Postmenopausal Bleeding After Coronavirus Disease 2019 (COVID-19) Vaccination: Vaccine Adverse Event Reporting System

We identified U.S. reports of postmenopausal bleeding in the VAERS (Vaccine Adverse Event Reporting System) between December 13, 2020, and December 13, 2021. Among 711,224 VAERS reports after coronavirus disease 2019 (COVID-19) vaccination, during our study period, we identified 554 presumptive postmenopausal bleeding reports; 434 were further classified as verified based on data abstracted from reports and medical records, when available. In the United States, by December 14, 2021, 58.8 million women aged 50 years or older had received at least one dose of a COVID-19 vaccine, corresponding to approximately seven verified VAERS postmenopausal bleeding reports per 1 million women aged 50 years or older who received a COVID-19 vaccine. Reports of postmenopausal bleeding after COVID-19 vaccination in VAERS were rare, and causes of postmenopausal bleeding based on medical record review were consistent with known causes of postmenopausal bleeding.

A Contemporary Framework Update for Today's School Nursing Landscape: Introducing the School Nursing Practice Framework™

School nursing is a unique nursing specialty that benefits from a practice framework that aids school nurses in explaining and accomplishing their role. In 2016, the NASN debuted its Framework for 21st Century School Nursing Practice™, which has shaped school nursing practice as well as education, leadership, research, and collaboration with stakeholders. However, practice frameworks are not meant to remain the same indefinitely. Therefore, NASN evaluated and updated the Framework to ensure its continued alignment with the education and healthcare landscape. The purpose of this article is to share the history of the Framework for 21st Century School Nursing Practice™ development, provide the rationale for the update, and discuss the strategic process NASN used to update its Framework now entitled the School Nursing Practice Framework™.

Designing School Health Services to Provide Multi-Tiered Systems of Support (MTSS) for All Students

A system-level health equity lens is needed to meet the needs of today's students. School nurses stand at the intersection of health and education, poised to improve the health and academic outcomes for all children in collaboration with school health and education colleagues with a focus to reframe "learning and health losses" to "learning and health recovery." The Multi-Tiered System of Support is a familiar approach used in schools to address education equity for students. Working alongside educators, school nurses can demonstrate how including health in this framework augments reaching the goal of supporting student academic success.

Use of accelerometers in determining risk of falls in individuals post-stroke: A systematic review

OBJECTIVE

The aim of this systematic review was to determine if the diagnostic capabilities of wearable accelerometers enhanced, provided earlier detection, or improved fall risk assessment when evaluating individuals with chronic stroke.

DATA SOURCES

CINAHL and PubMed databases were searched for articles from 2015 to 2023 utilizing key terms.

REVIEW METHODS

A team of researchers reviewed articles for bias via the Quality in Prognostic Studies tool, and further analyzed the data to answer the research question.

RESULTS

Four studies were included in the systematic review. When utilizing an accelerometer, the vertical axis was most predictive of falls, followed by the medio-lateral axis and the anterior-posterior axis. L2-3 was the most common accelerometer placement for fall risk assessment, however no uniformity existed in the literature on placement, number of accelerometers, or type. It was determined that gait symmetry, the Timed Up and Go, Berg Balance Scale, and Longitudinal Aging Study Amsterdam best predicted falls risk.

CONCLUSION

Based on limited available evidence, clinicians should continue to perform a comprehensive examination and evaluation for fall risk, that includes the use of a combination of evidence-based outcome measures and gait characteristics to develop an individualized plan of care for individuals post-stroke. However, further research is necessary to determine the added value of accelerometers as well as type, applicability of data, and placement.

Understanding leadership development in DPT and MOT graduates at AdventHealth University via focus groups

PURPOSE

While leadership knowledge, skills and behaviours develop during graduate education, faculty members engaged in curriculum design for doctor of physical therapy (DPT) and masters of occupational therapy (MOT) professionals want to understand how this occurs. The objective of this study was to understand what influenced the development of leadership in graduates.

PATIENTS AND METHODS

A detailed narrative was created for virtual focus groups. Purposive sampling was used and eligible participants were emailed. Those who agreed to participate reviewed an institutional review board approved consent form and were sent a link through an online, recorded Microsoft Teams session. Forty-three DPT and MOT Class of 2022 Graduates were eligible for participation. Recordings were exported, deidentified and validated for transcript accuracy and then deleted. Transcripts were analysed for emerging themes via NVivo.

RESULTS

Ten graduates consented to participate. Saturation was reached during thematic analysis and three weighted themes emerged: leadership characteristics, on-campus curriculum and off-campus curriculum. Further data analysis revealed progression in leadership skill attainment over time and graduates attributed leadership development to the programme and aligned with current frameworks of multiprofessional/interprofessional education.

CONCLUSION

These findings should be used to guide curriculum design for effective leadership development. These experiences align with the goal of advanced clinical practice of future healthcare leaders.

Champions for School Health-An NASN Initiative to Increase Vaccine Confidence, Equity, and Uptake in COVID-19 and School-Required Vaccinations Part 1

The National Association of School Nurses (NASN) received a U.S.$2 million grant from Kaiser Permanente in January 2022 to increase confidence, equity, and uptake in the COVID-19 vaccine and other school required vaccinations in children ages 5 to 11 in Kaiser's nine markets (eight states and the District of Columbia). NASN was partnered with the Institute of Educational Leadership (IEL) in this initiative to examine ways both organizations could learn how school nurses (SNs) and community schools (CSs) could collaborate to address the goals of this project. NASN gave 54 Implementation Grants in two funding cycles in 2022 and is co-funding two SN-CS collaboration projects with IEL. The Part 1 article provides an overview of the project's goals, grant strategy and processes, grantee information, NASN created tools that resulted from this funding, and successful implementation of the project, which demonstrates NASN's capacity for future similar projects.

Transcutaneous Functional Electrical Stimulation Controlled by a System of Sensors for the Lower Limbs: A Systematic Review

In the field of transcutaneous functional electrical stimulation (FES), open-loop and closed-loop control strategies have been developed to restore functions of the lower limbs: walking, standing up, maintaining posture, and cycling. These strategies require sensors that provide feedback information on muscle activity or biomechanics of movement. Since muscle response induced by transcutaneous FES is nonlinear, time-varying, and dependent on muscle fatigue evolution, the choice of sensor type and control strategy becomes critical. The main objective of this review is to provide state-of-the-art, emerging, current, and previous solutions in terms of control strategies. Focus is given on transcutaneous FES systems for the lower limbs. Using Compendex and Inspec databases, a total of 135 review and conference articles were included in this review. Recent studies mainly use inertial sensors, although the use of electromyograms for lower limbs has become more frequent. Currently, several researchers are opting for nonlinear controllers to overcome the nonlinear and time-varying effects of FES. More development is needed in the field of systems using inertial sensors for nonlinear control. Further studies are needed to validate nonlinear control systems in patients with neuromuscular disorders.

