Innovation and Competency Development in Occupational Therapy Fieldwork During the COVID-19 Pandemic

Background: Occupational therapy clinical education was disrupted because of the COVID-19 pandemic. This introduced both challenges and opportunities in clinical fieldwork education and created a naturalistic opportunity to study the innovations that occurred. Purpose: To identify and describe fieldwork education innovations that occurred during the COVID-19 pandemic and understand how these clinical learning contexts impacted competency development in occupational therapy learners. Method: A qualitative multi-case study methodology was used. The participants (N = 28) were occupational therapy learners and preceptors who self-identified as having participated in an innovative fieldwork placement during the pandemic either as a preceptor or learner. Data were collected via in-depth interviews and analyzed to identify cases of innovation. Within and across case analyses were conducted to describe innovations and competencies addressed. Findings: Three cases of fieldwork innovations were identified: (a) Virtual Care; (b) Intrapreneurship; and (c) Administration. The commonly addressed competency domains across the cases were OT Expertise, Excellence in Practice, and Communication and Collaboration. The competency domain, culture, equity, and justice, was only addressed in the virtual care case. Conclusion: Our findings indicate that innovative fieldwork placements can support competency development in occupational therapy; however, this development is complex and contextually based.

Contextual factors of financial capability and financial well-being for adults living with brain injury: a qualitative photovoice study

OBJECTIVE

To identify the contextual factors related to financial capability and financial well-being for adults living with acquired brain injury (ABI).

DESIGN & METHOD

We conducted a qualitative descriptive study using photovoice and included 17 adults who live with ABI in Manitoba, Canada. Over 3-to-5 weeks, participants took photos of their financial capability (i.e. knowledge, skills, and behaviors related to managing finances) or their financial well-being (i.e. subjective and objective financial outcomes). Participants were interviewed about their photos. Five researchers iteratively and thematically analyzed interview transcripts.

MAIN OUTCOMES/RESULTS

Analysis identified the importance of the economic, social, technology, and physical or sensory context. Subthemes related to: (i) hard times finding financial resources; (ii) processes not making sense; (iii) getting help from the right person; and (iv) invisible disability bias and stigma.

CONCLUSIONS

There is decreased literature about financial capability or financial well-being after ABI. The results of this study highlight the salience of finance to living with ABI and the importance of the context to addressing financial-related life participation for people living with ABI. Information about contextual factors related to finance can improve rehabilitation assessment and intervention practice as well as emphasize needed accessibility changes to financial environments.

Evaluating the usefulness of a wordless picture book for adults with intellectual disabilities about the COVID-19 vaccination programme using co-production: The CAREVIS study

AIM

To explore the usefulness of a co-designed wordless book showing processes of receiving COVID-19 vaccines designed by, and for, adults with intellectual disabilities.

METHODS

A qualitative evaluation of the resource using mixed methods. Semi-structured interviews were conducted with people with intellectual disabilities, carers and health professionals about resource content, and use. This was analysed thematically. A survey was circulated to intellectual disabilities networks to understand resource need, use, sharing and content.

RESULTS

Understanding the COVID-19 vaccine was a process, not a single event using one resource. A visual resource had a place in facilitating conversations about vaccines between people with intellectual disabilities and carers. Differing perspectives were expressed regarding personal needs, existing awareness of vaccine programmes and communication preferences. Changes were suggested to improve the suggested storyline and relevance around COVID-19 restrictions changing.

CONCLUSION

A visual resource may help conversations about the COVID-19 vaccine for people with intellectual disabilities.

Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery

BACKGROUND

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.

METHODS

Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.

RESULTS

The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.

CONCLUSION

The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.

The impact of an integrated, interprofessional knowledge translation intervention on access to inpatient rehabilitation for persons with cognitive impairment

Introduction

Stroke rehabilitation teams’ skills and knowledge in treating persons with cognitive impairment (CI) contribute to their reduced access to inpatient rehabilitation. This study examined stroke inpatient rehabilitation referral acceptance rates for persons with CI before and after the implementation of a multi-faceted integrated knowledge translation (KT) intervention aimed at improving clinicians’ skills in a cognitive-strategy based approach, Cognitive Orientation to daily Occupational Performance (CO-OP), CO-OP KT.

Methods

CO-OP KT was implemented at five inpatient rehabilitation centres, using an interrupted time series design and data from an electronic referral and database system called E-Stroke. CO-OP KT included a 2-day workshop, 4 months of implementation support, health system support, and a sustainability plan. A mixed effects model was used to model monthly acceptance rates for 12 months prior to the intervention and 6 months post.

Results

The dataset was comprised of 2604 pre-intervention referrals and 1354 post. In the mixed effects model, those with CI had a lower pre-intervention acceptance rate than those without. Post-intervention the model showed the acceptance rate for those with CI increased by 8.6% (p = 0.02), whereas those with no CI showed a non-significant increase of less than 1%.

Conclusions

Proportionally more persons with CI gained access to inpatient stroke rehabilitation following an integrated KT intervention.

Adolescent and parent experiences with Tele-Active Rehabilitation for concussion: an exploratory qualitative study

PURPOSE

To explore the experiences of adolescents with concussion and their parents who participated in a novel remotely delivered Tele-Active Rehabilitation (Tele-AR) intervention involving sub-symptom threshold exercise, education, and support. Specifically, we aimed to elicit perspectives regarding the remote delivery approach, valued aspects of the program, and perceived benefits of the intervention.

METHODS

This qualitative study took place within the context of a larger mixed-methods project exploring the feasibility of the Tele-AR intervention. A descriptive qualitative design was utilized. Semi-structured interviews were conducted with adolescents (n = 3; ages 14-17 years) with concussion and one of their parents (n = 3) within one week of completing the six-week Tele-AR intervention. Data were analyzed using thematic analysis.

