A26 DECONSTRUCTING DISTRESS: STAKEHOLDER ENGAGEMENT FOR EVIDENCE-BASED, PATIENT-CENTERED INTERVENTIONS FOR THE MANAGEMENT OF IBD-ASSOCIATED PSYCHOLOGICAL DISTRESS

Background

The growing prevalence of Inflammatory Bowel Disease (IBD) along with increasing complexity of providing high-quality, patient-centered care within a resource-constrained healthcare environment presents a major challenge. IBD-related psychological distress (IBD-PD) is the emotional impact of IBD and is associated with mental health disorders, increased disease severity, and premature mortality. With estimates of nearly 90% of IBD patients experiencing PD, the inability to provide high-quality, person-centered care for IBD-PD that is proportionate to clinical need is a significant care gap in the Canadian healthcare system.

Aims

To generate stakeholder-derived data to inform the design and development of stepped-intensity, cognitive behavioral therapy-based interventions for IBD-PD using evidence-based, patient–centered interventions and implementation strategies.

Methods

Virtual semi-structured interviews were conducted from September to October 2021. The interview guide was developed iteratively by researchers, IBD care providers, and patient research partners and guided by the COM-B Model of Behaviour and the Theoretical Domains Framework. Questions assessed perceptions, experiences, barriers, and facilitators to accessing IBD-PD care. Adults diagnosed with IBD were recruited from academic centers across Canada. Interviews were co-facilitated by a researcher and patient research partner, audio recorded, and transcribed. Using thematic analysis, codes were generated to identify themes using an inductive approach.

Results

As of October 2021, six interviews have been completed, with data collection ongoing. The mean participant age was 34.3 years (range 21–55 years) with 100% of respondents being female. The majority of participants worked full time (4/6, 67%) and all had completed at least high school. Diagnoses of Crohn’s Disease (3/6, 50%) and ulcerative colitis (3/6, 50%) were evenly distributed. Thematic analyses identified five major themes: 1) Lack of holistic care and acknowledgement of IBD-PD; 2) System-level and financial barriers to psychological support; 3) Lack of psychological support from providers with an understanding of IBD; 4) Preference for individualized virtual-based support; 5) Heavy reliance on informal support structures (caregivers) due to lack of access to formal psychological support.

Conclusions

As part of human-centered design, stakeholder engagement is key to understanding behavioral, social, attitudinal, and environmental barriers and facilitators for accessing IBD-PD care. Interviews are ongoing and specific intervention functions will be defined and incorporated into patient-centered implementation strategies.

Funding Agencies

None

Real world experience with heart failure risk status generated by cardiac resynchronisation therapy defibrillators: high heart failure risk status incidence, causes and timing of remote transmissions

Background

Proactive patient monitoring is of paramount importance in effective management of heart failure (HF) patients. Cardiac implantable electronic devices (CIEDs) used in HF patients are able to derive long-term trends in physiologic parameters and provide timely warning to clinicians. Little is known, however, on the real-world experience with device-generated HF risk-stratifying algorithms.

Purpose

Heart Failure Risk Score (HFRS) takes into account nine parameters and is calculated automatically based on long-term clinical trends. Remote transmissions provide information on the risk of HF event in next 30 days categorized as low, medium or high based on a maximum daily risk status in prior 30 days. We aimed to evaluate the ability of HFRS to alert HF specialists on the actual HF risk status.

Methods

The prospective registry included all patients with CIEDs featuring integrated Heart Failure Risk Score (HFRS) followed via Medtronic CareLink remote monitoring system and enabled for Co-management (CM) from May 2015 to August 2019 in a tertiary centre. High HFRS does not trigger automatic alert transmission. Study follow-up spanned between start of CM and last transmission in 2019. Inclusion criteria were CRT-D in situ, active Home Monitor, switched on OptiVol 2.0 remote alert and transmission data available on CareLink following study period completion. Transmissions were scheduled 3-monthly.