Abortion Surveillance - United States, 2020

Problem/Condition

CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.

Period Covered

2020.

Description of System

Each year, CDC requests abortion data from the central health agencies for the 50 states, the District of Columbia, and New York City. For 2020, a total of 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2011-2020. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2019 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS).

Results

A total of 620,327 abortions for 2020 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2011-2020, in 2020, a total of 615,911 abortions were reported, the abortion rate was 11.2 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 198 abortions per 1,000 live births. From 2019 to 2020, the total number of abortions decreased 2% (from 625,346 total abortions), the abortion rate decreased 2% (from 11.4 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 2% (from 195 abortions per 1,000 live births). From 2011 to 2020, the total number of reported abortions decreased 15% (from 727,554), the abortion rate decreased 18% (from 13.7 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 9% (from 217 abortions per 1,000 live births).In 2020, women in their 20s accounted for more than half of abortions (57.2%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (27.9% and 29.3%, respectively) and had the highest abortion rates (19.2 and 19.0 abortions per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.6 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios were highest among adolescents (aged ≤19 years) and lowest among women aged 25-39 years.Abortion rates decreased from 2011 to 2020 among all age groups. The decrease in abortion rate was highest among adolescents compared with any other age group. From 2019 to 2020, abortion rates decreased or did not change for all age groups. Abortion ratios decreased from 2011 to 2020 for all age groups, except adolescents aged 15-19 years and women aged 25-29 years for whom abortion ratios increased. The decrease in abortion ratio was highest among women aged ≥40 years compared with any other age group. From 2019 to 2020, abortion ratios decreased for adolescents aged <15 years and women aged ≥35 and increased for women 15-34 years.In 2020, 80.9% of abortions were performed at ≤9 weeks' gestation, and nearly all (93.1%) were performed at ≤13 weeks' gestation. During 2011-2020, the percentage of abortions performed at >13 weeks' gestation remained consistently low (≤9.2%). In 2020, the highest percentage of abortions were performed by early medical abortion at ≤9 weeks' gestation (51.0%), followed by surgical abortion at ≤13 weeks' gestation (40.0%), surgical abortion at >13 weeks' gestation (6.7%), and medical abortion at >9 weeks' gestation (2.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 63.9% of abortions were early medical abortions. In 2019, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, four women died as a result of complications from legal induced abortion.

Interpretation

Among the 48 areas that reported data continuously during 2011-2020, overall decreases were observed during 2011-2020 in the total number, rate, and ratio of reported abortions. From 2019 to 2020, decreases also were observed in the total number and rate of reported abortions; however, a 2% increase was observed in the total abortion ratio.

Public Health Action

Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

OP0243 OSTEOPOROSIS CASE-FINDING IN PEOPLE UNDERGOING ROUTINE DIAGNOSTIC CT SCANS ALMOST TRIPLED THE RATE OF OSTEOPOROSIS TREATMENT AT 12 MONTHS. A RANDOMISED, MULTI-CENTRE FEASIBILITY STUDY USING WAITING ROOM FRAX, OPPORTUNISTIC CT BONE DENSITY AND VERTEBRAL FRACTURE ASSESSMENT VERSUS USUAL CARE

Background

Up to 40% of all diagnostic computed tomography (CT) scans include views of the spine or hips. Among older people, osteoporosis or vertebral fractures have been found in 30% of such CT scans. Our ‘PHOENIX’ intervention repurposes CT scans taken for other reasons to identify fractures and measure bone density as an ‘added extra’. Early detection and treatment of osteoporosis in CT-attending patients could improve health outcomes.

Objectives

To determine the feasibility and efficacy of PHOENIX versus usual care in a multi-centre, randomised, pragmatic study conducted in Eastern England involving our Cambridge Specialist Hospital ‘hub’ and four regional General Hospital ‘spokes’.

Methods

Women ≥65 and men ≥75 years attending for routine diagnostic CT scans were invited to participate via a novel consent form incorporating FRAX Fracture Risk Assessment questions. After calculating their FRAX 10-year risk score, higher risk patients were block randomised (1:1:1) to Group 1) PHOENIX intervention, 2) Active Control, where the GP was sent the patients’ FRAX answers only, or 3) Usual Care where data were only analysed after 13 months had elapsed. The CT scans of high FRAX risk patients in Group 1 were retrieved by the Cambridge team using NHS Connecting for Health (Burnbank, UK). The team performed vertebral fracture assessment and measured bone density using QCT Pro (Mindways, USA). They added patient-specific treatment and investigation management advice from ‘drop down’ menus before results were reviewed by a physician, authorised and sent to general practitioners (GPs). Baseline CT scans from groups 2 and 3 were assessed in the same way after 13 months to ensure no patient with osteoporosis/fractures was neglected long term. Assuming 25% attrition, the study was powered to find a superior osteoporosis treatment rate in Group 1 (estimated 20%) versus 16% (Active Control) and 5% (Usual Care). Co-primary feasibility endpoints were the ability to a) randomise 375 patients within 10 months and b) retain 75% of survivors able to complete a 1-year bone health outcome questionnaire. Secondary outcomes included osteoporosis/vertebral fracture identification rates and osteoporosis treatment rates. Stakeholder acceptability and economic aspects will be reported separately.

Results

From 1828 invites, 595 participants consented to participate of whom 213 were excluded due to ‘low’ FRAX score. Mortality at 12 months was 20%. Both feasibility objectives were achieved: 1) 382 people were randomised within 10 months; 2) 84.4% of survivors at 1 year (95%CI: 80.5, 88.3) were successfully followed-up. Groups were well matched at baseline. The average age of 375 patients (334 female, 41 male) was 75.2 years (74.6, 75.9). Osteoporosis of the hip/spine was present in 41% of 362 analysable CT scans. From the 264 spines that were suitable for VFA, 20% (n=53) were found to have vertebral fractures, with 8.3% having multiple vertebral fractures (n=22). Osteoporosis treatment was reported in 8.5% of Usual Care group (2.9, 14.2) and 24.2% (15.4, 33.0) of PHOENIX group participants, while in the Active Control group (FRAX only) it was 18.8% (10.9, 26.6 p=0.021). In the PHOENIX group, a recommendation to treat was sent to 50 patients’ GPs at baseline. Only 18 of the 50 patients (36%) were found to be taking osteoporosis treatment 12 months after this advice was sent.

