Cervical wear pathobiology by robot-simulated 3-year toothbrushing - New methodological approach

OBJECTIVES

An ex-vivo study was aimed at (i) programming clinically validated robot three-year random toothbrushing, (ii) evaluating cervical macro- and microwear patterns on all tooth groups of different functional age, (iii) documenting and codificating wear related morphological features at the cemento-enamel junction in young teeth and on roots in older teeth.

DESIGN

Following ethical approval random toothbrushing (44 strokes per tooth horizontally, rotating, vertically; 2x/d) with manual toothbrushes and low-abrasive dentifrice was performed in an artificial oral cavity with brushing-force 3.5 N on 14 extracted human teeth. Morphological features were examined by SEM at baseline and after simulated 3 years using the replication technique. 3D-SEM analyses were carried out with a four-quadrant back scattered electron detector. Wilcoxon-Mann-Whitney-test was used for statistical analyses.

RESULTS

3-year random toothbrushing with horizontal, rotating and vertical brushing movements revealed morphological features classified as four enamel patterns, one dentin pattern and three cervical patterns. Negative impacts were enamel, cementum and dentin loss. Positive impact on oral health was removing dental calculus and straightening cervical traumatic and iatrogenic damages. The volume loss varied from x̅=34.25nl to x̅=87.75nl. Wear extended apically from 100 to 1500 micrometres.

CONCLUSION

Robot simulated toothbrushing in an artificial oral cavity, with subsequent SEM and 3D-SEM assessment, elucidated both negative and oral health-contributing micromorphology patterns of cervical wear after simulated 3-year random toothbrushing. Cervical macro- and microwear of cementum revealed, for the first time, what we describe as overhanging enamel peninsulas and enamel islands on roots in young teeth, but no enamel islands on roots from older teeth after root cementum loss. In contrast, many older teeth exhibited enamel peninsulas.

Choosing wisely in burn care

BACKGROUND

The Choosing Wisely Campaign was launched in 2012 and has been applied to a broad spectrum of disciplines in almost thirty countries, with the objective of reducing unnecessary or potentially harmful investigations and procedures, thus limiting costs and improving outcomes. In Canada, patients with burn injuries are usually initially assessed by primary care and emergency providers, while plastic or general surgeons provide ongoing management. We sought to develop a series of Choosing Wisely statements for burn care to guide these practitioners and inform suitable, cost-effective investigations and treatment choices.

METHODS

The Choosing Wisely Canada list for Burns was developed by members of the Canadian Special Interest Group of the American Burn Association. Eleven recommendations were generated from an initial list of 29 statements using a modified Delphi process and SurveyMonkey™.

RESULTS

Recommendations included statements on avoidance of prophylactic antibiotics, restriction of blood products, use of adjunctive analgesic medications, monitoring and titration of opioid analgesics, and minimizing 'routine' bloodwork, microbiology or radiological investigations.

CONCLUSIONS

The Choosing Wisely recommendations aim to encourage greater discussion between those involved in burn care, other health care professionals, and their patients, with a view to reduce the cost and adverse effects associated with unnecessary therapeutic and diagnostic procedures, while still maintaining high standards of evidence-based burn care.

Remote genetic counselling provision for heart failure patients at a UK transplant centre

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiomyopathy has been highlighted as one of the key drivers of heart failure, particularly dilated cardiomyopathy (DCM) (5,1). Finding the correct diagnosis for patients is not only important to their health, but to that of their family members (2).

European guidelines recommend genetic counselling and testing for all patients with a cardiomyopathy diagnosis (3). Genetic counselling involves communicating complex information and providing support to patients and families with inherited conditions. It is recommended that patients undergo genetic counselling alongside genetic testing (6).

Purpose

historically, the heart failure team had no formal pathway in place for genetic testing. We set to establish a remote provision for genetic counselling and testing. We hoped to increase access to genetic services, without additional trips to the hospital in this already burdened patient group.

Methods

A genetic counsellor (GC) attended the weekly team meeting to raise awareness of the genetic service and help identify eligible patients. Eligibility was determined using criteria from the national genomic test directory (4).

Eligible patients had appointments via video or phone call. Outpatients who consented to genetic testing had blood samples arranged locally or at an upcoming hospital appointment. Inpatients had blood samples taken during their hospital stay.

Forty-one eligible patients were identified, the majority had DCM (n=40) and one had arrhythmogenic right ventricular cardiomyopathy (ARVC). Genetic testing was performed using a diagnostic DCM or ARVC panel. Results were classified as positive, i.e. pathogenic or likely pathogenic variant identified; negative, i.e. no pathogenic variant identified; or inconclusive, i.e. variant of unknown significance identified. Results were fed back to patients by virtual genetic counselling appointment. GCs facilitated screening of family members as appropriate.

