MRI order appropriateness for chronic neck pain: Comparison of ordering practices and treatment outcomes for primary care physicians and specialists

Chronic neck pain is a common reason for doctor visits in the United States. This diagnosis can be evaluated through patient history, physical examination, and judicious use of radiographs. However, possible inappropriate magnetic resonance imaging (MRI) ordering persists. We hypothesized that no difference in ordering practices, ordering appropriateness, and subsequent intervention would be appreciated regarding physician specialty, location, patient characteristics, and history and physical exam findings. A multisite retrospective review of cervical spine MRI between 2014 and 2018 was performed. A total of 332 patients were included. Statistical analysis was used to assess MRI order appropriateness, detail of history and physical exam findings, and intervention decision-making among different specialties. If significant differences were found, multiple linear regression was performed to evaluate the association of MRI order appropriateness regarding physician specialty, location, patient characteristics and history, and physical exam findings. The significance level for all tests was set at <0.05 Orthopedic surgeons ordered MRIs most appropriately with an average American College of Radiology (ACR) score of 8.4 (p < 0.005). Orthopedic surgeons had more comprehensive physical exams as compared to the remaining specialties. The decision for intervention did not vary by physician specialty or ACR score, except for patients of pain medicine physicians who received pain management (p = 0.000). Orthopedic surgeons utilize MRI most appropriately and have more comprehensive physical exams. These findings suggest a need for increased physician education on what indicates an appropriate MRI order to improve the use of resources and further protect patient risk-benefit profiles. Further research elucidating factors to minimize negative findings in "appropriate" MRIs is indicated. Clinical significance: More detailed physical exams may lead to more appropriately ordered MRIs, subsequently resulting in surgery or procedures being performed when appropriately indicated. This suggests the need for increased physician education on when MRI ordering is appropriate for chronic neck pain to improve the use of resources and further protect patient risk-benefit profiles.

Rare Guest-Induced Electrical Conductivity of Zn-Porphyrin Metallacage Inclusion Complexes Featuring π-Donor/Acceptor/Donor Stacks

Charge-transfer (CT) interactions between co-facially aligned π-donor/acceptor (π-D/A) arrays engender unique optical and electronic properties that could benefit (supra)molecular electronics and energy technologies. Herein, we demonstrate that a tetragonal prismatic metal-organic cage (MOC18+) having two parallel π-donor tetrakis(4-carboxyphenyl)-Zn-porphyrin (ZnTCPP) faces selectively intercalate planar π-acceptor guests, such as hexaazatriphenylene hexacarbonitrile (HATHCN), hexacyanotriphenylene (HCTP), and napthanelediimide (NDI) derivatives, forming 1:1 πA@MOC18+ inclusion complexes featuring supramolecular π-D/A/D triads. The π-acidity of intercalated π-acceptors (HATHCN ≫ HCTP ≈ NDIs) dictated the nature and strength of their interactions with the ZnTCPP faces, which in turn influenced the binding affinities (Ka) and optical and electronic properties of corresponding πA@MOC18+ inclusion complexes. Owing to its strongest CT interaction with ZnTCPP faces, the most π-acidic HATHCN guest enjoyed the largest Ka (5 × 106 M-1), competitively displaced weaker π-acceptors from the MOC18+ cavity, and generated the highest electrical conductivity (2.1 × 10-6 S/m) among the πA@MOC18+ inclusion complexes. This work demonstrates a unique through-space charge transport capability of πA@MOC18+ inclusion complexes featuring supramolecular π-D/A/D triads, which generated tunable electrical conductivity, which is a rare but much coveted electronic property of such supramolecular assemblies that could further expand their utility in future technologies.

Effects of free versus restricted arm movements on postural control in normal and modified sensory conditions in young and older adults

The purpose of this study was to explore the effects of arm movements on postural control when standing under different sensory conditions in healthy young and older adults. Fifteen young (mean ± SD age; 21.3 ± 4.2 years) and 15 older (mean ± SD age; 73.3 ± 5.0 years) adults completed the modified Romberg test, which uses four task manipulations (i.e. eyes open and eyes closed on a firm and foam surface) to compromise the fidelity of sensory feedback mechanisms. Each participant completed the tasks under two arm movement conditions: restricted and free arm movements. Centre of pressure (COP) range and frequency were calculated to characterise postural performance and strategy, respectively. Older adults showed greater COP range with restricted compared to free arm movements during all modified sensory conditions, with these effects most prominent in the medio-lateral (ML) plane (all p < .05, Cohen's d = 0.69-1.61). Compared to the free arm movement condition, there was an increase in ML displacement and frequency when arm movements were restricted during only the most challenging (i.e. vestibular dominant) task in young adults (all p < .05, d = 0.645-0.83). Finally, main age effects for the arm restriction cost (p < .05) indicates a greater reliance on an upper body strategy in older compared to young adults, independent of sensory availability/accuracy. These findings indicate that older adults compensate for the loss of accuracy in sensory input by increasing reliance on upper body movement strategies.

Implementing a cirrhosis order set in a tertiary healthcare system: a theory-informed formative evaluation

BACKGROUND

Standardized order sets are a means of increasing adherence to clinical practice guidelines and improving the quality of patient care. Implementation of novel quality improvement initiatives like order sets can be challenging. Before the COVID-19 pandemic, we conducted a formative evaluation to understand healthcare providers' perspectives on implementing clinical changes and the individual, collective and organizational contextual factors that might impact implementation at eight hospital sites in Alberta, Canada.

METHODS

We utilized concepts from the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT) to understand the context, past implementation experiences, and perceptions of the cirrhosis order set. Eight focus groups were held with healthcare professionals caring for patients with cirrhosis. Data were coded deductively using relevant constructs of NPT and CFIR. A total of 54 healthcare professionals, including physicians, nurses, nurse practitioners, social workers and pharmacists and a physiotherapist, participated in the focus groups.

RESULTS

Key findings revealed that participants recognized the value of the cirrhosis order set and its potential to improve the quality of care. Participants highlighted potential implementation challenges, including multiple competing quality improvement initiatives, feelings of burnout, lack of communication between healthcare provider groups, and a lack of dedicated resources to support implementation.

CONCLUSIONS

Implementing a complex improvement initiative across clinician groups and acute care sites presents challenges. This work yielded insights into the significant influence of past implementation of similar interventions and highlighted the importance of communication between clinician groups and resources to support implementation. However, by using multiple theoretical lenses to illuminate what and how contextual and social processes will influence uptake, we can better anticipate challenges during the implementation process.

Exploring how arm movement moderates the effect of task difficulty on balance performance in young and older adults

Emerging evidence highlights that arm movements exert a substantial and functionally relevant contribution on quiet standing balance control in young adults. Ageing is associated with "non-functional" compensatory postural control strategies (i.e., lower limb co-contraction), which in turn, may increase the reliance on an upper body strategy to control upright stance. Thus, the primary purpose of this study was to compare the effects of free versus restricted arm movements on balance performance in young and older adults, during tasks of different difficulty. Fifteen young (mean ± SD age; 21.3 ± 4.2 years) and fifteen older (mean ± SD age; 73.3 ± 5.0 years) adults performed bipedal, semi-tandem and tandem balance tasks under two arm position conditions: restricted arm movements and free arm movements. Centre of pressure (COP) amplitude and frequency were calculated as indices of postural performance and strategy, respectively. Especially in older adults, restriction of arm movement resulted in increased sway amplitude and frequency, which was primarily observed for the mediolateral direction. Further, increasing balance task difficulty raised the arm restriction cost (ARC; a new measure to quantify free vs. restricted arm movement differences in postural control) that was more prominent in older adults. These findings indicate the ARC provides a measure of reliance on the upper body for balance control and that arm movement is important for postural control in older adults, especially during tasks of greater difficulty.

