Examining readiness for implementing practice changes in federally qualified health centers: A rapid qualitative study

Implementing evidence-based interventions remains slow in federally qualified health centers (FQHCs). The purpose of this study is to qualitatively examine the R = MC2 (Readiness = motivation × innovation specific capacity × general capacity) heuristic subcomponents in the context of implementing general and colorectal cancer screening (CRCS)-related practice changes in FQHCs. We conducted 17 interviews with FQHC employees to examine (1) experiences with successful or unsuccessful practice change efforts, (2) using approaches to promote CRCS, and (3) opinions about R = MC2 subcomponents. We conducted a rapid qualitative analysis to examine the frequency, depth, and spontaneity of subcomponents. Priority, compatibility, observability (motivation), intra- and interorganizational relationships (innovation-specific capacity), and organizational structure and resource utilization (general capacity) emerged as highly relevant. For example, organizational structure was described as related to an organization's open communication during meetings to help with scheduling procedures. The results contribute to understanding organizational readiness in the FQHC setting and can be helpful when identifying and prioritizing barriers and facilitators that affect implementation.

Technology-enabled multidisciplinary team in-reach for oral corticosteroid stewardship and optimizing care of suspected airways disease exacerbations

Overuse of corticosteroids is an important problem not only in asthma but also the management of other airways diseases including bronchiectasis and COPD and results in associated risks of serious side effects and irreversible harm. We report a pilot using an in-reach solution to review patients, optimise their care and facilitate early discharge. We discharged >20% of our patients immediately, which is potentially a significant reduction in hospital bed use and, most importantly, through this approach we were able to establish early diagnosis and reduce inappropriate oral corticosteroid use.

Accuracy of identifcation of traumatic brain injuries in routine hospital data

Background

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Much work on the epidemiology of TBI uses routinely collected health care data. There is no separate code for TBI in ICD-10, a common coding system for acute care. One reason for reported variations in TBI prevalence between countries is differences in the identification of TBI from routine data. This study assessed the performance of an Australian classification system (Pozzatto et al 2019), using a standardised approach to ICD-10 codes to identify cases of likely TBI in routine hospital discharge data.

Methods

The original study was done on hospital data from New South Wales. We replicated their approach using Irish hospital data, held by Health Intelligence, from 2013 to 2020. Cases not classified as TBI by this system, but with codes, such as loss-of-consciousness, skull fracture or intra-cranial injury were manually reviewed.

Results

All 98,419 discharges with any code in S00 to S99 were reviewed. 27,851 (28.3%) had a skull fracture or intracranial injury. 12,106 (12.3%) had loss-of-consciousness and/or post-traumatic amnesia. 11,976 (98.9%) of these (12.2% of the total) had either a skull fracture or an intra-cranial injury reported. 26,085 (26.5%) of the original 98,419 cases were classified as TBI using the NSW classification. Manual review of 1.3% (1,356) cases added a maximum of 0.32% (321) further possible cases of TBI, suggesting a sensitivity of the classification of 98.8% (95% CI 98.6% - 98.9%).

Discussion

The main limitation is that it is not possible to identify false positive cases - those coded as TBI, but where no TBI was present. This approach to identifying TBI works well, and is feasible for wider implementation. It provides comparability between different studies.

Pozzato I et al. (2019), Epidemiology of hospitalised traumatic brain injury in the state of New South Wales, Australia: a population-based study. Australian and New Zealand Journal of Public Health. 2019

Key messages

There are problems comparing data on TBI between different countries because no single code for TBI exists in ICD-10, and this is a real challenge for epidemiologists and health services researchers. The use of an agreed system, developed in Australia, for recoding injury data to identify TBI has promise, and shows excellent sensitivity in two countries.

P04.11 10-Year Institutional Retrospective Case Series of WHO Grade II Gliomas and Correlation of Seizures, Lobar Location, Histopathological Subtype and IDH-1 Mutation (2010–2020)

BACKGROUND

A 10-year retrospective case series was undertaken of all patients who had a tissue diagnosis of a World Health Organisation (WHO) Grade II glioma, i.e. low grade glioma (LGGM), at the Institute of Neurological Sciences (INS) between January 2010 and January 2020 (NB: pre-2016 World Health Organisation classification). The objective was to assess the correlation of World Health Organisation (WHO) Grade II gliomas to seizure symptomology, intracerebral tumour location, histopathological glioma sub-type and molecular markers including isocitrate dehydrogenase-1 (IDH-1) mutation.

