A Repurposing Programme Evaluating Transdermal Oestradiol Patches for the Treatment of Prostate Cancer Within the PATCH and STAMPEDE Trials: Current Results and Adapting Trial Design

AIMS

Androgen deprivation therapy (ADT), usually achieved with luteinising hormone releasing hormone analogues (LHRHa), is central to prostate cancer management. LHRHa reduce both testosterone and oestrogen and are associated with significant long-term toxicity. Previous use of oral oestrogens as ADT was curtailed because of cardiovascular toxicity. Transdermal oestrogen (tE2) patches are a potential alternative ADT, supressing testosterone without the associated oestrogen-depletion toxicities (osteoporosis, hot flushes, metabolic abnormalities) and avoiding cardiovascular toxicity, and we here describe their evaluation in men with prostate cancer.

MATERIALS AND METHODS

The PATCH (NCT00303784) adaptive trials programme (incorporating recruitment through the STAMPEDE [NCT00268476] platform) is evaluating the safety and efficacy of tE2 patches as ADT for men with prostate cancer. An initial randomised (LHRHa versus tE2) phase II study (n = 251) with cardiovascular toxicity as the primary outcome measure has expanded into a phase III evaluation. Those with locally advanced (M0) or metastatic (M1) prostate cancer are eligible. To reflect changes in both management and prognosis, the PATCH programme is now evaluating these cohorts separately.

RESULTS

Recruitment is complete, with 1362 and 1128 in the M0 and M1 cohorts, respectively. Rates of androgen suppression with tE2 were equivalent to LHRHa, with improved metabolic parameters, quality of life and bone health indices (mean absolute change in lumbar spine bone mineral density of -3.0% for LHRHa and +7.9% for tE2 with an estimated difference between arms of 9.3% (95% confidence interval 5.3-13.4). Importantly, rates of cardiovascular events were not significantly different between the two arms and the time to first cardiovascular event did not differ between treatment groups (hazard ratio 1.11, 95% confidence interval 0.80-1.53; P = 0.54). Oncological outcomes are awaited.

FUTURE

Efficacy results for the M0 cohort (primary outcome measure metastases-free survival) are expected in the final quarter of 2023. For M1 patients (primary outcome measure - overall survival), analysis using restricted mean survival time is being explored. Allied translational work on longitudinal samples is underway.

#Menopause: Examining the frequency of communications about menopause on twitter between 2014 and 2022

This study explored the use of Twitter to communicate about menopause. Tweets in English posted between January 2014 and December 2022 with the hashtag "menopause" were extracted. Total global tweets and those from the UK, USA, Australia and Canada were examined. Globally, there were 314,974 tweets about menopause over this period, with an annual average of 34,997. There were notable differences between countries, with a large increase in use in the UK in 2018 and 2019, a reducing trend in use in the USA with a smaller increase in 2018 and 2019, and low stable usage in Australia and Canada.

A39 HEALTHY FIRST-DEGREE RELATIVES FROM MULTIPLEX FAMILIES VERSUS SIMPLEX HARBOR A HIGHER RISK OF DEVELOPING CROHN'S DISEASE AND ARE ASSOCIATED WITH SUBCLINICAL INFLAMMATION AND ALTERED MICROBIOME COMPOSITION

Background

Healthy individuals within families with multiple affected members (multiplex families) with Crohn’s disease (CD) have a notably high risk of developing CD. No large prospective pre-disease cohort has assessed differences in preclinical intestinal inflammation, permeability, fecal microbiome, and genetics in healthy at-risk subjects from multiplex families.

Purpose

We aimed to assess differences in subclinical gut inflammation, genetic risk, gut barrier function, and fecal microbiota composition between first-degree relatives (FDRs) from families with 2 or more affected members (multiplex) and families with only one affected member (simplex). Also, we aimed to assess the risk of future CD onset in subjects from multiplex versus simplex families.

Method

We utilized the GEM Project cohort of healthy FDRs of CD patients. Subclinical gut inflammation was assessed using fecal calprotectin (FCP) at recruitment. Gut barrier function was assessed using the lactulose-to-mannitol ratio (LMR). For assessment of the CD-related genetic risk, CD-polygenic risk scores (CD-PRS) were calculated. Microbiome composition was assessed by sequencing fecal 16S ribosomal RNA. Generalized estimating equations logistic regression and LEfSe (PMID: 21702898) were used to assess the associations between multiplex status and different outcomes. A Cox proportional hazards model was used to assess time-related risk of future onset of CD.

Result(s)

4385 subjects were included. Median age was 17 [IQR 12-24] years, 52.9% were female, 69.4% were siblings and 30.6% were offspring. 4052 (92.4%) and 333 (7.6 %) were simplex and multiplex subjects, respectively. After adjusting for age, sex, family size, and relation to proband, multiplex status was significantly associated with higher baseline FCP (p=0.038), but was not associated with either baseline LMR or CD-PRS (p=0.19 and p=0.33, respectively).

We found no significant differences in alpha diversity (Shannon index) (p=0.57) between simplex and multiplex subjects. Beta diversity analysis assessed by the Bray-Curtis dissimilarity index did not reveal significant differences (R2=3e-04, p=0.607). The genera Eisenbergiella, Eggerthellaceae uncultured, and Morganella, were significantly more abundant in multiplex subjects, whereas Lachnospira, Sutterella, Lachnospiraceae_NK4A136_group, and Lachnospiraceae_UCG_004 less abundant.

The risk of CD onset was significantly higher in multiplex subjects. In multivariable analysis, multiplex status at recruitment was associated with increased risk of CD onset (adjusted HR 3.41, 95% CI 1.70-6.87, p=0.00055), after adjusting for demographics, FCP, LMR, and CD-PRS.

Conclusion(s)

Multiplex status compared to simplex is associated with a 3.4-fold increased risk of CD onset, a higher FCP, and fecal bacterial composition. A comprehensive assessment of environmental factors that increase CD risk in multiplex families remains to be elucidated in future studies.

Disclosure of Interest

None Declared

A267 IDENTIFYING ENTEROBACTERIACEAE VIRULENCE GENES ASSOCIATED WITH ACTIVE DISEASE IN ULCERATIVE COLITIS PATIENTS USING CULTURE-DEPENDENT AND -INDEPENDENT APPROACHES

Background

The prevalence of inflammatory bowel disease (IBD) in Canada is among the highest in the world and is estimated to affect 1 in 100 Canadians by 2030. Ulcerative colitis (UC) is a type of IBD characterized by mucosal inflammation of the large intestine. UC is believed to arise through a complex interplay of the host immune responses and changes in the gut microbiota in a genetically susceptible individual. Therapies targeting the gut microbiota, such as antibiotics and fecal microbiota transplantation (FMT), have been effective in treating UC, suggesting infectious triggers should be explored.

Purpose

Some data suggests the development of UC can be driven by pathogenic bacteria of the family Enterobacteriaceae, which can carry virulence genes important for colonizing the gut (e.g. fimH) and disrupting the intestinal epithelium (e.g. hylA). However, many studies have focused on a single species (e.g. Escherichia coli) and thereby underestimate the importance of these virulence genes that are shared across the Enterobacteriaceae family. I aim to investigate whether specific virulence genes contribute to disease activity in some patients with UC and to show that these virulence genes are carried by strains of many Enterobacteriaceae species.

