348 WHAT IS THE OLDER PATIENT’S VIEW ON RECEIVING DETAILED MEDICAL LETTERS?

Background

Sending copies of clinic letters to patients involves additional work for medical staff in formatting letters, administrative staff in printing and posting and is an added cost to the healthcare service. Though seen largely as good practice in some specialities, it is not done routinely in Geriatric medical services. We introduced this practice as standard in our service and wished to evaluate whether from the patient perspective, it is worthwhile.

Methods

We sent a questionnaire to n=80 older patients who were evaluated in the home setting (by the Integrated Care Team for Older People – ICTOP) or recently attended CGA (Comprehensive Geriatric Assessment) clinic or FLS (Fracture Liaison Service) clinic. We asked their opinion on the detailed medical letter sent to their General Practitioner (GP), which they received a copy of. The questionnaire could be completed by patient/carer/relative, and returned anonymously.

Results

N=30/80 were returned. Two said they found the letter difficult to understand; 1/30 said the letter caused them to worry but all said they still preferred that they had received it. N= 2 said they would like to have contributed to the letter for accuracy. All said they felt they should receive copies of all their medical correspondence. Free text comments showed overwhelming support for the process, in allowing them to self-manage their health, enhance communication with other healthcare professionals and was a useful document to refer back to when they are trying to process information during short consultations.

Conclusion

Though a small survey and limited by low response rate, older people expressed high levels of satisfaction in receiving copies of medical letters about their health. It supports the ongoing practice and should be adopted widely.

Intravenous Fluid Bag as a Substitute for Gel Standoff Pad in Musculoskeletal Point-of-care Ultrasound

INTRODUCTION

Point-of-care ultrasound (POCUS) is a tool undergoing expanding use in military medicine, including routine inpatient, outpatient, and operational environments. Specific musculoskeletal POCUS examinations require additional equipment in the form of a standoff assist device to maximize image acquisition. These devices may not be readily available to POCUS users in more austere or resource-constrained environments. We devised a study to determine if intravenous fluid bags of various volumes could be substituted for standard standoff devices in musculoskeletal POCUS.

MATERIALS AND METHODS

Sequential images of a soft tissue foreign body model, an interphalangeal joint, and a chest wall were taken using a gel standoff pad or water bath and compared to images acquired using three different sizes of intravenous fluid bags after removing excess air from the bags. Images were de-identified and scored for quality using a visual analog scale. We used a two-factor analysis of variance without replication to analyze the differences in image quality between standoff devices, with a P-value less than.05 considered statistically significant.

RESULTS

We performed 13 POCUS studies and had a group of eight POCUS-trained physicians and physician assistants score these studies, resulting in 104 total quality scores. There was no significant difference in image quality between standoff devices for chest (P-value.280) and hand (P-value 0.947) images. We found a significant difference in image quality between standoff devices for the soft tissue foreign body model (P-value 0.039), favoring larger intravenous fluid bag standoff over standard devices.

CONCLUSIONS

In the absence of a standard commercial gel standoff device or water bath, intravenous fluid bags of 50, 100, and 250 mL can facilitate quality image acquisition for musculoskeletal POCUS.

AB0070 LORECIVIVINT (SM04690), A POTENTIAL DISEASE-MODIFYING TREATMENT FOR KNEE OSTEOARTHRITIS, DEMONSTRATED CARTILAGE-PROTECTIVE EFFECTS ON HUMAN OSTEOARTHRITIC EXPLANTS

Background:

Wnt pathway upregulation contributes to knee osteoarthritis (OA) through osteocyte differentiation, cartilage thinning, and inflammation. Lorecivivint (LOR; SM04690), a novel, small-molecule CLK/DYRK1A inhibitor that modulates the Wnt pathway, demonstrated disease-modifying potential for knee OA in preclinical studies.1However, the specific mechanisms by which LOR protects cartilage in knee OA are unclear.

Objectives:

To evaluate the cartilage-protective effects of LOR on human OA explants from total knee replacement (TKR) donors.