Results

In the period, July 2020 to January 2022, 41 patients attended virtual genetic counselling appointments and consented to genetic testing. Of these, 19 received a positive genetic result, 4 an inconclusive result, and 18 a negative result. The majority of positive results were identified in the TTN gene (n=9) (see Figure 1).

To date, six family members have been identified as gene positive and requiring ongoing screening, whilst six have now been discharged on the basis of a gene negative result. These are preliminary figures and expected to grow as more family members are able to access genetic counselling

Conclusion

Heart failure patients represent an underserved population who may benefit from genetic testing alongside genetic counselling. Remote genetic counselling is an effective service delivery model. A significant proportion of patients (46.3%) received a positive genetic result. This has potential benefits, not only to the patient but to family members.

Attachment-based family therapy in the age of telehealth and COVID-19

The COVID-19 pandemic has transformed so many aspects of our lives. For psychotherapists, telehealth is likely a permanent part of the future mental health landscape. For family therapists using a manualized treatment, this brings unique challenges and creative opportunities. In this article, we describe the adaptation of attachment-based family therapy (ABFT) in the context of telehealth and COVID-19. ABFT is an empirically supported treatment model designed for adolescents and young adults struggling with depression, anxiety, trauma, and suicide. ABFT is a semi-structured, process-oriented, and trauma-informed family therapy model which presents its own unique challenges and benefits in telehealth environments. We present our adaptations based on years of telehealth clinical experience and address how this model supports the impact of COVID-19 on families.

Evaluation of Pirfenidone and Nintedanib in a Human Lung Model of Fibrogenesis

Introduction: Idiopathic pulmonary fibrosis (IPF) is a progressive, fatal lung disease with a poor prognosis and increasing incidence. Pirfenidone and nintedanib are the only approved treatments for IPF but have limited efficacy and their mechanisms of action are poorly understood. Here we have examined the effects of pirfenidone and nintedanib in a human model of lung fibrogenesis, and compared these with the putative anti-fibrotic compounds Lipoxin A4 (LXA4), and senicapoc, a K_Ca3.1 ion channel blocker. Methods: Early fibrosis was induced in cultured human lung parenchyma using TGFβ1 for 7 days, ± pirfenidone, nintedanib, or LXA4. Pro-fibrotic responses were examined by RT-PCR, immunohistochemistry and soluble collagen secretion. Results: Thirty six out of eighty four IPF and fibrosis-associated genes tested were significantly upregulated by TGFβ1 in human lung parenchyma with a ≥0.5 log2FC (n = 32). Nintedanib (n = 13) reduced the mRNA expression of 14 fibrosis-associated genes including MMPs (MMP1,-4,-13,-14), integrin α2, CXCR4 and PDGFB, but upregulated α-smooth muscle actin (αSMA). Pirfenidone only reduced mRNA expression for MMP3 and -13. Senicapoc (n = 11) previously attenuated the expression of 28 fibrosis-associated genes, including αSMA, several growth factors, collagen type III, and αV/β6 integrins. Pirfenidone and nintedanib significantly inhibited TGFβ1-induced fibroblast proliferation within the tissue, but unlike senicapoc, neither pirfenidone nor nintedanib prevented increases in tissue αSMA expression. LXA4 was ineffective. Conclusions: Pirfenidone and nintedanib demonstrate modest anti-fibrotic effects and provide a benchmark for anti-fibrotic activity of new drugs in human lung tissue. Based on these data, we predict that the K_Ca3.1 blocker senicapoc will show greater benefit than either of these licensed drugs in IPF.

The Ocean 100: Transnational corporations in the ocean economy

The ocean economy is growing as commercial use of the ocean accelerates, while progress toward achieving international goals for ocean conservation and sustainability is lagging. In this context, the private sector is increasingly recognized as having the capacity to hamper efforts to achieve aspirations of sustainable ocean-based development or alternatively to bend current trajectories of ocean use by taking on the mantle of corporate biosphere stewardship. Here, we identify levels of industry concentration to assess where this capacity rests. We show that the 10 largest companies in eight core ocean economy industries generate, on average, 45% of each industry's total revenues. Aggregating across all eight industries, the 100 largest corporations (the "Ocean 100") account for 60% of total revenues. This level of concentration in the ocean economy presents both risks and opportunities for ensuring sustainability and equity of global ocean use.

Toward a uniform pathway in managing incidental lung nodules on computerised tomography [CT] coronary angiography; for a cost effective and safe outcome

Background

National Institute for Health and Care Excellence guidelines (NICE CG95) recommends computed tomography coronary angiography [CTCA] as the first line investigation for all patients with suspected typical or atypical angina irrespective of pre-test probability due to its excellent performance and cost effectiveness. However previous cost effectiveness analyses have not factored in the burden of lung nodules [LN] or extracardiac incidentalomas, which are commonly identified on CTCA.