RESULTS

Four themes were identified that capture participant experiences in the intervention: (1) Enabling access to active rehabilitation; (2) Focusing on individual needs; (3) Learning to take responsibility for recovery; and (4) Convenience and comfort of engaging in rehabilitation from home.

CONCLUSIONS

A small sample of 3 adolescents with concussion and their parents were satisfied with the Tele-AR intervention and appreciated the convenience and comfort of engaging in rehabilitation from home, which facilitated adolescents taking responsibility for their own recovery. Findings support continued study of Tele-AR, which may be an accessible intervention to facilitate recovery in adolescents with concussion.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Tele-Active Rehabilitation for Youth With Concussion: Evidence-Based and Theory-Informed Intervention Development

BACKGROUND

Active rehabilitation involving subsymptom threshold exercise combined with education and support promotes recovery in youth with concussion but is typically delivered in person, which may limit accessibility for families because of a lack of services in their communities or logistical challenges to attending in-person sessions.

OBJECTIVE

This paper describes the evidence-based and theory-informed development of the Tele-Active Rehabilitation (Tele-AR) intervention for pediatric concussion, which was specifically designed for remote service delivery.

METHODS

The intervention was designed by clinician-researchers with experience in pediatric concussion rehabilitation following the Medical Research Council guidance for developing complex interventions. Development involved a critical review of the literature to identify existing evidence, the expansion of the theoretical basis for active rehabilitation, and the modeling of the intervention process and outcomes.

RESULTS

Tele-AR is a 6-week home exercise and education and support program facilitated through weekly videoconferencing appointments with a clinician. Exercise consists of low- to moderate-intensity subsymptom threshold aerobic activity and coordination drills that are individualized to participant needs and interests (prescribed for 3 days per week). Education includes the evidence-supported Concussion & You self-management program, which covers topics related to energy management, nutrition, hydration, sleep hygiene, and return to activity. Elements of self-determination theory are incorporated to support motivation and engagement. We present a logic model describing predicted intervention effects using a biopsychosocial conceptualization of outcomes after concussion.

CONCLUSIONS

The Tele-AR intervention may help to increase access to care that improves recovery and promotes a timely return to activity in youth with concussion. Future research is needed to evaluate the feasibility and efficacy of this approach.

Tele-Active Rehabilitation for adolescents with concussion: a feasibility study

Objectives

Active rehabilitation involving subsymptom threshold exercise and education/support promotes recovery among adolescents with concussion, but is typically delivered in-person, which limits accessibility. This study explored the feasibility of a remotely delivered Tele-Active Rehabilitation (Tele-AR) intervention for adolescents with concussion.

Methods

A precase–postcase series design was used. Three adolescents (ages 14–17 years) experiencing postconcussion symptoms ≥2 weeks postinjury participated with a parent. The Tele-AR intervention was a 6-week programme supervised by a rehabilitation clinician through weekly videoconferencing appointments and included (1) aerobic exercise, (2) coordination drills and (3) comprehensive education and support. Feasibility indicators included rates of recruitment, retention, adherence, as well as adolescent and parent ratings of technology usability using an adapted Telehealth Usability Questionnaire and satisfaction using the Client Satisfaction Questionnaire-8. Prechanges to postchanges in postconcussion symptoms, illness perceptions, and occupational performance and satisfaction were also assessed.

Results

Rates of recruitment (n=3/4) and retention (n=3/3) achieved success criteria. Adherence was high among all participants (77%–100%), and there were no adverse events. Participant ratings of technology usability and satisfaction approached 90%. All participants reported improvements in postconcussion symptoms and illness perception. Clinically significant positive changes were also observed in occupational performance and satisfaction.

Conclusions

The Tele-AR intervention appears feasible in a small group of adolescents with concussion, and positive changes were observed in postconcussion symptoms, illness perception and occupational performance. Further study is warranted to evaluate the efficacy of this approach, which may enable access to care that supports recovery in adolescents with concussion.

176 Did Hand Washing and Use of Personal Protective Equipment (PPE) Reduce Transmission of Surgical Site Infections During the SARS-CoV-2 Pandemic?

Aim

A retrospective case-control study comparing Surgical Site Infections (SSIs) following primary hip and knee arthroplasty before and during the SARS-CoV-2 pandemic across East Sussex NHS Trust (ESHT). The aim of this study was to evaluate whether the government advice relating to increased vigilance surrounding hand hygiene and use of personal protective equipment (PPE) reduced SSIs following elective arthroplasty.

Method

Data was obtained from Public Health England website relating to SSIs following primary hip and knee arthroplasty between April 2019 and March 2020 (pre-pandemic) performed at ESHT and compared to April 2020 to March 2021 (pandemic).

Results

A total of 454 patients underwent a total hip replacement (THR) during the pre-pandemic period with 12 patients developing an SSI (2.6%). Comparatively, during the pandemic period, 146 patients underwent a THR with 4 reporting an SSI (2.7%). A total of 449 patients underwent a total knee replacement (TKR) during the pre-pandemic period with 11 reporting an SSI (2.5%). In contrast, 9 of the 138 patients undergoing a TKR during the pandemic group developed an SSI (6.5%).

Conclusions

As the data shows, there was no significant difference observed between SSIs following THR performed at ESHT prior to and during the pandemic. Surprisingly, there was a 2.6-fold increase in SSI following TKR during the pandemic period compared with pre-pandemic. Both of these findings seemingly reject the null hypothesis that increased vigilance to hand hygiene and use of PPE mandated by the government and echoed by healthcare trusts during this time would reduce transmission of infections.