Results

Out of 229 consecutive patients, 132 met study criteria. Mean age was 74±10 years, 18% were female. Median follow-up duration was 2.7 years (IQR 1.3). Total number of transmissions was 2652, median per patient was 18 (IQR 13); scheduled, unscheduled and care alerts constituted 42%, 44% and 14%, respectively. One third of transmissions were automatically sent for CM review. There were 398 high HFRS episodes. OptiVol fluid index was below the threshold throughout 128 (32%) episodes. Missed episodes (not transmitted within 30 days from the final day of high HFRS) amounted to 130 (33%) and the reasons behind this included OptiVol alerting before the first day of high HFRS or persistently elevated when HFRS changed from low/medium to high (52%), low OptiVol index during the episode (38%) or other (10%). Median duration of high HFRS was 7 days (IQR 12, range, 1–187). Among timely picked-up high HFRS episodes, 38% were transmitted during the relevant episode and 62% afterwards with median delay of 10 days (IQR 15) from the last day of high HFRS; 21% of transmissions showing high HFRS were not highlighted for CM review which correlated with low OptiVol index, P<0.001. The factors contributing to high HFRS included: raised OptiVol (60%), patient activity (83%), AT/AF (46%), ventricular rate (VR) during AF (6%), % of VP (40%), shocks (2%), treated VT/VF (2%), night VR (72%) and HR variability (34%).

Conclusions

In a real-world clinical setting high HFRS was frequently under-reported. The investigation into clinical implications is warranted.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Our department has benefited from unrestricted grants from Boston Scientific and Medtronic Inc during the last 5 years.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Recording of electric signal passing through a pylon in direct skeletal attachment of leg prostheses with neuromuscular control

Direct recordings were made of electrical signals emanating from the muscles in a rabbit's residuum. The signals were transmitted via wires attached on one end to the muscles, and on the other to an external recording system. The cable was held in a titanium tube inside a pylon that had been transcutaneously implanted into the residuum's bone. The tube was surrounded by porous titanium cladding to enhance its bond with the bone and with the skin of the residuum. This study was the first known attempt to merge the technology of direct skeletal attachment of limb prostheses with the technology of neuromuscular control of prostheses, providing a safe and reliable passage of the electrical signal from the muscles inside the residuum to the outside recording system.

Deliberate Self-Harm (DSH): a follow-up study of Irish children

This study aimed to look at rates of repetition in children presenting with Deliberate Self-Harm (DSH) to a paediatric A&E department. Children presenting with DSH to a paediatric A&E between 2000 and 2005 were invited to participate in the study. Telephone interviews collected information on demographic details and mental health functioning, including repetition of DSH. Data was obtained from 39 parents and 10 children (31 girls and 8 boys, mean age 15) 1 in 5 females (20%) had made a repeat attempt of DSH and 1 in 10 (10%) had repeated more than once. No males repeated self-harm. On going parental concern rather than clinician risk assessment at index episode predicted subsequent DSH. Given the poor predictive value of clinician risk assessment, all attempts of DSH must be taken seriously, especially those associated with ongoing parental concern.

Factors influencing relapse during a 2-year follow-up of first-episode psychosis in a specialized early intervention service

BACKGROUND

Differential association of risk factors associated with relapse following treatment of first-episode psychosis (FEP) have not been studied adequately, especially for patients treated in specialized early intervention (SEI) services, where some of the usual risk factors may be ameliorated.

METHOD

Consecutive FEP patients treated in an SEI service over a 4-year period were evaluated for relapse during a 2-year follow-up. Relapse was based on ratings on the Scale for Assessment of Positive Symptoms (SAPS) and weekly ratings based on the Life Chart Schedule (LCS). Predictor variables included gender, duration of untreated psychosis (DUP), total duration of untreated illness (DUI), age of onset, pre-morbid adjustment, co-morbid diagnosis of substance abuse during follow-up and adherence to medication. Univariate analyses were followed by logistic regression for rate of relapse and survival analysis with the Cox proportional-hazards regression model for time to relapse as the dependent variables.

