BEVA primary care clinical guidelines: Equine parasite control

BACKGROUND

There is a lack of consensus on how best to balance our need to minimise the risk of parasite-associated disease in the individual horse, with the need to limit the use of anthelmintics in the population to preserve their efficacy through delaying further development of resistance.

OBJECTIVES

To develop evidence-based guidelines utilising a modified GRADE framework.

METHODS

A panel of veterinary scientists with relevant expertise and experience was convened. Relevant research questions were identified and developed with associated search terms being defined. Evidence in the veterinary literature was evaluated using the GRADE evidence-to-decision framework. Literature searches were performed utilising CAB abstracts and PubMed. Where there was insufficient evidence to answer the research question the panel developed practical guidance based on their collective knowledge and experience.

RESULTS

Search results are presented, and recommendation or practical guidance were made in response to 37 clinically relevant questions relating to the use of anthelmintics in horses.

MAIN LIMITATIONS

There was insufficient evidence to answer many of the questions with any degree of certainty and practical guidance frequently had to be based upon extrapolation of relevant information and the panel members' collective experience and opinions.

CONCLUSIONS

Equine parasite control practices and current recommendations have a weak evidence base. These guidelines highlight changes in equine parasite control that should be considered to reduce the threat of parasite-associated disease and delay the development of further anthelmintic resistance.

Implementation of a frailty intervention in the transition from hospital to home: a realist process evaluation protocol for the FORTRESS trial

INTRODUCTION

Frailty in Older people: Rehabilitation, Treatment, Research Examining Separate Settings (the FORTRESS study) is a multisite, hybrid type II, stepped wedge, cluster, randomised trial examining the uptake and outcomes of a frailty intervention. The intervention is based on the 2017 Asia Pacific Clinical Practice Guidelines for the Management of Frailty and begins in the acute hospital setting and transitions to the community. The success of the intervention will require individual and organisational behaviour change within a dynamic health system. This process evaluation will examine the multiple variables at play in the context and mechanism of the frailty intervention to enhance understanding of the outcomes of the FORTRESS study and how the outcomes can be translated from the trial into broader practice.

METHODS AND ANALYSIS

The FORTRESS intervention will recruit participants from six wards in New South Wales and South Australia, Australia. Participants of the process evaluation will include trial investigators, ward-based clinicians, FORTRESS implementation clinicians, general practitioners and FORTRESS participants. The process evaluation has been designed using realist methodology and will occur in parallel to the FORTRESS trial. A mixed-method approach will be used with qualitative and quantitative data collected from interviews, questionnaires, checklists and outcome assessments. Qualitative and quantitative data will be examined for CMOCs (Context, Mechanism, Outcome Configurations) and programme theories will be developed, tested and refined. This will facilitate development of more generalisable theories to inform translation of frailty intervention within complex healthcare systems.

ETHICS AND DISSEMINATION

Ethical approval for the FORTRESS trial, inclusive of the process evaluation, has been obtained from the Northern Sydney Local Health District Human Research Ethics Committees reference number 2020/ETH01057. Recruitment for the FORTRESS trial uses opt-out consent. Dissemination will be via publications, conferences and social media.

TRIAL REGISTRATION NUMBER

ACTRN12620000760976p (FORTRESS trial).

Michael David Nicholas Hunt

A dedicated and highly gifted equine clinician who helped found a remarkably successful practice.

Validity of chronometric TMS for probing the time-course of word production: a modified replication

In the present study, we used chronometric TMS to probe the time-course of 3 brain regions during a picture naming task. The left inferior frontal gyrus, left posterior middle temporal gyrus, and left posterior superior temporal gyrus were all separately stimulated in 1 of 5 time-windows (225, 300, 375, 450, and 525 ms) from picture onset. We found posterior temporal areas to be causally involved in picture naming in earlier time-windows, whereas all 3 regions appear to be involved in the later time-windows. However, chronometric TMS produces nonspecific effects that may impact behavior, and furthermore, the time-course of any given process is a product of both the involved processing stages along with individual variation in the duration of each stage. We therefore extend previous work in the field by accounting for both individual variations in naming latencies and directly testing for nonspecific effects of TMS. Our findings reveal that both factors influence behavioral outcomes at the group level, underlining the importance of accounting for individual variations in naming latencies, especially for late processing stages closer to articulation, and recognizing the presence of nonspecific effects of TMS. The paper advances key considerations and avenues for future work using chronometric TMS to study overt production.

Dealing with the heterogeneous presentations of freezing of gait: how reliable are the freezing index and heart rate for freezing detection?