A64 THE UPTAKE AND IMPACT OF AN ELECTRONIC CIRRHOSIS ADMISSION ORDER SET: AN EARLY EXPERIENCE AT A SINGLE CENTRE

Background

Cirrhosis is a chronic disease that confers high morbidity and mortality. It is a leading cause for hospital admissions and leads to significant healthcare resource utilization. Several guidelines outline recommendations to provide best practice to hospitalized patients with cirrhosis. Despite studies supporting a reduction in mortality when guideline based care is followed, this is achieved in less than 50% of hospitalized patients with cirrhosis¹. Standardized electronic order sets can be a potential tool to improving clinical outcomes and bridging this gap in care.

Purpose

Since March 2021, an electronic cirrhosis admission order set has been available for at our hospital site. Using administrative data, we aimed to describe our early experience with: a) order set uptake by various services, b) characteristics of the population in which the order set was used versus not used, and explore c) the impact of order set use on in-hospital mortality.

Method

In this single centre cohort study, patients with cirrhosis were identified based an administrative data algorithm containing codes for cirrhosis and complications. This data was used to retrieve parameters such as patient age, sex, primary admitting service, resource intensity weight (RIW), Charlson comorbidity index (CCI) and in-hospital mortality. The chi-squared test and independent samples t-test were used to compare characteristics of patients in whom the order set was used versus not used. Multivariable logistic regression was used to determine the impact of order set use on in-hospital mortality. P value significance was established at <0.05.

Result(s)

A total of 825 patients were included in the analysis. The overall mean age (standard deviation) of patients was 58.5 (14.2) years with 57.5% being male. Average length of stay was 11.3 days with a mean CCI of 3.2 (2.3) and RIW of 3.3 (7.2). The primary admitting service was Gastroenterology in 36.1%, Internal Medicine in 35.6% and other services in 28.3% of cases. Of those admitted, the order set was used in 27.2% of cases. The overall in-hospital mortality of patients was 14.2%.

Mean age, sex and CCI were not significantly different in patients admitted with the order set versus without. In patients admitted with the order set compared to without, RIW was significantly lower (2.06 (2.62) versus 3.80 (8.2), p<0.001), as was length of stay (9.5 (11.8) days compared to 12.0 (18.6) days, p =0.03) and in-hospital mortality (8.5% versus 16.3%, p =0.003). On multivariable regression analysis (Table 1), after adjustment for age, RIW and CCI, use of the order set was associated with lower in-hospital mortality (odds ratio 0.53 (95% CI 0.3 to 0.9), p=0.02).

Image

Conclusion(s)

Uptake of the electronic cirrhosis admission order set was modest at only 27% of eligible admissions. Although it appears to be associated with lower in-hospital mortality, a chart review is in process to assess if this association still holds after accounting for the impact of additional confounders.

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Disclosure of Interest

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1215 IMPROVING THE QUALITY OF ANTICIPATORY CARE PLANNING FOR PATIENTS WITH RECURRENT ASPIRATION PNEUMONIA

Introduction

Recurrent episodes of aspiration pneumonia (RAP) are a significant problem in frail patients leading to high re-hospitalization and mortality. Anticipatory care planning (ACP) enables improved quality of life and end of life care. We reviewed the assessment, ACP discussions and communication with Primary Care in these patients.

Methods

We used a PDSA methodology, reviewing 116 patients with RAP referred to Speech and Language Therapy (SLT) in Elderly Medicine wards over six months, including the winter. Educational interventions were implemented. An illustrative case and pre-intervention results were presented at an online hospital-wide seminar and subsequently at an online departmental medical staff teaching session. Post-intervention analysis of 10 patients with RAP admitted over two summer months was conducted. The second round of interventions included departmental induction teaching for newly rotated doctors and creating an electronic ACP document (RAP ACP) for inclusion within the medical record.

Results

Baseline data was collected from 116 patients (mean age 85, 47% female). After the educational interventions, data was collected from 10 patients (mean age 88, 70% female). Data is being collected from winter months after the second intervention. This will be available before the conference. Baseline data demonstrated the need for improvements in documentation of Mental Capacity Assessment (MCA) specific to feeding (21.5%), ACP completion (26.7%) and flagging patients suitable for the Gold Standards Framework (GSF) on discharge (15%). Following educational interventions, there was a substantial improvement in MCA documentation (80%). Furthermore, there was a marked improvement in the completion of ACP discussions (70%). Communication of patients eligible for GSF was similar (14.2%) post-intervention.

Conclusions

Educational interventions substantially improved the quality of individualised care provided to patients with RAP. Mortality was high in both groups, yet documentation of eligibility for GSF was low, prompting further interventions targeting discharge communication.

Percutaneous thrombectomy of upper extremity and thoracic central veins using Inari ClotTriever System: Experience in 14 patients

Objective

In the present report, we have described the technical and clinical outcomes of percutaneous thrombectomy in the deep veins of the upper extremity and thorax using the ClotTriever system (Inari Medical, Irvine, CA).

Methods

Fourteen patients with symptomatic deep venous occlusive disease in the upper extremity deep veins and thoracic central veins who had undergone thrombectomy using the ClotTriever system between October 2020 and January 2022 were reviewed. The technical results, adverse events, imaging follow-up data, and clinical outcomes were recorded.

Results

Fourteen patients (seven men and seven women; mean age, 53.6 ± 13.3 years) constituted the study cohort. Of the 14 patients, 9 (64.3%) had had DVT due to intravascular invasion or external compression from known malignancy, 2 (14.3%) had had infected thrombi and/or vegetation due to Staphylococcus aureus refractory to intravenous antibiotic therapy, and 3 (21.4%) had had a benign etiology for thrombus formation. The presenting symptoms included upper extremity and/or facial swelling (n = 14), upper extremity pain (n = 6), fever (n = 2), and dyspnea (n = 1). Thrombectomy with the ClotTriever system was successfully completed in all 14 patients. Seven patients (50.0%) had required additional venous stent reconstruction after thrombectomy to address the underlying stenosis. No major adverse events were noted. All the patients had experienced resolution of the presenting symptoms.

Conclusions

For the management of symptomatic deep venous occlusive disease of the upper extremity deep veins and thoracic central veins, thrombectomy using the ClotTriever system was feasible with excellent technical and clinical success.

Age-related differences in vertical jump height and handgrip strength measurements

PURPOSE

This study aimed to examine the effects of age on vertical jump height and handgrip strength measurements in women. A secondary aim was to investigate the correlations between vertical jump height and handgrip strength.

METHODS

Twenty young (21.5 ± 2.8 years) and twenty older (67.0 ± 5.5 years) healthy women participated in this study. Handgrip contractions were used to assess strength measurements of peak force and rate of force development at different time intervals. Vertical jumps were performed on a jump mat. The jump mat measured vertical jump height based on flight time.

RESULTS

The older women had lower vertical jump height (P < 0.001) and handgrip peak force (P = 0.028) and rate of force development values (P = 0.003-0.016) than the younger women. A larger difference was observed between the groups for vertical jump height (41%) than handgrip peak force and rate of force development (12-17%). Of all the strength measurements, handgrip rate of force development at 200 ms in the young (r = 0.502, P = 0.024) and older (r = 0.446, P = 0.049) women exhibited the strongest correlation with vertical jump height.

CONCLUSIONS

This investigation showed significantly lower vertical jump height and handgrip peak force and rate of force development values in older compared to younger women. Interestingly, the difference between age groups was larger for jump height than handgrip peak force and rate of force development. This suggests that vertical jump performance may be more severely affected by age than handgrip strength characteristics.