MATERIAL AND METHODS

We extracted data regarding clinical, radiological, histological, molecular discriminators and functional outcomes in patients. The pre-operative symptomology was restricted to seizures, headache and focal neurological deficits.

RESULTS

84 patients underwent resection and had a mean age of 42rs (range: 21-77yrs]). Seizures (NB: pre-2017 International League against Epilepsy classification [ILAE]) occurred in 71% and of these 52% were generalised, 37% partial and 11% mixed. 31% had ongoing seizures postoperatively. Headache occurred in 38% (of these 50% had headache and seizures). Focal neurological deficits (FNDs) occurred in 21% (of these 61% had FNDs and seizures). Seizure, as an isolated pre-operative symptom occurred in 48% patients compared to isolated headache in 10% and isolated FNDs in 4%. Anatomically, 58% of lesions were frontal. The seizure spatial frequency was 60% frontal. Histologically, 60% were diffuse astrocytomas and 40% oligodendrogliomas. Furthermore, 71% of oligodendrogliomas and 49% of diffuse astrocytomas had a frontal location. IDH-1 mutation occurred in 80% patients (75% of these had seizures) and of these 66% were frontal.

CONCLUSIONS

Our analysis confirms a correlation between incidence of seizures, frontal lobar location, histopathological subtype and IDH-1 mutations (p = <0.05

A matching-adjusted indirect comparison of combination nivolumab plus ipilimumab with BRAF plus MEK inhibitors for the treatment of BRAF-mutant advanced melanoma☆

Background

Approved first-line treatments for patients with BRAF V600–mutant advanced melanoma include nivolumab (a programmed cell death protein 1 inhibitor) plus ipilimumab (a cytotoxic T lymphocyte antigen-4 inhibitor; NIVO+IPI) and the BRAF/MEK inhibitors dabrafenib plus trametinib (DAB+TRAM), encorafenib plus binimetinib (ENCO+BINI), and vemurafenib plus cobimetinib (VEM+COBI). Results from prospective randomized clinical trials (RCTs) comparing these treatments have not yet been reported. This analysis evaluated the relative efficacy and safety of NIVO+IPI versus DAB+TRAM, ENCO+BINI, and VEM+COBI in patients with BRAF-mutant advanced melanoma using a matching-adjusted indirect comparison (MAIC).

Patients and methods

A systematic literature review identified RCTs for DAB+TRAM, ENCO+BINI, and VEM+COBI in patients with BRAF-mutant advanced melanoma. Individual patient-level data for NIVO+IPI were derived from the phase III CheckMate 067 trial (BRAF-mutant cohort) and restricted to match the inclusion/exclusion criteria of the comparator trials. Treatment effects for overall survival (OS) and progression-free survival (PFS) were estimated using Cox proportional hazards and time-varying hazard ratio (HR) models. Safety outcomes (grade 3 or 4 treatment-related adverse events) with NIVO+IPI and the comparators were compared.

Results

In the Cox proportional hazards analysis, NIVO+IPI showed improved OS compared with DAB+TRAM (HR = 0.53; 95% confidence interval [CI], 0.39-0.73), ENCO+BINI (HR = 0.60; CI, 0.42-0.85), and VEM+COBI (HR = 0.50; CI, 0.36-0.70) for the overall study period. In the time-varying analysis, NIVO+IPI was associated with significant improvements in OS and PFS compared with the BRAF/MEK inhibitors 12 months after treatment initiation. There were no significant differences between NIVO+IPI and BRAF/MEK inhibitor treatment from 0 to 12 months. Safety outcomes favored DAB+TRAM over NIVO+IPI, whereas NIVO+IPI was comparable to VEM+COBI.

Conclusion

Results of this MAIC demonstrated durable OS and PFS benefits for patients with BRAF-mutant advanced melanoma treated with NIVO+IPI compared with BRAF/MEK inhibitors, with the greatest benefits noted after 12 months.