Purpose

As we increasingly detect LN on CTCA scans, it is prudent that a uniform pathway is followed for surveillance of LN. The British Thoracic Society (BTS) has enabled evidence-based development of an algorithm for the management of LN which defines a cut off LN size of ≥5mm requiring further follow up. We aimed to assess the compliance of LN follow up in our patients according to radiology recommendation on CTCA reports and also to assess how well these recommendations adhere to BTS guidelines.

Method

117 patients who underwent CTCA as the initial diagnostic investigation were retrospectively identified from the rapid access chest pain clinic database. Data was collected during a 1 year period between January - December 2017. Data was analysed to determine whether appropriate surveillance pathway was followed for repeat imaging. According to BTS guidelines, nodules ≥5mm should have a systematic work up for surveillance and hence we have stratified our data based on the nodule size. In case of multiple nodules, the largest nodule size was considered.

Results

Out of 117 patients, 77% patients were female with average age 57.8±9.0 years. 40% patients were found to have incidental LN with an average size of 4.63±1.92mm; 44% had a history of cigarette smoking.

Among patient with nodules, 22 (19%) had CT thorax to assess interval change and interestingly 16 (73%) had persisting LN; whereas in 4 (18%), the LN resolved and only 2 (9%) showed increase in LN size. Repeat CT chest was advised for these 2 patients; 1 was advised to undergo biopsy which eventually ruled out malignancy. 6 patients (5%) from group 1 were recommended for repeat CT despite having LN size <5mm.

In the remaining 25 patients (21%) with LN, 15 (60%) did not have further surveillance imaging even though this was recommended by the reporting radiologist. Of these only 3 (12%) had LN ≥5mm which qualified for surveillance CT.

Conclusion

CTCA frequently detects incidentalomas especially LN which cannot be overlooked and require further imaging irrespective of the primary presentation. Our findings also suggest a discrepancy on surveillance CT recommendation against the current BTS guidelines, with potential significant impact on the overall cost effectiveness of CTCA. A systematic approach to LN surveillance could be best achieved with a multidisciplinary team approach (e.g. referral pathway to nodule MDT) and adherence to a standard guideline.

Lung nodule surveillance following CTCA

Funding Acknowledgement

Type of funding source: None

Role of toll-like receptor 7 (TLR7) in voluntary alcohol consumption

Overactivation of neuroimmune signaling has been linked to excessive ethanol consumption. Toll-like receptors (TLRs) are a major component of innate immune signaling and initiate anti- and pro-inflammatory responses via intracellular signal transduction cascades. TLR7 is upregulated in post-mortem brain tissue from humans with alcohol use disorder (AUD) and animals with prior exposure to ethanol. Despite this evidence, the role of TLR7 in the regulation of voluntary ethanol consumption has not been studied. We test the hypothesis that TLR7 activation regulates voluntary ethanol drinking behavior by administering a TLR7 agonist (R848) during an intermittent access drinking procedure in mice. Acute activation of TLR7 reduced ethanol intake, preference, and total fluid intake due, at least in part, to an acute sickness response. However, chronic pre-treatment with R848 resulted in tolerance to the adverse effects of the drug and a subsequent increase in ethanol consumption. To determine the molecular machinery that mediates these behavioral changes, we evaluated gene expression after acute and chronic TLR7 activation. We found that acute TLR7 activation produces brain region specific changes in expression of immune pathway genes, whereas chronic TLR7 activation causes downregulation of TLRs and blunted cytokine induction, suggesting molecular tolerance. Our results demonstrate a novel role for TLR7 signaling in regulating voluntary ethanol consumption. Taken together, our findings suggest TLR7 may be a viable target for development of therapies to treat AUD.

An evaluation of continuous subcutaneous infusions across seven NHS acute hospitals: is there potential for 48-hour infusions?

BACKGROUND

Continuous subcutaneous infusions (CSCIs) are commonly used in the United Kingdom as a way of administering medication to patients requiring symptom control when the oral route is compromised. These infusions are typically administered over 24 h due to currently available safety data. The ability to deliver prescribed medication by CSCI over 48 h may have numerous benefits in both patient care and health service resource utilisation. This service evaluation aims to identify the frequency at which CSCI prescriptions are altered at NHS Acute Hospitals.

METHODS

Pharmacists or members of palliative care teams at seven acute NHS hospitals recorded anonymised prescription data relating to the drug combination(s), doses, diluent and compatibility of CSCIs containing two or more drugs on a daily basis for a minimum of 2 days, to a maximum of 7 days.

RESULTS

A total of 1301 prescriptions from 288 patients were recorded across the seven sites, yielding 584 discrete drug combinations. Of the 584 combinations, 91% (n = 533) included an opioid. The 10 most-common CSCI drug combinations represented 37% of the combinations recorded. Median duration of an unchanged CSCI prescription across all sites was 2 days.