A dedicated breast-PET/CT scanner: Numerical observer study of lesion detection

BACKGROUND

Dedicated, breast-specific positron emission tomography (BPET)-cone-beam computed tomography (BPET/CT) systems have been developed to improve detection and diagnosis of cancer in women with indeterminate mammograms caused by radiodense breasts. The absorption of X-rays that often vexes mammography in this subset of women does not affect the detection of the high energy annihilation photons used in PET. PET imaging of the breast, however, is subject to limitations caused by their comparatively low spatial resolution (∼2 mm) and often moderate radiotracer uptake in lesions.

PURPOSE

The purpose of this investigation is to explore the PET-based lesion detection capabilities of a BPET/CT scanner developed by the Department of Radiology Instrumentation group at West Virginia University.

METHODS

The PET component of the system consists of a rotating pair of 96 × 72 arrays of 2 × 2 × 15 mm3 LYSO scintillator elements. The cone-beam-CT component utilized a pulsed X-ray source and flat panel detector operated in portrait orientation. The density maps created by the CT scanner were used to correct the BPET data for photon attenuation and Compton scattering. The nonuniform uptake of 18 F-fluorodeoxyglucose (FDG) in normal breast tissue was emulated in a specially designed phantom consisting of an acrylic cylinder filled with a mixture of acrylic beads and liquid containing FDG. FDG-avid lesions were simulated with agar spheres (3, 4, 6, 8, and 10 mm diameters) containing vary amounts of FDG to produce target-to-background ratios (TBR) of 6:1, 8:1, and 10:1. The spheres also contained X-ray contrast agent to make even the smallest ones readily visible in CT images. Positions of all the lesions were identified in the CT images. These positions were used to extract signal present and signal absent sub-images from the PET images. The sub-images were then input to software that calculated areas-under-the-curve for two numerical model observers (Laguerre-Gauss channelized Hotelling observer and non-prewhitening matched filter).

RESULTS

The results showed that the smallest detectable lesion with this system is no smaller than ∼3 mm in diameter with a TBR of 6:1. Simulated lesions with diameters of 4 mm and greater were calculated to have good to excellent likelihood of detection for all TBRs tested.

CONCLUSION

The results from this investigation identified the detectability capabilities and limitations for a dedicated breast-PET/CT scanner. Its ability to detect relatively small simulated FDG-avid breast lesions for a range of TBRs indicates its potential for clinical application. Finally, the study used methodologies that could be applied to a detectability assessment of other PET/CT scanners.

146 GOLD STANDARD GOAL-SETTING: ARE WE HITTING THE MARK? IMPLEMENTING AN INTERDISCIPLINARY GOAL-SETTING PATHWAY IN STROKE REHABILITATION

Background

The cornerstone of rehabilitation is effective and realistic interdisciplinary goal-setting with patient and family engagement across the continuum of recovery. The Royal College of Physicians National Clinical Guidelines for Stroke (2016) highlights the importance of encouraging self-management and self-efficacy to support a more person-orientated approach. This quality improvement initiative aimed to introduce a structured interdisciplinary goal-setting pathway on a post-acute 14-bed stroke unit.

Methods

An interdisciplinary working group was established comprising of Physiotherapy, Occupational Therapy, Speech & Language Therapy, Medical Social Work and Nursing. Quality improvement methodology was used to sequentially implement change over a 6-month period. The restructure included the introduction of an initial and review goal-focused family meeting. An interdisciplinary tool was developed based on the East Kent Outcome System (EKOS). A series of workshops was delivered to support implementation.

Results

An interdisciplinary goal-setting pathway is currently being piloted for 6 months on the stroke unit. To date, 22 staff have been trained and 9 patients have progressed through the updated pathway. Analysis has provided useful clinical insights and qualitative feedback has been collated regarding the benefits of the early opportunity to meet the team, establishing patient’s personal goal priorities and clear timeframes.Furthermore, repeat trials followed by reflections have enabled the team to develop consistency and confidence in person-centred, interdisciplinary goal-setting. It is acknowledged that this initiative has been a significant change process for the team and that adjustments are being made, in line with the principles of quality improvement.

Conclusion

This person-orientated interdisciplinary process is evidence-based and in line with national standards and guidelines for stroke rehabilitation. Formal training in EKOS is planned and a clinical audit will follow the pilot phase to systematically evaluate the change in practice.

Development of a Three-Dimensional Multi-Modal Perfusion-Thermal Electrode System for Complete Tumor Eradication

Background: Residual viable tumor cells after ablation at the tumor periphery serve as the source for tumor recurrence, leading to treatment failure. Purpose: To develop a novel three-dimensional (3D) multi-modal perfusion-thermal electrode system completely eradicating medium-to-large malignancies. Materials and Methods: This study included five steps: (i) design of the new system; (ii) production of the new system; (iii) ex vivo evaluation of its perfusion-thermal functions; (iv) mathematic modeling and computer simulation to confirm the optimal temperature profiles during the thermal ablation process, and; (v) in vivo technical validation using five living rabbits with orthotopic liver tumors. Results: In ex vivo experiments, gross pathology and optical imaging demonstrated the successful spherical distribution/deposition of motexafin gadolinium administered through the new electrode, with a temperature gradient from the electrode core at 80 °C to its periphery at 42 °C. An excellent repeatable correlation of temperature profiles at varying spots, from the center to periphery of the liver tumor, was found between the mathematic simulation and actual animal tumor models (Pearson coefficient ≥0.977). For in vivo validation, indocyanine green (ICG) was directly delivered into the peritumoral zones during simultaneous generation of central tumoral lethal radiofrequency (RF) heat (>60 °C) and peritumoral sublethal RF hyperthermia (<60 °C). Both optical imaging and fluorescent microscopy confirmed successful peritumoral ICG distribution/deposition with increased heat shock protein 70 expression. Conclusion: This new 3D, perfusion-thermal electrode system provided the evidence on the potential to enable simultaneous delivery of therapeutic agents and RF hyperthermia into the difficult-to-treat peritumoral zones, creating a new strategy to address the critical limitation, i.e., the high incidence of residual and recurrent tumor following thermal ablation of unresectable medium-to-large and irregular tumors.

462 - Renforcement des capacités des acteurs de riposte de la COVID-19 en Afrique de l'Ouest - Expérience de l'Organisation Ouest Africaine de la Santé (OOAS)

Contexte

En mars 2020, l'avènement de la pandémie COVID-19 et les mesures de restriction mises en place afin de la contenir limitaient l'organisation des formations physiques. Le besoin de mise à jour des connaissances, compétences et pratiques des agents de riposte des pays de l'Afrique de l'Ouest a conduit l'Organisation Ouest Africaine de la Santé, à mettre en place un programme de formations en ligne au profit des acteurs de riposte de l'Afrique de l'Ouest.

Méthodes

Il s'est agit de la revue des rapports des formations organisées et des expériences vécues par les organisateurs de ces formations. Cette revue a pris en compte les résultats des pré et post-test qui étaient réalisées au cours de la formation.

Résultats

De mars à juillet 2020, 33 formations ont été organisées dans les trois langues officielles de l'Afrique de l'Ouest (17 francophones, 14 anglophones et 02 lusophones). Les formations ont couvert l’épidémiologie/surveillance, le diagnostic du laboratoire, la prise en charge des cas, la communication sur les risques, la prévention et du contrôle infections. Le contenu des formations était basé sur les guides internationaux édités et les formateurs étaient des experts expérimentés. Les bénéficiaires au nombre de 3241, venaient de tous les niveaux du système de santé et étaient des médecins, des infirmiers, des aides-soignants, des biologistes, des hygiénistes, des communicateurs et acteurs de la surveillance. Les évaluations pré et post test ont permis de noter l'amélioration dans l'acquisition des connaissances dans 92 % des cas des formations.