Conclusion

Osteoporosis treatment rates were almost tripled by screening patients attending for routine diagnostic CT scans with waiting room FRAX, CT-bone densitometry and vertebral fracture analysis.

Acknowledgements

This project is funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0816-20027) and by the Cambridge NIHR Biomedical Research Centre (BRC-1215-20014). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Funding is in place to 31.03.2022. Three individuals, Mr Jeremy Dearling, Mrs Tessa Plume and Dr Ann Frost joined our trial group as PPI representatives; they were specifically involved in patient documentation design (particularly the PHOENIX pack, informed consent form which facilitated consent without having a researcher present) and contributed to suggestions for increasing patient recruitment and follow up.

Disclosure of Interests

None declared

POS1514-HPR UNDERSTANDING AND CHARACTERISING PATIENT PATHWAYS TO TREATMENT FOR VERTEBRAL FRACTURES: A QUALITATIVE STUDY

Background

Osteoporosis involves thinning of the bones, making them more prone to break. The most common osteoporotic fracture is a vertebral fracture (OVF). People with OVFs are at high risk of further fractures. To reduce this risk, guidelines recommend prescription of bone protection therapies to people who have experienced a fracture. However, many patients do not receive diagnosis. Understanding patient pathways to treatment for OVFs will provide information to improve practice and aid in effective identification and management.

Objectives

To understand and characterise patient pathways to treatment for OVFs.

Methods

Twenty-three semi-structured qualitative interviews were conducted with patients aged ≥50 years with diagnosis of OVF. Patients were recruited through two hospitals in England and were purposively sampled to capture variation in pathways to diagnosis, sex, age, comorbidities and other relevant characteristics. Interviews were audio-recorded, transcribed and analysed thematically, with themes transposed onto key stages of the patient pathway.

Results

Several factors influenced patient pathways to treatment:

Patient appraisal and self-management: Characteristics and attitudes towards back pain impacted treatment-seeking behaviour. Patients who appraised their pain as ‘different’, severe or disruptive, or associated with an injury such as a fall, were more likely to seek help. Limited availability of information about OVFs and risk factors meant most patients did not associate symptoms with a potential OVF. Factors contributing to delayed consultation included the normalisation of back pain and prioritisation of comorbid conditions. Several misappraised their symptoms as a “pulled muscle” or other minor injury. Many adopted strategies to manage pain, including use of painkillers, lying flat or resting. For some, a lack of improvement in symptoms over time, combined with worsening pain, created a ‘tipping point’ in seeking care. There was a moral dimension for some patients who did not want to “bother” healthcare professionals.

Healthcare professional appraisal: Differential diagnosis was a barrier to treatment and healthcare professionals interpreted OVF pain as broken ribs, muscular pain, kidney pain or sciatica. GPs tended to instigate watchful waiting, in which patients were asked to re-consult if pain did not improve. Feeling disbelieved caused some patients to become disillusioned and reluctant to re-consult and a small number of patients presented at Accident and Emergency. Those already having treatment for musculoskeletal conditions with access to specialist care, were more likely to receive timely diagnosis.

Communication of diagnosis: Patients discussed multiple methods of communication, including written communication and clinical conversations. Several expressed confusion around the use of unfamiliar medical terminology, the implications of OVFs, how many OVFs they had experienced and how they had been identified.

Treatment initiation: Bone protection therapies were not consistently prescribed after diagnosis. Patients who were familiar with these therapies were unsure whether treatment should be initiated in primary or secondary care. Patients described how they felt a need to be proactive by arranging appointments and asking for treatment.

Conclusion

The study provides novel findings about patient pathways to treatment and will be used to identify targeted solutions to improve management of OVFs. This work addresses stages of the Model of Pathways to Treatment[1] and provides detailed understanding of patients’ experiences of these stages. Further work with healthcare professionals in primary care is underway to identify additional system-level factors that may impact patients’ journeys to treatment.

References

[1]Scott, S.E., et al., The model of pathways to treatment: conceptualization and integration with existing theory. Br J Health Psychol, 2013. 18(1): p. 45-65.

Acknowledgements

This study is funded by the National Institute for Health Research (NIHR) Research for Patient Benefit (RfPB) programme NIHR201523. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Disclosure of Interests

None declared

Post-authorization surveillance of adverse events following COVID-19 vaccines in pregnant persons in the Vaccine Adverse Event Reporting System (VAERS), December 2020 – October 2021

Background

Objective

Methods

Results

Conclusions

Duodenal volvulus: a rare cause of small bowel obstruction

Small bowel volvulus is a rare but life-threatening emergency. Volvulus of the duodenum is even rarer without the presence of predisposing factors. The clinical presentation is vague, including abdominal pain, nausea and vomiting, prompt diagnosis of volvulus therefore relies heavily on radiographs. The treatment options lie between conservative or surgical management, where the decision is influenced by the patient and their presentation. This case is of a 100-year-old female with an extensive surgical and medical background presenting with signs of small bowel obstruction. With the help of imaging, a rare case of duodenal volvulus was diagnosed but managed conservatively due to the patient's background, age and personal wishes.

Abortion Surveillance - United States, 2019

Problem/Condition

CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.

Period Covered

2019.

Description of System

Each year, CDC requests abortion data from the central health agencies for 50 states, the District of Columbia, and New York City. For 2019, 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2010–2019. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15–44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2018 were assessed as part of CDC’s Pregnancy Mortality Surveillance System (PMSS).

Results

A total of 629,898 abortions for 2019 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2010–2019, in 2019, a total of 625,346 abortions were reported, the abortion rate was 11.4 abortions per 1,000 women aged 15–44 years, and the abortion ratio was 195 abortions per 1,000 live births. From 2018 to 2019, the total number of abortions increased 2% (from 614,820 total abortions), the abortion rate increased 0.9% (from 11.3 abortions per 1,000 women aged 15–44 years), and the abortion ratio increased 3% (from 189 abortions per 1,000 live births). From 2010 to 2019, the total number of reported abortions, abortion rate, and abortion ratio decreased 18% (from 762,755), 21% (from 14.4 abortions per 1,000 women aged 15–44 years), and 13% (from 225 abortions per 1,000 live births), respectively.

