomalies (adjusted hazard ratio, 1.96; P=0.06). By contrast, de novo variants in patients without extra-cardiac anomalies were associated with worse transplant-free survival during follow-up (hazard ratio, 11.21; P=1.61×10⁻⁰⁵) than that of patients with no de novo variants. Using agnostic machine-learning algorithms, we identified de novo copy number variants at 15q25.2 and 15q11.2 as being associated with worse transplant-free survival and 15q25.2, 22q11.21, and 3p25.2 as being associated with prolonged time to final extubation.

Conclusions:

In patients with congenital heart disease undergoing open-heart surgery, de novo variants were associated with worse transplant-free survival and longer times on the ventilator. De novo variants were most strongly associated with adverse outcomes among patients without extra-cardiac anomalies, suggesting a benefit for preoperative genetic testing even when genetic abnormalities are not suspected during routine clinical practice.

Registration:

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01196182.

Factors influencing sedentary behaviours after stroke: findings from qualitative observations and interviews with stroke survivors and their caregivers

BACKGROUND

Stroke survivors are more sedentary than healthy, age-matched controls, independent of functional capacity. Interventions are needed to encourage a reduction in overall sedentary time, and regular breaks in prolonged periods of sedentary behaviour. This study captured the views and experiences of stroke survivors and their caregivers related to sedentary behaviour after stroke, to inform the development of an intervention to reduce sedentary behaviour.

METHODS

Mixed-methods qualitative study. Non-participant observations were completed in two stroke services, inclusive of inpatient and community settings in the United Kingdom. Semi-structured interviews were conducted with stroke survivors and their caregivers (if available) at six- or nine-months post-stroke. Underpinned by the capability, opportunity and motivation (COM-B) model of behaviour change, observational data (132 h) were analysed thematically and interview data (n = 31 stroke survivors, n = 12 caregivers) were analysed using the Framework approach.

RESULTS

Observation participants differed in functional ability whereas stroke survivor interviewees were all ambulant. Six themes related to sedentary behaviour after stroke were generated: (1) sedentary behaviour levels and patterns after stroke; (2) the physical and social environment in the stroke service and in the home; (3) standing and movement capability after stroke; (4) emotion and motivation after stroke; (5) caregivers' influence on, and role in influencing stroke survivors' sedentary behaviour; and (6) intervening to reduce sedentary behaviour after stroke. Capability, opportunity and motivation were influenced by the impact of the stroke and caregivers' inclination to support sedentary behaviour reduction. Stroke survivors reported being more sedentary than they were pre-stroke due to impaired balance and co-ordination, increased fatigue, and reduced confidence in mobilising. Caregivers inclination to support stroke survivors to reduce sedentary behaviour depended on factors including their willingness to withdraw from the caregiver role, and their perception of whether the stroke survivor would act on their encouragement.

CONCLUSIONS

Many stroke survivors indicate being open to reducing sedentary behaviour, with appropriate support from stroke service staff and caregivers. The findings from this study have contributed to an intervention development process using the Behaviour Change Wheel (BCW) approach to develop strategies to reduce sedentary behaviour after stroke.

SAT0067 SEVERE INFECTIONS REMAIN COMMON IN A REAL-WORLD RHEUMATOID ARTHRITIS COHORT: A SIMPLE CLINICAL MODEL TO PREDICT INFECTION RISK

Background:

Patients with rheumatoid arthritis (RA) have a higher risk of infection due to immunological dysfunction, immunosuppressive use, and coexisting comorbidities1. An understanding of these risk factors has helped develop infection risk calculators2. However, there are currently no screening tools available torapidlyidentify patients with high infection risk.

Objectives:

To investigate the incidence of severe infection in a real-world RA cohort, identify associated risk factors, and propose a simple infection risk screening tool.

Methods:

Between January and July 2019, patients were recruited consecutively from an Australian tertiary hospital’s RA clinic. We included all adult patients with RA. The primary outcome was a severe infection (any infection requiring hospital admission) between January 2018 and July 2019. We collected data using hospital notes, medical records and pathology results. We used validated scores such as the disease activity score of 28 joints (DAS28) and the Charlson comorbidity index to assess disease activity and comorbidity burden. Multivariable regression was used for statistical analysis.

Results:

We recruited 263 eligible patients. 45 severe infections occurred in 34 patients (13%), corresponding to 10.8 infections per 100 patient years. Respiratory (53%) and urinary tract infections (13%) were the most common. On multivariable analysis, the most significant risk factors for severe infection included low lymphocyte counts (odds ratio (OR) 4.08), a previous infection within the last three years (OR 3.58), a Charlson comorbidity index of two or more (OR 2.69) and higher disease activity (OR 1.35 per 0.5-increase in DAS-28). The multivariable model incorporating these factors had a large area under receiver operating characteristic (ROC) curve of 0.82. Glucocorticoid and biologic use were not significantly associated with infection.

Conclusion:

To our knowledge, this was one of the first Australian studies to evaluate severe infection rates in a real-world RA cohort. Rates remained high and comparable with older studies3. Lymphopenia, high disease activity, comorbidity burden and a previous infection were independent risk factors for infection. Our multivariable model is a composite of easily assessible clinical and biological parameters, with excellent predictive potential for infection. Once validated, it may be developed into a screening tool to help clinicians rapidly identify high risk patients and inform tailored clinical decision making.

References:

[1] Listing J, Gerhold K, Zink A. The risk of infections associated with rheumatoid arthritis, with its comorbidity and treatment. Rheumatology. 2012;52(1):53-61.

[2] Strangfeld A, Eveslage M, Schneider M, Bergerhausen HJ, Klopsch T, Zink A, et al. Treatment benefit or survival of the fittest: What drives the time-dependent decrease in serious infection rates under TNF inhibition and what does this imply for the individual patient? Ann Rheum Dis. 2011;70(11):1914-20.

[3] Doran MF, Crowson CS, Pond GR, O’Fallon WM, Gabriel SE. Frequency of infection in patients with rheumatoid arthritis compared with controls: A population-based study. Arthritis Rheum. 2002;46(9):2287-93.

Table 1.

Cohort Demographics

CharacteristicMedian (Interquartile Range) or Number (%)Age (years)62 (50-70)Sex (female)191 (73)Length of diagnosis (years)9 (5-18)Biologic use over study period106 (40)Steroid use over study period77 (29)Charlson comorbidity index (excluding age)0 (0-1)Table 2.

multivariable logistic regression model for severe infection

VariablesOdds RatiopvalueAge ≥50*0.600.368Charlson comorbidity index (≥2)2.690.043Previous severe infection in last 3 years3.580.015Disease activity score of 28 joints (per 0.5 increase)1.350.005Low lymphocyte counts (<1)4.080.028

*Age was included despite insignificance due to ana prioridecision about its clinical relevance

Figure 1.

Receiver operating characteristic curve (ROC) of the multivariable model for infection

Disclosure of Interests:

None declared