Discussions/Conclusion

Cette expérience, qui était une innovation en Afrique de l'Ouest, a contribué à la mise à niveau des acteurs. Les leçons tirées vont aider au développement du programme de renforcement continu des capacités professionnelles en Afrique de l'Ouest.

Déclaration de liens d'intérêts

Les auteurs déclarent ne pas avoir de liens d'intérêts.

Effect of treatment adherence on the association between sex and unfavourable treatment outcomes among tuberculosis patients in Puducherry, India: a mediation analysis

BACKGROUND

A better understanding of the complex interplay between risk factors of tuberculosis (TB) is essential. This study was part of the Regional Prospective Observational Research for Tuberculosis (RePORT) India consortium and includes newly diagnosed TB patients in Puducherry between 2014 and 2018. We employed mediation analysis to identify the effect of treatment adherence on association between sex and unfavourable TB treatment outcomes.

METHODS

Required demographic and treatment-related variables were extracted from the RePORT India consortium database and causal mediation analysis using parametric regression models was done.

RESULTS

Of the 712 TB patients, ~87 (12.2%) had unfavourable TB treatment outcomes. Total effect of male sex was significantly associated with the unfavourable TB treatment outcomes [adjusted odds ratio (aOR) = 2.48; 95% confidence interval (CI): 1.11-5.55]. However, the overall association between male sex and TB treatment outcomes was dominated by the indirect pathway, as the direct pathway does not show significant association (aOR = 1.67; 95% CI: 0.75-3.75), while the indirect pathway shows significantly higher odds of TB treatment outcomes (aOR = 1.48; 95% CI:1.27-1.73), indicating complete mediation by the treatment adherence.

CONCLUSIONS

The study has shown a complete mediation of sexes through TB treatment adherence for unfavourable treatment outcomes. Developing of treatment strategies require better understanding between the biological and social factors related to TB.

Representation of Racial and Ethnic Minority Populations in Dementia Prevention Trials: A Systematic Review

Despite older racial and ethnic minorities (REMs) being more likely to develop dementia they are underrepresented in clinical trials focused on neurological disorders. Inclusion of REMs in dementia prevention studies is vital to reducing the impact of disparities in dementia risk. We conducted a systematic review to characterize the number of REM enrolled in brain health and prevention randomized controlled trials (RCTs). RTCs published from January 1, 2004 to April 21, 2020 were included. Participants were normal cognitive adults aged 45 years and older who participated in a Phase II or Phase III U.S. based preventative trial. Analyses were performed to examine differences in trial characteristics between RCTs that did and those that did not report race/ethnicity and to calculate the pooled proportion of each racial/ethnic group in randomized brain healthy prevention trials. A total of 42 studies consisting of 100,748 participants were included in the final analyses. A total of 26 (62%) reported some racial/ethnic identity data. The pooled proportion of REM participants was 0.256 (95% CI, 0.191, 0.326). There is a lack of racial/ethnic reporting of participants and REMs remain underrepresented in brain health prevention RCTs.

A88 UNDERSTANDING NURSE PERCEPTIONS OF CARING FOR PATIENTS WITH ALCOHOL USE DISORDER: A CROSS-SECTIONAL STUDY

Background

Alcohol Use Disorder (AUD), the problematic consumption of alcohol, affects 107 million people worldwide. AUD increases morbidity and mortality and has a substantial impact on daily functioning including quality of life, relationships and employment. AUD is particularly detrimental in patients who already have liver damage like cirrhosis. The management of AUD includes screening, brief intervention and referral to treatment for psychological and pharmacotherapy based treatment. People with AUD have frequent interactions with the healthcare system. These interactions represent opportunities to engage patients with therapy. As front-line workers who have maximal contact with patients, nurses practicing in acute care are in an ideal position to initiate AUD related discussion with patients. Prior to the design of an educational intervention to increase nursing engagement with AUD screening and brief intervention, there is a need to understand baseline knowledge, attitudes and perceptions in this group.

Aims

The aim of the present study was to explore the knowledge, attitudes and perceptions of nurses caring for patients with cirrhosis and AUD.

Methods

We conducted a cross-sectional survey using the Survey of Attitudes and Perceptions (SAP). The SAP is derived from a validated tool to assess attitudes and perceptions towards patients with AUD. Anonymous surveys were distributed on inpatient medicine units across 5 geographic zones in Alberta between September 2019-March 2020. Data were analyzed using descriptive and inferential statistics.

Results

A total of 93 nurses from 7 inpatient medicine units across Alberta participated in the study. The majority of participants were Registered Nurses (74.9%), who practiced in an urban setting (69%), and had worked in their role for an average of 9.9 years. Few (22.6%) participants reported any prior structured education on caring for patients with AUD, with the majority reporting limited knowledge of alcohol and effects of alcohol consumption. Though most reported that caring for patients with AUD was part of their professional role, only 15.7% felt motivated to work with this group of patients. Responses to individual questions or sub-domains of the survey did not significantly differ by length or time in professional role, or practice setting.

Conclusions

Our results indicate that nurses have limited knowledge on caring for patients with AUD. Given the importance of AUD in the development and progression of cirrhosis as well as the frequency of hospitalizations for patients with cirrhosis, increasing nurse knowledge of AUD is crucial to improving the quality of care for these patients. The results of this study will be used to inform the development of an educational intervention to increase nursing knowledge of caring for patients with cirrhosis and AUD.

Funding Agencies

Alberta Innovates

A78 “CHALLENGING PERSPECTIVES:” UNDERSTANDING CLINICIANS VIEWS ON MANAGING ALCOHOL USE DISORDER AND CIRRHOSIS

Background

Alcohol use disorder (AUD) is one of the leading etiologies for liver cirrhosis and liver transplantation. Few individuals with AUD receive guideline-based care in the form of screening, brief intervention, referral to treatment, or prescription of anti-relapse pharmacotherapies. We interviewed clinicians across Alberta to assess the current experience and perceived barriers to managing AUD in people who have cirrhosis.

Aims

The aim of this project is to summarize these findings to inform the development of an educational intervention.

Methods

We used a qualitative descriptive approach to explore the experiences of clinicians who provide care for patients with cirrhosis and AUD in Alberta. We conducted semi-structured interviews directed by an interview guide. Interviews were recorded and transcribed verbatim. We used an inductive thematic analysis approach whereby transcripts were coded, with codes grouped into larger categories, then themes.

Results

Sixteen clinicians participated in this study. Many participants acknowledged that they do not use a standardized approach to screening, brief intervention, and referral to treatment. Through thematic analysis we identified three themes surrounding barriers to managing AUD in patients with cirrhosis: (i) Practicing within knowledge constraints, (ii) Navigating limited resources and system challenges, and (iii) Acknowledging the complexity of patients who have cirrhosis and AUD.

Conclusions

This research presents the perspectives of clinicians who manage people who have AUD and cirrhosis. Our results indicate that significant barriers exist that affect how clinicians manage AUD in the context of cirrhosis, including limited knowledge and resources, systemic challenges, and patient complexity. The information gathered in this investigation will be used to develop an accredited educational intervention that will delve deeper into these issues in order to have the greatest impact on clinicians who routinely interface with this patient population.

Funding Agencies

Alberta Innovates Health Solutions

A87 CHANGES IN CLINICIAN KNOWLEDGE, COMFORT, PREPAREDNESS, AND ATTITUDES ABOUT ALCOHOL USE DISORDER AND CIRRHOSIS AFTER A BRIEF EDUCATIONAL INTERVENTION

Background

Alcohol use disorder (AUD) is increasing in prevalence and has a substantial impact on morbidity and mortality in people with cirrhosis. The use of screening, brief intervention and referral to treatment (SBIRT) and relapse prevention medications (e.g. acamprosate) are recommended by recent guidelines. Unfortunately, many clinicians report insufficient training to feel confident using these interventions

Aims

We aimed to compare the effect of a brief educational intervention on AUD knowledge, comfort, attitudes, and preparedness in clinicians who provide care to patients with cirrhosis.