In 2019, women in their 20s accounted for more than half of abortions (56.9%). Women aged 20–24 and 25–29 years accounted for the highest percentages of abortions (27.6% and 29.3%, respectively) and had the highest abortion rates (19.0 and 18.6 abortions per 1,000 women aged 20–24 and 25–29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.7 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios in 2019 were highest among adolescents (aged ≤19 years) and lowest among women aged 25–39 years. Abortion rates decreased from 2010 to 2019 for all women, regardless of age. The decrease in abortion rate was highest among adolescents compared with any other age group. From 2018 to 2019, abortion rates decreased or did not change among women aged ≤24 years; however, the abortion rate increased among those aged ≥25 years. Abortion ratios also decreased or did not change from 2010 to 2019 for all age groups, except adolescents aged <15 years. The decrease in abortion ratio was highest among women aged ≥40 years compared with any other age group. From 2018 to 2019, abortion ratios increased for all age groups, except adolescents aged <15 years.

In 2019, 79.3% of abortions were performed at ≤9 weeks’ gestation, and nearly all (92.7%) were performed at ≤13 weeks’ gestation. During 2010–2019, the percentage of abortions performed at >13 weeks’ gestation remained consistently low (≤9.0%). In 2019, the highest proportion of abortions were performed by surgical abortion at ≤13 weeks’ gestation (49.0%), followed by early medical abortion at ≤9 weeks’ gestation (42.3%), surgical abortion at >13 weeks’ gestation (7.2%), and medical abortion at >9 weeks’ gestation (1.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks’ gestation), 53.7% of abortions were early medical abortions. In 2018, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, two women died as a result of complications from legal induced abortion.

Interpretation

Among the 48 areas that reported data continuously during 2010–2019, overall decreases were observed during 2010–2019 in the total number, rate, and ratio of reported abortions; however, from 2018 to 2019, 1%–3% increases were observed across all measures.

Public Health Action

Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

Informing policy on school and daycare operations during COVID-19 with a living rapid evidence review

Background

To support evidence-informed decision making (EIDM) for safe re-opening and operation of schools and daycares, the National Collaborating Centre for Methods and Tools (NCCMT) has maintained since May 2020 a living rapid review answering the following question: “What is the role of schools and daycares in COVID-19 transmission”. Traditional rapid review methodology was modified for the COVID-19 context. This presentation will describe the global reach and usefulness of this living rapid review.

Methods

Following completion of each update of the living rapid review, findings were disseminated broadly with the aim of informing policy and public health practice. Key dissemination strategies include e-mails to key contacts and a subscriber list; highlight in a monthly newsletter; media outreach; and social media. The review's reach was analyzed using Google Analytics, citation tracking, and qualitative feedback.

Results

Between May 2020 and April 2021, the living review has been updated 14 times. The posted review has been viewed over 5000 times across 46 countries. The review has been cited and indexed in over 40 sources, including key governmental and non-governmental reports and guidelines. The NCCMT has received positive qualitative feedback on the review's value in informing the public health response related to schools and daycares in various jurisdictions across Canada. Key stakeholders have expanded the review's reach organically as they use the evidence in practice and share the review with their networks.

Lessons

Using a living rapid review to continuously provide high-quality synthesized evidence amidst the evolving COVID-19 research literature demonstrates a responsive approach to decision makers' requests for evidence. An emerging challenge is reaching the proper stakeholders responsible for EIDM, particularly during public health emergencies with many competing high-priority questions and decisions to be made.

Key messages

As the evidence landscape changes due to a surge in literature, evidence-informed decision making can be supported by rapid but rigorous syntheses that evaluate quality and emerging recommendations. A long-standing, trusting relationship with decision makers is key to optimizing living rapid review methodology to meet the evidence needs of decision makers despite the changing literature.

Coronavirus Disease 2019

In this article, the authors review manifestations of COVID-19 in older adults, normal physiologic changes and frequent comorbidities of aging that increase pathogenicity, factors contributing to overwhelming viral spread among seniors, negative effects on health and well-being resulting from measures to control the virus, and health-system improvements necessary to protect and care for this vulnerable population.

Perspectives on pharmacy access to hormonal contraception among rural New Mexico women

Objective

In 2017, New Mexico approved an amendment allowing pharmacists to prescribe and dispense hormonal contraception. We interviewed rural New Mexico women to determine their perceptions of pharmacy access to hormonal contraception.

Study design

We conducted semi-structured telephone interviews with women recruited from rural New Mexico communities. The interview guide explained the amendment followed by questions about the advantages and disadvantages of pharmacy access to hormonal contraception within rural communities.

Results

Between November 2017 and May 2018, we recruited 32 women to participate. Participants were young (26/32 18–29 years old), gravid (27/31), employed (30/32), white (22/32) and Hispanic (26/31). The majority used Medicaid as their primary insurance (16/28). Most participants were supportive of pharmacy access to hormonal contraception. Participants saw their rural communities as facing health care barriers, some of which could be alleviated by pharmacy access. Perceived benefits of pharmacy access included convenience of pharmacy hours, shorter wait times, and no need for an appointment. Participants expressed concerns about lack of privacy in their pharmacies. Many expressed trust in their pharmacist to review side effects and explain usage of contraception- a role that was considered separate from that of a primary care provider who offers regular medical visits for routine screening and nuanced or complex discussions about contraception. Some participants expressed that pharmacy access could be especially beneficial for teens.

Conclusions

Rural New Mexico women were supportive of pharmacy access to contraception and accept pharmacists as trusted members of the health care team.

Implications

Rural New Mexico women find benefit in pharmacy access to hormonal contraception, citing improved access to contraceptives in their communities.

The effect of intestinal microbiota dysbiosis on growth and detection of carbapenemase-producing Enterobacterales within an in vitro gut model

BACKGROUND

Carbapenemase-producing Enterobacterales (CPE) can colonize the gut and are of major clinical concern. Identification of CPE colonization is problematic; there is no gold-standard detection method, and the effects of antibiotic exposure and microbiota dysbiosis on detection are unknown.

AIM

Based on a national survey we selected four CPE screening assays in common use. We used a clinically reflective in vitro model of human gut microbiota to investigate the performance of each test to detect three different CPE strains under different, clinically relevant antibiotic exposures.

METHODS

Twelve gut models were seeded with a pooled faecal slurry and exposed to CPE either before, after, concomitant with, or in the absence of piperacillin-tazobactam (358 mg/L, 3 × daily, seven days). Total Enterobacterales and CPE populations were enumerated daily. Regular screening for CPE was performed using Cepheid Xpert® Carba-R molecular test, and with Brilliance™ CRE, Colorex™ mSuperCARBA and CHROMID® CARBA SMART agars.