•

First-line treatments for BRAF V600-mutant melanoma include NIVO+IPI and BRAF/MEK inhibitors.

•

Results from prospective RCTs comparing NIVO+IPI and BRAF/MEK inhibitors have not yet been reported.

•

This MAIC evaluated NIVO+IPI versus BRAF/MEK inhibitors for BRAF-mutant advanced melanoma.

•

OS and PFS benefits were noted with NIVO+IPI versus BRAF/MEK inhibitors beginning at 12 months.

•

These findings may provide information relevant to the selection of treatments for BRAF-mutant advanced melanoma.

Optimizing surgery of metaphyseal-diaphyseal fractures of the fifth metatarsal: a cadaveric study on implications of intramedullary screw position, screw parameters and surrounding anatomic structures

AIMS

Many advocate screw fixation of fractures to the metaphyseal-diaphyseal junction of the fifth metatarsal base, better known as Jones fractures (JF), to facilitate quicker ambulation and return to sport. Maximizing screw parameters based on fifth metatarsal (MT5) anatomy, alongside understanding the anatomic structures compromised by screw insertion, may optimize surgical outcomes. This study aims to (1) correlate the proximity of JF to the peroneus brevis (PB) and plantar fascia (PF) footprints and (2) quantify optimal screw parameters given MT5 anatomy.

MATERIALS AND METHODS

3D CT-scan reconstructions were made of 21 cadaveric MT5s, followed by meticulous mapping of the PB and PF onto the reconstructions. Based on bone length, shape, narrowest intramedullary canal (IMC) diameter, and surrounding anatomy, two traditional debated screw positions were modeled for each reconstruction: (1) an anatomically positioned screw (AP), predicated on maximizing screw length by following the IMC for as long as possible, and (2) a clinically achievable screw (CA), predicated on maximizing screw length without violating the fifth tarso-metatarsal joint or adjacent cuboid bone. Fixation parameters were calculated for all models.

RESULTS

The PB and PF extended into the JF site in 29% and 43%, respectively. AP's did not affect PB and PF footprint but required screw entry through the cuboid and fifth tarso-metatarsal joint in all specimens. CA screw entry sites, avoiding the cuboid and fifth tarso-metatarsal joint, partially compromised the PB and PF insertions in 33% and 62% with a median surface loss of 1.6%%(range 0.2-3.2%) and 0.81%%(range 0.05-1.6%), respectively. Mean AP screw length was 64±3.6mm and thread length 49±4.2mm. Mean CA screw length was 48±5.8mm and thread length 28±6.9mm.

CONCLUSION

This study underscores the challenges associated with surrounding MT5 anatomy as they relate to optimal JF treatment. Both the extent of JF as well as a clinically achievable positioned screw violate the PB and PF footprints - although the degree to which even partial disruption of these footprints has on outcome remains unclear. To minimize damage to surrounding structures, including the PB and PF footprint, while allowing a screw length approximately two thirds of the metatarsal length, the CA screw position is recommended. This position balances the desire to maximize pull out strength while avoiding cortical penetration or inadvertent fracture site distraction.

Event history and topological data analysis

Persistent homology is used to track the appearance and disappearance of features as we move through a nested sequence of topological spaces. Equating the nested sequence to a filtration and the appearance and disappearance of features to events, we show that simple event history methods can be used for the analysis of topological data. We propose a version of the well-known Nelson–Aalen cumulative hazard estimator for the comparison of topological features of random fields and for testing parametric assumptions. We suggest a Cox proportional hazards approach for the analysis of embedded metric trees. The Nelson–Aalen method is illustrated on globally distributed climate data and on neutral hydrogen distribution in the Milky Way. The Cox method is used to compare vascular patterns in fundus images of the eyes of healthy and diabetic retinopathy patients.