Methods

Clinicians were invited to participate in a 1.5-hour educational session conducted by a hepatologist and addiction medicine specialist. The session included information about SBIRT and pharmacotherapy. Pre-training knowledge, comfort, and practice behaviors were assessed using previously published questions. Baseline attitudes were measured using the Short Alcohol and Alcohol Problems Perception Questionnaire. Participants were invited to repeat the questionnaires immediately post-training and statistical analysis conducted.

Results

Eighty-two clinicians attended the session. Among the 38 attendees who completed both the pre- and post-questionnaires, 34% were GIs/internists, 45% were family medicine physicians, and the remainder (21%) did not specify or were not prescribers. Scores for self-reported intention and preparedness to treat AUD, comfort, and knowledge improved significantly from the pre-training phase. Attitudes also improved from the pre-training phase, with significant improvements in the SAAPPQ subscales of role adequacy (p=0.03) and motivation (p=0.04).

Conclusions

Recognizing the small sample size, a brief educational session demonstrated promising results in the promotion of knowledge, attitudes, preparedness, and comfort for clinicians managing AUD in patients with cirrhosis. Feedback from these sessions will be used to design an accredited educational series for roll-out in 2022.

Funding Agencies

Alberta Innovates Health Solutions

A208 ASSESSING FEASIBILITY AND ACCEPTABILITY OF AN ONLINE MIND-BODY WELLNESS PROGRAM FOR PRIMARY BILIARY CHOLANGITIS

Background

Persons with primary biliary cholangitis (PBC) experience significantly higher rates of fatigue, stress, anxiety, depression, and impaired health related quality of life (HRQOL) as compared to the general population. While online wellness programming has been shown to be effective in decreasing fatigue and improving mental wellness in a variety of chronic disease populations, limited data is available for PBC.

Aims

This pilot study aimed to assess the hypothesis that a 12-week, online, mind-body wellness program would be feasible (assessed through adherence and retention) and acceptable in people with PBC. We also aimed to explore indicators of impact on measures of wellbeing.

Methods

Persons with PBC were recruited across Alberta and British Columbia in January 2021. The program included a 20–30 minute video containing low intensity mindful movement, meditation, and breathwork (goal 2–3 times/week) as well as a weekly behaviour change tip, PBC tip from a physician, and PBC nutrition tip. The online programming was accompanied by brief (10-minute) once weekly phone check-ins from a member of the study team, and optional once monthly zoom group sessions hosted by the Canadian PBC Society. Satisfaction and adherence were assessed at the end of the study using a survey. The pre-post exploratory efficacy assessment included: fatigue (Modified Fatigue Impact Scale), perceived stress (Perceived Stress Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and HRQOL (PBC-40). Using a qualitative descriptive approach, we conducted semi-structured interviews at the end of the study to explore experiences with the intervention, and gather feedback for improvement.

Results

Participants (N = 32) completed baseline surveys and 29 (91%) were retained to end-of-study. Twenty-five (86%) adhered to the program goal of carrying out the mind-body practice at least 2–3 days per week. Comparing baseline to end-of-study, significant reductions were observed in fatigue (13%, p=0.004), anxiety (30%, p=0.005), and depression (28%, p=0.022), and significant improvements were observed in the PBC-40 itch (22%, 0.043), fatigue (13%, 0.005), cognitive (17%, 0.006), and emotional (18%, 0.001) domains. Eleven individuals participated in qualitative interviews, reporting an increase in energy, a more positive outlook, and increased knowledge of PBC. Feedback supported acceptability (satisfaction score of 90%), with fatigue cited as the primary barrier to increased program participation.

Conclusions

These findings suggest that a 12-week online mind-body intervention is feasible and acceptable to persons with PBC and has promising impact on efficacy. Recognizing the limitations of a single-arm study with a small sample size, a future RCT will be designed using this feedback.

Funding Agencies

MITACS Accelerate, Canadian PBC Society

Recognizing and treating trigger finger

This inflammatory condition can leave your patient in pain and with impaired function. Here's what you need to know about the diagnosis and Tx options to provide relief.

Odderon Exchange from Elastic Scattering Differences between pp and pp[over ¯] Data at 1.96 TeV and from pp Forward Scattering Measurements

We describe an analysis comparing the pp[over ¯] elastic cross section as measured by the D0 Collaboration at a center-of-mass energy of 1.96 TeV to that in pp collisions as measured by the TOTEM Collaboration at 2.76, 7, 8, and 13 TeV using a model-independent approach. The TOTEM cross sections, extrapolated to a center-of-mass energy of sqrt[s]=1.96  TeV, are compared with the D0 measurement in the region of the diffractive minimum and the second maximum of the pp cross section. The two data sets disagree at the 3.4σ level and thus provide evidence for the t-channel exchange of a colorless, C-odd gluonic compound, also known as the odderon. We combine these results with a TOTEM analysis of the same C-odd exchange based on the total cross section and the ratio of the real to imaginary parts of the forward elastic strong interaction scattering amplitude in pp scattering for which the significance is between 3.4σ and 4.6σ. The combined significance is larger than 5σ and is interpreted as the first observation of the exchange of a colorless, C-odd gluonic compound.

P–738 Fertility Preservation: Comparative analysis about the knowledge of the topic between two female populations in Argentina and the United States

Study question

Is there any difference in the knowledge that women in Córdoba (Argentina) and South Carolina (United States) have about fertility preservation, according to their socioeconomic and educational level?

Summary answer

Scarce knowledge about fertility preservation in both populations was registered. Only sectors of higher socioeconomic and educational level responded correctly with values close to 60%.

What is known already

There are numerous factors that may motivate the need to preserve fertility in young individuals. These factors can be grouped into two causes: social (postponement of motherhood, gender change, etc.), or medical (oncological or surgical treatments). In these situations, it is important that society in general has access to information about fertility and the possibilities of preserving it, if necessary. On the other hand, in each country and region in particular the information on this topic is distributed in different ways, which could generate differences in the level of knowledge on these issues in different population groups.

Study design, size, duration

Descriptive quantitative study. A total of 3,041 answers were obtained, 88.8% from Argentina and 10.00% from the United States. An 83.72% (2,521) of the answers were made by women.

Participants/materials, setting, methods

A closed-ended questionnaire of 20 questions was designed (segmentation and aspects of knowledge about fertility and its preservation) and distributed to different sectors of society through social networks. The survey was answered by people from Córdoba (Argentina) and South Carolina (US), of both sexes and different age groups, educational levels (basic/higher) and socioeconomic levels (medium-low/high). All answers were collected through SurveyMonkey and were analyzed using calculation programs and statistical tools (Excel 2016, Statistica 8.0).

Main results and the role of chance

Data showed that the 47.98% of Argentine women and 42.68% of American women surveyed do not know the age at which fertility begins to decline. The group with the highest percentage of incorrect answers (61.11%) for this question was that of Argentine women who had no previous experience with assisted fertility and come from the lower-middle social class. When asked about the knowledge about the factors that affect fertility, only 55% of Argentine women answered correctly, compared to 64.85% of American women. For the Argentine group, the proportion of correct answers increased to 62.23% for higher education level and to 56.60% for higher socioeconomic level. Regarding whether they know what fertility preservation procedure consists of, only 47.98% of Argentine women and 42.68% of American women answered correctly. On the other hand, 69.37% of the former and 63.18% of the latter do not know which biological materials can be cryopreserved. Finally, only 25.68% of women in Argentina know about the extent of their medical coverage in terms of fertility preservation procedures, while this percentage is 7.95% for the US population.