Methods:

Knee joint tissue from 22 TKR donors was obtained. IRB approval was obtained from Scripps Health. Cartilage was scored using the Outerbridge classification system based on gross appearance (grade 1=least-damaged tissue, grade 4=most-damaged tissue). Cartilage explants (4 mm in diameter) with Outerbridge grades 2–3 were harvested and cultured for 48 hours to reach metabolic stability. They were then treated with LOR (10 nM, 30 nM) or DMSO and stimulated with either IL-1β (10 ng/ml) or TNF-α (20 ng/ml)+oncostatin M (OM) (10 ng/ml) or left unstimulated. After 72 hours, supernatants and explants were collected. Gene expression of matrix metalloproteinases (MMPs) 1, 3, and 13 was measured by qPCR and protein levels of MMP-1, MMP-3, MMP-13, and thrombospondin-motif-containing disintegrins/metalloproteinases ADAMTS-4 and ADAMTS-5 were measured in supernatants by ELISA. Glycosaminoglycan (GAG) and nitric oxide (NO) levels were measured in supernatants using the dimethylmethylene blue assay and Griess assay, respectively. One-way ANOVA was used for multiple group comparisons.

Results:

Treatment with IL-1β or TNF-α+OM led to statistically significant increases in gene expression ofMMP1,MMP3, andMMP13and increased secretion of GAG, MMP-1, MMP-3, MMP-13, ADAMTS-4, ADAMTS-5, and NO in supernatants compared to unstimulated control. Treatment with LOR decreased both IL-1β-stimulated and TNF-α+OM-stimulated gene expression ofMMP1,MMP3, andMMP13and secretion of GAG, MMP-1, MMP-3, MMP-13, ADAMTS-4, ADAMTS-5, and NO in supernatants compared to treatment with DMSO.

Conclusion:

LOR demonstrated potent inhibition of cartilage catabolism enzyme production in human OA explants compared to controls. These cartilage-protective effects support the development of LOR as a potential disease-modifying treatment for knee OA. Human trials are ongoing.

References:

[1]Deshmukh V, et al.Osteoarthr Cartil. 2019.

Disclosure of Interests:

Vishal Deshmukh Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Shawn Grogan: None declared, Tim Seo Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Deepti Bhat Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, William Bugbee: None declared, Darryl D’Lima: None declared, Yusuf Yazici Shareholder of: Samumed, LLC, Grant/research support from: Bristol-Myers Squibb, Celgene, and Genentech, Consultant of: Celgene and Sanofi, Employee of: Samumed, LLC

A qualitative study of disengagement in disadvantaged areas of the UK: 'You come through your door and you lock that door'

Health inequalities are a major concern in the UK. Power imbalances are associated with health inequalities and should be challenged through health promotion and empowering strategies, enabling individuals who feel powerless to take control over their own life and act on the determinants of health (Green and Tones, 2010). This study aimed to explore resident expectations of a community engagement programme that intended to empower communities to take action on pre-identified priorities. The programme targeted communities in deprived areas of a mid-sized city in the UK. A qualitative design was implemented. In-depth semi-structured interviews were undertaken with 28 adult residents at the start of the programme. Transcripts were analysed using an inductive approach to thematic analysis. Resident expectations were explored from a constructivist epistemological perspective. The qualitative inductive approach allowed a second research question to develop which led this paper to focus on exploring how disempowerment was experienced by individuals before taking part in a community engagement programme. Analysis of interviews revealed a 'process of deterioration' that provided insight into how communities might become (more) disadvantaged through disempowerment. Five master themes were identified: external abandonment at the institutional-level (master theme 1); a resulting loss of sense of community (master theme 2); this negatively affected psychological wellbeing of residents (master theme 3); who adopted coping strategies (e.g., disengagement) to aid living in such challenging areas; (master theme 4); disengagement further perpetuated the deterioration of the area (master theme 5). Distrust was identified as a major barrier to participation in community engagement programmes. Overall, our data suggested that community engagement approaches must prioritise restoration of trust and be accompanied by supportive policies to mitigate feelings of abandonment in communities.

A Point System as Catalyst to Increase Resident Scholarship: An MPCRN Study

INTRODUCTION

Encouraging resident scholarly activity has been a longstanding challenge for medical educators. The Accreditation Council for Graduate Medical Education (ACGME) has been increasing its emphasis on scholarly activity, forcing programs to evaluate their existing processes. This study sought to evaluate the impact of a scholarly activity point system on the resident scholarly productivity at multiple programs.

METHODS

Five military family medicine residencies evaluated resident outcomes 2 years before and 2 years after the introduction of a scholarly activity point system. Outcome measures included peer-reviewed publications with a resident as first author, peer-reviewed publications with a resident as any author, resident presentation of scholarship at a regional, national, and international conference, IRB-approved protocols with a resident as principal investigator, and IRB-approved protocols with a resident in any role.