The impact of a randomized dietary and physical activity intervention on chronic inflammation among obese African-American women

Lifestyle interventions may reduce inflammation and lower breast cancer (BrCa) risk. This randomized trial assessed the impact of the Sistas Inspiring Sistas Through Activity and Support (SISTAS) study on plasma C-reactive protein (CRP), interleukin-6 (IL-6) and Dietary Inflammatory Index (DII). This unblinded, dietary and physical activity trial was implemented in 337 obese (body mass index [BMI] ≥30 kg/m²) African American (AA) women recruited between 2011 and 2015 in South Carolina through a community-based participatory approach with measurements at baseline, 3 months, and 12 months. Participants were randomized into either intervention (n = 176) or wait-list control group (n = 161). Linear mixed-effect models were used for analyses of CRP and IL-6. Baseline CRP was significantly higher in those with greater obesity, body fat percentage, and waist circumference (all p <.01). No difference was observed between groups for CRP or IL-6 at 3 or 12 months; however, improvements in diet were observed in the intervention group compared to the control group (p = .02) at 3 months but were not sustained at 12 months. Although the intervention was not successful at reducing levels of CRP or IL-6, a significant decrease was observed in DII score for the intervention group, indicating short-term positive dietary change.

The effects of monoclonal anti-CD47 on RBCs, compatibility testing, and transfusion requirements in refractory acute myeloid leukemia

BACKGROUND

CD47 is a novel therapeutic target in the treatment of solid-organ and hematologic malignancies. CD47 is also expressed on RBCs. Here, we report our experience of the RBC effects and the impact on blood bank testing and transfusion management in a Phase 1 trial of the humanized anti-CD47 monoclonal antibody Hu5F9-G4 in relapsed or primary refractory acute myeloid leukemia (AML) (NCT02678338).

STUDY DESIGN AND METHODS

Nineteen patients with relapsed or primary refractory AML treated across five UK centers were included for analysis. Patients received escalating doses of Hu5F9-G4. Serial laboratory data were collected to evaluate impact on hemoglobin (Hb), markers of hemolysis (bilirubin, lactate dehydrogenase, reticulocyte count), transfusion requirements, and blood compatibility testing.

RESULTS

A decline in Hb was observed with drug administration (median Hb change, -1.0 g/dL; range, 0.4-1.6) with associated increase in transfusion requirements. Patients responded to transfusion with a median Hb increment per unit of 1.0 g/dL. RBC agglutination was seen in all cases without associated change in Hb, lactate dehydrogenase, bilirubin, or reticulocyte count. Nine of 19 (47%) patients developed a newly positive antibody screen with a pan-agglutinin identified in plasma. Invalid ABO blood grouping occurred in 4 of 12 (33%) non-group O patients due to anomalous reactivity in the reverse ABO-type results.

CONCLUSIONS

Treatment with Hu5F9-G4 in patients with AML resulted in an Hb decline and increased transfusion requirements. Problems with ABO blood typing and compatibility testing were widely observed and should be expected by centers treating recipients of Hu5F9-G4.

A Comparison of Summer and Winter Emergency Hospitalisations in Ireland

There is increasing demand on the Irish health service, particularly in winter months. This study described and compared acute hospitals admissions across summer and winter periods from 2015 to 2018. The analysis used Hospital In-Patient Enquiry data accessed through the National Quality Assurance Information System – NQAIS Clinical. There were 84 additional emergency hospitalisations in winter per week compared with summer (1.2% increase). Across diagnostic categories, emergency hospitalisations reduced in winter, except respiratory conditions which increased by 379 per week representing a 40.5% increase. The profile of emergency respiratory admissions were similar in summer and winter in terms of age, length of stay, day of week and medical card status. Length of stay was approximately one day longer for weekend admissions in both seasons. This research highlights the importance of taking a whole-population approach to winter resilience planning, focussing on prevention and optimal management of respiratory conditions.

Can We Accurately Predict Cost Effectiveness Without Access to Overall Survival Data? The Case Study of Nivolumab in Combination with Ipilimumab for the Treatment of Patients with Advanced Melanoma in England

BACKGROUND

Nivolumab with ipilimumab (the Regimen) is the first immuno-oncology combination treatment to demonstrate long-term clinical benefit for advanced melanoma patients. We evaluated the cost effectiveness of the Regimen in this population, with and without the availability of overall survival (OS) data.

METHODS

A partitioned survival model and a Markov state-transition model were developed to estimate the lifetime costs and benefits of the Regimen versus ipilimumab. These models were built with and without the availability of OS data, as only progression-free survival data were available from the head-to-head, phase III trial against ipilimumab at the time of the National Institute for Health and Care Excellence (NICE) submission. Patient utilities and resource use data were sourced from trial data or the literature.