FINDINGS

Detection of CPE when the microbiota are intact is problematic. Antibiotic exposure disrupts microbiota populations and allows CPE proliferation, increasing detection. The performances of assays varied, particularly with respect to different CPE strains. The Cepheid assay performed better than the three agar methods for detecting a low level of CPE within an intact microbiota, although performance of all screening methods was comparable when CPE populations increased in a disrupted microbiota.

CONCLUSION

CPE strains differed in their dynamics of colonization in an in vitro gut model and in their subsequent response to antibiotic exposure. This affected detection by molecular and screening methods, which has implications for the sensitivity of CPE screening in healthcare settings.

Perceptual reasoning skills mediate the relationship between attention and math proficiency in individuals with a neurodevelopmental condition

BACKGROUND

An important component of academic success in typically developing students is the development of math skills, which is associated with attention and perceptual reasoning (PR) skills. For children with a neurodevelopmental condition (NDC), the relationship is confounded by diagnostic-specific cognitive characteristics. Specifically, enhanced PR is specific to individuals with Autism Spectrum Disorder (ASD).

AIMS

The purpose of this study was to test: (i) a mediation model where PR skills would mediate the relationship between attention and math proficiency for students with an NCD, and (ii) whether this mediation model is moderated by a diagnostic profile.

METHODS AND PROCEDURES

One hundred and thirty-seven students with an NDC participated in a school-based study examining the effectiveness of using a standardized measure of attention in predicting math capabilities.

OUTCOMES AND RESULTS

PR mediated the relationship between attention and math proficiency for students diagnosed with an NDC. However, the model was not moderated by diagnostic profile.

CONCLUSIONS AND IMPLICATIONS

The results of this study provide a better understanding of the roles of higher-level cognitive ability specific to students with NDCs. Additionally, the superior PR skills demonstrated by the ASD sample further supports the research suggesting this population possesses cognitive strengths in this domain.

A non-randomised pilot study of the Solutions for Medication Adherence Problems (S-MAP) intervention in community pharmacies to support older adults adhere to multiple medications

BACKGROUND

Older patients prescribed multiple medications commonly experience difficulties with adherence. High-quality evidence on interventions targeting older patients is lacking. Theory is rarely used to tailor adherence solutions. This study aimed to pilot test a novel intervention, developed using the Theoretical Domains Framework, which guides community pharmacists in identifying adherence barriers and delivering tailored solutions (behaviour change techniques). Key study procedures (e.g. recruitment, data collection) for a future randomised controlled trial (cRCT) were also assessed.

METHODS

Using purposive sampling, this non-randomised pilot study aimed to recruit 12 community pharmacies (six in Northern Ireland; six in London, England). Pharmacists were trained to deliver the intervention to non-adherent older patients (maximum 10 per pharmacy; target n = 60-120) aged ≥ 65 years (reduced to 50 years due to recruitment challenges) and prescribed ≥ 4 regular medicines. The intervention, guided by an iPad web-application, was delivered over 3-4 face-to-face or telephone sessions, tailored to specific barriers to adherence. We assessed the feasibility of collecting adherence data (primary outcome: self-report and dispensing records), health-related quality of life (HRQOL) and unplanned hospitalisations (secondary outcomes) at baseline and 6-months. The final decision on progressing to a cRCT, using pre-defined 'stop-amend-go' criteria, is presented.

RESULTS

Fifteen pharmacists from 12 pharmacies were recruited and trained. One pharmacy subsequently dropped out. Sixty patients were recruited (meeting the 'Amend' progression criteria), with 56 receiving the intervention. Adherence barriers were identified for 55 patients (98%) and a wide range of behaviour change solutions delivered (median: 5 per patient). Self-report and dispensing adherence data were available for 37 (61.7%) and 44 (73.3%) patients, respectively. HRQOL data were available for 35 (58.3%) patients. GP-reported and self-reported hospitalisations data were available for 47 (78.3%) and 23 (38.3%) patients, respectively. All progression concepts were met (nine 'Go' and three 'Amend' criteria).

CONCLUSION

This study demonstrates the feasibility of key study procedures (e.g. pharmacy recruitment) and delivery of a tailored adherence intervention in community pharmacies. However, modifications are required to enhance issues identified with patient recruitment, retention and missing data. A future definitive cRCT will explore the effectiveness of the intervention.

TRIAL REGISTRATION

ISRCTN, ISRCTN73831533 , Registered 12 January 2018.

Macro-reentrant Single-loop Biatrial Flutter Appearing as Typical Atrial Flutter: Case Study and Review

Biatrial flutter is a rare form of macro-reentrant atrial tachycardia that involves both the right and left atria. Single-loop biatrial flutter is typically associated with scarring of the septum from prior ablation or surgery and is generally made up of two interatrial connections—that is, the coronary sinus and Bachmann’s bundle. Entrainment and high-density mapping allow for rapid diagnosis and development of a treatment strategy. Ablation planning should also take into consideration the preservation of interatrial conduction. We herein discuss a case of single-loop biatrial flutter presenting as a typical atrial flutter and review the differential diagnosis and physiology of the arrhythmia.

A new tool to assess community-level evidence to inform public health decision making

Background

As public health responds to evolving challenges around the globe, it is critical to draw on community-level evidence to inform decisions on emerging needs. There are existing tools for assessing the quality of research evidence, but none that explicitly focus on quality assessment of evidence from community sources, including local health status and ever-changing community and political preferences and actions.

Methods

The National Collaborating Centre for Methods and Tools (NCCMT) in Canada has developed new tools, called Quality Assessment of Community Evidence (QACE), to help public health decision makers assess the quality of community evidence. The QACE tools were drafted through extensive review of existing frameworks, tools and measures for appraising population health and community evidence, and diverse key informants. We identified three consistent themes that became the core dimensions in these tools. By using the QACE tools, practitioners can answer the question: “Is the quality of this evidence about local context, community needs and political preferences good enough to influence decision making?”

Results

The QACE tools provide probing questions for each of three dimensions: relevant, trustworthy and equity-informed. Supplementary resources help users delve more deeply into different aspects of quality assessment. The QACE tools are intended for public health practitioners who provide and use evidence to support or make decisions about public health practice and policy, including public health practitioners, senior leaders, policy makers and funders.

Conclusions

The QACE tool is a new addition to the public health toolbox for evidence-informed decision making, providing questions to ask about evidence from community sources. By using the tool as part of a decision-making process, public health practitioners can be assured that their decisions are based on the best-available evidence for their communities.