RESULTS

Of the 189 eligible patients, 145 achieved remission of positive symptoms. A high rate of medication adherence (85%) and relatively low relapse rates (29.7%) were observed over the 2-year follow-up. A higher relapse rate was associated with a co-morbid diagnosis of substance abuse assessed during the follow-up period [odds ratio (OR) 2.84, 95% confidence interval (CI) 1.24-6.51]. The length of time to relapse was not associated with any single predictor.

CONCLUSIONS

Specialized treatment of substance abuse may be necessary to further reduce risk of relapse even after improving adherence to medication.

Diagnostic utility of laboratory tests in septic arthritis

BACKGROUND

Septic arthritis remains a challenging diagnosis in which the doctor often relies on laboratory tests.

OBJECTIVE

To examine the diagnostic utility of three ancillary tests--namely, white blood cells (WBC), erythrocyte sedimentation rate (ESR) and the WBC in the joint fluid (jWBC)--using likelihood ratios (LRs) and receiver operating characteristic (ROC) curves.

METHODS

This was a retrospective cohort study at the Jacobi Medical Center. Medical charts of patients who had undergone arthrocentesis were included. Patients who had "dry taps" were excluded from the study. Patients were considered to have septic arthritis if they had a positive arthrocentesis culture or operative findings. The primary outcomes of this study were the sensitivities, specificities, LR(+) and LR(-) values of the laboratory tests for septic arthritis. The performance characteristics of the laboratory tests were analysed using ROC curves.

RESULTS

156 patients were enrolled, 16 (10%) had septic arthritis. The sensitivities for WBC, ESR and jWBC were 0.75, 0.75 and 0.50, and the specificities were 0.55, 0.11 and 0.88, respectively. The LR(+) values were 1.7, 0.84 and 4.0, and the LR(-) values were 0.46, 2.4 and 0.57, respectively. In ROC curve analysis, jWBC was the best test (area under the curve (AUC) 0.75, 95% confidence interval (CI) 0.58 to 0.92), followed by WBC (AUC 0.69, 95% CI 0.57 to 0.80) and ESR (AUC 0.55, 95% CI 0.37 to 0.74). A cut-off of jWBC = 17 500 maximised sensitivity and specificity on the ROC curve.

CONCLUSIONS

jWBC was the best diagnostic test for septic arthritis, WBC and ESR were poor tests. However, no test was diagnostic, and the clinician must be careful with patients with a potential septic joint.

Correlation of low-barrier hydrogen bonding and oxyanion binding in transition state analogue complexes of chymotrypsin