RESULTS

Incremental cost-effectiveness ratios (ICERs) and absolute costs were similar between the models with and without OS data, but the model with OS data generated more than 1 additional quality-adjusted life-year (QALY) across both treatment arms. In both models, based on list prices, the Regimen was the most cost-effective treatment.

CONCLUSIONS

The analyses show that the Regimen is a cost-effective treatment for advanced melanoma patients in England, and methods to overcome the lack of OS can give reasonable estimates of QALYs gained and ICERs.

Correction to: Can We Accurately Predict Cost Effectiveness Without Access to Overall Survival Data? The Case Study of Nivolumab in Combination with Ipilimumab for the Treatment of Patients with Advanced Melanoma in England

The second Key Point for Decision Makers, which reads.

Sistas Inspiring Sistas Through Activity and Support (SISTAS): Study Design and Demographics of Participants

Introduction

Recruiting racial, ethnic, and other underserved minorities into conventional clinic-based and other trials is known to be challenging. The Sistas Inspiring Sistas Through Activity and Support (SISTAS) Program was a one-year randomized controlled trial (RCT) to promote physical activity and healthy eating among AA women in SC to reduce inflammatory biomarkers, which are linked to increased breast cancer (BrCa) risk and mortality. This study describes the development, recruitment, and implementation of the SISTAS clinical trial and provides baseline characteristics of the study participants.

Methods

SISTAS was developed using community-based participatory research (CBPR) approaches. At baseline, study participants completed assessments and underwent clinical measurements and blood draws to measure C-reactive protein (CRP) and interleukin-6 (IL-6). Participants randomized to the intervention received 12 weekly classes followed by nine monthly booster sessions. Post-intervention measurements were assessed at 12-week and 12-month follow-ups.

Results

We recruited a total of 337 women who tended to: be middle-aged (mean age 48.2 years); have some college education; be employed full-time; have Medicare as their primary insurance; be non-smokers; and perceive their personal health as good. On average, the women were pre-hypertensive at baseline (mean systolic blood pressure = 133.9 mm Hg; mean diastolic blood pressure = 84.0 mm Hg) and morbidly obese (mean BMI >40.0 kg/m²); the mean fat mass and fat-free mass among participants were 106.4 lb and 121.0 lb, respectively.

Conclusion

The SISTAS RCT addresses some of the gaps in the literature with respect to CBPR interventions targeting AA women, such as implementing diet and physical activity in CBPR-based studies to decrease BrCa risk.

Is Increasing Life Expectancy Leading To More Complexity?

Life expectancy is increasing in Ireland, but whether this has resulted in healthier life years among the elderly and its impact (if any) on hospital services is unknown. The purpose of the study was to use routinely available data to explore the relationship of age and indicators of clinical complexity in acute hospitals over ten years. The study included all in-patients aged 65+ years from the Hospital In-Patient Enquiry (HIPE) discharged between 2005 and 2014. Indicators of complexity included the Charlson index, overall length of stay (LOS), intensive care unit LOS and deaths in hospital, analysed by the major clinical classification software (CCS). Over the period, the number and rate of admissions increased, especially among those aged 85+. Indicators of patient complexity increased and LOS decreased. In-hospital mortality decreased from 5.9% to 4.7%. Hospitals appear to be managing the emergency care of the older and more complex patient more efficiently and with better outcomes.

White matter predicts functional connectivity in premanifest Huntington's disease

Objectives

The distribution of pathology in neurodegenerative disease can be predicted by the organizational characteristics of white matter in healthy brains. However, we have very little evidence for the impact these pathological changes have on brain function. Understanding any such link between structure and function is critical for understanding how underlying brain pathology influences the progressive behavioral changes associated with neurodegeneration. Here, we demonstrate such a link between structure and function in individuals with premanifest Huntington's.

Methods

Using diffusion tractography and resting state functional magnetic resonance imaging to characterize white matter organization and functional connectivity, we investigate whether characteristic patterns of white matter organization in the healthy human brain shape the changes in functional coupling between brain regions in premanifest Huntington's disease.