Key messages

The new Quality Assessment of Community Evidence (QACE) tools fill the gap in assessing quality of community-level evidence for public health decision-makers. Community evidence, including local health status and needs and community and political preferences and actions, should be assessed for quality in three critical domains.

Enhancing partnerships and collaboration in times of change

Issue

In 2019, the government of the Canadian province of Ontario announced major changes to the structure, governance and funding of public health services. Throughout these changes, publicly funded local and regional public health organizations are still expected to provide effective, evidence-informed programming to their communities. The National Collaborating Centre for Methods and Tools (NCCMT) has facilitated collaborations to support Ontario public health through this transition.

Description of the problem

In order to support evidence-informed public health in Ontario during this transition, the NCCMT reached out to current and potential partners, within and beyond the public health sector for a multidisciplinary approach. We conducted a needs assessment for an evidence review repository, which would allow public health practitioners to share and build upon each other's work. Finally, demonstrating the value of public health to policymakers can be inherently challenging as the return on investment in public health is often very long term. We partnered with health units in varying capacities to find and synthesize evidence to advocate for continued investment in public health.

Results

This initiative has provided important lessons in developing and maintaining strong partnerships. Looking beyond the public health sector can establish mutually beneficial partners and allies in other disciplines. A key finding was the need to establish infrastructure to support collaboration and resource sharing. Finally, we learned that big picture questions like demonstrating the value of public health require many different perspectives, inputs and areas of expertise.

Lessons

Through this initiative, we have developed a multidisciplinary, collaborative approach to supporting evidence-informed public health through times of major restructuring. This approach can be applied to future changes to public health on smaller or larger scales, or within other geographic regions.

Key messages

Multidisciplinary approaches can support collaboration, unity and advocacy in times of change. Establishing infrastructure to support collaboration and sharing of resources is valuable.

The NCCMT’s dynamic model for evidence-informed public health

Issue

It is well accepted that public health decision makers should use the best available research evidence in their decision-making process. However, research evidence alone is insufficient to inform public health decision making.

Description of the problem

As new challenges to public health emerge, there can be a paucity of high quality research evidence to inform decisions on new topics. Public health decision makers must combine various sources of evidence with their public health expertise to make evidence-informed decisions. The National Collaborating Centre for Methods and Tools (NCCMT) has developed a model which combines research evidence with other critical sources of evidence that can help guide decision makers in evidence-informed decision making.

Results

The NCCMT's model for evidence-informed public health combines findings from research evidence with local data and context, community and political preferences and actions and evidence on available resources. The model has been widely used across Canada and worldwide, and has been integrated into many public health organizations' decision-making processes. The model is also used for teaching an evidence-informed public health approach in Masters of Public Health programs around the globe. The model provides a structured approach to integrating evidence from several critical sources into public health decision making. Use of the model helps ensure that important research, contextual and preference information is sought and incorporated.

Lessons

Next steps for the model include development of a tool to facilitate synthesis of evidence across all four domains. Although Indigenous knowledges are relevant for public health decision making and should be considered as part of a complete assessment the current model does not capture Indigenous knowledges.

Key messages

Decision making in public health requires integrating the best available evidence, including research findings, local data and context, community and political preferences and available resources. The NCCMT’s model for evidence-informed public health provides a structured approach to integrating evidence from several critical sources into public health decision making.

Mission Accomplished: The ACVP/STP Coalition for Veterinary Pathology Fellows Completes Its Objectives, but Its Legacy and Spirit Live On

After 15 years of existence, the ACVP/STP Coalition for Veterinary Pathology Fellows will dissolve, primarily due to lack of renewed financial sponsorship. While in operation, the Coalition organized 32 new training position for veterinary pathologists, supported by $7.4 M from sponsors, including pharmaceutical and biotechnology companies, contract research organizations, private individuals and allied veterinary pathology support groups. All residual funds will be donated to ACVP and STP with the understanding that the two organizations will use these funds to enhance training by collaborating on outreach efforts, thus maintaining the legacy and spirit of the Coalition.

Mission Accomplished: The ACVP/STP Coalition for Veterinary Pathology Fellows Completes Its Objectives, but Its Legacy and Spirit Live On

After 15 years of existence, the ACVP/STP Coalition for Veterinary Pathology Fellows will dissolve, primarily due to lack of renewed financial sponsorship. While in operation, the Coalition organized 32 new training position for veterinary pathologists, supported by $7.4 M from sponsors, including pharmaceutical and biotechnology companies, contract research organizations, private individuals and allied veterinary pathology support groups. All residual funds will be donated to ACVP and STP with the understanding that the two organizations will use these funds to enhance training by collaborating on outreach efforts, thus maintaining the legacy and spirit of the Coalition.

A pilot study of the S-MAP (Solutions for Medications Adherence Problems) intervention for older adults prescribed polypharmacy in primary care: study protocol

Background

Adhering to multiple medications as prescribed is challenging for older patients (aged ≥ 65 years) and a difficult behaviour to improve. Previous interventions designed to address this have been largely complex in nature but have shown limited effectiveness and have rarely used theory in their design. It has been recognised that theory (‘a systematic way of understanding events or situations’) can guide intervention development and help researchers better understand how complex adherence interventions work. This pilot study aims to test a novel community pharmacy-based intervention that has been systematically developed using the Theoretical Domains Framework (12-domain version) of behaviour change.

Methods

As part of a non-randomised pilot study, pharmacists in 12 community pharmacies across Northern Ireland (n = 6) and London, England (n = 6), will be trained to deliver the intervention to older patients who are prescribed ≥ 4 regular medicines and are non-adherent (self-reported). Ten patients will be recruited per pharmacy (n = 120) and offered up to four tailored one-to-one sessions, in the pharmacy or via telephone depending on their adherence, over a 3–4-month period. Guided by an electronic application (app) on iPads, the intervention content will be tailored to each patient’s underlying reasons for non-adherence and mapped to the most appropriate solutions using established behaviour change techniques. This study will assess the feasibility of collecting data on the primary outcome of medication adherence (self-report and dispensing data) and secondary outcomes (health-related quality of life and unplanned hospitalisations). An embedded process evaluation will assess training fidelity for pharmacy staff, intervention fidelity, acceptability to patients and pharmacists and the intervention’s mechanism of action. Process evaluation data will include audio-recordings of training workshops, intervention sessions, feedback interviews and patient surveys. Analysis will be largely descriptive.