Limitations, reasons for caution

The comparison between the two countries may be challenged by the inequality in the response rate to the survey. However, even the smaller number of responses obtained in the USA is sufficient to obtain valid conclusions.

Wider implications of the findings: The level of misinformation registered in this study could imply reduced chances of achieving pregnancy in the future, especially for older women, those who wish to postpone motherhood or those who must undergo cancer treatments. This work provides important information in the politics designing promoting information access on fertility preservation.

Trial registration number

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P–739 Fertility and its Preservation: Comparative Analysis about the Knowledge between Two Populations of Doctors and Health Professionals from Argentina and the United States

Study question

Is there any difference in the knowledge that doctors and health professionals from Córdoba (Argentina) and South Carolina (USA) have about fertility preservation or about when it should be applied?

Summary answer

Both populations have enough knowledge about some aspects of fertility preservation, but its training must be improved so they can give adequate counseling

What is known already

During the last decades, it has been observed that more young individuals need/decide to preserve fertility, whether for social or medical reasons. This presents a new challenge for the medical community, since, faced with this situation, it is important that society in general has access to information about fertility and the possibilities of preserving it, if necessary. To this end, it is essential that doctors and other health professionals have valid knowledge of the subject and are able to communicate it to their patients.

Study design, size, duration

Descriptive quantitative study. A total of 721 answers were obtained, 88.7% from Argentina and 11.3% from the United States. 28.43% (205) were doctors and 71.57% (516) were other health professionals.

Participants/materials, setting, methods

A closed-ended questionnaire of 20 questions was designed (segmentation and aspects about fertility preservation) and distributed to society through social networks. The survey was answered by people from Córdoba (Argentina) and South Carolina (US), of both sexes and different age, educational and socioeconomic levels. Only those with a medical degree or involved in some medical-related activity were selected. All answers were collected through SurveyMonkey and analyzed using calculation programs and statistical tools (Excel–2016, Statistica 8.0).

Main results and the role of chance

Data showed percentages of correct answers greater than 70% in all groups for the questions that analyze what factors can affect fertility, what situations can determine the need to preserve it, and what is the appropriate age for a woman to cryopreserve her eggs. On average, 82.4% of doctors and 72.87% of other health professionals know when it is the right time for patients diagnosed with cancer to receive information about the possibility of preserving their fertility. However, on average between both countries, only 34.63% of doctors has information about the legal medical coverage of their patients, while the 39.51% is completely unaware of their country’s laws. Finally, the percentages of professionals who do not know what material can be cryopreserved in girls who need to undergo oncological treatments reach 46.34 and 64.33% (doctors and other health professionals respectively).

Limitations, reasons for caution

The comparison between the two countries may be challenged by the inequality in the response rate to the survey. However, even the smaller number of responses obtained in the USA is sufficient to obtain valid conclusions.

Wider implications of the findings: Both populations have sufficient information about factors which affect fertility and its preservation, especially in cancer situations. Misinformation in health personnel about these aspects directly affects possibilities of achieving future pregnancies for patients. Continuous updating and guidance should be a priority, as well as information dissemination and adequate medical counseling.

Trial registration number

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Detection and PI-RADS classification of focal lesions in prostate MRI: Performance comparison between a deep learning-based algorithm (DLA) and radiologists with various levels of experience

PURPOSE

To compare the performance of lesion detection and Prostate Imaging-Reporting and Data System (PI-RADS) classification between a deep learning-based algorithm (DLA), clinical reports and radiologists with different levels of experience in prostate MRI.

METHODS

This retrospective study included 121 patients who underwent prebiopsy MRI and prostate biopsy. More than five radiologists (Reader groups 1, 2: residents; Readers 3, 4: less-experienced radiologists; Reader 5: expert) independently reviewed biparametric MRI (bpMRI). The DLA results were obtained using bpMRI. The reference standard was based on pathologic reports. The diagnostic performance of the PI-RADS classification of DLA, clinical reports, and radiologists was analyzed using AUROC. Dichotomous analysis (PI-RADS cutoff value ≥ 3 or 4) was performed, and the sensitivities and specificities were compared using McNemar's test.

RESULTS

Clinically significant cancer [CSC, Gleason score ≥ 7] was confirmed in 43 patients (35.5%). The AUROC of the DLA (0.828) for diagnosing CSC was significantly higher than that of Reader 1 (AUROC, 0.706; p = 0.011), significantly lower than that of Reader 5 (AUROC, 0.914; p = 0.013), and similar to clinical reports and other readers (p = 0.060-0.661). The sensitivity of DLA (76.7%) was comparable to those of all readers and the clinical reports at a PI-RADS cutoff value ≥ 4. The specificity of the DLA (85.9%) was significantly higher than those of clinical reports and Readers 2-3 and comparable to all others at a PI-RADS cutoff value ≥ 4.

CONCLUSIONS

The DLA showed moderate diagnostic performance at a level between those of residents and an expert in detecting and classifying according to PI-RADS. The performance of DLA was similar to that of clinical reports from various radiologists in clinical practice.

A75 IMPLEMENTING A CIRRHOSIS ORDER SET: A QUALITATIVE ANALYSIS OF PROVIDER-IDENTIFIED BARRIERS AND FACILITATORS

Background

Cirrhosis is the leading cause of mortality and morbidity in individuals with gastrointestinal disease. Multiple care gaps exist for hospitalized patients with cirrhosis, resulting in high rates of re-hospitalization (e.g. 44% at 90 days in Alberta). The Cirrhosis Care Alberta (CCAB) is a 4-year multi-component pragmatic trial with an aim to reduce acute-care utilization by implementing an electronic order set and supporting education across eight hospital sites in Alberta.

Aims

As part of the pre-implementation evaluation, this qualitative study analyzed data from provider focus groups to identify barriers and facilitators to implementation.

Methods

We conducted focus groups at eight hospital sites with a total of 54 healthcare providers (3–12 per site). A semi-structured interview guide based upon constructs of the Consolidated Framework for Implementation Research (CFIR) and Normalization Process Theory (NPT) frameworks was used to guide the focus groups. Focus groups were recorded and transcribed verbatim. Data was analyzed thematically and inductively.

Results

Five major themes emerged across all eight sites: (i) understanding past implementation experiences, (ii) resource challenges, (iii) competing priorities among healthcare providers, (iv) system challenges, and (v) urban versus rural differences. Site-specific barriers included perceived lack of patient flow, time restraints, and concerns about the quality and quantity of past implementation interventions. Facilitators included passionate project champions, and an ample feedback process.

Conclusions

Focus groups were useful for identifying pre-implementation barriers and facilitators of an electronic orders set. Findings from this study are being refined to address the influence of COVID-19, and the data will be used to inform the intervention roll-out at each of the sites.

Funding Agencies

Alberta Innovates

Mycoplasma Genitalium And Streptococcus Agalactiae Colonization In Pregnant Women: An Emerging Relationship

Introduction/Objective

Mycoplasma genitalium has been identified as an emerging sexually transmitted infection (STI) causing cervicitis, pelvic inflammatory disease and other gynecologic pathology. The prevalence of M. genitalium in pregnant women has not been determined, nor has frequency of co-infection with Streptococcus agalactiae (GBS). Neonatal sepsis caused by GBS is associated with black race and young maternal age with approximately 10%-30% of pregnant women colonized. The aim of this retrospective study was to investigate the possible association between M. genitalium infection and colonization with GBS in a large cohort of pregnant women from a tertiary care center in Houston, Texas.