BACKGROUND

Freezing of gait (FOG) is an unpredictable gait arrest that hampers the lives of 40% of people with Parkinson's disease. Because the symptom is heterogeneous in phenotypical presentation (it can present as trembling/shuffling, or akinesia) and manifests during various circumstances (it can be triggered by e.g. turning, passing doors, and dual-tasking), it is particularly difficult to detect with motion sensors. The freezing index (FI) is one of the most frequently used accelerometer-based methods for FOG detection. However, it might not adequately distinguish FOG from voluntary stops, certainly for the akinetic type of FOG. Interestingly, a previous study showed that heart rate signals could distinguish FOG from stopping and turning movements. This study aimed to investigate for which phenotypes and evoking circumstances the FI and heart rate might provide reliable signals for FOG detection.

METHODS

Sixteen people with Parkinson's disease and daily freezing completed a gait trajectory designed to provoke FOG including turns, narrow passages, starting, and stopping, with and without a cognitive or motor dual-task. We compared the FI and heart rate of 378 FOG events to baseline levels, and to stopping and normal gait events (i.e. turns and narrow passages without FOG) using mixed-effects models. We specifically evaluated the influence of different types of FOG (trembling vs akinesia) and triggering situations (turning vs narrow passages; no dual-task vs cognitive dual-task vs motor dual-task) on both outcome measures.

RESULTS

The FI increased significantly during trembling and akinetic FOG, but increased similarly during stopping and was therefore not significantly different from FOG. In contrast, heart rate change during FOG was for all types and during all triggering situations statistically different from stopping, but not from normal gait events.

CONCLUSION

When the power in the locomotion band (0.5-3 Hz) decreases, the FI increases and is unable to specify whether a stop is voluntary or involuntary (i.e. trembling or akinetic FOG). In contrast, the heart rate can reveal whether there is the intention to move, thus distinguishing FOG from stopping. We suggest that the combination of a motion sensor and a heart rate monitor may be promising for future FOG detection.

fNIRS is sensitive to leg activity in the primary motor cortex after systemic artifact correction

BACKGROUND

functional near-infrared spectroscopy (fNIRS) is an increasingly popular tool to study cortical activity during movement and gait that requires further validation. This study aimed to assess (1) whether fNIRS can detect the difficult-to-measure leg area of the primary motor cortex (M1) and distinguish it from the hand area; and (2) whether fNIRS can differentiate between automatic (i.e., not requiring one's attention) and non-automatic movement processes. Special attention was attributed to systemic artifacts (i.e., changes in blood pressure, heart rate, breathing) which were assessed and corrected by short channels, i.e., fNIRS channels which are mainly sensitive to superficial scalp hemodynamics.

METHODS

Twenty-three seated, healthy participants tapped four fingers on a keyboard or tapped the right foot on four squares on the floor in a specific order given by a 12-digit sequence (e.g., 434141243212). Two different sequences were executed: a beforehand learned (i.e., automatic) version and a newly learned (i.e., non-automatic) version. A 36-channel fNIRS device including 12 short channels covered multiple motor-related cortical areas including M1. The fNIRS data were analyzed with a general linear model (GLM). Correlation between the expected functional hemodynamic responses (i.e. task regressor) and the short channels (i.e. nuisance regressors), necessitated performing a separate short channel regression instead of integrating them in the GLM.

RESULTS

Consistent with the M1 somatotopy, we found significant HbO increases of very large effect size in the lateral M1 channels during finger tapping (Cohen's d = 1.35, p<0.001) and significant HbO increases of moderate effect size in the medial M1 channels during foot tapping (Cohen's d = 0.8, p<0.05). The cortical activity differences between automatic and non-automatic tasks were not significantly different. Importantly, leg movements produced large systemic fluctuations, which were adequately removed by the use of all available short channels.

DISCUSSION

Our results indicate that fNIRS is sensitive to leg activity in M1, though the sensitivity is lower than for finger activity and requires rigorous correction for systemic fluctuations. We furthermore highlight that systemic artifacts may result in an unreliable GLM analysis when short channels show signals that are similar to the expected hemodynamic responses.

From the ground up: assessing the face validity of the Quality of Life – Aged Care Consumers (QOL-ACC) measure with older Australians

Purpose

This paper aims to assess the face validity to inform content validity of the Quality of Life – Aged Care Consumers (QOL-ACC), a new measure for quality assessment and economic evaluation in aged care.

Design/methodology/approach

Semi-structured interviews were conducted with older adults (66–100 years) receiving aged care services at home (n = 31) and in residential care (n = 28). Participants provided feedback on draft items to take forward to the next stage of psychometric assessment. Items were removed according to several decision criteria: ambiguity, sensitive wording, not easy to answer and/or least preferred by participants.