CONCLUSION

Data suggests medication delivered by CSCI over 48 h may be a viable option. Before a clinical feasibility study can be undertaken, a pharmacoeconomic assessment and robust chemical and microbiological stability data will be required, as will the assessment of the perceptions from clinical staff, patients and their families on the acceptability of such a change in practice.

SAT0234 SERUM AXL, FERRITIN, IGFBP4 AND STNFR2 AS BIOMARKERS OF PEDIATRIC SLE

Background:

Proteomic screening is an efficient approach for identifying protein biomarkers in various inflammatory diseases. Our preliminary proteomic analysis revealed elevated levels of serum Axl, Ferritin, IGFBP4 and sTNFR2 in adult patients with active lupus nephritis (LN) (1). However, the role of these serum biomarkers in pediatric systemic lupus erythematosus (SLE) patients has not been examined.

Objectives:

To evaluate the performance of 4 serum protein markers for detecting disease activity in pediatric patients with SLE.

Methods:

83 pediatric patients who fulfilled ≥4 ACR criteria for SLE and 25 healthy controls were recruited for serological testing of 4 protein markers identified by antibody-coated microarray screen, namely Axl, ferritin, IGFBP4 and sTNFR2. SLE disease activity was assessed using the SLEDAI-2k score, renal disease activity was assessed by the renal SLEDAI (range 0-16; 0= inactive LN, ≥ 8= active renal). 57 patients had clinically active SLE (SLEDAI score ≥ 4 or having a flare) (28 active renal and 29 active non-renal SLE patients). In active renal patients, concurrent renal biopsy was performed, unless contraindicated. The ISN/RPS criteria were used to assess the histopathologic features of LN. Those Patients were further subcategorized into 2 groups; active proliferative (ISN/RPS classes III/IV) and non-proliferative (classes I/II/V).

Results:

The serum concentrations of Axl and ferritin were significantly higher in patients with active SLE than inactive SLE (3765±235 vs. 2513±130 pg/ml,P= 0.001) and (111±26 vs. 18±4 ng/ml,P =0.0001) respectively. Serum Axl levels were significantly higher in active renal versus active non-renal SLE patients (3765±235.3 vs. 2825±200.7 pg/ml,P= 0.04). In the active renal patients with paired kidney tissue and blood samples, none of the biomarkers tested discriminated classes of LN, although serum Axl, ferritin and IGBPB4 levels were higher in the proliferative subgroup. The levels of Axl, ferritin and IGFBP4 correlated significantly with SLEDAI scores (Axl, r= 0.58,P<0.0001; ferritin, r= 0.53,P<0.0001; IGFBP4, r= 0.229,P= 0.03). However, only serum Axl levels correlated significantly with the renal SLEDAI (r= 0.46,P= 0.01). The levels of Axl, IFGBP4 and sTNFR2 correlated with decreased C3 levels (r= - 0.54,P<0.0001; r= - 0.29,P= 0.007; r= - 0.29,P= 0.007) respectively. Only serum Axl and ferritin correlated with urinary PCR (r= 0.42,P<0.0001; r= 0.22,P=0.04) respectively. These markers were more specific, but less sensitive, in detecting concurrent SLE activity than elevated anti-dsDNA or decreased C3. The specificity values of serum ferritin and IGFBP4 for concurrent active lupus nephritis were higher than anti-dsDNA or C3. Serum ferritin was the best predictor of global SLE activity (AUC 0.81,P<0.0001), followed by C3 (AUC 0.79,P<0.0001) then Axl (AUC 0.71,P= 0.002), while both Axl and C3 were the best predictors of lupus nephritis activity (AUC 0.72, both).

Conclusion:

In pediatric SLE patients, serum ferritin and Axl perform better than traditional yardsticks in identifying disease activity, either global or renal. The performance of these serum markers should be explored further in a longitudinal cohort of pediatric SLE patients.

References:

[1]Wu T, Ding H, Han J, et al. Antibody-Array-Based Proteomic Screening of Serum Markers in Systemic Lupus Erythematosus: A Discovery Study. J Proteome Res. 2016 Jul 1;15 (7): 2102-14.

Disclosure of Interests:

None declared

103 A Review of Reviews of Emergency Department Interventions for Older People: Outcomes, Costs and Implementation Factors

Introduction

Older people’s emergency care is an international public health priority and remains sub-optimal in the UK. Strategies are needed to manage older patients sensitively and effectively. We reviewed emergency care interventions, evaluating evidence for outcomes, costs, and implementation.

Methods

We developed and registered (with PROSPERO, CRD42018111461) a review of reviews protocol. Screening was according to inclusion criteria for subject and reporting standards. Data were extracted and summarised in tabular and narrative form. Quality was assessed using AMSTAR2 and Joanna Briggs Institute tools. Due to intervention and outcome heterogeneity, findings were synthesised narratively. McCusker’s Elder-Friendly Emergency Department assessment tool was used as a classification framework.