Method

UC patient stool samples were collected throughout enrolment in randomized control trials of FMT for adult UC and microbiome studies in early-onset pediatric UC. The stool samples were cultured on MacConkey agar to enrich for Enterobacteriaceae. Samples from before and after treatment were sent for targetted cultured-enriched metagenomic sequencing and strains were isolated from baseline samples only for whole genome sequencing. The taxonomy of each genome and taxonomic composition of each metagenome were annotated along with virulence genes and antimicrobial resistance genes. Phenotypic assays of cultured isolates were used to capture diversity and virulence activity.

Result(s)

Approximately 7500 colonies from UC patient stool samples were isolated and phenotyped. Based on the initial screens, 130 isolates were selected to comprise our Enterobacteriaceae strain collection. Across all patient samples, we detected 19 different species of the Enterobacteriaceae family across six genera from the genomic and metagenomic data. We identified virulence genes found across multiple species from the Enterobacteriaceae family within genomes and metagenomes, and by performing phenotypic assays of the cultured isolates.

Conclusion(s)

Further exploration of the distribution of these virulence genes in UC patients during active disease or remission and healthy controls can provide insight into the pathogenesis of UC. Identifying infectious agents in even a subset of UC patients will allow for more targeted diagnosis and treatment approaches.

Disclosure of Interest

None Declared

Effectiveness of Intranasal Mometasone Furoate vs Saline for Sleep-Disordered Breathing in Children: A Randomized Clinical Trial

Importance

Obstructive sleep-disordered breathing (SDB) in children is characterized by snoring and difficulty breathing during sleep. SDB affects at least 12% of otherwise healthy children and is associated with significant morbidity. Evidence from small clinical trials suggests that intranasal corticosteroids improve SDB as measured by polysomnography; however, the effect on symptoms and quality of life is unclear.

Objective

To determine whether intranasal mometasone furoate is more effective than intranasal saline for improving symptoms and quality of life in children with SDB.

Design, Setting, and Participants

The MIST trial was a multicenter, randomized, double-blind, placebo-controlled trial, recruiting participants from June 8, 2018, to February 13, 2020. Children aged 3 to 12 years who were referred to a specialist for significant SDB symptoms were included; exclusions were previous adenotonsillectomy, body mass index greater than the 97th percentile, and severe SDB. Randomization was stratified by site, and data were analyzed on an intention-to-treat basis from October 28, 2020, to September 25, 2022.

Interventions

Participants were randomly assigned to receive mometasone furoate, 50 μg, or sodium chloride (saline), 0.9%, 1 spray per nostril daily, dispensed in identical bottles.

Main Outcomes and Measures

The primary outcome was resolution of significant SDB symptoms (ie, reduction to a level no longer requiring referral to a specialist as per the American Academy of Pediatrics guidelines) at 6 weeks, measured by parental report of symptoms using the SDB Score.

Results

A total of 276 participants (mean [SD] age, 6.1 [2.3] years; 146 male individuals [53%]) were recruited, 138 in each treatment arm. Resolution of significant SDB symptoms occurred in 56 of 127 participants (44%) in the mometasone group and 50 of 123 participants (41%) in the saline group (risk difference, 4%; 95% CI, -8% to 16%; P = .51) with 26 participants lost to follow-up and missing values managed by multiple imputation. The main adverse effects were epistaxis, affecting 12 of 124 participants (9.7%) in the mometasone group and 18 of 120 participants (15%) in the saline group, and nasal itch/irritation, affecting 12 of 124 participants (9.7%) in the mometasone group and 22 of 120 participants (18%) in the saline group.

Conclusions and Relevance

Results of this randomized clinical trial suggest that there was no difference in treatment effect between intranasal mometasone and saline for the management of SDB symptoms. The results suggest that almost one-half of children with SDB could be initially managed in the primary care setting and may not require referral to specialist services, as is currently recommended.

Trial Registration

Australian New Zealand Clinical Trials Registry: ANZCTRN12618000448246.

Developing and testing a case-management intervention to support the return to work of health care workers with common mental health disorders

BACKGROUND

To assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of a new case-management intervention to facilitate the return to work of health care workers, on sick leave, having a common mental disorder (CMD).

METHODS

A mixed methods feasibility study.

RESULTS

Systematic review examined 40 articles and 2 guidelines. Forty-nine National Health Service Occupational Health (OH) providers completed a usual care survey. We trained six OH nurses as case managers and established six recruitment sites. Forty-two out of 1938 staff on sick leave with a CMD were screened for eligibility, and 24 participants were recruited. Out of them, 94% were female. Eleven participants received the intervention and 13 received usual care. Engagement with most intervention components was excellent. Return-to-work self-efficacy improved more in the intervention group than in the usual care group. Qualitative feedback showed the intervention was acceptable.

CONCLUSIONS

The intervention was acceptable, feasible and low cost to deliver, but it was not considered feasible to recommend a large-scale effectiveness trial unless an effective method could be devised to improve the early OH referral of staff sick with CMD. Alternatively, the intervention could be trialled as a new stand-alone OH intervention initiated at the time of usual OH referral.

Microaggressions, Everyday Discrimination, Workplace Incivilities, and Other Subtle Slights at Work: A Meta-Synthesis

Subtle slights refer to a wide range of ambiguous negative interactions between people that may harm individual health, wellbeing and performance at work. This literature review aims to help human resource development practitioners and researchers understand the similarities and distinguishing features of disparate bodies of subtle slight research. A systematic review yielded 338 papers, the majority of which concerned three constructs: microaggressions, everyday discrimination and workplace incivilities. Meta-synthesis revealed that all three categories related to subtle, low-intensity interactions but differed in their descriptions of the type of perceived violation. The most common demographic factors under scrutiny were race or ethnicity, gender, sexual orientation, and age. We propose a framework that involves four dimensions common to all subtle slights: type of violation, intensity, duration and intent (VIDI). This framework may help future efforts to understand, monitor and address this issue of contemporary concern in the workplace.

Telehealth-supported level 2 pediatric home polysomnography

STUDY OBJECTIVES

The gold standard for diagnosis of pediatric obstructive sleep apnea is level 1 polysomnography (PSG). Some children are selected for unattended level 2 home sleep apnea testing (HSAT) with telehealth support, and we sought to review this home service.

METHODS

A retrospective audit was conducted from 2013 to 2020. All level 2 HSAT reports in children aged 5-18 years referred for suspected OSA were analyzed. American Academy of Sleep Medicine compliant portable PSG acquisition equipment with EEG was used. The primary outcome was the proportion of technically successful tests achieved, and of these the % with potential underestimation of diagnostic category. Secondary outcomes included sleep quality and parental acceptance by non-validated service-specific questionnaire. Data were analyzed using descriptive & inferential statistics. χ² tests were used for categorical variables.