The structures of the hemiketal adducts of Ser 195 in chymotrypsin with N-acetyl-L-leucyl-L-phenylalanyl trifluoromethyl ketone (AcLF-CF3) and N-acetyl-L-phenylalanyl trifluoromethyl ketone (AcF-CF3) were determined to 1.4-1.5 A by X-ray crystallography. The structures confirm those previously reported at 1.8-2.1 A [Brady, K., Wei, A., Ringe, D., and Abeles, R. H. (1990) Biochemistry 29, 7600-7607]. The 2.6 A spacings between Ndelta1 of His 57 and Odelta1 of Asp 102 are confirmed at 1.3 A resolution, consistent with the low-barrier hydrogen bonds (LBHBs) between His 57 and Asp 102 postulated on the basis of spectroscopy and deuterium isotope effects. The X-ray crystal structure of the hemiacetal adduct between Ser 195 of chymotrypsin and N-acetyl-L-leucyl-L-phenylalanal (AcLF-CHO) has also been determined at pH 7.0. The structure is similar to the AcLF-CF3 adduct, except for the presence of two epimeric adducts in the R- and S-configurations at the hemiacetal carbons. In the (R)-hemiacetal, oxygen is hydrogen bonded to His 57, not the oxyanion site. On the basis of the downfield 1H NMR spectrum in solution, His 57 is not protonated at Nepsilon2, and there is no LBHB at pH >7.0. Because addition of AcLF-CHO to chymotrypsin neither releases nor takes up a proton from solution, it is concluded that the hemiacetal oxygen of the chymotrypsin-AcLF-CHO complex is a hydroxyl group and not attracted to the oxyanion site. The protonation states of the hemiacetal and His 57 are explained by the high basicity of the hemiacetal oxygen (pK(a) > 13.5) relative to that of His 57. The 13C NMR signal for the adduct of AcLF-13CHO with chymotrypsin is consistent with a neutral hemiacetal between pH 7 and 13. At pH <7.0, His 57 in the AcLF-CHO-hemiacetal complex of chymotrypsin undergoes protonation at Nepsilon2 of His 57, leading to a transition of the 15.1 ppm downfield signal to 17.8 ppm. The pK(a)s in the active sites of the AcLF-CF3 and AcLF-CHO adducts suggest an energy barrier of 6-7 kcal x mol(-1) against ionizations that change the electrostatic charge at the active site. However, ionizations of neutral His 57 in the AcLF-CHO-chymotrypsin adduct, or in free chymotrypsin, proceed with no apparent barrier. Protonation of His 57 is accompanied by LBHB formation, suggesting that stabilization by the LBHB overcomes the barrier to ionization. On the basis of the hydration constant for AcLF-13CHO and its inhibition constant, its K(d) is 16 microM, 8000-fold larger than the comparable value for AcLF-CF3.

The distal radioulnar joint in rheumatoid arthritis

This article outlines the relevant pathoanatomy and kinematics, clinical and radiographic findings, and treatment alternatives for the rheumatoid distal radioulnar joint. A summary of the authors preferred techniques is presented.

Base deficit: an indicator of tissue hypoperfusion

The clinical parameters used to evaluate hypovolemia each lack a certain degree of sensitivity and specificity. Indicators that reflect metabolic processes may have more potential for recognizing subtle changes. The use of base deficit for monitoring tissue hypoperfusion is discussed, along with a review of the research. Nurses caring for trauma patients may find monitoring base deficit to be a valuable aid in determining whether the patient continues to have hypoperfusion.

A reassessment of spinal stabilization in severe cerebral palsy

A homogenous population of 37 institutionalized patients with scoliosis and severe cerebral palsy was evaluated to assess the impact of spinal stabilization on comfort, function, health, and ease of nursing care. Through a prospective care-burden study, a 34-month retrospective analysis, and a healthcare worker questionnaire, 17 fused patients with a mean current scoliosis of 35 degrees were compared with 20 nonfused patients with a mean scoliosis of 76 degrees. No clinically significant differences were noted in pain or pulmonary medication utilization or therapy, decubiti, function, or time for daily care. Nevertheless, the majority of healthcare workers believed that the fused patients were more comfortable.

High-risk surgery as an alternative to transplantation

Between April 1992 and April 1994, 185 patients were waiting for a cardiac transplant at our institution. Transplantation was performed in 118 of these patients. Twenty-six patients (14%) died while awaiting a donor heart: 13 of these were in the intensive care unit on multiple inotropic medications, mechanical support, or both; another 13 were either in the hospital on a single inotropic medication or at home with or without inotropic support. The remaining 41 patients were still awaiting transplantation at the end of the study period. During the same interval, 20 comparably ill patients who were referred to our institution for transplantation were considered for high-risk conventional surgical procedures. These patients underwent clinical evaluation to determine whether they had viable muscle that was salvageable and electrophysiologic status that was alterable. On this basis, these 20 patients underwent a variety of combined high-risk procedures. Two patients died; the operative mortality was 5% and the cumulative mortality was 10%. We conclude that these initial results support our original impression that mortality rates are higher in patients waiting for cardiac donation than in patients undergoing high-risk surgical procedures. Therefore, we will continue to investigate high-risk conventional surgery as an alternative to cardiac transplantation.