Results

Eighteen review articles and three conference abstracts fulfilled inclusion criteria. The majority were systematic reviews, with four using meta-analysis. Fourteen reviews reported interventions initiated or wholly delivered within the ED, and four focussed on quality indicators or patient preferences.

Confidence was limited to each review’s interpretation of primary studies. Descriptions of interventions were inconsistent, and there was high variability in reporting standards. Interventions mostly focussed on screening and assessment, discharge planning, referrals and follow-up, and multi-disciplinary team composition and professional activities. 26 patient and health service outcomes were reported, including admissions and readmissions, length of stay, mortality, functional decline, and quality of life.

Conclusions

Our review of reviews demonstrated that the current, extensive evidence base of review studies lacks complexity, with limited or no evidence for the effectiveness of interventions; reviews commonly called for more primary research using rigorous methods. There is little review evidence for factors influencing implementation.

There was evidence that among interventions initiated in ED, those continued into the community yielded better outcomes. Service metrics (as valued by care commissioners) were evaluated as intervention outcomes more frequently than person-centred attributes (as valued by older people). Interventions were broadly holistic in nature.

CommWalker: correctly evaluating modules in molecular networks in light of annotation bias

Motivation

Detecting novel functional modules in molecular networks is an important step in biological research. In the absence of gold standard functional modules, functional annotations are often used to verify whether detected modules/communities have biological meaning. However, as we show, the uneven distribution of functional annotations means that such evaluation methods favor communities of well-studied proteins.

Results

We propose a novel framework for the evaluation of communities as functional modules. Our proposed framework, CommWalker, takes communities as inputs and evaluates them in their local network environment by performing short random walks. We test CommWalker’s ability to overcome annotation bias using input communities from four community detection methods on two protein interaction networks. We find that modules accepted by CommWalker are similarly co-expressed as those accepted by current methods. Crucially, CommWalker performs well not only in well-annotated regions, but also in regions otherwise obscured by poor annotation. CommWalker community prioritization both faithfully captures well-validated communities and identifies functional modules that may correspond to more novel biology.

Availability and implementation

The CommWalker algorithm is freely available at opig.stats.ox.ac.uk/resources or as a docker image on the Docker Hub at hub.docker.com/r/lueckenmd/commwalker/.

Supplementary information

Supplementary data are available at Bioinformatics online.

Comparison of effects of routine topical treatments in the milking parlor on digital dermatitis lesions

Digital dermatitis (DD), an infectious bacterial disease affecting the feet of dairy cattle, can cause lameness and decrease milk production, fertility, and animal welfare. Current DD treatment typically involves routine hoof trimming and topical antibiotics. Several nonantibiotic commercial topical products are used for controlling DD lesions; however, there is limited or no evidence regarding their effectiveness. The objectives of this study were to evaluate 2 commercially available topical applications on their ability to (1) clinically cure active DD lesions to nonactive lesions and (2) prevent recurrence of active DD lesions. Ten farms were visited weekly. In the milking parlor, the hind feet of lactating cattle were cleaned and scored (M-stage scoring system). Cattle with DD lesions at the first visit were randomly allocated to 1 of 4 treatment groups: positive control (tetracycline solution), HealMax (AgroChem Inc., Saratoga Springs, NY), HoofSol (Diamond Hoof Care Ltd., Intracare BV, Veghel, the Netherlands), and a negative control (saline). All products were applied to lesions using a spray bottle. Tetracycline, HealMax, and HoofSol had a higher probability of clinical cure for active lesions compared with saline 1 wk after the first treatment (wk 1), with 69, 52, and 79% clinical cure of active lesions, respectively, compared with 34% with saline. At wk 7, the probability of clinical cure for active lesions was 10, 33, 31, and 45% of lesions treated weekly with saline, tetracycline, HealMax, and HoofSol, respectively (no difference among treatments). The substantial clinical cure with saline highlighted the potential importance of cleaning feet. In wk 1, treatment with saline, tetracycline, HealMax, and HoofSol resulted in a probability of recurrence of active DD lesions of 9, 11, 11, and 8%, respectively, with no product being superior to saline. After 7 wk, the probability of recurrence of active lesions was 5, 7, 6, and 6% for saline, tetracycline, HealMax, and HoofSol respectively, with no difference among groups in wk 7. These results provide alternatives to antibiotics for treatment of DD lesions and highlight the potential importance of cleaning feet in the milking parlor.

Factors impacting antiretroviral therapy adherence among human immunodeficiency virus-positive adolescents in Sub-Saharan Africa: a systematic review

OBJECTIVES

Eighty-two percent of human immunodeficiency virus (HIV)-positive adolescents live in Sub-Saharan Africa (SSA). Despite the availability of antiretroviral therapy (ART), adherence levels are suboptimal, leading to poor outcomes. This systematic review investigated factors impacting ART adherence among adolescents in SSA, including religious beliefs and intimate relationships.