RESULTS

There were 233 (139 male, 59.6%) patients studied between 2013 and 2020 (7 years). The mean age was 10.8 (SD 3.6) years. 67 patients (28.8%) had comorbidities. Technically successful studies were obtained in almost 90% (209/233) and failed studies occurred in just over 10% (24/233). One failed study still achieved a diagnosis. There was no significant difference between failed studies set up by HITH nurses compared with Sleep scientists (p=0.2). Overall, an accurate diagnosis was made in 80% (167/209) of patients, with potential for under-estimation in 20% (42/209). Six hours or more of sleep was obtained in 89.5%. Parental questionnaires revealed 89.3% perceived high-level care, 91% perceived increased convenience and 76% good/excellent telehealth support.

CONCLUSIONS

Telehealth-supported pediatric HSAT achieves technical success in almost 90% of patients investigated for OSA, with 89.5% achieving ≥6 hours sleep duration, and excellent family acceptability.

A176 UTILITY OF MACHINE LEARNING FOR SERUM METABOLOMIC DATA ANALYSIS IN PEDIATRIC CROHN DISEASE

Background

The pathogenesis of pCD remains poorly understood, but evidence suggests roles for genetics, environment, immune response, and gut microbes. Microbial changes can contribute to chronic inflammation and correlate with disease severity. Metabolomics reflects interactions between host immune and gut microbial function by quantifying compounds in biological samples. Therefore, metabolomics provides a unique opportunity to gain insight into pCD pathogenesis.

Aims

To correlate disease severity, metabolites, and clinical data by applying machine learning algorithms in pediatric Crohn Disease (pCD).

Methods

ImageKids is a multicenter, prospective, cohort observational study, conducted to develop magnetic resonance enterography (MRE) indices for pCD. Paired serum specimens were collected at study initiation (Visit One; V1) and completion (Visit Four; V4; 18 months) for 120 pCD patients. Serum from patients with representative clinical scenarios and paired samples was analyzed at The Metabolomics Innovation Centre (TMIC; University of Alberta) and 131 metabolites were identified. Metabolites were analyzed via Unsupervised (U.ML) and Supervised (S.ML) Machine Learning algorithms based on Scikit-learn library in Python. Principal Component Analysis (PCA) was used to identify the variation pattern of the patients’ metabolome. Classifiers and regression algorithms were trained to assess correlation with disease activity.

Results

Results were available for the 56 paired samples. U.ML demonstrated distinct metabolome profiles with V1 clustering mainly attributed to aspartic acid, glutamic acid, and kynurenine. V4 clustering was mainly attributed to spermidine, spermine, total dimethylarginine. Furthermore, demographics was found as an important environmental factor driving distinct patterns of the metabolomics profile.

After training different classifiers and regressors with S. ML algorithms, metabolome data were correlated with disease severity (defined by C-reactive protein and fecal calprotectin). Isoleucine, p-hydroxyhippuric acid, and putrescine were the top three compounds associated with disease severity. The accuracy of our classification models was of 80% and the coefficient of determination of our regression models was 0.5

Conclusions

Metabolomic analysis can provide insight into disease pathogenesis and help predict disease severity among pCD patients. The correlation between metabolomics and disease severity might allow a better understanding of changes in host-microbe interactions and introduce new diagnostic or therapeutic options.

Funding Agencies

CIHR

A23 ESTIMATING INDIRECT AND OUT-OF-POCKET COSTS IN PEDIATRIC INFLAMMATORY BOWEL DISEASE: A NATION-WIDE CROSS-SECTIONAL ANALYSIS

Background

Identifying disease-related costs is a crucial step to plan for proper allocation of resources and future healthcare services for persons with inflammatory bowel disease (IBD). Data on pediatric inflammatory bowel disease-associated costs are limited.

Aims

We aimed to estimate indirect and out of pocket (OOP) pediatric IBD-associated costs in Canada.

Methods

In a nation-wide cross-sectional analysis, caregivers of children and young adults (<17 years) with IBD were invited to complete a questionnaire on lost work hours and OOP costs related to IBD in the 4 weeks prior to the survey. Participants were re-invited to periodically answer the same questionnaire every 3–9 months for 2 years. Lost productivity was calculated using the Human Capital method. Costs were reported in 2018 inflation-adjusted Canadian dollars. Predictors of high cost users (top 25%) were examined using negative binomial regression.

Results

Consecutive 243 (82 incident cases) of 262 (92.7%) approached participants completed the first survey with a total of 450 surveys longitudinally completed over 2 years. The annual median indirect costs per patient were $5,951 (IQR $1,812- $12,278), with $5,776 (IQR $1,465-$11,733) for Crohn’s disease (CD) and $6,084 (IQR $2,470-$13,371) for ulcerative colitis (UC) (p=0.77). The annual median per patient OOP costs were $2,925 (IQR $978- $8,125) with $3,021 (IQR $978- $8,125) for CD and $2,600 (IQR $975- $8,125) for UC (p=0.55). Older age (10-17y) at diagnosis (p=0.04) and parents in part-time employment (p=0.01) were predictors of higher indirect costs, while female sex (p<0.001), parents with a lower education level (p<0.001) and lower annual family income (p<0.01) were associated with higher OOP costs.

Conclusions

Indirect and OOP IBD-associated costs are substantial and more likely to affect families with unstable employment and lower annual income. Examining different strategies and interventions to reduce these costs such as virtual platforms, telephone and outreach clinics especially in poor communities and families with low annual income is warranted.

Funding Agencies

CIHRThe Children’s Hospital Research Institute of Manitoba

A238 ALTERED GUT MICROBIOME COMPOSITION AND FUNCTION ARE ASSOCIATED WITH GUT BARRIER DYSFUNCTION IN HEALTHY RELATIVES OF CROHN’S DISEASE PATIENTS

Background

The gut microbiome may play a role in gut barrier homeostasis including epithelial barrier function, but data are scarce and limited to animal studies

Aims

To assess if alterations in gut microbiome are associated with gut barrier function

Methods

We utilized the Genetic Environmental Microbial (CCC GEM) cohort of healthy first-degree relatives (FDRs) of Crohn’s disease (CD) patients. Gut barrier function was assessed using the ratio of urinary fractional excretion of lactulose to mannitol (LMR). Stool bacterial DNA was extracted and sequenced for the V4 hypervariable region of the 16S rRNA gene using MiSeq and processed using QIIME2. Microbial functions were imputed using PICRUSt2. The cohort was divided into a North American discovery cohort (n=2,472) and non-North American external validation cohort (n=655). LMR>0.025 was defined as abnormal. LMR-microbiome associations were assessed using multivariable regression model and Random Forest (RF) classifier algorithm. q<0.05 was considered significant when multiple tests were performed