Findings

The initial candidate set was reduced from 34 items to 15 items to include in the next stage of the QOL-ACC development alongside the preferred response category. The reduced set reflected the views of older adults, increasing the measure’s acceptability, reliability and relevance.

Originality/value

Quality of life is a key person-centred quality indicator recommended by the recent Royal Commission into Aged Care Quality and Safety. Responding to this policy reform objective, this study documents a key stage in the development of the QOL-ACC measure, a new measure designed to assess aged care specific quality of life.

HPB P37 Outcomes following EUS choledocho-duodenostomy for the palliative treatment of peri-ampullary cancer following unsuccessful ERCP – A single centre experience

Background

EUS-guided choledocho-duodenostomy is an option to relieve jaundice after a failed ERCP, in patients with locally advanced or metastatic peri-ampullary cancers. We aim to assess the technical success, safety and outcomes of the procedure in our practice.

Methods

All consecutive adult patients that underwent EUS-guided CBD stent placement after a failed ERCP between December 2019 and May 2022 at the Queens Medical Centre, Nottingham were included. Studied variables included demographics, technical characteristics and outcomes including length of stay, normalisation of bilirubin level, complication rate and 30-day mortality rate.

Results

Twenty-six consecutive patients were included in this study (12 males, 14 females). The mean age was 75 (range 52–92) years. Pancreatic cancer was present in 15 patients (57.6%), 4 patients (15.3%) each had ampullary cancer and other malignant peri-ampullary lesions while 3 patients (11.5%) had duodenal cancer. Metastatic disease was present in 13 patients (50%). Mean ECOG status was 2 (n= 13). ERCP was unsuccessful due to an inability to cannulate the CBD (n= 3), duodenal tumour infiltration (n=10), destroyed ampulla (n=6) and inaccessible papilla (n=5).

EUS-guided CBD stent placement was successful in 24 patients (92.3%). The mean CBD diameter at presentation was 19.5 mm (range 14–32) and mean distance between the bile duct and duodenum was 4.2 mm.

The complication rate was 15.3% (4/26 patients). Complications included cholecystitis, stent blockage, slow bleeding and bowel perforation after a displaced stent. Median post-procedure LOS was 5.5 days. A reduction in bilirubin to &lt;50% was observed in 19 patients (73%) by discharge. There were 2 biliary re-interventions in the group. The overall 30-day mortality rate was 38.4% (n=10) with a procedure specific mortality of 11.5% (n=3).

Conclusions

EUS-guided choledocho-duodenostomy is an effective and safe option to relieve jaundice in this group of patients.

327 To Fuse or Not to Fuse: The Elderly Patient with Lumbar Stenosis and Low-Grade Spondylolisthesis. Systematic Review and Meta-Analysis of Randomised Controlled Trials

Aim

The optimum surgical intervention for elderly patients with lumbar spinal stenosis(LSS) and low-grade degenerative-spondylolisthesis(LGDS) has been extensively debated. We conducted a systematic review and meta-analysis of randomised-controlled-trials(RCTs) comparing the effectiveness of decompression-alone against gold-standard decompression-with-fusion(D+F) in elderly patients with LSS and LGDS.

Method

A systematic literature search was performed on published databases from inception to October-2021. English-language RCTs of elderly patients (mean age over-65) with LSS and LGDS, who had undergone DA or D+F were included. The quality and weight of evidence was assessed, and a meta-analysis performed.

Results

Seven RCTs (n=581; mean age:65.9 years; 59.9% female) were included. There was no difference in visual-analogue-scale(VAS) scores of back-pain(BP) or leg-pain(LP) at mean follow-up of 28.6 months between both DA and D+F groups (BP: mean-difference (MD)-0.22, 95%CI:-0.76–0.32; LP: MD:-0.26, 95%CI:-0.79–0.27). In addition, subgroup analysis of long-term follow-up (&gt;3 years) showed lower VAS scores for BP and LP in patients who underwent DA (BP MD:-1.70, 95%CI:-2.8-(-0.60); LP MD:-1.00, 95%CI:-1.77-(-0.23)). No difference in disability, measured by Oswestry-Disability-Index(ODI) scores, was found between both groups (MD:0.50, 95%CI: -3.31–4.31). However, patients in DA group had less hospital complications and fewer adverse events (total-surgical-complications OR:0.57, 95%CI:0.36–0.90), despite a higher rate of post-operative DS (OR:8.63, 95%CI:3.35–22.26).

Conclusions

DA is not inferior to D+F in elderly patients with LSS and LGDS. DA has better pain outcomes at three-years follow-up and carries lower risk hospital-complications and fewer adverse-events. Surgeons should weigh these findings with increased risk of DS-progression.