A discussion of the issue of football helmet removal in suspected cervical spine injuries

In some areas, it is a commonly accepted emergency medical technician protocol to remove a helmet during the initial management of suspected cervical spine injures. After a comprehensive survey of relevant literature, four primary reasons why Emergency Medical Services professionals would desire to remove a helmet emerge. Sources suggest that the presence of a helmet might: 1) interfere with immobilization of the athlete; 2) interfere with the ability to visualize injuries; 3) cause hyperflexion of the cervical spine; and 4) prevent proper airway management during a cardiorespiratory emergency. Many available protocols are designed for the removal of closed chamber motorcycle helmets that do not have removable face masks. There are a great number of differing viewpoints regarding this issue. The varying viewpoints are results of the failure of many emergency medical technician management protocols to address the unique situation presented by a football helmet. We: 1) demonstrate that football helmet removal is potentially dangerous and unnecessary, 2) suggest that cardiorespiratory emergencies can be effectively managed without removing the helmet, and 3) provide sports medicine professional with information that may be used to establish a joint Emergency Medical Services/Sports Medicine emergency action plan.

The resting release of acetylcholine by a retinal neuron

The cholinergic amacrine cells of the rabbit retina secrete acetylcholine by two mechanisms. One is activated by stimulation of the retina by light or depolarization of the amacrine cells by K+ ions. It requires the presence of extracellular Ca2+. The second is independent of extracellular Ca2+ and is unaffected by large depolarizations of the cells. It bears some similarity to the acetylcholine 'leakage' described at the neuromuscular junction. Although the Ca2+-independent mechanism accounts for about two thirds of the total acetylcholine release in the dark, the amount of acetylcholine released in this way is small compared with the release of acetylcholine triggered by stimulation of the retina with light. Its biological significance is unclear.

Phase I and clinical pharmacology study of trimetrexate administered weekly for three weeks

Trimetrexate, a new antifolate compound, was administered by 30-min infusions weekly for 3 weeks to 29 patients with solid tumors in a Phase I study. Thrombocytopenia was dose limiting, but highly variable among patients at a given dose level; other toxicity was mild and uncommon. Twenty-three patients participated in pharmacokinetic studies and five patients participated in a study of the effects of trimetrexate on [6-3H]-deoxyuridine incorporation into hematopoietic cell DNA. The median total body clearance of trimetrexate for each dose level was independent of dose but the total body clearance varied widely among patients at a given dose level. The magnitude of the fall in platelet count in individual patients correlated well with the amount of exposure to trimetrexate, but not with the extent of prior therapy. The amount of [6-3H]deoxyuridine incorporation into hematopoietic cell DNA at 72 h after drug administration correlated with the total body clearance of trimetrexate. The total body clearance of trimetrexate was reduced in patients with impaired hepatic synthetic function, as judged by low pretreatment serum albumin concentrations. The recommended Phase II starting dose on this schedule is 130 mg/m2 weekly for 3 weeks; patients with hypoalbuminemia should be treated at lower doses.

A prospective randomized comparison of epirubicin and doxorubicin in patients with advanced breast cancer