RESULTS

Four of the five programs experienced substantial increases in nearly every outcome. The fifth program, which had a more robust culture of inquiry at baseline, did not experience an increase in resident scholarly productivity.

CONCLUSIONS

A scholarly activity point system was associated with an increase in resident scholarly production in family medicine programs. It appears to work best in programs that start from a lower level of scholarly productivity at baseline. A point system appears to be a useful addition to scholarly activity curricula.

Diagnosis and management of kawasaki disease

Kawasaki disease is an acute, systemic vasculitis that predominantly affects patients younger than five years. It represents the most prominent cause of acquired coronary artery disease in childhood. In the United States, 19 per 100,000 children younger than five years are hospitalized with Kawasaki disease annually. According to U.S. and Japanese guidelines, Kawasaki disease is a clinical diagnosis. Classic (typical) Kawasaki disease is diagnosed based on the presence of a fever lasting five or more days, accompanied by four out of five findings: bilateral conjunctival injection, oral changes such as cracked and erythematous lips and strawberry tongue, cervical lymphadenopathy, extremity changes such as erythema or palm and sole desquamation, and polymorphous rash. Incomplete (atypical) Kawasaki disease occurs in persons with fever lasting five or more days and with two or three of these findings. Transthoracic echocardiography is the diagnostic imaging modality of choice to screen for coronary aneurysms, although other techniques are being evaluated for diagnosis and management. Treatment for acute disease is intravenous immunoglobulin and aspirin. If there is no response to treatment, patients are given a second dose of intravenous immunoglobulin with or without corticosteroids or other adjunctive treatments. The presence and severity of coronary aneurysms and obstruction at diagnosis determine treatment options and the need, periodicity, and intensity of long-term cardiovascular monitoring for potential atherosclerosis.

Multimodal hyperspectral imaging for the noninvasive diagnosis of cervical neoplasia

OBJECTIVE

To determine the ability of Multimodal Hyperspectral Imaging (MHI) to noninvasively detect, localize and diagnose cervical neoplasia.

MATERIALS AND METHODS

The cervical epithelium was interrogated by MHI using tissue fluorescence and reflectance measurements after the probe was placed on the ectocervix. A Papanicolaou smear was taken, and a colposcopic examination was performed and cervical histologic specimens were collected, when indicated. MHI and Pap smear sensitivity and specificity data were compared with colposcopic and histologic results.

RESULTS

Nineteen patients had CIN2 or higher, 30 had CIN1, 34 had benign cellular changes or metaplasia, and 28 were normal by both Pap smear and colposcopic examination. At equal specificity (70%) for both tests, the sensitivity of MHI was 97%, compared to 72% for the Pap smear.

CONCLUSION

MHI detected cervical cancer precursors at a rate greater than that obtained by a simultaneously collected Pap smear.

Information and support needs of callers to the Cancer Helpline, The Cancer Council Victoria

The broad aims of the present evaluation were, firstly, to describe the information and support needs of callers to a Cancer Helpline and, secondly, to describe the response of the service to these needs. A further aim was to use these results to develop strategies to improve the service. Anonymous caller information collected over a 6-year period was analysed. The setting of the study was the Cancer Helpline service operated by the Cancer Council Victoria within the state of Victoria, Australia. The caller profile was similar to that described in the literature, with the majority of callers being women, younger than the general cancer population and enquiring most commonly about breast cancer. Patients and their relatives called to obtain information about cancer diagnosis, treatment and management and to obtain psychological and emotional support. Callers received emotional support, were supplied with verbal and written information and were referred to a variety of support services. Some population groups are underrepresented in the data. Changes to the Helpline and other services over the 6-year period are described. The pattern of callers to the Cancer Helpline appears similar to that described in the USA and Europe. Many issues and challenges are common. The paper discusses additional strategies for meeting the information and support needs of those affected by cancer and describes current and suggested research areas.

Australia's Cancer Helpline--an audit of utility and caller profile

BACKGROUND

The Cancer Helpline is a telephone information and support service operated throughout Australia.

METHODS

Data from all calls received during the months of July, August and September from 2001 to 2003 were collected and analysed.