Results

The median age of the entire cohort was 17.0 years [IQR 12.0; 24.0], 52.6% were females and 25.4% had LMR>0.025. In the discovery cohort, subjects with LMR>0.025 had markedly reduced alpha diversity (Chao1 index, estimate= -0.0037, p=4.0e-04) and altered beta diversity (Bray-Curtis dissimilarity index, PERMANOVA: pseudo-F statistic = 2.99, p=1.0e-03). We identified eight bacterial genera and 52 microbial pathways associated with LMR>0.025 (q<0.05). Four genera (decreased Adlercreutzia [odds ratio(OR)=0.74, 95% confidence interval (CI) 0.6–0.91], Clostridia-UCG-014 [OR=0.71, 95%CI 0.59–0.86], and Clostridium-sensu-stricto-1 [OR=0.75, 95%CI 0.61–0.92] and increased Colidextribacter [OR=1.65, 95%CI 1.2–2.26]) and eight pathways (including decreased biosynthesis of glutamate [OR=0.4, 95%CI 0.21–0.74], tryptophan [OR=0.06, 95%CI 0.01–0.27] and threonine [OR=0.038, 95%CI 0.003–0.41]) were replicated. Bacterial community composition was associated with gut barrier homeostasis as defined by the RF analysis (p= 1.4e-6)

Conclusions

Gut microbiome community and pathways are associated with gut barrier function. These findings may identify potential microbial targets to modulate barrier function

Submitted on behalf of the CCC-GEM Consortium

Funding Agencies

CCC, CIHRCrohn’s and Colitis Canada Genetics Environment Microbial (CCC-GEM) III; The Leona M. and Harry B. Helmsley Charitable Trust; Kenneth Croitoru is the recipient of the Canada Research Chair in Inflammatory Bowel Diseases

A42 HETEROGENEITY IN EFFICACY AND SAFETY ENDPOINTS FOR PEDIATRIC CLINICAL TRIALS IN INFLAMMATORY BOWEL DISEASE: A NEED FOR HARMONIZATION

NOT PUBLISHED AT AUTHOR’S REQUEST

Funding Agencies: None

A157 DEFINITIONS OF MEDITERRANEAN DIET INCONSISTENTLY ASSOCIATE WITH MARKERS OF GUT BARRIER FUNCTION OR SUBCLINICAL INFLAMMATION IN A POPULATION-BASED COHORT

Background

The Mediterranean Diet (MD) is proposed to reduce the risk of Crohn’s disease (CD) onset in cohort studies, with inconsistent results. This inconsistency may be due to heterogeneity in defining MD scores. Additionally, relationships between MD compliance and intestinal permeability or sub-clinical inflammation are not defined.

Aims

We examined correlations between different MD scores, and determined associations between MD compliance and intestinal permeability or subclinical inflammation in a cohort of first degree relatives of CD patients.

Methods

We used food frequency questionnaire data from 2,112 subjects of the Crohn’s Colitis Canada- Genes, Environment, Microbial (CCC-GEM) project. We obtained 12 MD definitions from the literature and calculated daily percent compliance, we further compared MD scores via pairwise correlations (Kendall’s Tau). We measured intestinal permeability via urinary fractional excretion ratio of lactulose to mannitol (LMR) (LMR≥0.03 defined abnormal), and subclinical inflammation via fecal calprotectin (FCP) measured with BÜHLMANN fCAL® ELISA (FCP≥250 defined abnormal). We fit multivariable regression models between MD compliance and abnormal LMR and FCP, respectively. Two-sided p&lt;0.05 defined significance.

Results

There was large variation in cross-correlations among MD scores, from nil (t=0.0, p=0.54) to highly significant (t=0.97, p&lt;2.2e-16). Associations of MD compliance and abnormal LMR or FCP were in both directions of effect, largely non-significant. Of the 12 MD scores, none associated with abnormal LMR, while 4 associated with abnormal FCP-Odds Ratios =1.22, 1.23, 1.24, and 1.30; p=0.02, 0.02, 0.01, and 0.009, and 95% Confidence Intervals = [1.03,1.45], [1.04,1.45], [1.05,1.47], and [1.07,1.59] respectively. No diet remained significant after correcting for multiple testing.

Conclusions

Currently MD definitions vary widely. Despite discrepancies, we expected consistent directions of effect for MD compliance on LMR or FCP. The largely non-significant associations between MDs suggest limitations in definition, interpretation, and relation to biological outcomes.

Submitted on behalf of the CCC-GEM consortium.

Funding Agencies

CIHRCrohn’s and Colitis Canada Genetics Environment Microbial (CCC-GEM) III;The Leona M. and Harry B. Helmsley Charitable Trust; Justine Timpano is a recipient of a fellowship award from Mount Sinai Hospital; Kenneth Croitoru is the recipient of the Canada Research Chair in Inflammatory Bowel Diseases

A236 ASSOCIATION OF STOOL METABOLOMIC PROFILE AND MICROBIOME COMPOSITION RISK SCORE WITH FUTURE ONSET OF CROHN’S DISEASE

Background

Microbial composition-based risk score (MRS) was recently developed and validated to predict future risk of developing Crohn’s disease (CD) among healthy first-degree relatives (FDR) of CD patients. We hypothesized that stool metabolomic profiles, some of which are linked to the gut microbiome, are associated with future risk of CD.

Aims

To assess the association of stool metabolomic profile with onset of CD and to determine the correlation between stool metabolites and the MRS

Methods

Healthy FDR of CD patients were recruited as part of the nested case-control cohort of the CCC-GEM Project. Healthy FDRs who later developed CD (n=56) were matched approximately 1:1 by age, sex, follow-up duration, and geographical location with control FDRs remaining healthy (n=66). Stool metabolomics were assessed using the Metabolon’s DiscoveryHD4™ platform, and the stool microbiome characterised by 16s rDNA amplicon sequencing. We fitted a multivariable conditional logistic regression model on the disease status as a function of individual stool metabolites. We additionally performed Spearman correlation between each stool metabolite and the MRS.

Results

Among 1,029 stool metabolites that were analyzed, 79 were associated with future risk of CD (p&lt;0.05); however, none remained significant after multiple testing correction (FDR correction). Considering the exploratory nature of this study with limited sample size, we focused on the top seven metabolites associated with CD onset (p&lt;0.01). Of these, two stool metabolites (dimethylglycine, methylmyristate) were associated with increased risk of CD onset while five (cytosine, guanine, cytidine, hydroxyglutarate, nervonate) were associated with decreased risk of developing CD. The two metabolites positively associated with CD onset were positively correlated with the MRS, while the five metabolites negatively associated with CD onset, were negatively correlated with the MRS. Meanwhile, 24 stool metabolites had significant correlation with MRS (FDR-corrected p&lt;0.2). Among those, a total of four stool metabolites (cytosine, guanine, methymyristate, cytidine) overlapped with the top seven stool metabolites associated with CD onset.

Conclusions

Stool metabolite profiles may predict future risk of CD. A subset of these metabolites have significant correlation with the MRS with consistent direction of effect. This may suggest that stool metabolites mediate the putative effect of the gut microbiome on CD risk. Further validation in the full GEM cohort is warranted.

Funding Agencies

CCC, CIHRThe Leona M. and Harry B. Helmsley Charitable Trust; Kenneth Croitoru is the recipient of the Canada Research Chair in Inflammatory Bowel Diseases; Sun-Ho Lee is a recipient of the Imagine/ CIHR/CAG Fellowship Award; Sun-Ho Lee, Juan Antonio Raygoza Garay, and Williams Turpin are recipients of fellowship awards from the Department of Medicine, Mount Sinai Hospital, Toronto, Canada.