Reachable workspace analysis is a potential measurement for impairment of the upper extremity in neuralgic amyotrophy

INTRODUCTION/AIMS

Neuralgic amyotrophy (NA) is a multifocal neuropathy involving the nerves of the upper extremity, limiting functional capability and reducing range of motion. The reachable workspace (RWS) is a computerized three-dimensinal analysis system that evaluates the relative surface area (RSA) of an individual's arm reachability and has shown utility in several neuromuscular disorders. The aims of this study were to examine the ability of the RWS to quantitatively detect limitations in upper extremity active range of motion in patients with NA, and correlate these with other upper extremity functional outcome measures.

METHODS

Forty-seven patients with NA and 25 healthy age- and sex-matched controls were measured with the RWS. Study participants' RSAs were correlated with scores on the Shoulder Rating Questionnaire (SRQ), the Disabilities of Arm Shoulder and Hand (DASH) questionnaire, and upper extremity strength measurements using hand-held dynamometry.

RESULTS

Patients with NA showed significantly lower values in the affected arm for all quadrants (except for the ipsilateral lower quadrant) and total RSA compared with controls (P < 0.001). We found moderate correlations between the reachable workspace, the DASH questionnaire result (r = -0.415), and serratus anterior muscle strength (r = 0.414).

DISCUSSION

RWS is able to detect limitations in active range of motion of the affected arm in patients with NA, and is moderately correlated with upper extremity functional measures. RWS can demonstrate impairment of the affected upper extremity in NA and it has potential as a clinical outcome measure.

Interventions to reduce falls in hospitals: a systematic review and meta-analysis

BACKGROUND

Falls remain a common and debilitating problem in hospitals worldwide. The aim of this study was to investigate the effects of falls prevention interventions on falls rates and the risk of falling in hospital.

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

Hospitalised adults.

INTERVENTION

Prevention methods included staff and patient education, environmental modifications, assistive devices, policies and systems, rehabilitation, medication management and management of cognitive impairment. We evaluated single and multi-factorial approaches.

OUTCOME MEASURES

Falls rate ratios (rate ratio: RaR) and falls risk, as defined by the odds of being a faller in the intervention compared to control group (odds ratio: OR).

RESULTS

There were 43 studies that satisfied the systematic review criteria and 23 were included in meta-analyses. There was marked heterogeneity in intervention methods and study designs. The only intervention that yielded a significant result in the meta-analysis was education, with a reduction in falls rates (RaR = 0.70 [0.51-0.96], P = 0.03) and the odds of falling (OR = 0.62 [0.47-0.83], P = 0.001). The patient and staff education studies in the meta-analysis were of high quality on the GRADE tool. Individual trials in the systematic review showed evidence for clinician education, some multi-factorial interventions, select rehabilitation therapies, and systems, with low to moderate risk of bias.

CONCLUSION

Patient and staff education can reduce hospital falls. Multi-factorial interventions had a tendency towards producing a positive impact. Chair alarms, bed alarms, wearable sensors and use of scored risk assessment tools were not associated with significant fall reductions.

Peter Daniel Rossdale

A dedicated equine clinician and scientist who had varied interests and published widely. He founded a remarkably successful practice and was one of the first to embrace evidence-based veterinary medicine.

Implementation of a novel stratified PAthway of CarE for common musculoskeletal (MSK) conditions in primary care: protocol for a multicentre pragmatic randomised controlled trial (the PACE MSK trial)

Introduction

Musculoskeletal (MSK) conditions constitute the highest burden of disease globally, with healthcare services often utilised inappropriately and overburdened. The aim of this trial is to evaluate the effectiveness of a novel clinical PAthway of CarE programme (PACE programme), where care is provided based on people’s risk of poor outcome.

Methods and analysis

Multicentre randomised controlled trial. 716 people with MSK conditions (low back pain, neck pain or knee osteoarthritis) will be recruited in primary care. They will be stratified for risk of a poor outcome (low risk/high risk) using the Short Form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMSPQ) then randomised to usual care (n=358) or the PACE programme (n=358). Participants at low risk in the PACE programme will receive up to 3 sessions of guideline based care from their primary healthcare professional (HCP) supported by a custom designed website (mypainhub.com). Those at high risk will be referred to an allied health MSK specialist who will conduct a comprehensive patient-centred assessment then liaise with the primary HCP to determine further care. Primary outcome (SF 12-item PCS) and secondary outcomes (eg, pain self-efficacy, psychological health) will be collected at baseline, 3, 6 and 12 months. Cost-effectiveness will be measured as cost per quality-adjusted life-year gained. Health economic analysis will include direct and indirect costs. Analyses will be conducted on an intention-to-treat basis. Primary and secondary outcomes will be analysed independently, using generalised linear models. Qualitative and mixed-methods studies embedded within the trial will evaluate patient experience, health professional practice and interprofessional collaboration.