RESULTS

Over 76,000 contacts were made, mostly from women (79%). Almost half of all calls were from people with general inquiries (rather than cancer patients, their families, or health professionals). The most common cancer type discussed was breast cancer, (26% of all calls, 42% of calls from people with cancer). Diagnosed cancer patients most frequently called about treatment/management and practical issues. People with general inquiries called to obtain information about the prevention and early detection of cancer.

DISCUSSION

The helpline can complement the role of other information and support providers for people living with or concerned about cancer.

Articular cartilage repair using a tissue-engineered cartilage-like implant: an animal study

OBJECTIVE

Because articular cartilage has limited ability to repair itself, treatment of (osteo)chondral lesions remains a clinical challenge. We aimed to evaluate how well a tissue-engineered cartilage-like implant, derived from chondrocytes cultured in a novel patented, scaffold-free bioreactor system, would perform in minipig knees with chondral, superficial osteochondral, and full-thickness articular defects.

DESIGN

For in vitro implant preparation, we used full-thickness porcine articular cartilage and digested chondrocytes. Bioreactors were seeded with 20x10(6) cells and incubated for 3 weeks. Subsequent to culture, tissue cartilage-like implants were divided for assessment of viability, formaldehyde-fixed and processed by standard histological methods. Some samples were also prepared for electron microscopy (TEM). Proteoglycans and collagens were identified and quantified by SDS-PAGE gels. For in vivo studies in adult minipigs, medial parapatellar arthrotomy was performed unilaterally. Three types of defects were created mechanically in the patellar groove of the femoral condyle. Tissue-engineered cartilage-like implants were placed using press-fit fixation, without supplementary fixation devices. Control defects were not grafted. Animals could bear full weight with an unlimited range of motion. At 4 and 24 weeks postsurgery, explanted knees were assessed using the modified ICRS classification for cartilage repair.

RESULTS

After 3-4 weeks of bioreactor incubation, cultured chondrocytes developed a 700-microm- to 1-mm-thick cartilage-like tissue. Cell density was similar to that of fetal cartilage, and cells stained strongly for Alcian blue and safranin O. The percentage of viable cells remained nearly constant (approximately 90%). Collagen content was similar to that of articular cartilage, as shown by SDS-PAGE. At explantation, the gross morphological appearance of grafted defects appeared like normal cartilage, whereas controls showed irregular fibrous tissue covering the defect. Improved histologic appearance was maintained for 6 months postoperatively. Although defects were not always perfectly level upon implantation at explanation the implant level matched native cartilage levels with no tissue hypertrophy. Once in place, implants remodelled to tissues with decreased cell density and a columnar organization.

CONCLUSIONS

Repair of cartilage defects with a tissue-engineered implant yielded a consistent gross cartilage repair with a matrix predominantly composed of type II collagen up to 6 months after implantation. This initial result holds promise for the use of this unique bioreactor/tissue-engineered implant in humans.

Quantification of laser-induced cartilage injury by confocal microscopy in an ex vivo model

BACKGROUND

The application of lasers in orthopaedic surgery is increasing. However, some investigators have reported that osteonecrosis may occur after laser meniscectomy. The objective of the present study was to evaluate the effect of laser wavelength and energy on cartilage injury in an ex vivo model.

METHODS

Fresh bovine articular cartilage was exposed to either holmium:yttrium-aluminum-garnet (Ho:YAG) or erbium:YAG-laser (Er:YAG) irradiation. Both lasers were operated in a free-running mode and at a pulse-repetition rate of 8 Hz. The effect of laser treatment at several energy levels (Er:YAG at 100 and 150 mJ and Ho:YAG at 500 and 800 mJ) was examined. For each light source and energy level, ten cartilage samples were assessed by conventional histological analysis and by confocal microscopy. Thermal damage was assessed by determining cell viability.

RESULTS

The extent of thermal damage demonstrated by confocal microscopy was much greater than that demonstrated by histological analysis. The extent of thermal injury after Ho:YAG-laser irradiation was much greater than that after Er:YAG-laser irradiation, which was associated with almost no damage. In addition, the ablation depth was greater after treatment with the Er:YAG laser than after treatment with the Ho:YAG laser.

CONCLUSIONS

In the present study, histological analysis underestimated thermal damage after laser irradiation. In addition, our findings highlighted problems associated with use of high-power settings of Ho:YAG lasers during arthroscopic surgery.