Highly efficient and selective aqueous phase hydrogenation of aryl ketones, aldehydes, furfural and levulinic acid and its ethyl ester catalyzed by phosphine oxide-decorated polymer immobilized ionic liquid-stabilized ruthenium nanoparticles

Phosphine oxide-decorated polymer immobilized ionic liquid stabilized RuNPs catalyse the hydrogenation of aryl ketones with remarkable selectivity for the CO bond, complete hydrogenation to the cyclohexylalcohol and hydrogenation of levulinic acid to γ-valerolactone.

Evidence-based orthopaedic trauma care in the United Kingdom: Guidelines, registries, carrots and sticks

In the United Kingdom (UK), orthopaedic trauma surgeons utilise evidence-based practice through distillation of high-quality primary research, interrogation of registries and implementation of evidence-based guidelines. Concurrent with this ambition of providing exemplar care based on robust patient centred research, there has evolved a culture of remuneration 'by results'. Therefore, there is a drive for excellence combined with a system of collation and validation of data input as well as remuneration where care excels. There are several organisations involved in each stage of this process, the output of which has much that is pertinent to the globally similar consequences of physical injury. However, their relevance and impact within the UK is magnified as they are written against the backdrop of a unified healthcare system. In this article, we will describe the roles of the different organisations guiding and regulating trauma practice across the UK and discuss how the interplay of these impacts on clinical care.

A178 USTEKINUMAB FOLLOWING PRIMARY ANTI-TNF FAILURE AND SECONDARY LOSS OF RESPONSE TO VEDOLIZUMAB IN AN ADOLESCENT WITH ULCERATIVE PANCOLITIS

Background

Infliximab is, to date, the only biologic therapy approved for the treatment of ulcerative colitis (UC) in paediatric patients. Although often effective, primary mechanistic failure is more common in UC than in luminal inflammatory paediatric Crohn’s disease (CD). Alternate pathway biologics, specifically vedolizumab (anti-α4β7 integrin) and ustekinumab (anti-interleukins 12/23) are increasingly used in adults with UC. Emerging data from head to head trials of biologics and network meta-analyses of placebo-controlled trial data are being used to guide choice and sequencing of therapeutic agents. Even among adults with UC data concerning combination biologics are very limited.

Aims

To report the outcomes of addition of ustekinumab to vedolizumab in a patient with steroid dependent colitis, previous primary non-response to infliximab and secondary loss of response to vedolizumab monotherapy.

Methods

Case report

Results

A 17 years old girl was hospitalized with acute severe colitis (PUCAI 85) developing as oral prednisone was tapered below 30 mg daily despite ongoing intensified vedolizumab therapy (300 mg q4 weekly) and per rectal steroids. First presentation 2 years earlier with UC pancolitis, responsive to oral prednisone, maintained on oral 5-ASA until first exacerbation 8 months later. Responsive then to IV steroids, but unable to maintain steroid-free remission despite intensified infliximab with therapeutic levels. Vedolizumab initiated in setting of primary mechanistic anti-TNF failure. Steroid-free clinical remission for 7 months of q 8 weekly dosing with normalization of fecal calprotectin (16, 115 µg/g) when symptoms recurred and persisted despite shortening of vedolizumab dosing interval to 4 weeks. Vedolizumab level 34 µg/mL. Symptomatic response to oral prednisone 40 mg, but unsustained with tapering. Hospitalized with up to 10 bloody stools per day, nocturnal stools, abdominal pain and anemia requiring blood transfusion. High doses of IV steroids were given with slow response. Colectomy refused by family. IV ustekinumab 390 mg given. Vedolizumab continued q 8 weekly in view of prior responsiveness. Ustekinumab subcutaneous maintenance therapy initiated at week 8 and continuing q 4 weekly (levels 3.3 mg/L). Oral prednisone tapered and discontinued. At 5 months post ustekinumab initiation, patient is in steroid-free clinical remission (PUCAI 0). Fecal calprotectin has declined from &gt;1800 to 723 µg/g.

Conclusions

In this patient with UC and primary failure of anti-TNF, ustekinumab has demonstrated short-term efficacy in alleviating steroid-dependency. The contribution of continued vedolizumab, to which there had previously been secondary loss of response, is unknown. Nevertheless, the safety profile of vedolizumab allows it to be combined with other therapies in selected treatment-refractory patients.

Funding Agencies

None

A case management occupational health model to facilitate earlier return to work of NHS staff with common mental health disorders: a feasibility study

BACKGROUND

The NHS is the biggest employer in the UK. Depression and anxiety are common reasons for sickness absence among staff. Evidence suggests that an intervention based on a case management model using a biopsychosocial approach could be cost-effective and lead to earlier return to work for staff with common mental health disorders.

OBJECTIVE

The objective was to assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of an early occupational health referral and case management intervention to facilitate the return to work of NHS staff on sick leave with any common mental health disorder (e.g. depression or anxiety).

DESIGN

A multicentre mixed-methods feasibility study with embedded process evaluation and economic analyses. The study comprised an updated systematic review, survey of care as usual, and development of an intervention in consultation with key stakeholders. Although this was not a randomised controlled trial, the study design comprised two arms where participants received either the intervention or care as usual.

PARTICIPANTS

Participants were NHS staff on sick leave for 7 or more consecutive days but less than 90 consecutive days, with a common mental health disorder.

INTERVENTION

The intervention involved early referral to occupational health combined with standardised work-focused case management.

CONTROL/COMPARATOR

Participants in the control arm received care as usual.

PRIMARY OUTCOME

The primary outcome was the feasibility and acceptability of the intervention, study processes (including methods of recruiting participants) and data collection tools to measure return to work, episodes of sickness absence, workability (a worker's functional ability to perform their job), occupational functioning, symptomatology and cost-effectiveness proposed for use in a main trial.

RESULTS

Forty articles and two guidelines were included in an updated systematic review. A total of 49 of the 126 (39%) occupational health providers who were approached participated in a national survey of care as usual. Selected multidisciplinary stakeholders contributed to the development of the work-focused case management intervention (including a training workshop). Six NHS trusts (occupational health departments) agreed to take part in the study, although one trust withdrew prior to participant recruitment, citing staff shortages. At mixed intervention sites, participants were sequentially allocated to each arm, where possible. Approximately 1938 (3.9%) NHS staff from the participating sites were on sick leave with a common mental health disorder during the study period. Forty-two sick-listed NHS staff were screened for eligibility on receipt of occupational health management referrals. Twenty-four (57%) participants were consented: 11 (46%) received the case management intervention and 13 (54%) received care as usual. Follow-up data were collected from 11 out of 24 (46%) participants at 3 months and 10 out of 24 (42%) participants at 6 months. The case management intervention and case manager training were found to be acceptable and inexpensive to deliver. Possible contamination issues are likely in a future trial if participants are individually randomised at mixed intervention sites.