398 Outcome of Laparoscopic Cholecystectomy in Patients Over 80 Years Old

Background

Gallstone disease is a common cause of morbidity in old patients. Conservative treatment is usually the first line of treatment due to concerns about the risk of surgery. In our study we are trying to assess the outcome of laparoscopic cholecystectomy in patients over 80 years old.

Method

Retrospective cohort study done in a large district general hospital where good number of laparoscopic cholecystectomy is done every year. Main outcome is Mortality, return to theatre and post op ITU admission. Data collected from patients records.

Results

74 patients in total were operated on. 14 operations were done as emergency (during the same inpatient admission). Indication for surgery varied between cholecystitis, pancreatitis and biliary colic. But the main indication in the emergency group was acute cholecystitis. 55 % of the patients had significant medical background with ASA 3. 30 days mortality was 0 in both emergency and elective groups. 2 patients required ITU admission post op, mainly for premorbid status, and both were in the emergency group. There was only one return to theatre in the emergency group for washout. 90% of the elective group patients were done as day case with no post op complications.

Conclusions

Laparoscopic cholecystectomy is safe operation to be done in the elderly population. ITU admission is mainly because of the patient’s co-morbidities so patients should be selected carefully and have proper pre op assessment.

508 The Early Use of Intratympanic Steroid Injections in the Treatment of Labyrinthitis Obliterans – A Case Report

Introduction

Labyrinthitis Obliterans is an inner ear condition characterised by pathological sclerosis and ossification of the membranous labyrinth as a response to inflammatory insult. It is associated with profound sensorineural hearing loss and occasionally dizziness and/or vertigo.In this case report, we describe the use of intratympanic steroid injections in a patient presenting with sudden sensorineural hearing loss (SSNHL) with a radiological diagnosis of Labyrinthitis Obliterans. Whilst many studies suggest the role of oral steroids in SSNHL, there is no current evidence regarding the role of intratympanic steroid injections specifically for the treatment of this condition.

Case Presentation

A 60-year-old gentleman was referred to ENT with a 3-day history of sudden right sided hearing loss. There was no improvement in his Pure Tone Audiometry (PTA) results after 7 days of oral Prednisolone. Subsequently, an MRI Internal Acoustic Meatus showed evidence of right sided Labyrinthitis Obliterans. The patient was initiated on a course of intratympanic Methylprednisolone injections 10 days after initial onset of symptoms. A significant improvement in his baseline hearing of over 60dB was demonstrated after 4 courses of injections over a 3-month period.

Discussion

Our findings reveal that despite a diagnosis of Labyrinthitis Obliterans, the early use of intratympanic steroid injections can significantly improve hearing threshold and quality of life of the patient. The biggest hurdle in the management of Labyrinthitis Obliterans is establishing the diagnosis early and ensuring timely treatment, therefore we would advocate the early use of MRI and early intervention with intratympanic steroid injections.

512 The Management of Aural Foreign Bodies During the COVID-19 Pandemic - MKUH ENT Department Experience

Aim

During the initial wave of the COVID-19 pandemic, ENT UK published a clinical guide on surgical prioritisation which suggested that aural foreign bodies can be removed between one and three months from initial presentation. This case series aims to investigate the impact of leaving aural foreign bodies in situ for a prolonged period of time, including the risk of complications, success rates of subsequent removal attempts and whether foreign bodies can clear themselves without intervention.

Method

Retrospective study of all aural foreign body referrals to the ENT emergency clinic over a 6-month period.

Results

Thirty-four patients were identified. The duration of foreign bodies left in-situ ranged from 1 to 78 days. Four patients suffered from traumatic removal upon initial attempts, however there were no other significant complications. First attempts made by non-ENT specialists (68.8%) all failed and were associated with a high risk of trauma (36.4%). The chances of successful removal on second attempt (28.6%) reduced dramatically when compared to the first attempt (52.9%). Two patients had no foreign body visualised upon second attempt, suggesting it has cleared itself. A total of 7 patients (20.6%) required removal under general anaesthesia.

Conclusions

Due to the unique circumstances of the COVID-19 pandemic, this is the first case series to look specifically at the relationship between duration of aural foreign bodies left in situ for over 30 days from presentation and the risk of complications. Our data suggests that prolonged duration did not increase the incidence of complications.

Building Obstetric Provider Capacity to Address Perinatal Depression Through Online Training

Background: Perinatal depression is common, underdiagnosed, and undertreated. Obstetric providers often do not receive training in perinatal depression, despite being the frontline providers for perinatal individuals. The objective of this study was to develop and pilot test an online training module to assess feasibility, efficacy, and acceptance in improving obstetric providers' knowledge, skills, and practices regarding perinatal depression. Materials and Methods: We designed, developed, and implemented an online, asynchronous, interactive educational module that trains obstetric providers to: (1) know the prevalence and impact of perinatal depression; (2) use validated tools for depression screening; (3) assess for depression; and (4) start and/or refer for treatment. Formative evaluation with five providers, iterative module and question refinement, and a pilot test with pre- and post-test knowledge and self-efficacy questions were conducted. Results: Sixteen obstetric providers averaged a 32% improvement in their pre- to post-test scores (p < 0.01). The average pretest score was 49% (range 20%-70%), and the average post-test score was 81% (range 70%-95%). Provider beliefs (p = 0.01), self-efficacy (p < 0.01), and confidence (p < 0.01) in treating perinatal depression were also significantly increased between pre- and post-test. Average Likert scores on overall training satisfaction were very high post-training completion (4.44 out of 5, with 5 being most positive). Conclusions: The module was feasible and effective at improving provider knowledge of perinatal depression, self-rated confidence, and self-efficacy. Improving the knowledge and skills of obstetric providers regarding depression is a critical part of any intervention aimed to close gaps in care and help ensure that patients receive optimal treatment.