Methods

Remnant endocervical samples collected from pregnant women attending clinics at the Baylor College of Medicine between September 2019 and December 2019 were screened for M. genitalium by transcription mediated amplification (Hologic, Inc. Marlborough, MA). Demographic, STI co-infection [Human papillomavirus (types 16,18), Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, and Herpes simplex virus], and GBS status data were recorded. Fisher’s exact test was performed for statistical analysis.

Results

719 total samples were collected and tested for M. genitalium. Of these, 41 (5.7%) were positive. The mean age of infected women was younger than noninfected women (24.9 vs. 28.1 years respectively p = 0.0004). More black women (34.2%) were infected with M. genitalium compared to white (14.6%) or other (51.2%) (p = 0.0003).

Rates of GBS colonization was significantly higher among women infected with M. genitalium compared to women who tested negative (58.3% vs. 16.1% respectively p = 0.002) and increased compared to national reported rates of GBS colonization. M. genitalium also showed a significant association with T. vaginalis (p=0.03), but no other STI co- infections studied.

Conclusion

Our data demonstrates that infection with M. genitalium may be associated with persistent GBS colonization. Further prospective studies are needed to further elucidate this relationship.

A realism-based approach to an ontological representation of symbiotic interactions

Background

The symbiotic interactions that occur between humans and organisms in our environment have a tremendous impact on our health. Recently, there has been a surge in interest in understanding the complex relationships between the microbiome and human health and host immunity against microbial pathogens, among other things. To collect and manage data about these interactions and their complexity, scientists will need ontologies that represent symbiotic interactions as they occur in reality.

Methods

We began with two papers that reviewed the usage of ‘symbiosis’ and related terms in the biology and ecology literature and prominent textbooks. We then analyzed several prominent standard terminologies and ontologies that contain representations of symbiotic interactions, to determine if they appropriately defined ‘symbiosis’ and related terms according to current scientific usage as identified by the review papers. In the process, we identified several subtypes of symbiotic interactions, as well as the characteristics that differentiate them, which we used to propose textual and axiomatic definitions for each subtype of interaction. To both illustrate how to use the ontological representations and definitions we created and provide additional quality assurance on key definitions, we carried out a referent tracking analysis and representation of three scenarios involving symbiotic interactions among organisms.

Results

We found one definition of ‘symbiosis’ in an existing ontology that was consistent with the vast preponderance of scientific usage in biology and ecology. However, that ontology changed its definition during the course of our work, and discussions are ongoing. We present a new definition that we have proposed. We also define 34 subtypes of symbiosis. Our referent tracking analysis showed that it is necessary to define symbiotic interactions at the level of the individual, rather than at the species level, due to the complex nature in which organisms can go from participating in one type of symbiosis with one organism to participating in another type of symbiosis with a different organism.

Conclusion

As a result of our efforts here, we have developed a robust representation of symbiotic interactions using a realism-based approach, which fills a gap in existing biomedical ontologies.

Barriers to management of diabetes foot ulcer: Experiential note from a setting with free medical services

The imperative need for behavioral agreement to overcome barriers of self-management of diabetes foot complication was recently articulated. A few journals have done parallel publications, which thereby stresses the significance of the issue. This article is to add to the "Overcoming barriers to self-management: the person-centred diabetes foot behavioural agreement". It presents experiential note with four tabulated cases of clients who have access to free state-of-the-art medical service; and non-adherence as a barrier to self-management is not due to affordances. It is to draw attention to the deliberately non-adherent patients where behavioral agreement process should be really driven by the client as in the real context of person-centered therapy.

Highly multimodal structure of high topological charge extreme ultraviolet vortex beams

Optical beams carrying orbital angular momentum are a very active field of research for their prospective applications, especially at short wavelengths. We consider here such beams produced through high-harmonic generation (HHG) in a rare gas and analyze the characterization of their high-charge vortex structure by an extreme ultraviolet Hartmann wavefront sensor. We show that such HHG beams are generally composed of a set of numerous vortex modes. The sensitivity of the intensity and phase of the HHG beam to the infrared laser aberrations is investigated using a deformable mirror.

Zinkicide Is a ZnO-Based Nanoformulation with Bactericidal Activity against Liberibacter crescens in Batch Cultures and in Microfluidic Chambers Simulating Plant Vascular Systems

Phloem-limited bacterial "Candidatus Liberibacter" species are associated with incurable plant diseases worldwide. Antimicrobial treatments for these pathogens are challenging due to the difficulty of reaching the vascular tissue they occupy at bactericidal concentrations. Here, in vitro antimicrobial mechanisms of Zinkicide TMN110 (ZnK), a nonphytotoxic zinc oxide (ZnO)-based nanoformulation, were compared to those of bulk ZnO (b-ZnO) using as a model the only culturable species of the genus, Liberibacter crescens Minimum bactericidal concentration (MBC) determination and time-kill assays showed that ZnK has a bactericidal effect against L. crescens, whereas b-ZnO is bacteriostatic. When ZnK was used at the MBC (150 ppm), its antimicrobial mechanisms included an increase in Zn solubility, generation of intracellular reactive oxygen species, lipid peroxidation, and cell membrane disruption; all of these were of greater intensity than those of b-ZnO. Inhibition of biofilms, which are important during insect vector colonization, was stronger by ZnK than by b-ZnO at concentrations between 2.5 and 10 ppm in batch cultures; however, neither ZnK nor b-ZnO removed L. crescens preformed biofilms when applied between 100 and 400 ppm. In microfluidic chambers simulating source-to-sink phloem movement, ZnK significantly outperformed b-ZnO in Zn mobilization and bactericidal activity against L. crescens planktonic cells in sink reservoirs. In microfluidic chamber assays assessing antibiofilm activity, ZnK displayed a significantly enhanced bactericidal activity against L. crescens individual attached cells as well as preformed biofilms compared to that of b-ZnO. The superior mobility and antimicrobial activity of ZnK in microenvironments make this formulation a promising product to control plant diseases caused by "Candidatus Liberibacter" species and other plant vascular pathogens.IMPORTANCE "Candidatus Liberibacter" species are associated with incurable plant diseases that have caused billions of dollars of losses for United States and world agriculture. Chemical control of these pathogens is complicated, because their life cycle combines intracellular vascular stages in plant hosts with transmission by highly mobile insect vectors. To date, "Candidatus Liberibacter" species are mostly unculturable, except for Liberibacter crescens, a member of the genus that has been used as a model for in vitro assays. Here, we evaluated the potential of Zinkicide (ZnK) as an antimicrobial against "Candidatus Liberibacter" species in batch cultures and under flow conditions, using L. crescens as a biological model. ZnK displayed bactericidal activity against L. crescens in batch cultures and showed increased mobility and bactericidal activity in microfluidic devices resembling "Candidatus Liberibacter" species natural habitats. ZnK performance observed here against L. crescens makes this compound a promising candidate to control plant diseases caused by vascular pathogens.

Phytophthora nicotianae Infection of Citrus Leaves and Host Defense Activation Compared to Root Infection

Currently, little is known about the host pathogen interaction between Phytophthora spp. and citrus roots versus leaves. Therefore, we compared the molecular events occurring in citrus roots and leaves after zoospore inoculation with Phytophthora nicotianae. We analyzed the physical characteristics and genetic responses to P. nicotianae infection of leaves and roots for susceptible and tolerant citrus rootstocks to examine the potential for leaves to model root responses to P. nicotianae infection. Leaves responded faster and stronger to P. nicotianae infection than roots, and leaves showed greater differential response than roots. In addition to differences in hormonal responses, sugar, phospholipase D (PLD), and phospholipase A (PLA) involvement in the interaction between citrus and P. nicotianae was identified. This work, for the first time, creates a solid P. nicotianae zoospore infection protocol, reports P. nicotianae infection on citrus leaves through stomata, and provides evidence that different host organs respond to the pathogen differentially in timing and magnitude. This work identifies the hormones, sugars, pathogenesis-related genes, PLDs, and PLAs that are involved in the molecular events occurring in citrus under infection of P. nicotianae zoospore, and advances our understanding of the mechanisms underlying the interaction.