Discussion

Using pre-defined progression criteria, the findings from this pilot study will guide the decision whether to proceed to a cluster randomised controlled trial to test the effectiveness of the S-MAP intervention in comparison to usual care in community pharmacies. The study will also explore how the intervention components may work to bring about change in older patients’ adherence behaviour and guide further refinement of the intervention and study procedures.

Trial registration

This study is registered at ISRCTN: 10.1186/ISRCTN73831533

The impact of central IRB's on informed consent readability and trial adherence in SPRINT

Background

Federal agencies have encouraged the use of central institutional review boards (CIRBs) for multi-site clinical trials. There is limited evidence supporting the use of CIRBs. Our aim is to evaluate how SPRINT sites regulated by CIRBs performed regarding informed consent readability and participant trial adherence compared to those regulated by local IRBs.

Methods

We conducted a cohort study using the SPRINT clinical trial. We collected the IRB of record from the stamped and approved 2012 informed consents from each of the sites. We defined CIRB as an IRB for more than one SPRINT site. Our outcomes were informed consent readability measured using the Flesch-Kincaid readability scale and trial adherence defined as a loss to follow-up, consent withdrawal, and missed last 3-month visit.

Results

Sixty-one percent of all SPRINT sites used a CIRB as their IRB of record. The adjusted mean grade reading level for CIRB consents was 13.4 (95% CI 12.6–13.8) compared to 12.3 (95% CI 12.1–13.1) for non CIRB consents (p = 0.07). CIRB sites had similar rates of withdrawal of consent and loss to follow-up as non-CIRB sites; subjects missing the last appointment of the study were more likely to come from sites regulated by a CIRB. The Veterans Affairs CIRB had the lowest rate of withdrawal of consent (1.9%) and the lowest rate of missed appointments (1.9%) among CIRBs.

Conclusions

Niether CIRB-regulated sites nor IRB regulated sites enforce the recommended readability level of the informed consent documents. Sites regulated by both IRBs had similar participant trial adherence.

Caries-preventive efficacy of a supervised school toothbrushing programme in Northland, New Zealand

BACKGROUND

Toothbrushing with fluoride toothpaste reduces the incidence of dental caries.

OBJECTIVE

To evaluate a supervised school toothbrushing programme to reduce dental caries experience in children.

BASIC RESEARCH DESIGN

Quasi-experimental study. All children had routine dental examinations at baseline using the ICDAS to record dental caries, along with bitewing radiographs. Half of the children were involved in a supervised toothbrushing programme. Examinations were repeated at the end of the school year.

CLINICAL SETTING

Northland, New Zealand.

PARTICIPANTS

335 10-13-year-old New Zealand children with high caries experience.

INTERVENTIONS

Half of the children participated in the supervised toothbrushing session each school day; the other half had no intervention.

MAIN OUTCOME MEASURES

Caries increment, determined by comparing the baseline and follow-up status of each tooth surface.

RESULTS

At baseline, there were 335 children, of whom 240 (71.6%) were followed up. The ICDAS net caries increment for those in the toothbrushing group was a mean of 11.7 surfaces improved; the control group had a mean of 8.6 surfaces which had deteriorated. Caries incidence for those in the toothbrushing group was 7.3%; that for the control group was 71.5%. Multivariate analysis showed that membership of the brushing group was the only statistically significant predictor of a lower net caries increment.

CONCLUSION

A supervised school toothbrushing programme can reduce caries increment in a population experiencing high levels of dental disease.

Impact of an International Service Learning Experience in India for DPT Students: Short- and Long-Term Benefits

PURPOSE

Awareness of global issues and cultural competence are essential for health professions students. Educational programs utilize International Service Learning (ISL) to address global issues and diverse cultures. This study describes short- and long-term benefits of ISL on Doctor of Physical Therapy (DPT) students.

PROCEDURES

The ISL included study of Ayurveda, clinical service, collaborative learning, and cultural activities. A mixed-methods design included the Cross Cultural Adaptability Index (CCAI) administered to 14 students pre- and post-ISL and qualitative analysis of reflective papers. Interviews of participants were completed 2 to 3 years later.

FINDINGS

Overall CCAI scores showed a statistically significant difference of 0.001 (p<0.01) pre and post ISL. Three subscales also showed a statistically significant difference (p<0.01). Qualitative analysis of reflective papers revealed three categories of impact: environmental connectedness, personal growth, and professional growth. Interviews conducted years following the ISL indicate that participants attribute several aspects of their professional and personal way of being to the ISL, including the importance of whole person care.

CONCLUSIONS

Studies have shown benefits to health professions students immediately following an ISL. This study demonstrates that benefits persist years later. The long-term impact strengthens the rationale for including ISL during professional education.

Abstract P1-13-07: Incidence and management of diarrhea with adjuvant pertuzumab and trastuzumab in HER2-Positive breast cancer

Background

Diarrhea is the most commonly reported adverse event (AE) on pertuzumab (Ptz) in both early and metastatic breast cancer (BC) settings. We report safety analyses of diarrhea from the large adjuvant APHINTY study in HER2 positive early breast cancer (EBC).

Patients and methods

In this exploratory analysis, the safety population included 2364 patients in the Ptz arm and 2405 in the placebo (Pla) arm. No specific prophylaxis was mandated by the protocol, however early intervention with loperamide as well as fluid and electrolyte replacement was recommended. Diarrhea incidence, severity (NCI-CTCAE v4.0), onset and management were analyzed.

Results

Diarrhea was the most common AE in the Ptz arm (71.3% vs. 45.2% in the Pla arm) and the events were mostly G1. Diarrhea ≥G3 was observed in 9.8% and 3.7% in Ptz and Pla arms, respectively. The highest incidence was reported during administration of HER2 targeted therapy and taxane (61.4% vs. 33.8% with Ptz and Pla, respectively) with a marked decrease observed upon chemotherapy cessation (18.1% vs. 9.2% with Ptz and Pla, respectively). The median time from first targeted treatment to onset of diarrhea during the chemotherapy phase was 7 and 10 days (Ptz/Pla). On average, diarrhea events lasted longer in the Ptz than in the Pla arm (median 8 vs. 6 days). Diarrhea events were more frequent with the administration of docetaxel + carboplatin and targeted agents, irrespective of the severity. Detailed results are reported in Table 1.

Conclusions

In the curative setting, diarrhea due to Ptz was mild, generally manageable with common antidiarrheals and did not affect patients' ability to receive treatment. The APHINITY findings are consistent with the well-characterized pattern of pertuzumab-related diarrhea across the HER2 BC spectrum.