Understanding the Needs of Ontario Educators in Supporting Students With Acquired Brain Injury in the Classroom

BACKGROUND

When a child sustains an acquired brain injury (ABI), the impact extends to significant environments in their life, including school. Educator knowledge of ABI can influence a child's success with academic and social reintegration. An assessment of educator ABI knowledge was conducted to determine what information they require to support school reintegration.

METHODS

A mixed-methods approach included a sampling of educators in a needs assessment survey and workshop. The survey determined levels of educator knowledge regarding ABI in the classroom, and the workshop scoped educator views in the development of a user-driven ABI learning program to enrich their expertise.

RESULTS

Our sample reported being somewhat knowledgeable about ABI and the impact on students. There were no differences based on respondents' educational role. Teachers reported having minimal and inadequate supports for students following ABI during school transitions, feeling unprepared to assist students during these transitions, and that families also appeared unprepared for school reintegration following ABI. The workshop identified the need for a 2-part educational course.

CONCLUSIONS

Supportive school environments are essential for the reintegration of students following ABI. This study identified educators' needs for ABI knowledge and resources to support their existing expertise.

Feasibility of magnetic resonance guided radiotherapy for the treatment of bladder cancer

Whole bladder magnetic resonance image-guided radiotherapy using the 1.5 Telsa MR-linac is feasible. Full online adaptive planning workflow based on the anatomy seen at each fraction was performed. This was delivered within 45 min. Intra-fraction bladder filling did not compromise target coverage. Patients reported acceptable tolerance of treatment.

Rehabilitation interventions in Rett syndrome: a scoping review

AIM

To summarize existing interventions and their outcomes in Rett syndrome (RTT) rehabilitation and identify gaps in the literature.

METHOD

Five databases (Ovid MEDLINE, Ovid Embase Classic, Ovid PsycINFO, EBSCO CINAHL Plus, and ProQuest ERIC) were systematically searched up to 23rd July 2018 for studies describing rehabilitation interventions. Data on study participants, design, and outcomes were extracted.

RESULTS

Sixty-two articles were included in the final review. Evidence consistently demonstrated that females with RTT can improve their gross motor, fine motor, and communicative skills with rehabilitation. All 11 interventions targeting gross motor function, namely ambulation, achieved functional improvements. Twenty of 24 articles describing fine motor rehabilitation studies succeeded in decreasing stereotypies, improving functional hand use, and/or reducing self-injurious behaviors. Twenty-one of 22 studies describing communication interventions succeeded in training choice-making, communicative language, or socialization behavior. Other key findings include the positive interplay between physical and communicative rehabilitation outcomes, and the ability of females with RTT to improve their cognitive abilities during intervention.

INTERPRETATION

Rehabilitation can impact the daily lives of females with RTT and their caregivers in clinically meaningful ways.

SAT0615-HPR FACTORS ASSOCIATED WITH PATIENT ACTIVATION IN PEOPLE WITH RHEUMATIC CONDITIONS

Background:

Patient activation describes the skills, abilities and confidence someone uses to actively manage their health. Patient activation abilities in rheumatology are unclear, and there is little knowledge about factors that explain variation in patient activation. Therefore, understanding these factors can contribute to the development of appropriate, rheumatology-specific interventions targeting activation. The Patient Activation Measure (PAM) captures patient activation and provides people with both a score and a level to describe how able they are to actively manage their health.

Objectives:

To explore longitudinal changes to patient activation (measured using the PAM) (Hibbardet al., 2005), and the PAM’s associations with related constructs (including self-efficacy, health literacy and health beliefs) in a sample of participants with inflammatory arthritis.

Methods:

A postal survey was administered at two time points that were nine months apart. This survey captured the PAM and a range of clinical, demographic and psychosocial variables in a sample of rheumatology patients from 6 NHS sites in England. The measures included in the survey had been selected based on both theory and prior qualitative research and the survey pack was designed in collaboration with a patient partner. Following data collection, candidate variables for a multiple regression analysis were initially identified using univariable analysis. These variables were included in a forced entry multiple regression at each time point, and the variables that were statistically significant contributors at a 0.1 level were included in the final models. Changes to PAM scores over time were investigated using a Wilcoxon matched-pair signed rank test.

Results:

251 participants completed the first survey and 154 participants completed both full surveys. Self-efficacy, illness beliefs, health literacy and health locus of control were consistently associated with variance in PAM scores. The first three factors were also predictive of variance in PAM levels. With the 154 participants who fully completed both surveys, there was a statistically significant difference in participants’ PAM scores between the two surveys.

Conclusion:

The findings suggest factors that may be targets for interventions that aim to increase patient activation. The changes to PAM scores across the data collection period also suggest that when using the PAM as a clinical tool, healthcare professionals would benefit from incorporating regular reviews and preparations for any increases or reductions in patient activation.

References:

[1]Hibbard, J.H., Mahoney, E.R., Stockard, J. and Tusler, M. (2005) Development and testing of a short form of the patient activation measure.Health Services Research. 40 (6 I), pp. 1918–1930.

Disclosure of Interests:

Bethan Jones Speakers bureau: Honorarium for Lilly in their work with the British Society of Rheumatology for the delivery of 2 webinars due to be held on 30th January 2020., Andrew Hunt: None declared, Sarah Hewlett Grant/research support from: Received independent learning grant from Pfizer for the STRIDE project. However, the work has been completed and the grant closed, Diana Harcourt: None declared, Emma Dures Grant/research support from: Independent Learning Grant from Pfizer, combined funding for a research fellow from Celgene, Abbvie and Novartis, Paid instructor for: A fee from Novartis to deliver training to nurses.