HARMS

No adverse events were reported.

LIMITATIONS

The method of identification and recruitment of eligible sick-listed staff was ineffective in practice because uptake of referral to occupational health was low, but a new targeted method has been devised.

CONCLUSION

All study questions were addressed. Difficulties raising organisational awareness of the study coupled with a lack of change in occupational health referral practices by line managers affected the identification and recruitment of participants. Strategies to overcome these barriers in a main trial were identified. The case management intervention was fit for purpose and acceptable to deliver in the NHS.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14621901.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 12. See the NIHR Journals Library website for further project information.

Nurses' illness perceptions during presenteeism and absenteeism

BACKGROUND

Presenteeism has been linked with lost productivity, impaired health and absence. Whilst much research has focused on types of diseases associated with presenteeism and absenteeism, there has been little investigation into the role of individuals' illness perceptions in these episodes.

AIMS

To assess how illness perceptions vary between presenteeism and absenteeism episodes.

METHODS

A cross-sectional questionnaire was distributed to ward-based nurses working with older adults. Data on illness perceptions during presenteeism and absenteeism episodes were collected. Data were analysed via the Paired-Samples t-test, Wilcoxon test and McNemar test.

RESULTS

Two hundred and seventy cases were analysed (88% response rate). Compared with presenteeism, illnesses during absenteeism were thought to affect lives more (P < 0.001), to have more serious symptoms (P < 0.001), to be more concerning (P = 0.003), more likely to be treated (P = 0.009), more infectious (P < 0.001) and perceived as more legitimate reasons for absenteeism (P < 0.001). Treatment was considered more effective during absenteeism (P < 0.001), whilst workability was better during presenteeism (P < 0.001). Presenteeism was perceived as harmful and absenteeism beneficial for illness. Individuals attended work when presenteeism was expected to be less harmful (P < 0.001) and avoided work when absenteeism was expected to be more beneficial for illness (P < 0.001).

CONCLUSIONS

Illness perceptions varied significantly between presenteeism and absenteeism episodes and should be included in models of illness behaviour. Findings also highlight that policy may influence illness behaviour and that nurses may attend work despite concerning levels of illness.

Improving emotional well-being for hospital-based patients with dementia

Purpose

Improving hospital care for people with dementia is a well-established priority. There is limited research evidence to guide nursing staff in delivering person-centred care, particularly under conditions where patients are emotionally distressed. Misunderstood distress has negative implications for patient well-being and hospital resources. The purpose of this study is to use the expertise of nurses to recommend ways to care for the emotional well-being of patients with dementia that are achievable within the current hospital setting.

Design/methodology/approach

A qualitative study was conducted in two long-stay wards providing dementia care in a UK hospital. Nursing staff (n = 12) were asked about facilitators and barriers to providing emotion-focused care. Data were analysed using thematic analysis.

Findings

Nursing staff said that resources existed within the ward team, including ways to gather and present personal information about patients, share multidisciplinary and personal approaches, work around routine hospital tasks and agree an ethos of being connected with patients in their experience. Staff said these did not incur financial cost and did not depend upon staffing numbers but did take an emotional toll. Examples are given within each of these broader themes.

Research limitations/implications

The outcome is a short-list of recommended staff actions that hospital staff say could improve the emotional well-being of people with dementia when in hospital. These support and develop previous research.

Originality/value

In this paper, frontline nurses describe ways to improve person-centred hospital care for people with dementia.

Nurses' perceived work performance and health during presenteeism: Cross-sectional associations with personal and organisational factors

AIM

To determine personal and organisational factors associated with work performance and illness outcomes during presenteeism in a cohort of nurses.

BACKGROUND

Presenteeism is prevalent in nursing populations. It is known to be associated with impaired health and performance loss. Knowledge about the factors associated with presenteeism may help foster better health and performance in this group.

METHODS

A survey (N = 270) was conducted in a population of nurses working with older adults. Hierarchical multiple regression was used to explore factors associated with performance loss and illness outcomes during presenteeism.

RESULTS

Work performance and illness outcomes were often reported as poor during presenteeism. Less negative illness perceptions and work engagement were associated with better work performance and illness outcomes. Older age and manager support were also associated with better work performance. Non-organisational causes of illness were associated with better illness outcomes.

CONCLUSION

Performance levels and illness outcomes during presenteeism are associated with a combination of illness-related, individual, attitudinal and organisational factors.

IMPLICATIONS FOR NURSING MANAGEMENT

Fostering engagement, support, good relationships and a hazard-free environment may improve performance and health during presenteeism.

How to interpret polysomnography

A 5-year-old child presents to a paediatric clinic with their parents because of concerns about snoring, which is loud, every night and associated with respiratory pauses. This has been present for 6 months. Can clinical evaluation diagnose sleep-disordered breathing in children or are further investigations required? Should further investigations include oximetry or polysomnography? If a polysomnogram is performed, how are the results interpreted? In this paper we describe the indications for polysomnography, outline the parameters measured and decode a clinical polysomnography report.

A26 PEDIATRIC-ONSET INFLAMMATORY BOWEL DISEASE INCREASES THE RISK OF VENOUS THROMBOEMBOLISM: A CANGIEC POPULATION-BASED STUDY

Background

Inflammatory bowel disease (IBD) increases the risk of venous thromboembolism (VTE) in patients of all ages but the risk of VTE among Canadian children with IBD has not previously been investigated.

Aims

Report the incidence of VTE and subtypes pulmonary embolism (PE) and deep vein thrombosis (DVT) in children with and without IBD.

Methods

Children diagnosed with IBD &lt;16y were identified from health administrative data in Ontario (2002–2014), Alberta (2007–2015), and Nova Scotia (2002–2012) using validated algorithms and matched by age and sex to children without IBD (1:5 ratio). Validated ICD-10 codes identified hospitalizations for incident VTE (DVT, PE, and sinovenous thrombosis). Province-specific 5-year cumulative incidence per 1000 person-years (PY) of VTEs were pooled using fixed-effects generalized linear mixed models with a Freeman-Tukey double arcsine transformation. Incidence rate ratios (IRR) within 5 years of diagnosis were pooled using fixed-effects generalized linear mixed models to compare children with and without IBD, and children with Crohn’s disease (CD) and ulcerative colitis (UC).

Results

3127 children with IBD (1826 CD; 1045 UC) were matched to 15,635 children without IBD. The cumulative incidence of VTE within 5 years of IBD diagnosis was 2.8 (95% CI 2.1–3.8) per 1000 PYs compared to 0.13 (95% CI 0.07–0.24) per 1000 PYs in children without IBD (Table). The 5-year cumulative incidences of VTE, DVT, and PE were significantly higher in children with IBD than in children without IBD (VTE: IRR 21.44, 95% CI 10.73–42.82; DVT: IRR 25.15, 95% CI 11.12–56.89; PE: IRR 4.01, 95% CI 1.22–13.18). Compared to UC patients, children with CD were at lower risk of VTE (IRR 0.53, 95% CI 0.29–0.96) and numerically, but not statistically, lower risk of DVT (IRR 0.59, 95% CI 0.30–1.14).