Validation of a questionnaire measuring patient satisfaction with general practitioner services

BACKGROUND

In order that patient satisfaction may be assessed in a meaningful way, measures that are valid and reliable are required. This study was undertaken to assess the construct validity and internal reliability of the previously developed Patient Satisfaction Questionnaire (PSQ).

METHOD

A total of 1390 patients from five practices in the North of England, the Midlands, and Scotland completed the questionnaire. Responses were checked for construct validity (including confirmatory factor analysis to check the factor structure of the scale) and internal reliability.

RESULTS

Confirmatory factor analysis showed that items loaded on the appropriate factors in a five factor model (doctors, nurses, access, appointments, and facilities). Scores on the specific subscales showed highly significant positive correlations with general satisfaction subscale scores suggesting construct validity. Also, the prediction (derived from past research) that older people would be more satisfied with the service was borne out by the results (F (4, 1312) = 57.10; p < 0.0001), providing further construct validation. The five specific subscales (doctors, nurses, access, appointments, and facilities), the general satisfaction subscale, and the questionnaire as a whole were found to have high internal reliability (Cronbach's alpha = 0.74-0.95).

CONCLUSION

The results suggest that the PSQ is a valid and internally reliable tool for assessing patient satisfaction with general practitioner services.

Involving families in the production of patient information literature

Many information booklets are written by health-care staff and may not address patients' needs. Collaboration between patients and staff in the production of patient information can improve patient understanding and empower the patient and family to take an active part in treatment.

Outcome measurement in adult stuttering therapy: a self-rating profile

The speech and language therapy profession is committed to the use of outcome measurement to maximise both efficiency and efficacy. However, measuring change in adult stuttering therapy is particularly problematic. It is proposed that outcomes of therapy should include stuttering behaviours, reactions to stuttering and handicap resulting from stuttering. Current methods of measuring change are reviewed. The Wright & Ayre Stuttering Self-Rating Profile (WASSP) is described which includes clients' perceptions of stuttering behaviours, avoidance, feelings and disadvantage. Issues of reliability and validity are considered.

Development of a questionnaire to measure patients' satisfaction with general practitioners' services

BACKGROUND

It is now a requirement that patients' satisfaction with the services obtained from their general practitioner should be surveyed.

AIM

The aim of the study was to produce a reliable and valid multidimensional patient satisfaction questionnaire that could be used in general practice.

METHOD

Items were originally derived from patients' responses to open-ended questions. The resulting 148-item Likert-scale questionnaire was completed by 1193 patients. General satisfaction items were removed from the set, and responses to remaining items underwent factor analysis. Subscales were produced from items representing each factor. Reliability and validity of each subscale were examined.

RESULTS

Five subscales with a total of 40 items resulted from the factor analysis: doctors, access, nurses, appointments and facilities. Each subscale was internally reliable (Cronbach's alpha coefficient between 0.73 and 0.95), and initial tests of validity suggested that all subscales were valid.

CONCLUSION

The study has resulted in a 40-item scale that has been found to be reliable and valid after initial tests. Further work to test the reliability and validity of the final version of the patient satisfaction questionnaire is described.

Hemispheric lateralisation for verbal analysis: do children with reading problems differ from controls?

Specialisation for verbal-sequential analysis in 'dyslexics', poor readers and matched adequate readers was investigated. Groups did not differ on degree of right-ear advantage on the dichotic digits task, suggesting that the poor readers processed digits in the left hemisphere in a similar way to children who read normally. The results cast doubt on theories that 'dyslexia' is related to incomplete lateralisation for verbal analysis.

Hemispheric laterality for spatial analysis in children with reading problems

Lateralisation for tactile-spatial perception was studied in 21 10- to 15-yr.-old boys of average intelligence who were underachieving in reading and 21 matched controls. Controls showed a significant advantage at recognising shapes on a visual display when they had been actively felt with the left hand. There was no difference between left- and right-hand scores in the poor readers. This supports Witelson's (1977) finding that poor readers are less lateralised for spatial-processing than are average readers.

The Kidd minus-minus phenotype in a Caucasian

This is the reported example in a Caucasian with the phenotype Jk(a-b-). A strongly reacting antibody was present which was of a single specificity and which could be completely absorbed by either Jk(a+b-) or Jk(a-b+) cells. Since no compatible donors could be found, autotransfusion was done. Family study failed to reveal any other members with the Jk(a-b-) phenotype. The question of a third allele at the Kidd locus is considered.