Magnetic resonance imaging sequence evaluation of an MR Linac system; early clinical experience

OBJECTIVES

To systematically identify the preferred magnetic resonance imaging (MRI) sequences following volunteer imaging on a 1.5 Tesla (T) MR-Linear Accelerator (MR Linac) for future protocol development.

METHODS

Non-patient volunteers were recruited to a Research and Ethics committee approved prospective MR-only imaging study on a 1.5T MR Linac system. Volunteers attended 1-3 imaging sessions that included a combination of mDixon, T1w, T2w sequences using 2-dimensional (2D) and 3-dimensional (3D) acquisitions. Each sequence was acquired over 2-7 minutes and reviewed by a panel of 3 observers to evaluate image quality using a visual grading analysis based on a 4-point Likert scale. Sequences were acquired and modified iteratively until deemed fit for purpose (online image matching or re-planning) and all observers agreed they were suitable in 3 volunteers.

RESULTS

26 volunteers underwent 31 imaging sessions of six general anatomical regions. Images were acquired in one or two of six general anatomical regions: male pelvis (n = 9), female pelvis (n = 4), chestwall/breast (n = 5), lung/oesophagus (n = 5), abdomen (n = 3) and head and neck (n = 5). Images were acquired using a pre-defined exam-card that on average, included six sequences (range 2-10), with a maximum scan time of approximately one hour. The majority of observers preferred T2-weighted sequences. The thorax teams were the only groups to prefer T1-weighted imaging.

CONCLUSIONS

An iterative process identified sequence agreement in all anatomical regions. These sequences will now be evaluated in patient volunteers.

ADVANCES IN KNOWLEDGE

This manuscript is the first publication sharing the results of the first systematic selection of MRI sequences for use in on-board MRI-guided radiotherapy by end-users (therapeutic radiographers and clinical oncologists) in healthy volunteers.

Sepsis: an overview of the signs, symptoms, diagnosis, treatment and pathophysiology

Sepsis is a common phenomenon surrounded by uncertainty and misunderstanding. The urgency for treatment is complicated by the vagueness of signs and symptoms and lack of a conclusive diagnostic test. This article unpicks the signs and symptoms of sepsis with guidance for emergency department nurses who are responsible for assessing patients with potential sepsis. The article also relates monitoring, investigation and treatment expectations to the underlying pathophysiology and refers to the individual and global implications of the condition.

High Performance Bi-2212 Round Wires Made with Recent Powders

Multifilamentary Bi₂Sr₂CaCu₂O_x (Bi-2212) wire made by the powder-in-tube technique is the only high temperature superconductor made in the round shape preferred by magnet builders. The critical current density (J _C ) of Bi-2212 round wire was improved significantly by the development of overpressure heat treatment in the past few years. Bi-2212 wire is commercially available in multiple architectures and kilometer-long pieces and a very promising conductor for very high field NMR and accelerator magnets. We studied the effects of precursor powder and heat treatment conditions on the superconducting properties and microstructure of recent Bi-2212 wires. Short samples of recent wire with optimized overpressure processing showed J _C (4.2 K, 15 T) = 6640 A/mm² and J _C (4.2 K, 30 T) = 4670 A/mm², which correspond to engineering critical current densities J _E (4.2 K, 15 T) = 1320 A/mm² and J _E (4.2 K, 30 T) = 930 A/mm².

Implementing a function-based cognitive strategy intervention within inter-professional stroke rehabilitation teams: Changes in provider knowledge, self-efficacy and practice

BACKGROUND

The Cognitive Orientation to daily Occupational Performance (CO-OP) approach is a complex rehabilitation intervention in which clients are taught to use problem-solving cognitive strategies to acquire personally-meaningful functional skills, and health care providers are required to shift control regarding treatment goals and intervention strategies to their clients. A multi-faceted, supported, knowledge translation (KT) initiative was targeted at the implementation of CO-OP in inpatient stroke rehabilitation teams at five freestanding rehabilitation hospitals. The study objective was to estimate changes in rehabilitation clinicians' knowledge, self-efficacy, and practice related to implementing CO-OP.

METHODS

A single arm pre-post and 6-month follow up study was conducted. CO-OP KT consisted of a 2-day workshop, 4 months of implementation support, a consolidation session, and infrastructure support. In addition, a sustainability plan was implemented. Consistent with CO-OP principles, teams were given control over specific implementation goals and strategies. Multiple choice questions (MCQ) were used to assess knowledge. A self-efficacy questionnaire with 3 subscales (Promoting Cognitive Strategy Use, PCSU; Client-Focused Therapy, CFT; Top-Down Assessment and Treatment, TDAT) was developed for the study. Medical record audits were used to investigate practice change. Data analysis for knowledge and self-efficacy utilized mixed effects models. Medical record audits were analyzed with frequency counts and chi-squares.

RESULTS

Sixty-five health care providers consisting mainly of occupational and physical therapists entered the study. Mixed effects models revealed intervention effects for MCQs, CFT, and PCSU at post intervention and follow-up, but no effect on TDAT. No charts showed any evidence of CO-OP use at baseline, compared to 8/40 (20%) post intervention. Post intervention there was a trend towards reduction in impairment goals and significantly more component goals were set (z = 2.7, p = .007).