METHODS

A systematic review was conducted between June and August 2016 using eight electronic databases, including Cochrane and PubMed. Published, ongoing and unpublished research, conducted in SSA from 2004 to 2016, was identified and thematic analysis was used to summarise findings.

RESULTS

Eleven studies from eight SSA countries, published in English between 2011 and 2016, reported on factors impacting ART adherence among adolescents living with HIV (ALHIV). Forty-four barriers and 29 facilitators to adherence were identified, representing a complex web of factors. The main barriers were stigma, ART side-effects, lack of assistance and forgetfulness. Facilitators included caregiver support, peer support groups and knowledge of HIV status.

CONCLUSIONS

Stigma reflects difficult relations between ALHIV and their HIV-negative peers and adults. Most interventions target only those with HIV, suggesting a policy shift towards the wider community could be beneficial. Recommendations include engaging religious leaders and schools to change negative societal attitudes. Limitations of the review include the urban settings and recruitment of predominantly vertically infected participants in most included studies. Therefore, the findings cannot be extrapolated to ALHIV residing in rural locations or horizontally infected ALHIV, highlighting the need for further research in those areas.

Sofosbuvir and daclatasvir therapy in patients with hepatitis C-related advanced decompensated liver disease (MELD ≥ 15)

BACKGROUND

Antiviral therapy for hepatitis C has the potential to improve liver function in patients with decompensated cirrhosis.

AIMS

To examine the virological response and effect of viral clearance in patients with decompensated hepatitis C cirrhosis all with MELD scores ≥15 following sofosbuvir/daclatasvir ± ribavirin.

METHODS

We prospectively collected data on patients who commenced sofosbuvir/daclatasvir for 24-weeks under the Australian patient supply program (TOSCAR) and analysed outcomes including sustained viral response at 12 weeks (SVR12), death and transplant.

RESULTS

108 patients (M/F, 79/29; median age 56years; Child-Pugh 10; MELD 16; genotype 1/3, 55/47) received sofosbuvir/daclatasvir and two also received ribavirin. On intention-to-treat, the SVR12 rate was 70% (76/108). Seventy-eight patients completed 24-weeks therapy. SVR12 was achieved in 56 of these patients on per-protocol-analysis (76%). SVR12 was 80% in genotype 1 compared to 69% in genotype 3. Thirty patients failed to complete therapy. In patients achieving SVR12, median MELD and Child-Pugh fell from 16(IQR15-17) to 14(12-17) and 10(9-11) to 8(7-9), respectively (P<.001). In those who died, MELD increased from 16 to 23 at death (P=.036). Patients who required transplantation had a significantly higher baseline MELD (20) compared to those patients completing treatment (16) (P=.0010). The odds ratio for transplant in patients with baseline MELD ≥20 was 13.8(95%CI 2.78-69.04).

CONCLUSIONS

SVR12 rates with sofosbuvir/daclatasvir in advanced liver disease are lower than in compensated disease. Although treatment improves MELD and Child-Pugh in most patients, a significant proportion will die or require transplantation. In those with MELD ≥20, it may be better to delay treatment until post-transplant.

In Situ Study to Confirm the Anticaries Potential of a Sodium Monofluorophosphate Dentifrice Containing Calcium Sodium Phosphosilicate

OBJECTIVES

A randomized, investigator-blind, five-treatment, crossover, non-inferiority study was conducted to investigate the effect of the addition of calcium sodium phosphosilicate (CSPS), an agent known to relieve dentin hypersensitivity, to a sodium monofluorophosphate (SMFP)-containing dentifrice on the enamel remineralization potential of fluoride (F), as assessed by percentage surface microhardness recovery (%SMHR) and enamel fluoride uptake (EFU) using a standard in situ caries model.

METHODS

Seventy-seven subjects wearing bilateral mandibular partial dentures holding partially demineralized bovine enamel specimens 24 hours/day brushed their teeth with their assigned randomized dentifrice containing either 1500 or 0 ppm F with 5% CSPS or 1500, 500, or 0 ppm F with 0% CSPS twice daily for 21 days. The success criterion was to observe a difference in % SMHR between dentifrices containing 1500 ppm F of six units or less in the upper bound of the two-sided 95% confidence interval (CI).

RESULTS

Following 21 days of treatment, the upper bound CI of the %SMHR difference between the dentifrices containing 1500 ppm F was 1.66, thus within the non-inferiority limit. No statistically significant differences for %SMHR (p = 0.2601) and EFU (p = 0.2984) were noted between these two dentifrices.

CONCLUSIONS

The present in situ caries study provides evidence demonstrating that the addition of the calcium-containing compound CSPS to a 1500 ppm F dentifrice does not interfere with the ability of fluoride to remineralize surface-softened enamel; i.e., CSPS neither impairs nor improves the potential cariostatic value of SMFP dentifrice.