Conclusions

Although VTEs are relatively rare among children with IBD, these children are at much greater risk than children without IBD. Gastroenterologists caring for these patients should be cognizant of VTE risk and provide appropriate prophylaxis to those at high risk of VTE.

Funding Agencies

CCC

A228 EVOLUTION OF MRE FINDINGS IN PAEDIATRIC PATIENTS WITH SMALL BOWEL CROHN’S DISEASE ON MAINTENANCE METHOTREXATE

Background

Observational data in children and RCT data in adults indicate that methotrexate (MTX) is associated with induction and maintenance of clinical remission in luminal Crohn’s disease, but efficacy in achieving intestinal healing has not been examined.

Aims

To examine the evolution of MRE signs of inflammation in children treated with MTX.

Methods

In this retrospective cohort study, we reviewed paediatric CD patients on maintenance MTX monotherapy for &gt;4 months who underwent serial MREs between July 2010 and October 2015. MREs were reviewed by a radiologist blind to clinical data. Overall inflammatory activity on each MRE was scored as minimal, mild, moderate or severe, informed by the presence of bowel wall thickness, wall enhancement, T2 hyperintensity, comb sign, mesenteric edema, penetrating disease, stricturing, diffusion restriction and motility. The radiologist’s global assessment of change from MRE 1 to MRE 2 was scored as improved, unchanged or worsened. Clinical findings, disease activity (assessed by weighted paediatric CD activity index [wPCDAI]) and surgical history were also extracted from medical records by a clinician blind to MRE results.

Results

Thirty-five patients were included (median age at diagnosis 12 [IQR 11–14] years; 77% male; 60% inflammatory (B1), 17% stricturing (B2), 23% penetrating (B3) disease). Between baseline and follow-up MRE, wPCDAI (median 15 [IQR 7–43] decreased to 8 [IQR 0–18]; p=0.006) and CRP (median 9 [IQR 2–36] decreased to 5 [IQR 5–9]; p=0.013) and 74% (N=26) were in clinical remission (wPCDAI &lt; 12.5) at MRE 2. MRE features that significantly improved from MRE 1 to 2 were comb sign from 63% (N=37) to 38% (N=14) (p=0.02) and penetrating disease from 14% (N=8) to 0 (p=0.03). After a median of 17 months (IQR 13–23), 51% (N=18) of patients improved, 29% (N=10) worsened and 20% (N=7) had no change based on the radiologist’s global assessment. Of the 21 patients with moderate/severe disease at MRE 1, 33% (N=7) had minimal/mild disease by MRE 2. 66% (N=14/21) continued to have moderate/severe disease at MRE 2. Additionally, a further 14% (N=2/14) of those with minimal/mild disease at baseline MRE progressed to moderate/severe disease at MRE 2. Complete details of change between MRE 1 and MRE 2 are displayed in Figure 1.

Conclusions

Despite signs of clinical improvement, many paediatric CD patients on maintenance MTX therapy for &gt;4 months have unchanged or worsened MRE findings. This underscores the need for follow-up imaging in these cases.

Funding Agencies

None

Menopause and work: an overview of UK guidance

Background

Recent evidence suggests that some women experience menopausal symptoms that impact on their working lives, and that work environments can impact upon the experience of menopause. As a result, guidance for employers and other key stakeholders about this potential occupational health issue has emerged. To date there has not been a review of these documents to identify their main recommendations for policy and practice.

Aims

To provide a narrative overview of such guidance and summary of content.

Methods

Documents published in the UK and available in a major UK trade union library were searched systematically to identify guidance on the topic of menopause and work. An inductive thematic analysis was performed to identify the main themes addressed.

Results

Twenty-five relevant documents, on average eight pages long, were identified. A minority indicated that the use of scientific evidence informed the content. Five overarching themes were identified: (i) legislation; (ii) policy; (iii) information and training needs; (iv) workplace support; and (v) the physical work environment.

Conclusions

This overview of UK guidance revealed common areas of concern about reducing and managing difficulties experienced by working menopausal women. Possible areas for action were identified. Some recommendations were common across much of the guidance, whereas others were exclusive. Future guidance might include consideration of all these issues, while making reference both to the evidence base and sources of further information.

Importance of personal and professional experience for hospital staff in person-centred dementia care: a cross-sectional interview study using freelisting in a UK hospital ward

OBJECTIVE

To detail how hospital staff with differing personal and professional caregiving experiences approach the care of patients with dementia, in order to make practical recommendations for practice.

DESIGN

Cross-sectional qualitative interviews.

SETTING

A UK hospital ward providing dementia care.

PARTICIPANTS

A complete hospital ward staff team, constituting 47 hospital staff from 10 professions.

METHODS

Hospital staff were asked to list their approaches to emotion-focused care in individual, ethnographic freelisting interviews. Cultural consensus analysis was used to detail variations in approaches to dementia care between staff subgroups.

MAIN OUTCOME MEASURES

The most salient listed descriptions of care emphasised by staff members with personal experience of dementia caregiving when compared with staff members without such experience, and descriptions from staff newer to the profession compared with staff with more years of professional dementia caregiving experience.

RESULTS

Subgroups of hospital staff showed different patterns of responses both in how they noticed the emotional distress of patients with dementia, and in prioritised responses that they deemed to work. Hospital staff with professional experience of dementia caregiving and staff with fewer years of professional experience prioritised mutual communication and getting to know each patient.

CONCLUSIONS

Subgroups of hospital staff with personal caregiving experiences and fewer years of professional care experience were more likely to describe person-centred care as their routine ways of working with patients with dementia. It is recommended that personal experience and the novice curiosity of hospital staff be considered as valuable resources that exist within multidisciplinary staff teams that could enhance staff training to improve the hospital care for patients with dementia.

Managing employees with dementia: a systematic review

BACKGROUND

The experience of developing dementia while in employment has been explored from the point of view of the employee, but less is known about the perspectives, experiences and needs of employers.

AIMS

To review systematically literature about the management of employees who develop dementia whilst in employment.

METHODS

Databases searched included MEDLINE, EMBASE, PsycINFO, CINAHL, BNI, ABI Inform, ISI Web of Science, Open Grey and dementia journals database; 44 documents were identified for inclusion in the review: 22 journal papers, one PhD thesis and 21 articles, reports and webpages from the grey literature. As all documents were qualitative in nature a thematic synthesis of their content was undertaken.

RESULTS

Three main themes and ten sub-themes were identified. The main themes concerned early presentation and identification in the workplace; reasonable adjustments for people with working age dementia; and the provision of information to raise awareness and facilitate informed choice. The evidence suggested that there is a lack of awareness about working age dementia and that this may impact negatively on employees. Guidance for employers offered suggestions for good practice.

CONCLUSIONS

Guidance for employers is increasingly available although it rarely refers to the evidence base. There is a need for future studies that explore the effectiveness of guidance and training initiatives for employers. Examples of good practice where employees with dementia have been well supported in the workplace and who have been able to leave the workforce with dignity, would be helpful.