Adaptive Radiotherapy Enabled by MRI Guidance

Adaptive radiotherapy (ART) strategies systematically monitor variations in target and neighbouring structures to inform treatment-plan modification during radiotherapy. This is necessary because a single plan designed before treatment is insufficient to capture the actual dose delivered to the target and adjacent critical structures during the course of radiotherapy. Magnetic resonance imaging (MRI) provides superior soft-tissue image contrast over current standard X-ray-based technologies without additional radiation exposure. With integrated MRI and radiotherapy platforms permitting motion monitoring during treatment delivery, it is possible that adaption can be informed by real-time anatomical imaging. This allows greater treatment accuracy in terms of dose delivered to target with smaller, individualised treatment margins. The use of functional MRI sequences would permit ART to be informed by imaging biomarkers, so allowing both personalised geometric and biological adaption. In this review, we discuss ART solutions enabled by MRI guidance and its potential gains for our patients across tumour types.

Impact of previous hepatitis B infection on the clinical outcomes from chronic hepatitis C? A population-level analysis

Chronic coinfection with hepatitis C virus (HCV) and hepatitis B virus (HBV) is associated with adverse liver outcomes. The clinical impact of previous HBV infection on liver disease in HCV infection is unknown. We aimed at determining any association of previous HBV infection with liver outcomes using antibodies to the hepatitis B core antigen (HBcAb) positivity as a marker of exposure. The Scottish Hepatitis C Clinical Database containing data for all patients attending HCV clinics in participating health boards was linked to the HBV diagnostic registry and mortality data from Information Services Division, Scotland. Survival analyses with competing risks were constructed for time from the first appointment to decompensated cirrhosis, hepatocellular carcinoma (HCC) and liver-related mortality. Records of 8513 chronic HCV patients were included in the analyses (87 HBcAb positive and HBV surface antigen [HBsAg] positive, 1577 HBcAb positive and HBsAg negative, and 6849 HBcAb negative). Multivariate cause-specific proportional hazards models showed previous HBV infection (HBcAb positive and HBsAg negative) significantly increased the risks of decompensated cirrhosis (hazard ratio [HR]: 1.29, 95% CI: 1.01-1.65) and HCC (HR: 1.64, 95% CI: 1.09-2.49), but not liver-related death (HR: 1.02, 95% CI: 0.80-1.30). This is the largest study to date showing an association between previous HBV infection and certain adverse liver outcomes in HCV infection. Our analyses add significantly to evidence which suggests that HBV infection adversely affects liver health despite apparent clearance. This has important implications for HBV vaccination policy and indications for prioritization of HCV therapy.

Postural Stability in Healthy Child and Youth Athletes: The Effect of Age, Sex, and Concussion-Related Factors on Performance

Background:

Postural stability plays a key role in sport performance, especially after concussion. Specific to healthy child and youth athletes, little is known about the influence development and sex may have on postural stability while considering other subjective clinical measures used in baseline/preinjury concussion assessment. This study aims to describe age- and sex-based trends in postural stability in uninjured child and youth athletes at baseline while accounting for concussion-related factors.

Hypotheses:

(1) Postural stability performance will improve with age, (2) females will display better postural stability compared to males, and (3) concussion-like symptoms will affect postural stability performance in healthy children and youth.

Study Design:

Cross-sectional study.

Level of Evidence:

Level 3.

Methods:

This study comprised 889 healthy/uninjured child and youth athletes (54% female, 46% male) between the ages of 9 and 18 years old. Participants completed preseason baseline testing, which included demographic information (age, sex, concussion history), self-report of concussion-like symptoms (Post-Concussion Symptom Inventory [PCSI]–Child and PCSI-Youth), and measures of postural stability (BioSway; Biodex Medical Systems). Two versions of the PCSI were used (PCSI-C, 9- to 12-year-olds; PCSI-Y, 13- to 18-year-olds). Postural stability was assessed via sway index under 4 sway conditions of increasing difficulty by removing visual and proprioceptive cues.

Results:

In children aged 9 to 12 years old, there were significant age- (P < 0.05) and sex-based effects (P < 0.05) on postural stability. Performance improved with age, and girls performed better than boys. For youth ages 13 to 18 years old, postural stability also improved with age (P < 0.05). In both child and youth subgroups, postural stability worsened with increasing concussion-like symptoms (P < 0.05).

Conclusion:

There are developmental and baseline symptom trends regarding postural stability performance.

Clinical Relevance:

These findings provide a preliminary foundation for postconcussion comparisons and highlight the need for a multimodal approach in assessing and understanding physical measures such as postural stability.

Latino Health Behavior: An Exploratory Analysis of Health Risk and Health Protective Factors in a Community Sample

BACKGROUND

Demographic and cultural factors have been found to affect health behaviors in Latinos in both positive and negative ways, but few studies have examined the impact of culture and adherence to machismo norms on health behaviors in a mixed gender community sample of Latinos. Of particular interest was if positive (caballerismo) or negative aspects of machismo would affect Latino health behaviors.

METHODS

A paper survey was given to a community sample of Latinos in northern Utah to explore the variables that affect both health promoting and health risking behaviors in this cross-sectional study (final N = 144 participants).

RESULTS

Life satisfaction, self-reported health, health insurance status, language preference, and gender were significantly related to overall health score. Surprisingly, the cultural variables of fatalism, machismo, and caballerismo were nonsignificant in all analyses.

CONCLUSION

Access to health care mediated by health insurance and self-reported health status may be the most effective way to encourage Latinos to engage in protective health behaviors.

Exposure to Sodium Valproate during Pregnancy: Facial Features and Signs of Autism

BACKGROUND

Valproic acid (VPA) is the most teratogenic anticonvulsant drug in clinical use today. Children exposed prenatally to VPA have previously been shown to have dysmorphic craniofacial features, identified subjectively but not by anthropometric methods. Exposure to VPA has also been associated with an increased frequency of autism spectrum disorder (ASD). An increased cephalic index (the ratio of the cranial lateral width to the cranial anterior-posterior length) has been observed in children with ASD.