Impact of the size of the lesion in prenatal neural tube defect repair on imaging, neurosurgical and motor outcomes: a retrospective cohort study

OBJECTIVES

(1) To compare brain findings between large and non-large neural tube defect (NTD); (2) to evaluate the impact of large lesion on the surgical parameters; (3) to study any associations between the size of the lesions and brain findings 6 weeks postoperatively and neurological short-term outcomes.

DESIGN

Retrospective cohort study.

SETTING

Texas Children's Hospital, between 2011 and 2018.

POPULATION

Patients who underwent prenatal NTD repair.

METHODS

Large lesion was defined when the lesion's surface was >75th centile of our cohorts' lesions.

MAIN OUTCOME MEASURES

Time of referral: ventriculomegaly and anatomical level of the lesion; surgery: duration and need for relaxing incisions. 6 weeks postoperative: hindbrain herniation (HBH) and ventriculomegaly. After delivery: dehiscence, need for hydrocephalus treatment and motor function.

RESULTS

A total of 99 patients were included, 25 of whom presented with large lesions. Type of lesion and ventriculomegaly were comparable between individuals with large and non-large lesions. Individuals with large lesions were associated with increased need for relaxing incisions by 5.4 times (95% CI 1.3-23.2, P = 0.02). Six weeks postoperatively, having a large lesion decreased by ten times the likelihood of having a postoperative reversal of HBH (odds ratio = 0.1, 95% CI 0.1-0.4, P < 0.01). At birth, larger lesions increased the risk for repair dehiscence by 6.1 times (95% CI 1.6-22.5, P < 0.01) and the risk of dehiscence or leakage of cerebrospinal fluid at birth by 5.5 times (95% CI 1.6-18.9, P < 0.01).

CONCLUSION

Prenatal repair of patients with large NTD presents a lower proportion of HBH reversal 6 weeks after the surgery, a higher risk of dehiscence and a higher need for postnatal repair.

TWEETABLE ABSTRACT

Evaluation of the size of fetal NTD can predict adverse neurological outcomes after prenatal NTD repair.

Plain Water Intake Is Positively Associated with Physical Activity and Ambient Temperature in Free-Living Adults

Objectives

Water loss via sweating increases during exercise especially in the heat, however, the evidence is limited as to whether moderate physical activity (PA) and ambient temperature (Ta) influence water intake in daily life. The purpose of this study was to examine the influence of PA and Ta on water intake and hydration state in free-living individuals.

Methods

Ninety-five healthy, but non-athletic (&lt; 4 h of exercise per week), adults (52 females) participated in the study. PA was assessed via the International Physical Activity Questionnaire and scored/stratified into PAhigh, PAmoderate, and PAlow. Fluid consumption was assessed by a validated 7-day fluid diary and was used to assess water intake from liquids (WI-L), plain water intake (PWI) and water intake from other beverages (WI-B). Food consumption was also recorded for 7 days and analyzed with the Nutrition Data System for Research (NDSR) software and was used to calculate water from foods (WI-F). All sources of water were pooled to calculate total water intake (TWI). Hydration was assessed with blood and a 24-h urine sample.

Results

People with PAhigh had higher TWI (4.0 ± 1.4 L·d−1 vs. 2.8 ± 0.7 L·d−1; P = 0.010) and WI-L (3.2 ± 1.4 L·d−1 vs. 2.1 ± 0.5 L·d−1; P = 0.009), compared to PAlow. PWI was also higher in PAhigh group (2.20 ± 1.20 L·d-1) compared to PAlow (1.10 ± 0.72 L·d−1, P = 0.003), but there was no significant difference in WI-B and WI-F (P ≥ 0.05). PWI showed a significant association with Ta (R2 = 0.08; P = 0.008), while WI-B did not (P ≥ 0.05). Positive associations between PWI and Ta only remained in the PAhigh group when stratified by different PA levels (R2 = 0.40; P = 0.028). However, the hydration state was not affected by PA nor Ta (P ≥ 0.05).

Conclusions

Higher PA and Ta were associated with higher TWI, and this appeared to be driven by PWI, and not by other beverages nor water from food. Hydration state was similar across levels of PA, likely because of the higher TWI in the PAhigh group.

Funding Sources

This study was funded by Danone Research.

AB1353-HPR EMPOWERING LEARNERS TO “OWN” THEIR PERFORMANCE: PRESENTING EDUCATIONAL PERFORMANCE DATA BACK TO LEARNERS AS A COMPONENT OF AND RATIONALE FOR SUBSEQUENT EDUCATION

Background:

Beginning in 2016, RMEI created multiple accredited online education focused on RA and designed for rheumatologists. In 2018, the educational scope expanded to include live meetings, starting with a symposium at EULAR. For all programming from 2016-18 (6 courses, in both live and online settings), educational content was developed based on performance data from the previous RA courses. During the 2019 EULAR symposium, we presented the outcomes findings - from both the 2018 symposium and online courses – to the assembled rheumatologists, identifying ongoing educational gaps observed in their specialty population. The rationale: to create continuity between symposia over time by demonstrating incremental improvements and continuing areas of need, while also endowing learners with a greater sense of ownership and investment in forthcoming educational content.

Objectives:

To evaluate the impact of presenting learner’s educational performance data to them before education addressing persistent gaps identified in their performance the year prior.

Methods:

Data collected during the 2018 EULAR symposium was analyzed to understand the underlying drivers impacting poor performance in an identified area of ongoing educational need (cycling versus switching TNF inhibitors). A linear regression model was run including all non-related curriculum, demographic, and evaluation questions as possible drivers against those related low-scoring (at Post-Test) curriculum questions. The content of RMEI’s 2019 symposium at EULAR was developed to address the identified significant drivers to improve population proficiency in cycling versus switching. In addition to developing content based on the above findings, that data was also presented to learners in poster format prior to their participation in the 2019 symposium. During the period between on-site registration and the start of the symposium, attendees had the opportunity to explore data-driven insights, via audio-guided posters located around the meeting room. These insights included discussion of 2018 data analysis, identified drivers of poor performance, introduced the iterative data-driven methodology employed, and rationale behind content development for the 2019 symposium. At the conclusion of the 2019 symposium learners were asked to describe the impact/relevance of being presented with their performance data, their intention of incorporating course content into practice, and what specifically they intended to change.

Results:

Data was collected on 135 clinicians (primarily physicians who actively treat patients with rheumatoid arthritis) who attended, and participated in, the symposium. With specific regard to the impact of seeing their own data presented back to them, 80% reported that seeing the learner data from the 2018 symposium enhanced their current learning experience. Further, 86% reported that they intended to incorporate course content into their clinical practice. Specifically, this population reported an intent to change their treatment approach and patient education practices.

Conclusion:

Education is only as effective as the degree to which the audience is engaged. While year over year data from 2016 through 2018 demonstrated that an iterative approach facilitated the meaningful and necessary reinforcement of challenging concepts, learners in prior years were not aware of the methodological underpinnings of the educational offerings. Presenting this population with findings derived from their performance - as a rationale for the education they were about to participate in proved a compelling motivator for active learner engagement, and may have had a positive influence on the degree to which learners implemented course content into their clinical practice.

Disclosure of Interests:

None declared

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.