Results

We find changes in functional connectivity in premanifest Huntington's disease that link directly to underlying patterns of white matter organization in healthy brains. Specifically, brain areas with strong structural connectivity show decreases in functional connectivity in premanifest Huntington's disease relative to controls, while regions with weak structural connectivity show increases in functional connectivity. Furthermore, we identify a pattern of dissociation in the strongest functional connections between anterior and posterior brain regions such that anterior functional connectivity increases in strength in premanifest Huntington's disease, while posterior functional connectivity decreases.

Interpretation

Our findings demonstrate that organizational principles of white matter underlie changes in functional connectivity in premanifest Huntington's disease. Furthermore, we demonstrate functional antero–posterior dissociation that is in keeping with the caudo–rostral gradient of striatal pathology in HD.

Inpatient Children and Adolescent Mental Health Services (CAMHS): outcomes of young people with and without intellectual disability

BACKGROUND

Little is known about the effectiveness of inpatient care for young people with co-morbid mental illness and intellectual disability (ID). This study aims to compare the demographics and outcome of young people with mental illness with or without ID admitted to psychiatric hospital. A secondary aim is to look into the outcome of those with ID admitted to general mental health young people's units.

METHOD

Data were collected on the outcome of young people's admissions to specialist ID and general adolescent mental health units as part of a larger quality improvement project run by the College Centre for Quality Improvement. Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) scores were completed by local clinical staff at admission and discharge on 38 young people with and 113 people without ID from 14 units.

RESULTS

Young people with mental disorders significantly improved clinically over the admission whether or not they had ID. There were no differences between the groups in age or use of the Mental Health Act but people admitted with ID were more likely to be male and had longer lengths of stay. Admission to a general adolescent unit was associated with clinical improvement for people with ID.

CONCLUSIONS

This study needs replication because of the small sample and incomplete data but it suggests that young people with ID and mental disorders significantly improve clinically when admitted to hospital as do their non-disabled peers.

A comparison of a centralized versus de-centralized recruitment schema in two community-based participatory research studies for cancer prevention

Use of community-based participatory research (CBPR) approaches is increasing with the goal of making more meaningful and impactful advances in eliminating cancer-related health disparities. While many reports have espoused its advantages, few investigations have focused on comparing CBPR-oriented recruitment and retention. Consequently, the purpose of this analysis was to report and compare two different CBPR approaches in two cancer prevention studies. We utilized frequencies and Chi-squared tests to compare and contrast subject recruitment and retention for two studies that incorporated a randomized, controlled intervention design of a dietary and physical activity intervention among African Americans (AA). One study utilized a de-centralized approach to recruitment in which primary responsibility for recruitment was assigned to the general AA community of various church partners whereas the other incorporated a centralized approach to recruitment in which a single lay community individual was hired as research personnel to lead recruitment and intervention delivery. Both studies performed equally well for both recruitment and retention (75 and 88 % recruitment rates and 71 and 66 % retention rates) far exceeding those rates traditionally cited for cancer clinical trials (~5 %). The de-centralized approach to retention appeared to result in statistically greater retention for the control participants compared to the centralized approach (77 vs. 51 %, p < 0.01). Consequently, both CBPR approaches appeared to greatly enhance recruitment and retention rates of AA populations. We further note lessons learned and challenges to consider for future research opportunities.

Investigation of an association between onset of narcolepsy and vaccination with pandemic influenza vaccine, Ireland April 2009-December 2010

In 2011, the Irish Medicines Board received reports of onset of narcolepsy following vaccination against influenza A(H1N1)pdm09 with Pandemrix. A national steering committee was convened to examine the association between narcolepsy and pandemic vaccination. We conducted a retrospective population-based cohort study. Narcolepsy cases with onset from 1 April 2009 to 31 December 2010 were identified through active case finding. Narcolepsy history was gathered from medical records. Pandemic vaccination status was obtained from vaccination databases. Two independent experts classified cases using the Brighton case definition. Date of onset was defined as date of first healthcare contact for narcolepsy symptoms. Incidence of narcolepsy in vaccinated and non-vaccinated individuals was compared. Of 32 narcolepsy cases identified, 28 occurred in children/adolescents and for 24 first healthcare contact was between April 2009 and December 2010. Narcolepsy incidence was 5.7 (95% confidence interval (CI): 3.4–8.9) per 100,000 children/adolescents vaccinated with Pandemrix and 0.4 (95% CI: 0.1–1.0) per 100,000 unvaccinated children/adolescents (relative risk: 13.9; absolute attributable risk: 5.3 cases per 100,000 vaccinated children/adolescents). This study confirms the crude association between Pandemrix vaccination and narcolepsy as observed in Finland and Sweden. The vaccine is no longer in use in Ireland. Further studies are needed to explore the immunogenetic mechanism of narcolepsy.