Fifty-four patients with advanced breast cancer who had failed prior non-anthracycline combination chemotherapy were randomized to treatment with either epirubicin 85 mg/m2 or doxorubicin 60 mg/m2 intravenously every three weeks. Of 52 evaluable patients, 25% (six of 24) treated with epirubicin, and 25% (seven of 28) treated with doxorubicin experienced major therapeutic responses. The median duration of response to epirubicin was 11.9 months compared to 7.1 months with doxorubicin. Cardiotoxicity was monitored by serial multigated radionuclide cineangiocardiography performed at rest and after exercise. Laboratory evidence of cardiotoxicity was defined as a decrease in resting left ventricular ejection fraction of greater than 10% from the baseline value, or a decrease of 5% or greater with exercise compared with the resting study performed on the same day. Fifteen patients treated with epirubicin and 18 patients treated with doxorubicin had at least two determinations of left ventricular ejection fraction and were evaluable for laboratory cardiotoxicity. Using methods of survival analysis, the median doses to the development of laboratory cardiotoxicity were estimated to be 935 mg/m2 of epirubicin and 468 mg/m2 of doxorubicin. Four patients treated with epirubicin and five treated with doxorubicin developed symptomatic congestive heart failure. The median cumulative dose at which congestive heart failure occurred was 1,134 mg/m2 of epirubicin compared with 492 mg/m2 of doxorubicin. Fewer episodes of nausea and vomiting were observed in patients receiving epirubicin. Epirubicin is a new anthracycline with reduced cardiac toxicity, but preserved efficacy in the treatment of patients with advanced breast cancer.

The functions of acetylcholine in the rabbit retina

Rabbit retinas were incubated in vitro under conditions known to maintain their physiological function. The acetylcholine stores of the cholinergic amacrine cells were labelled by incubation in the presence of [3H]choline. The tissue was then mounted in a fast-flow superfusion chamber, and the release of [3H]acetylcholine under various conditions was measured by liquid cation exchange or high-voltage electrophoresis. When the retina was stimulated by flashing light, the rate of appearance of radioactive acetylcholine in the superfusate increased, with a latency shorter than the resolution of the system. The rate of release of acetylcholine remained elevated as long as the light was flashing, and returned rapidly to baseline when the light was extinguished. A one minute stimulation with steady light caused a burst of acetylcholine release following stimulus onset and a second, smaller, burst following stimulus cessation. In the presence of 2-amino-4-phosphonobutyrate (APB), an agent known to eliminate selectively the transmission of ON responses to the proximal retina, steady light caused acetylcholine release only at stimulus cessation. Other retinas were labelled with [3H]choline, then incubated for 10-80 min in the presence of flashing light (to promote acetylcholine release) and either control medium or medium containing 100 micron APB (to prevent release from cells activated by stimulus onset). These retinas were quick-frozen, freeze-dried and radioautographed on dry emulsion. In retinas incubated under control conditions [3H]acetylcholine was initially present within two bands within the inner plexiform layer. The two bands became fainter together as the tissue's [3H]acetylcholine was released. APB selectively retarded the depletion of [3H]acetylcholine from the band nearest the ganglion cell layer. We conclude that the displaced cholinergic amacrine cells release acetylcholine at the transient when light appears, and the conventionally placed cholinergic amacrine cells release acetylcholine at the transient when light is extinguished. The retinal ganglion cells that receive a light-driven cholinergic input are distinguished from those that do not by a great sensitivity to slow stimulus motion. It is proposed that the dense plexus of cholinergic dendrites and the transient nature of acetylcholine release combine to create the local subunit that enables detection of motion within regions smaller than those ganglion cells' receptive fields.

Phase I study of tricyclic nucleoside phosphate

A phase I study of tricyclic nucleoside phosphate was conducted in 20 adults with advanced cancer. Tricyclic nucleoside phosphate was given as an iv infusion over 15 minutes once every 3 weeks; the doses ranged from 25 to 350 mg/m2. Beginning at a dose of 250 mg/m2, hyperglycemia and elevation of hepatocellular enzymes were observed; at a dose of 350 mg/m2, two patients developed irreversible liver damage. Patients at all dose levels experienced reduction in serum phosphorus; reduction of serum calcium was noted only with the two highest doses. Nausea and vomiting occurred occasionally. Myelosuppression was not a prominent toxic effect. No major therapeutic responses were noted. Further clinical trials employing this schedule are probably not warranted.