Ethics and dissemination

Ethics approval has been received from the following Human Research Ethics Committees: The University of Sydney (2018/926), The University of Queensland (2019000700/2018/926), University of Melbourne (1954239), Curtin University (HRE2019-0263) and Northern Sydney Local Health District (2019/ETH03632). Dissemination of findings will occur via peer-reviewed publications, conference presentations and social media.

Trial registration number

ACTRN12619000871145.

Effect of occupational therapy home visit discharge planning on participation after stroke: protocol for the HOME Rehab trial

INTRODUCTION

After first stroke, the transition from rehabilitation to home can be confronting and fraught with challenges. Although stroke clinical practice guidelines recommend predischarge occupational therapy home visits to ensure safe discharge and provision of appropriate equipment, there is currently limited evidence to support this recommendation.

METHODS AND ANALYSIS

The HOME Rehab trial is a national, multicentre, phase III randomised controlled trial with concealed allocation, blinded assessment and intention-to-treat analysis being conducted in Australia. The trial aim is to determine the effect and potential cost-effectiveness of an enhanced occupational therapy discharge planning intervention that involves pre and postdischarge home visits, goal setting and occupational therapy in the home (the HOME programme) in comparison to an in-hospital predischarge planning intervention. Stroke survivors aged ≥45 years, admitted to a rehabilitation ward, expected to return to a community (private) dwelling after discharge, with no significant prestroke disability will be randomly allocated 1:1 to receive a standardised discharge planning intervention and the HOME programme or the standardised discharge planning intervention alone. The primary outcome is participation measured using the Nottingham Extended Activities of Daily Living. Secondary outcome areas include hospital readmission, disability, performance of instrumental activities of daily living, health-related quality of life, quality of care transition and carer burden. Resources used/costs will be collected for the cost-effectiveness analysis and hospital readmission. Recruitment commenced in 2019. Allowing for potential attrition, 360 participants will be recruited to detect a clinically important treatment difference with 80% power at a two-tailed significance level of 0.05.

ETHICS AND DISSEMINATION

This study is approved by the Alfred Health Human Research Ethics Committee and site-specific ethics approval has been obtained at all participating sites. Results of the main trial and the secondary endpoint of cost-effectiveness will be submitted for publication in peer-reviewed journalsTrial registration numberACTRN12618001360202.

How, why and under what circumstances does a quality improvement collaborative build knowledge and skills in clinicians working with people with dementia? A realist informed process evaluation

In increasingly constrained health and aged care services, strategies are needed to improve quality and translate evidence into practice. In dementia care, recent failures in quality and safety have led the WHO to prioritise the translation of known evidence into practice. While quality improvement collaboratives have been widely used in healthcare, there are few examples in dementia care.

We describe a recent quality improvement collaborative to improve dementia care across Australia and assess the implementation outcomes of acceptability and feasibility of this strategy to translate known evidence into practice. A realist-informed process evaluation was used to analyse how, why and under what circumstances a quality improvement collaborative built knowledge and skills in clinicians working in dementia care.

This realist-informed process evaluation developed, tested and refined the programme theory of a quality improvement collaborative. Data were collected pre-intervention and post-intervention using surveys and interviews with participants (n=28). A combined inductive and deductive data analysis process integrated three frameworks to examine the context and mechanisms of knowledge and skill building in participant clinicians.

A refined program theory showed how and why clinicians built knowledge and skills in quality improvement in dementia care. Six mechanisms were identified: motivation, accountability, identity, collective learning, credibility and reflective practice. These mechanisms, in combination, operated to overcome constraints, role boundaries and pessimism about improved practice in dementia care.

A quality improvement collaborative designed for clinicians in different contexts and roles was acceptable and feasible in building knowledge, skills and confidence of clinicians to improve dementia care. Supportive reflective practice and a credible, flexible and collaborative process optimised quality improvement knowledge and skills in clinicians working with people with dementia.

Trial registration number

ACTRN12618000268246.