METHODS

Forty-seven children exposed to VPA during the first trimester of pregnancy were evaluated for dysmorphic facial features, identified subjectively and by measurements. Each VPA-exposed child was evaluated for ASD using the Social Communication Questionnaire, Autism Diagnostic Interview-Revised, and Autism Diagnostic Observation Schedule. The same physical examination was carried out on an unexposed comparison group of 126 children. The unexposed children also had testing for cognitive performance by the Wechsler Intelligence Scale for Children.

RESULTS

Several dysmorphic craniofacial features, including telecanthus, wide philtrum, and increased length of the upper lip were identified subjectively. Anthropometric measurements confirmed the increased intercanthal distance and documented additional findings, including an increased cephalic index and decreased head circumference/height index. There were no differences between the craniofacial features of VPA-exposed children with and without ASD.

CONCLUSION

An increased frequency of dysmorphic craniofacial features was identified in children exposed to VPA during the first trimester of pregnancy. The most consistent finding was a larger cephalic index, which indicates a disproportion of increased width of the skull relative to the shortened anterior-posterior length. Birth Defects Research 109:1134-1143, 2017. © 2017 Wiley Periodicals, Inc.

Does the EarPopper(®) device improve hearing outcomes in children with persistent otitis media with effusion? A randomised single-blinded controlled trial

OBJECTIVE

To provide an independent evaluation of the efficacy and safety of the EarPopper(®) in improving hearing outcomes in children with otitis media with effusion (OME) and reducing the ventilation tube insertion rate.

STUDY DESIGN

Randomised single-blinded controlled trial.

SETTING

The Ear Nose and Throat Department of a district general hospital (Heatherwood and Wexham Park).

PARTICIPANTS AND METHODS

Twenty-nine children aged between 4 and 11 years diagnosed with persistent OME lasting at least 3 months with an average hearing of 25 dBHL or worse in the better ear were randomised to a treatment or control group for 7 weeks using random computer-generated codes. Syndromic children, children with developmental delay, previous grommets and cleft palate were excluded. The audiologists were blinded at the final post-treatment audiogram.

RESULTS

After the seven-week period, the mean improvement in air conduction across all frequencies was 10.9 dBHL in the treatment group (P < 0.001) and 3.6 dBHL in the control group (P = 0.201). At every frequency, the treatment group had larger improvements in air conduction, the largest being at 4 kHz where the mean air conduction in both ears improved by 14.8 dBHL. Compliance with the EarPopper(®) was over 90%, the only side-effect reported being discomfort in the ears immediately after use which resolved and did not affect compliance. The ventilation tube insertion rate was 53.3% in the treatment group and 78.6% in the control group. Median follow-up time for all patients is 47.7 months.

CONCLUSION

Our study shows that the EarPopper(®) is a safe, effective treatment option for children with hearing loss from persistent OME, and it reduces the rate of ventilation tube insertion. More studies with larger sample sizes are required to support our findings.

Pain experience, expression and coping in boys and young men with Duchenne Muscular Dystrophy - A pilot study using mixed methods

There is limited research exploring the pain experience of boys and young men with Duchenne Muscular Dystrophy.

METHODS

We conducted a mixed-methods pilot study to assess the feasibility of using particular measures of pain, pain coping and quality of life within semi-structured interviews with boys and young men with Duchenne Muscular Dystrophy and a postal survey of their parents. Non-probability, convenience sampling was used.

RESULTS

Twelve young men aged 11-21 years (median 15 years), three of whom were still ambulant, and their parents/guardians were recruited. The measures used were acceptable to the young men and demonstrated potential to provide useful data. Two-thirds of young men suffered from significant daily pain which was associated with reduced quality of life. Pain complaints were largely kept within the family. Young men's pain-coping strategies were limited by their restricted physical abilities. Statistical power based on these preliminary results suggests a study of approximately 50 boys/young men which appears feasible.

CONCLUSIONS

Further study is needed to explore acceptable and effective methods of pain management in this population and ways of enhancing pain-coping strategies. In clinical practice, assessment of pains and discomfort should form part of all routine consultations.

Measurement of the differential cross section for top quark pair production in pp collisions at [Formula: see text]

The normalized differential cross section for top quark pair ([Formula: see text]) production is measured in pp collisions at a centre-of-mass energy of 8[Formula: see text] at the CERN LHC using the CMS detector in data corresponding to an integrated luminosity of 19.7[Formula: see text]. The measurements are performed in the lepton[Formula: see text]jets ([Formula: see text][Formula: see text]jets) and in the dilepton ([Formula: see text], [Formula: see text], and [Formula: see text]) decay channels. The [Formula: see text] cross section is measured as a function of the kinematic properties of the charged leptons, the jets associated to b quarks, the top quarks, and the [Formula: see text] system. The data are compared with several predictions from perturbative quantum chromodynamic up to approximate next-to-next-to-leading-order precision. No significant deviations are observed relative to the standard model predictions.