Investigation of an association between onset of narcolepsy and vaccination with pandemic influenza vaccine, Ireland April 2009-December 2010

Binary file ES_Abstracts_Final_ECDC.txt matches

Eco-hydrological requirements of dune slack vegetation and the implications of climate change

Dune slacks are a seasonal coastal wetland habitat, whose plant assemblages and soil properties are strongly linked to a fluctuating water table. Climate change is predicted to cause major shifts in sand dune hydrological regimes, yet we know remarkably little about the tolerance of these communities to change, and their precise hydrological requirements are poorly quantified. Dune slack vegetation and soils were sampled within five vegetation types across four west coast UK sites. Relationships between vegetation assemblages, and parameters of soil development (moisture, loss on ignition, pH, KCl extractable ions) and groundwater hydrological regime (annual maximum and minimum water levels and range, duration of flooding) were established to define the environmental tolerances of different communities. In multivariate analysis of the vegetation, the dominant gradient was hydrological: dry to wet, followed by a secondary soil development gradient: young calcareous organic-poor soils to acidic/neutral soils with greater organic matter contents. Most measured hydrological and soil variables explained a significant proportion of observed variation in species composition when tested individually, with the exception of soil nitrate and soil calcium concentrations. Maximum water level was the key hydrological variable, and soil moisture and soil pH were the key soil variables. All hydrological and soil parameters together explained 22.5% of the total species variation. There were significant differences in hydrological and soil parameters between community types, with only 40 cm difference in mean annual minimum water levels (averaged over 4 years) separating the wettest and the driest dune slack communities. Therefore, predicted declines in water level exceeding 100 cm by 2080 are likely to have a major impact on the vegetation of these priority conservation habitats.

Use of a geographic information system to map cases of measles in real-time during an outbreak in Dublin, Ireland, 2011

In 2011, there was a large measles outbreak in Dublin. Nationally 285 cases were notified to the end of December 2011, and 250 (88%) were located in the Dublin region. After the first case was notified in week 6, numbers gradually increased, with 25 notified in June and a peak of 53 cases in August. Following public health intervention including a measles-mumps-rubella (MMR) vaccination campaign, no cases were reported in the Dublin region in December 2011. Most cases (82%) were children aged between 6 months and 14 years, and 46 cases (18%) were under 12 months-old. This is the first outbreak in Dublin to utilise a geographic information system for plotting measles cases on a digital map in real time. This approach, in combination with the analysis of case notifications, assisted the department of public health in demonstrating the extent of the outbreak. The digital mapping documented the evolution of two distinct clusters of 87 (35%) cases. These measles cases were infected with genotype D4-Manchester recently associated with large outbreaks across Europe. The two clusters occurred in socio-economically disadvantaged areas and were attributable to inadequate measles vaccination coverage due in part to the interruption of a school-based MMR2 vaccination programme.

Effectiveness of the antegrade colonic enema stopper at preventing stomal stenosis: long-term follow-up

AIM OF THE STUDY

Stomal stenosis is the commonest complication of the antegrade colonic enema (ACE) procedure, reportedly occurring in 25-55% of patients. As such, a simple ACE stopper device (a small silicone plug sited in the ACE conduit between catheterisations) was designed to prevent stenosis. We performed a long-term follow-up study to determine the effectiveness of the stopper device.

METHODS

A retrospective case note review was performed of all patients who successfully underwent a primary ACE procedure over an 8.5-year period (January 2002 to June 2010). The inclusion criteria were (i) a minimum of 6 months follow-up, (ii) simple appendicostomy, (iii) caecal/colonic flap. In all patients an ACE stopper was sited in the conduit for at least 4 months and removed only for catheterisation. Data are mean±SEM.