Examining the sources of occupational stress in an emergency department

BACKGROUND

Previous work has established that health care staff, in particular emergency department (ED) personnel, experience significant occupational stress but the underlying stressors have not been well quantified. Such data inform interventions that can reduce cases of occupational mental illness, burnout, staff turnover and early retirement associated with cumulative stress.

AIMS

To develop, implement and evaluate a questionnaire examining the origins of occupational stress in the ED.

METHODS

A questionnaire co-designed by an occupational health practitioner and ED management administered to nursing, medical and support staff in the ED of a large English teaching hospital in 2015. The questionnaire assessed participants' demographic characteristics and perceptions of stress across three dimensions (demand-control-support, effort-reward and organizational justice). Work-related stressors in ED staff were compared with those of an unmatched control group from the acute ear, nose and throat (ENT) and neurology directorate.

RESULTS

A total of 104 (59%) ED staff returned questionnaires compared to 72 staff (67%) from the acute ENT/neurology directorate. The ED respondents indicated lower levels of job autonomy, management support and involvement in organizational change, but not work demand. High levels of effort-reward imbalance and organizational injustice were reported by both groups.

CONCLUSIONS

Our findings suggest that internal ED interventions to improve workers' job control, increase support from management and involvement in organizational change may reduce work stress. The high levels of effort-reward imbalance and organizational injustice reported by both groups may indicate that wider interventions beyond the ED are also needed to address these issues.

Prevalence and distribution of foot lesions in dairy cattle in Alberta, Canada

The objectives of this cross-sectional study were to determine the prevalence and distribution of foot lesions and associated cow- and herd-level risk factors in dairy cows in Alberta, Canada. Foot lesion data were recorded electronically by 7 hoof trimmers on 28,607 cows in 156 dairy farms from June 2009 to November 2012. Foot lesion prevalence estimates differed between farms that had the whole herd trimmed at once (≥80% of lactating cows were trimmed; n=69 farms and 8,020 cows) and farms on which part of the herd was trimmed (selection of cows was determined by farmer and <80% of lactating cows were trimmed; n=87 and 20,587 cows). Estimates were consistently higher for the latter likely because farmers presumably prioritized lame cows in partial-herd trims. On farms with whole-herd trims, digital dermatitis was the most common lesion among all housing types, present in 15% of cows and 94% of herds. Sole ulcers and white line disease were detected in 6 and 4% of the cows and 92 and 93% of herds, respectively. Other infectious and claw horn lesions each affected 1 to 2% of cows and 62 to 78% of herds. Intraclass correlation coefficients for hoof trimmers ranged from 0.01 to 0.20 for all lesions, indicating some clustering of recorded lesions by trimmer. Multilevel mixed logistic regression models were constructed (including hoof trimmer as fixed and farm as random effects) for the 3 most frequently identified lesions. Prevalence of digital dermatitis decreased with increasing parity, but this effect interacted with days in milk (DIM); primiparous cows had higher odds of digital dermatitis in mid lactation (100-199 DIM) and late lactation (≥200 DIM) compared with cows at other stages of lactation. In contrast, prevalence of sole ulcers and white line disease increased with increasing parity; compared with cows in parity 1, those in parity 4 had 5 or 7 times higher odds of having these lesions, respectively. Cows in mid lactation and late lactation had higher odds of sole ulcers and white line disease than cows at other stages of lactation, regardless of parity. Digital dermatitis prevalence was 2 times higher in herds housed in barns with access to an exercise area. The odds of sole ulcers and white line disease were ≥2 times higher in cows housed in freestalls than those housed in deep-bedded packs. Therefore, preventive measures for control of digital dermatitis merit emphasis, especially in primiparous cows and on farms with exercise areas. In addition, improving housing environment by providing a deep-bedded area for older cows in mid lactation or late lactation could reduce prevalence of claw horn lesions. We inferred that foot lesion data recorded by hoof trimmers can provide useful information not only to develop effective foot health programs at herd level, but also for disease surveillance and genetic improvement at regional and national levels.

Associations between lying behavior and lameness in Canadian Holstein-Friesian cows housed in freestall barns