A multi-faceted knowledge translation approach to support persons with stroke and cognitive impairment: evaluation protocol

BACKGROUND

Patients with cognitive impairments following a stroke are often denied access to inpatient rehabilitation. The few patients with cognitive impairment admitted to rehabilitation generally receive services based on outdated impairment-reduction models, rather than recommended function-based approaches. Both reduced access to rehabilitation and the knowledge-to-practice gap stem from a reported lack of skills and knowledge regarding cognitive rehabilitation on the part of inpatient rehabilitation team members. To address these issues, a multi-faceted knowledge translation (KT) initiative will be implemented and evaluated. It will be targeted specifically at the inter-professional application of the cognitive orientation to daily occupational performance (CO-OP). CO-OP training combined with KT support is called CO-OP KT. The long-term objective of CO-OP KT is to optimize functional outcomes for individuals with stroke and cognitive impairments. Three research questions are posed: 1. Is the implementation of CO-OP KT associated with a change in the proportion of patients with cognitive impairment following a stroke accepted to inpatient rehabilitation? 2. Is the implementation of CO-OP KT associated with a change in rehabilitation clinicians' practice, knowledge, and self-efficacy related to implementing the CO-OP approach, immediately following and 1 year later? 3. Is CO-OP KT associated with changes in activity, participation, and self-efficacy to perform daily activities in patients with cognitive impairment following stroke at discharge from inpatient rehabilitation and at 1-, 3-, and 6-month follow-ups?

METHODS/DESIGN

Three interrelated studies will be conducted. Study 1 will be a quasi-experimental, interrupted time series design measuring monthly summaries of stroke unit level data. Study 2, which relates to changes in health care professional practice and self-efficacy, will be a single group pre-post evaluation design incorporating chart audits and a self-report survey. Study 3 will assess patient functional outcomes using a non-randomized design with historical controls. Assessments will occur during admission and discharge from rehabilitation and at 1, 3, and 6 months following discharge from rehabilitation.

DISCUSSION

This project will advance knowledge about the degree to which the implementation of a supported KT initiative can sustainably change health system, knowledge, and patient outcomes.

Randomized controlled trial of asthma risk with paracetamol use in infancy--a feasibility study

BACKGROUND

There is non-experimental evidence that paracetamol (acetaminophen) use may increase the risk of developing asthma. However, numerous methodological issues need to be resolved before undertaking a randomized controlled trial to investigate this hypothesis.

OBJECTIVE

To establish the feasibility of a randomized controlled trial of liberal paracetamol as usually given by parents/guardians vs. a comparator (restricted paracetamol in accordance with WHO guidelines, ibuprofen or placebo), and childhood asthma risk.

METHODS

Questionnaires were completed by parents/guardians of infants admitted to Wellington Hospital with bronchiolitis to assess views about comparator treatments. Subsequently, infants of parents/guardians who provided informed consent were randomized to restricted or liberal paracetamol use for 3 months with paracetamol use recorded.

RESULTS

Of 120 eligible participants, 72 (60%) parents/guardians completed the questionnaire. Ibuprofen, restricted paracetamol and placebo were acceptable to 42 (58%), 29 (40%) and 9 (12%) parents/guardians, respectively. 36 (30%) infants were randomized to restricted or liberal paracetamol. Paracetamol use was greater for the liberal vs. restricted group for reported [Hodges-Lehmann estimator of difference 0.94 mg/kg/day (95% CI 0.2-3.52), P = 0.02] and measured use [Hodges-Lehmann estimator of difference 2.11 mg/kg/day (95% CI 0.9-4.18), P = 0.004]. The median reported and measured use of paracetamol was 2.0-fold and 3.5-fold greater in the liberal vs. restricted group.

CONCLUSIONS AND CLINICAL RELEVANCE

Although separation in paracetamol dosing is likely to be achieved with a liberal vs. restricted paracetamol regime, ibuprofen is the preferred comparator treatment in the proposed RCT of paracetamol use and risk of asthma in childhood.

Inhalation of Polychlorinated Biphenyls (PCB) Produces Hyperactivity in Rats

Attention deficit hyperactivity disorder (ADHD) is a serious behavioral syndrome seen in children, and more common in males than females. There is increasing evidence that prenatal and/or early life exposure to persistent organic pollutants (POP) such as polychlorinated biphenyls (PCB) is associated with increased risk of ADHD occurrence. While PCB exposure is usually attributed to ingestion of contaminated food, recent reports of elevated PCB concentrations in indoor air, especially in schools, raised concern regarding inhalation as an important route of exposure to PCB with consequent effects on neurobehavior. The effects of exposure to air contaminated with Aroclor 1248 or contaminated sediment (SED) from the St. Lawrence River were examined on operant behavior of male and female Sprague-Dawley rats. Data showed that relative to controls, vapor-phase inhalation of PCB, whether from blowing air over Aroclor 1248 or from blowing air over sediment contaminated with PCB, resulted in hyperactivity and impatience in rats, more pronounced in males than females. These results are consistent with the hypothesis that inhalation of PCB may contribute to behavioral abnormalities in children.

‘Why does it happen like this?’ Consulting with users and providers prior to an evaluation of services for children with life limiting conditions and their families

Children with life limiting conditions and their families have complex needs. Evaluations must consider their views and perspectives to ensure care is relevant, appropriate and acceptable. We consulted with children, young people, their parents and local professionals to gain a more informed picture of issues affecting them prior to preparing a bid to evaluate services in the area. Multiple methods included focus groups, face-to-face and telephone interviews and participatory activities. Recordings and products from activities were analysed for content to identify areas of relevance and concern. An overarching theme from parents was 'Why does it happen like this?' Services did not seem designed to meet their needs. Whilst children and young people expressed ideas related to quality of environment, services and social life, professionals focused on ways of meeting the families' needs. The theme that linked families' concerns with those of professionals was 'assessing individual needs'. Two questions to be addressed by the evaluation are (1) to what extent are services designed to meet the needs of children and families and (2) to what extent are children, young people and their families consulted about what they need? Consultations with families and service providers encouraged us to continue their involvement as partners in the evaluation.