MAIN RESULTS

38 children were included in our study. Mean age at surgery was 9.6±0.5 years. Surgery was performed in 22 patients for incontinence and in 16 for chronic constipation. 31 underwent an appendicostomy and 7 had a caecal/colonic flap; all received an ACE stopper. The mean follow-up was 2.6±0.3 years. Only 3 patients (8%) developed stomal stenosis. The first occurred 6 months postoperatively, resulting from an ACE stopper which was too small and consequently persistently fell out. This conduit required dilatation. The second occurred at 27 months secondary to a stomal infection and required surgical revision. The third occurred 8 months postoperatively for no obvious cause, and was treated with dilation. 1 patient experienced stomal leakage.

CONCLUSION

The ACE stopper is a simple yet highly effective method of preventing stomal stenosis. We recommend using the stopper in all ACE patients.

Trends in COPD mortality and in-patient admissions in men & women: evidence of convergence

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality. Although more prevalent in men, it is anticipated that, due to the convergence in smoking rates, the prevalence rate in women will surpass that of men. There were 14,519 deaths attributable to COPD in the period 2000-2009. Although deaths decreased for both sexes, reduction in deaths was significantly higher among men (test for trend, p<0.01 for men vs. p=0.06 for women). Smoking rates decreased for both sexes from 1980-2009 with the percentage reduction in smoking significantly greater in men (11.5% vs. 7.0%, p<0.001). There has been a convergence in COPD deaths and COPD hospital in-patient discharges for men and women that mirrors the trend in the convergence of male and female smoking rates. This study provides evidence of the need for effective smoking cessation programmes that are targeted at women as well as men.

Botulinum toxin assessment, intervention and aftercare for paediatric and adult drooling: international consensus statement

Many individuals with neurological problems or anatomical abnormalities of the jaw, lips or oral cavity may drool, which can impact on health and quality of life. A thorough evaluation of the patient's history, examination of the oral region by a speech pathologist and, in individuals over 3 years, a dental examination is warranted. Questionnaires with established validity such as the Drooling Impact Scale are useful assessment tools. A hierarchical approach to treatment is taken from least invasive therapies, such as speech pathology, to more invasive, such as injection of botulinum neurotoxin type-A (BoNT-A) into the salivary glands (parotid and submandibular). The wishes of the individual and their carer are crucial considerations in determining the suitability of the intervention for the patient. In the presence of dysphagia and cerebral palsy (CP), careful assessment is required prior to the injection of BoNT-A. Favourable responses to intervention include a reduction in the secretion of saliva and in drooling, as well as psychosocial improvements. BoNT-A is usually well tolerated, although potential side effects should be discussed with the patient and carer.

Tapping linked to function and structure in premanifest and symptomatic Huntington disease

OBJECTIVE

Motor signs are functionally disabling features of Huntington disease. Characteristic motor signs define disease manifestation. Their severity and onset are assessed by the Total Motor Score of the Unified Huntington's Disease Rating Scale, a categorical scale limited by interrater variability and insensitivity in premanifest subjects. More objective, reliable, and precise measures are needed which permit clinical trials in premanifest populations. We hypothesized that motor deficits can be objectively quantified by force-transducer-based tapping and correlate with disease burden and brain atrophy.

METHODS

A total of 123 controls, 120 premanifest, and 123 early symptomatic gene carriers performed a speeded and a metronome tapping task in the multicenter study TRACK-HD. Total Motor Score, CAG repeat length, and MRIs were obtained. The premanifest group was subdivided into A and B, based on the proximity to estimated disease onset, the manifest group into stages 1 and 2, according to their Total Functional Capacity scores. Analyses were performed centrally and blinded.

RESULTS

Tapping variability distinguished between all groups and subgroups in both tasks and correlated with 1) disease burden, 2) clinical motor phenotype, 3) gray and white matter atrophy, and 4) cortical thinning. Speeded tapping was more sensitive to the detection of early changes.

CONCLUSION

Tapping deficits are evident throughout manifest and premanifest stages. Deficits are more pronounced in later stages and correlate with clinical scores as well as regional brain atrophy, which implies a link between structure and function. The ability to track motor phenotype progression with force-transducer-based tapping measures will be tested prospectively in the TRACK-HD study.