IMG-21. PROSPECTIVE PREOPERATIVE DETERMINATION OF ISOCITRATE DEHYDROGENASE MUTATION IN GLIOMAS USING SPECTRAL EDITING MAGNETIC RESONANCE SPECTROSCOPY

BACKGROUND

Gliomas are the most common malignant brain tumors in children and adults. A subset of these tumors harbour mutations in the enzyme isocitrate dehydrogenase (IDH) which produces the novel oncometabolite 2-hydroxyglutarate (2HG). In general, patients with an IDH mutant glioma have a longer survival—often necessitating more re-treatment sessions over the span of a patient’s life and surveillance monitoring for tumor recurrence. The need to non-invasively detect early evidence of tumor recurrence is therefore heightened in this unique subset of patients with extended survival. As magnetic resonance spectroscopy (MRS) has been demonstrated to measure biochemical components of intracranial tumors using MRI, we conducted a study in 58 pre-operative adult patients to determine if a diagnosis of IDH mutant glioma could be made confidently using imaging data.

METHODS

Patients underwent neuroimaging for diagnosis or preoperative planning on a 3 tesla MR scanner. A MEGA-PRESS spectral editing technique was employed. Imaging findings were directly compared to post-operative histopathologic diagnosis. RESUTLS: For all patients with gliomas from grade II to IV, detection of 2-HG with MEGA-PRESS sequence had a sensitivity between 48% and 81%, specificity between 60% and 100%, PPV between 53% and 100% and NPV between 77% and 85% depending on the CRLB threshold. Among the different metabolite ratios, a 2-HG/NAA ratio >0.034 had the highest sensitivity and specificity, 86% and 73% respectively.

DISCUSSION

Magnetic resonance spectroscopy (MRS) is an underused advanced MR technique that deserves consideration in pediatric neuro-oncology given its utility in non-invasively detecting malignant gliomas.

Preoperative Determination of Isocitrate Dehydrogenase Mutation in Gliomas Using Spectral Editing MRS: A Prospective Study

BACKGROUND

The edited magnetic resonance spectroscopy (MRS) technique has not yet been formally evaluated for the in vivo detection of 2-hydroxyglutarate (2-HG) in patients with gliomas of various grades.

PURPOSE

To evaluate the diagnostic accuracy of edited MRS in the preoperative identification of the isocitrate dehydrogenase (IDH) mutation status in patients with gliomas.

STUDY TYPE

Prospective.

POPULATION

Fifty-eight subjects (31 glioblastomas, 27 grade II and III gliomas).

FIELD STRENGTH/SEQUENCE

Mescher-Garwood (MEGA)-PRESS and routine clinical brain tumor MR sequences were used at 3T.

ASSESSMENT

Data were analyzed using an advanced method for accurate, robust, and efficient spectral fitting (AMARES) from jMRUI software. The amplitudes of the 2-HG, N-acetyl-aspartate (NAA), choline (Cho), and creatine/phosphocreatine (Cr) resonances were calculated with their associated Cramer-Rao lower bound (CRLB). The IDH1 R132H mutation status was assessed by immunohistochemistry for all patients. Patients with grades II and III gliomas with negative immunohistochemistry underwent DNA sequencing to further interrogate IDH mutation status.

STATISTICAL TEST

The differences in 2-HG amplitudes, 2-HG/NAA, 2-HG/Cho, and 2-HG/Cr between IDH-mutant and IDH-wildtype gliomas were assessed using Mann-Whitney U-tests. Receiver operating characteristic curve analysis was performed to evaluate the diagnostic accuracy of each parameter.

RESULTS

The 2-HG amplitudes, 2-HG/NAA, and 2-HG/Cho were higher for IDH-mutant gliomas than IDH-wildtype gliomas (P < 0.007). Using a CRLB threshold <30%, a 2-HG cutoff greater than 0 had a sensitivity of 80% (95% confidence interval [CI]: 52-96%) and a specificity of 81% (95% CI: 54-96%) in identifying IDH-mutant gliomas. In the subset of patients with grades II and III gliomas, the sensitivity was 80% (95% CI: 52-96%) and specificity was 100% (95% CI: 40-100%). Among 2-HG ratios, the highest AUC for the identification of IDH mutant status was achieved using the 2-HG/NAA (AUC = 0.8, 95% CI 0.67-.89).

DATA CONCLUSION

Preoperative edited MRS appears to be able to help identify IDH-mutant gliomas with high specificity. Level of Evidence 1 Technical Efficacy Stage 2 J. MAGN. RESON. IMAGING 2021;53:416-426.

A prospective cohort study investigating contributors to mild cognitive impairment in adults with spinal cord injury: study protocol

BACKGROUND

Studies report rates of mild cognitive impairment (MCI) in spinal cord injury (SCI) range between 10 and 60%. This broad estimate of MCI in SCI is most likely a result of: (i) inconsistent operationalization of MCI; (ii) heterogeneity among individuals with SCI; (iii) failure to account for MCI subtypes, thereby adding to the heterogeneity of samples; and, (iv) poor control for traumatic brain injury (TBI) that obscures differentiation of MCI attributable to TBI versus other factors. There is a paucity of longitudinal studies following the course of MCI in SCI, and none that account for multiple predictors of MCI, including interactions among predictors.