Lying behavior is an important measure of comfort and well-being in dairy cattle, and changes in lying behavior are potential indicators and predictors of lameness. Our objectives were to determine individual and herd-level risk factors associated with measures of lying behavior, and to evaluate whether automated measures of lying behavior can be used to detect lameness. A purposive sample of 40 Holstein cows was selected from each of 141 dairy farms in Alberta, Ontario, and Québec. Lying behavior of 5,135 cows between 10 and 120 d in milk was automatically and continuously recorded using accelerometers over 4 d. Data on factors hypothesized to influence lying behavior were collected, including information on individual cows, management practices, and facility design. Associations between predictor variables and measures of lying behavior were assessed using generalized linear mixed models, including farm and province as random and fixed effects, respectively. Logistic regression models were used to determine whether lying behavior was associated with lameness. At the cow-level, daily lying time increased with increasing days in milk, but this effect interacted with parity; primiparous cows had more frequent but shorter lying bouts in early lactation, changing to mature-cow patterns of lying behavior (fewer and longer lying bouts) in late lactation. In barns with stall curbs >22 cm high, the use of sand or >2 cm of bedding was associated with an increased average daily lying time of 1.44 and 0.06 h/d, respectively. Feed alleys ≥ 350 cm wide or stalls ≥ 114 cm wide were associated with increased daily lying time of 0.39 and 0.33 h/d, respectively, whereas rubber flooring in the feed alley was associated with 0.47 h/d lower average lying time. Lame cows had longer lying times, with fewer, longer, and more variable duration of bouts compared with nonlame cows. In that regard, cows with lying time ≥ 14 h/d, ≤ 5 lying bouts per day, bout duration ≥ 110 min/bout, or standard deviations of bout duration over 4 d ≥ 70 min had 3.7, 1.7, 2.5, and 3.0 higher odds of being lame, respectively. Factors related to comfort of lying and standing surfaces significantly affected lying behavior. Finally, we inferred that automated measures of lying behavior could contribute to lameness detection, especially when interpreted in the context of other factors known to affect lying behavior, including those associated with the individual cow (e.g., parity and stage of lactation) or environment (e.g., stall surface).

Prevalence of lameness and associated risk factors in Canadian Holstein-Friesian cows housed in freestall barns

Lameness is a severe welfare problem and a production-limiting disease in dairy farming. The objectives of this study were to determine prevalence of lameness and investigate cow- and herd-level factors associated with lameness in dairy cows housed in freestall barns in 3 Canadian provinces. A purposive sample of 40 Holstein-Friesian cows was selected from each of 141 dairy farms in Québec, Ontario, and Alberta. In total, 5,637 cows were scored once for lameness (presence of limping when walking). Data collected included information on individual cows (hock lesions, claw length, body condition score, parity, days in milk, and milk production), management practices (floor and stall cleaning routine, bedding routine, and footbath practices), and facility design (stall dimensions, stall base and bedding type, width of feed alley, flooring type, and slipperiness) hypothesized to be risk factors for lameness. Multilevel mixed logistic regression models were constructed (including farm as a random effect and province as a fixed effect). Herd-level lameness prevalence ranged from 0 to 69% (mean = 21%). Lameness prevalence increased with increasing parity; compared with first parity, cows in parity 2, 3, and ≥ 4 had 1.6, 3.3, and 4 times, respectively, higher odds of being lame. Furthermore, the odds of lameness were 1.6 times greater in cows with low body condition score (≤ 2.5) than in cows with a higher body condition score. In addition, injured hocks and overgrown claws were associated with 1.4- and 1.7-fold increased odds of being lame, respectively, whereas every 1 kg increase in daily milk production was associated with a 3% decrease in the odds of being lame. Lameness prevalence was higher in herds with ≤ 100 cows, but lower in barns with a sand or dirt stall base, or with bedding ≥ 2 cm deep. Cows exposed to very slippery floors had 2 times the odds of being lame compared with cows exposed to nonslippery floors. We attributed the wide range of lameness prevalence to the great variability in facilities and management practices among farms. Finally, we inferred that the prevalence of lameness could be decreased by improving management of multiparous, thin, or injured cows and by adopting management practices intended to improve cow comfort, namely the floor's slip resistance and the stall's lying surface.

PA3 Using the lived experience of volunteers to enhance the care of dying patients and their families

BACKGROUND

In the UK, the majority of people die in hospital.(1) Community presence is considered to be a significant component to achieving a "good death",(2,3) however many patients die with no/few visitors, spending their last weeks of life isolated or alone.

AIM

To establish a Volunteer Service and offer: A presence to dying patients. A connexion to the community outside the Hospital. Support to families, unable to visit or emotionally exhausted from their bedside vigil.

METHODS

The Service was piloted on 6 wards (October 2012-March 2013) within a large NHS Trust, in the North of England. This was followed by a comprehensive evaluation, according to MRC guidance.

RESULTS

Analysis of the service evaluation indicated that the service was extremely beneficial, meeting its aims in providing an emotional support and spiritual presence to dying patients, and their families.

CONCLUSION

The Service provides a model of best practice that could be replicated in other Trusts and within other care settings. There are plans to further develop and expand service provision across the Trust.

REFERENCES

National End of Life Care Intelligence Network. What we know now. 2013. http://www.endoflifecare-intelligence.org.uk/resources/publications/what_we_know_now_2013 Department of Health. End of Life Care Strategy. 2008. https://www.gov.uk/government/publications/end-of-life-care-strategy-promoting-high-quality-care-for-adults-at-the-end-of-their-life Kellehear A. The end of death in late modernity, an emerging public health challenge. Crit Public Health 2007;17(1):71-79.