Diarrhea incidence, severity (NCI-CTCAE v4.0), onset and management Ptz, n=2364Pla, n=2405Incidence and severityTotal number of patients with at least one adverse event$1685 (71.3%)1086 (45.2%)Total number of events$34151792NCI CTC AE Grade (highest grade per patient)!n1683 (71.2%)1085 (45.1%)Grade 1829 (35.1%)690 (28.7%)Grade 2622 (26.3%)305 (12.7%)Grade 3229 (9.7%)90 (3.7%)Grade 43 (0.1%)0Onset and duration$Median time (days) from 1st HER2 targeted treatment to onset (min-max)7 (1 – 358)10 (1 - 384)Median Duration (days) of each event (min-max)8 (1 - 811)6 (1 - 1022)ManagementAntidiarrheals$898 (38.0%)386 (16.0%)Dose modification* of any study drug!210 (8.9%)74 (3.1%)Dose modification* of HER2 targeted treatment!69 (2.9%)18 (0.7%)Discontinuation of any study drug!38 (1.6%)7 (0.3%)Discontinuation of HER2 Targeted treatment!20 (0.8%)2 (&lt;0.1%)$ Based on a basket of preferred terms for diarrhea ! Based only on the preferred term diarrhea * Includes dose reductions (chemotherapy only), delays or interruptions during infusion

Citation Format: Bines J, de Azambuja E, Zardavas D, Procter M, Restuccia E, Viale G, Suter T, Arahmani A, van Dooren V, Clark E, Eng-Wong J, Gelber R, Piccart M, von Minckwitz G, Baselga J. Incidence and management of diarrhea with adjuvant pertuzumab and trastuzumab in HER2-Positive breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-13-07.

There's a New Alphabet in Town: ESSA and Its Implications for Students, Schools, and School Nurses

The 2015 passage of the Every Student Succeeds Act (ESSA) provides state education agencies with more local control over educational planning, requires development of state accountability plans, and provides opportunities for advocacy surrounding school nursing-sensitive indicators of student success. Federal Title I, II, and IV funds are available for state and local education agency utilization in meeting educational needs of impoverished students and for development of high-quality instructional and support personnel. As Specialized Instructional Support Personnel, school nurses can utilize ESSA Title funding to positively impact chronic absenteeism, school climate, and school nurse staffing. ESSA can be a resource for funding school health services and professional education. This article will assist school nurses in better understanding ESSA and how funding is allocated to states and local education agencies.

Effect of powder oxidation on the impact toughness of electron beam melt Ti-6Al-4V

Powder quality in additive manufacturing (AM) electron beam melt (EBM) of Ti-6Al-4V components is crucial in determining the critical material properties of the end item. In this study, we report on the effect of powder oxidation on the Charpy impact energy of Ti-6Al-4V parts manufactured using EBM. In addition to oxidation, the effects on impact energy due to hot isostatic pressing (HIP), specimen orientation, and EBM process defects were also investigated. This research has shown that excessive powder oxidation (oxygen mass fraction above 0.25 % and up to 0.46 %) dramatically decreases the impact energy. It was determined that the room temperature impact energy of the parts after excessive oxidation was reduced by about seven times. We also report that HIP post-processing significantly increases the impact toughness, especially for specimens with lower or normal oxygen content. The specimen orientation effect was found to be more significant for low oxidation levels.

Delayed diagnosis and management of second trimester abdominal pregnancy

Second trimester abdominal ectopic pregnancies are rare and life threatening. Early diagnosis and treatment are paramount in reducing maternal morbidity and mortality. We describe an unusually late diagnosis of abdominal pregnancy despite multiple ultrasounds beginning in early pregnancy. A 28-year-old G2P1001 sought pregnancy termination at 22 weeks’ gestation after fetal anomalies were noted on an 18-week ultrasound during evaluation for elevated maternal serum alfa-fetoprotein. Due to abortion restrictions in her home state, she travelled over 500 miles for abortion care. During dilation and evacuation, suspected uterine perforation led to the finding of a previously undiagnosed abdominal pregnancy. At laparotomy, she underwent left salpingo-oophorectomy and removal of abdominal pregnancy and placenta. A multidisciplinary team approach was paramount in optimising the patient’s outcome. Abortion restrictions requiring travel away from the patient’s home community interrupted her continuity of care and created additional hardships, complicating management of an unexpected, rare and life-threatening condition.

Diagnostic and prognostic benefits of computed tomography coronary angiography using the 2016 National Institute for Health and Care Excellence guidance within a randomised trial

Objectives

To evaluate the diagnostic and prognostic benefits of CT coronary angiography (CTCA) using the 2016 National Institute for Health and Care Excellence (NICE) guidelines for the assessment of suspected stable angina.

Methods

Post hoc analysis of the Scottish COmputed Tomography of the HEART (SCOT-HEART) trial of 4146 participants with suspected angina randomised to CTCA. Patients were dichotomised into NICE guideline-defined possible angina and non-anginal presentations. Primary (diagnostic) endpoint was diagnostic certainty of angina at 6 weeks and prognostic endpoint comprised fatal and non-fatal myocardial infarction (MI).

Results

In 3770 eligible participants, CTCA increased diagnostic certainty more in those with possible angina (relative risk (RR) 2.22 (95% CI 1.91 to 2.60), p<0.001) than those with non-anginal symptoms (RR 1.30 (1.11 to 1.53), p=0.002; p_interaction <0.001). In the possible angina cohort, CTCA did not change rates of invasive angiography (p=0.481) but markedly reduced rates of normal coronary angiography (HR 0.32 (0.19 to 0.52), p<0.001). In the non-anginal cohort, rates of invasive angiography increased (HR 1.82 (1.13 to 2.92), p=0.014) without reducing rates of normal coronary angiography (HR 0.78 (0.30 to 2.05), p=0.622). At 3.2 years of follow-up, fatal or non-fatal MI was reduced in patients with possible angina (3.2% to 1.9%%; HR 0.58 (0.34 to 0.99), p=0.045) but not in those with non-anginal symptoms (HR 0.65 (0.25 to 1.69), p=0.379).

Conclusions

NICE-guided patient selection maximises the benefits of CTCA on diagnostic certainty, use of invasive coronary angiography and reductions in fatal and non-fatal myocardial infarction. Patients with non-anginal chest pain derive minimal benefit from CTCA and increase the rates of invasive investigation.

Trial registration number

ClinicalTrials.gov: NCT01149590;post results.