METHODS

An inception cohort longitudinal study will assess approximately 100 individuals aged 17-80 years with acute SCI, with measures taken at three timepoints (baseline, 3 months post-baseline, and 12 months post-injury). Data relevant to medical care received within the first 24-48 h of presentation to the emergency department will be analysed, as will measures of cognition, injury characteristics, medical history, personal factors, psychological status, psychosocial functioning, and quality of life. Latent class mixture modelling will determine trajectories for the primary outcome of interest, cognitive functioning and its subtypes, and secondary outcomes of interest such as depression. Multiple regression analyses will identify predictors of MCI and its subtypes.

DISCUSSION

The prospective design will reveal change in cognitive functioning across time and unveil different outcome trajectories; thus addressing the lack of knowledge on trajectories of MCI and MCI subtypes in SCI. Through subtyping MCI, we hope to yield groups of cognitively impaired individuals with SCI that are potentially more homogenous and thereby stable and predictable. This is the first study to capture emergency department and acute care diagnostic evidence of mild TBI, which has been poorly controlled in previous studies. Our study will also be the first to distinguish the contribution of TBI from other factors to the development of MCI in individuals with SCI.

TRIAL REGISTRATION

The study was prospectively registered with the Australian and New Zealand Clinical Trial Registry ( ACTRN12619001702101 ) on 3rd December 2019.

Are people in residential care entitled to receive rehabilitation services following hip fracture? Views of the public from a citizens' jury

BACKGROUND

Access to rehabilitation services for people living in residential care facilities is frequently limited. A randomised trial of a hospital outreach hip fracture rehabilitation program in residential care facilities has demonstrated improvements in mobility at four weeks and quality of life at 12 months but was not considered cost-effective by standard health economic metrics. The current study aimed to explore the general public's views on issues involved in the allocation of rehabilitation resources for residents of care facilities.

METHODS

A citizens' jury comprising 13 purposively sampled members of the general public, representative of the South Australian age, gender and household income profile. The jury considered the questions "Should there be an investment of physical rehabilitation services in residential care for older people following a hip fracture? If so, what is the best way of providing this service (considering funding, models of service delivery and equity)?" Deliberations were in the context of a state-wide health reform program. The jury was conducted over two days with an experienced independent facilitator, addressing questions developed by a steering group of research academics and clinicians.

RESULTS

The mean age of the citizens' jury members was 43 (range 26 to 61). Eleven members voted for investment in outreach hospital rehabilitation services in residential aged care. All jurors agreed a number of strategies in addition to investment should be implemented, including health care planning and decision making, increased emphasis on hip fracture prevention, training of aged care staff in rehabilitation and routine provision of hospital discharge summaries to families. The jury further advocated for an increased focus on rehabilitation in residential care, potentially through accreditation criteria, increasing health literacy of residents and families, implementation of age friendly environment strategies and improving connections of care facilities with community, hospital and tertiary services.

CONCLUSIONS

This citizens' jury representative of the general public recommends that regardless of dementia and frailty, people who live in residential care and are walking and fracture their hips should have access to hospital outreach rehabilitation and recovery services.

Challenges in the acute identification of mild traumatic brain injuries: results from an emergency department surveillance study

OBJECTIVES

To establish the proportion of mild traumatic brain injury (mTBI) diagnosis among people presenting to an emergency department (ED), to determine the accuracy of recorded ED diagnoses. We also aimed to describe challenges in mTBI case identification and its acute hospital management.

DESIGN AND SETTING

A retrospective chart review of all ED attendances to a major trauma hospital, over a 9-month period (June 2015-February 2016).

PARTICIPANTS

Adults aged 18-65 years consecutively presenting to an ED.

PRIMARY OUTCOME MEASURES

Proportion of mTBI diagnosis among ED attendances (ie, confirmed mTBI based on the WHO criteria or indeterminate mTBI based on secondary criteria), and proportion of accurately recorded mTBI diagnosis by ED clinicians (ie, 'mTBI', 'concussion').

RESULTS

Of 30 479 ED attendances, 351 (1.15%) confirmed mTBI diagnosis and 180 (0.6%) indeterminate diagnosis were identified. Only 81 (23.1%) individuals with a confirmed mTBI had a 'mTBI diagnosis' clearly recorded in the medical notes. Of the allocated discharge diagnosis codes to the two identified cohorts, 89.8% were not indicative of mTBI. Intracranial injuries were found in 31 (8.5%) confirmed cases. Glasgow Coma Scale scores were consistently assessed in the ED but identified only 117 (33.3%) confirmed mTBI cases. Post-traumatic amnesia (PTA) testing was able to confirm acute cognitive impairment in 113 (62.1%) of those who were tested (182, 51.3%).