Effects of care assistant communication style on communicative behaviours of residents with dementia: a systematic multiple case study

OBJECTIVES

To determine whether varying the communication style of care assistants, encouraging them to use direct instructions and allowing more time for residents' responses influenced the communicative behaviour of care home residents living with dementia.

DESIGN

This study used a multiple systematic case study design. Participants were video-recorded during morning care routines in three communication conditions: usual communication, direct instructions and pacing (allowing more time for resident responses). Each dyad acted as its own control.

SETTING

The study took place in a residential care home in the East Midlands, UK.

PARTICIPANTS

Three dyads (person with dementia/care worker) MEASURES: The level of compliance with instructions was measured. Validated measures were used to rate positive communicative behaviour (engagement with care tasks, eye contact and initiation of interaction) and negative communicative behaviour (e.g. shouting and kicking).

RESULTS

Care assistants were able to employ direct instructions after brief training. The use of direct instructions was positively correlated with positive communicative behaviour from residents (p < 0.05). The pacing condition was not employed adequately to evaluate effectiveness. Negative communicative behaviour (resistiveness to care) was rare.

CONCLUSION

The use of direct instructions by care assistants holds promise for effective communication with people with dementia and warrants further investigation in larger samples and in varied contexts.

Reasons for presenteeism in nurses working in geriatric settings: A qualitative study

Objective: To explore the perceived causes of presenteeism in nurses on geriatric wards.Background: Presenteeism, defined as working when unwell, is associated with lost productivity and increased absenteeism. It is more commonly reported by employees in the healthcare sector than other sectors.Methods: An exploratory, qualitative study using semi-structured interviews, thematically analysed. Data collected via 18 recorded interviews with nurses working with patients on geriatric medical wards in Malta.Results: Four major themes emerged that related to nurses’ decisions to engage in presenteeism: illness perceptions, which included participants’ views and experiences of their own health complaints; attitudes to their employing organisation, co-workers and patients; organisational aspects such as culture and administrative arrangements; and personal reasons including illness behaviour preference and personal circumstances.Conclusions: Nurses’ decisions to attend work when unwell were reported as dependent upon four themes. Further studies are warranted to determine if findings are applicable to nurse populations other than those represented in this study.Implications: Workplace health promotion initiatives should target nurses’ management of their own health, particularly if they have chronic illnesses. Workplace policies and arrangements should be examined with a view to controlling presenteeism.

Emotional distress with dementia: A systematic review using corpus-based analysis and meta-ethnography

OBJECTIVE

More understanding is needed about the emotional experiences of dementia from the perspective of the individual. This understanding can then inform the provision of health care to meet individual needs. This systematic review aimed to present all available descriptions of emotional distress and explanations for emotional distress experienced by individuals with dementia, articulated personally and by others.

METHODS

A systematic mixed-method review identified literature that was screened and quality appraised. Data were analysed quantitatively and qualitatively using corpus-based methods and meta-ethnography.

RESULTS

The 121 included studies showed that individuals with dementia have expressed emotional distress comprehensibly. Family, professional caregivers, clinicians, and academic writers have also observed and described extreme emotional experiences. Feeling fearful and lonely were predominant and show the importance of anxiety in dementia. Explanations for emotional distress included threats to universal, human needs for identity, belonging, hope, and predictability.

CONCLUSIONS

The variable and personal emotional experiences of individuals with dementia are well described and should not continue to be overlooked. Limitations, future research, and clinical implications are discussed.

Scaling the Peaks Research Protocol: understanding the barriers and drivers to providing and using dementia-friendly community services in rural areas-a mixed methods study

INTRODUCTION

Scaling the Peaks is a cross-disciplinary research study that draws on medical ethnography, human geography and Geospatial Information Science (GIS) to address the issues surrounding the design and delivery of dementia-friendly services in rural communities. The research question seeks to understand the barriers and drivers to the development of relevant, robust, reliable and accessible services that make a difference among older rural families affected by dementia.

METHODS AND ANALYSIS

This mixed methods study recruits both families affected by dementia who reside within the Peak District National Park, Derbyshire, and their service providers. The study explores the expectations and experiences of rural dementia by adopting a three-part approach ¹ : longitudinal ethnographic enquiry with up to 32 families affected by dementia (aged 70 years plus) who identify themselves as rural residents ² ; ethnographic semistructured interviews and systematic observations of a range of statutory, third sector, private and local community initiatives that seek to support older people living with dementia ³ ; and geospatial visual mapping of the qualitative and quantitative data. The ethnographic data will be used to explore the ideas of belonging in a community, perceptions of place and identity to determine the factors that influence everyday decisions about living well with dementia and, for the providers, working in a rural community. The geospatial component of the study seeks to incorporate quantitative and qualitative data, such as types, locations and allocation of services to produce an interactive web-based map for local communities to determine the future design and delivery of services when considering dementia-friendly services.

ETHICS AND DISSEMINATION

The study is approved by the Leeds and Humberside Health Research Authority 16/YH/0163. The study is also approved by other participating organisations as required by their own governance procedures. The study includes people with dementia and as such adheres to the ethical considerations when including people with dementia. A publicly available interactive visual map of the findings will be produced in relation to current services related to location and, by default, identify gaps in provision. Formal reports and dissemination activities will be undertaken in collaboration with the study advisory group members.

STUDY PROGRESS

The recruitment began in September 2016. The data analysis commenced June 2017, using 59 provider interviews and 27 family participants. Data collection will be completed June 2018.

NOTE ON TERMINOLOGY

Please note that the term 'families affected by dementia' is the preferred term of usage by the family members of the Scaling the Peaks Study Advisory Group. The group wish to emphasise that they consider this term to be more representative of their lives than the term living with dementia.

TRIAL REGISTRATION NUMBER

NIHR IRAS 188103; Pre-results.

Work outcomes in midlife women: the impact of menopause, work stress and working environment

Background

There is growing research interest in the question of whether menopause impacts upon mid-aged women’s work outcomes, but the evidence to date is inconclusive. This paper examines whether: (i) menopausal status, and experience of hot flushes and night sweats (HFNS), and whether (ii) work stress and work environment, are associated with work outcomes (absenteeism, job performance, turnover intention, and intention to leave the labor force).

Methods

An online survey (sociodemographic, menopause, health, well-being and aspects of work) was completed by 216 (pre-, peri- and postmenopausal) women aged 45–60 years.

Results

Work outcomes were not associated with menopausal status but were significantly associated with job stress and aspects of the work environment, such as demand, control and support. HFNS presence, frequency and problem-rating were not significantly associated with work outcomes. HF problem rating at work was significantly associated with intention to leave the labor force, after controlling for age (F(2,101), 6.742, p = .002).

Conclusions

The main predictors of work outcomes in this sample of mid-aged women were aspects of the working environment (particularly role clarity and work stress). Menopausal status was not associated with work outcomes but having problematic hot flushes at work was associated with intention to stop working. These results challenge assumptions about the menopause transition by providing evidence that the menopause does not impact on women’s self-reported work performance and absence. However, support for women with problematic HFNS at work may be beneficial, as might addressing working environment issues for mid-aged women.