CONCLUSIONS

mTBI is a common, but an under-recognised cause for ED attendance. Despite challenges, the use of an operational definition such as the WHO diagnostic criteria can improve accuracy in mTBI identification. Acute management may be enhanced by rapid assessment of PTA.

Effect of Additional Rehabilitation After Botulinum Toxin-A on Upper Limb Activity in Chronic Stroke: The InTENSE Trial

Supplemental Digital Content is available in the text.

The aim of this trial was to determine the effect of additional upper limb rehabilitation following botulinum toxin-A for upper limb activity in chronic stroke.

Developing a new quality of life instrument with older people for economic evaluation in aged care: study protocol

INTRODUCTION

The ageing of the population represents a significant challenge for aged care in Australia and in many other countries internationally. In an environment of increasing resource constraints, new methods, techniques and evaluative frameworks are needed to support resource allocation decisions that maximise the quality of life and well-being of older people. Economic evaluation offers a rigorous, systematical and transparent framework for measuring quality and efficiency, but there is currently no composite mechanism for incorporating older people's values into the measurement and valuation of quality of life for quality assessment and economic evaluation. In addition, to date relatively few economic evaluations have been conducted in aged care despite the large potential benefits associated with their application in this sector. This study will generate a new preference based older person-specific quality of life instrument designed for application in economic evaluation and co-created from its inception with older people.

METHODS AND ANALYSIS

A candidate descriptive system for the new instrument will be developed by synthesising the findings from a series of in-depth qualitative interviews with 40 older people currently in receipt of aged care services about the salient factors which make up their quality of life. The candidate descriptive system will be tested for construct validity, practicality and reliability with a new independent sample of older people (n=100). Quality of life state valuation tasks using best worst scaling (a form of discrete choice experiment) will then be undertaken with a representative sample of older people currently receiving aged care services across five Australian states (n=500). A multinomial (conditional) logistical framework will be used to analyse responses and generate a scoring algorithm for the new preference-based instrument.

ETHICS AND DISSEMINATION

The new quality of life instrument will have wide potential applicability in assessing the cost effectiveness of new service innovations and for quality assessment across the spectrum of ageing and aged care. Results will be disseminated in ageing, quality of life research and health economics journals and through professional conferences and policy forums. This study has been reviewed by the Human Research Ethics Committee of the University of South Australia and has ethics approval (Application ID: 201644).

Biomarkers of autonomic regulation for predicting psychological distress and functional recovery following road traffic injuries: protocol for a prospective cohort study

INTRODUCTION

Psychological distress is a prevalent condition often overlooked following a motor vehicle crash (MVC), particularly when injuries are not severe. The aim of this study is to examine whether biomarkers of autonomic regulation alone or in combination with other factors assessed shortly after MVC could predict risk of elevated psychological distress and poor functional recovery in the long term, and clarify links between mental and physical health consequences of traffic injury.

METHODS AND ANALYSIS

This is a controlled longitudinal cohort study, with follow-up occurring at 3, 6 and 12 months. Participants include up to 120 mild to moderately injured MVC survivors who consecutively present to the emergency departments of two hospitals in Sydney and who agree to participate, and a group of up to 120 non-MVC controls, recruited with matched demographic characteristics, for comparison. WHO International Classification of Functioning is used as the framework for study assessment. The primary outcomes are the development of psychological distress (depressive mood and anxiety, post-traumatic stress symptoms, driving phobia, adjustment disorder) and biomarkers of autonomic regulation. Secondary outcomes include indicators of physical health (presence of pain/fatigue, physical functioning) and functional recovery (quality of life, return to function, participation) as well as measures of emotional and cognitive functioning. For each outcome, risk will be described by the frequency of occurrence over the 12 months, and pathways determined via latent class mixture growth modelling. Regression models will be used to identify best predictors/biomarkers and to study associations between mental and physical health.

ETHICS AND DISSEMINATION

Ethical approvals were obtained from the Sydney Local Health District and the research sites Ethics Committees. Study findings will be disseminated to health professionals, related policy makers and the community through peer-reviewed journals, conference presentations and health forums.

TRIAL REGISTRATION NUMBER

ACTRN12616001445460.

Implementing a Trauma-Informed Model of Care in a Community Acute Mental Health Team

In this paper, we demonstrate the value of implementing a Trauma-Informed Model of Care in a Community Acute Mental Health Team by providing brief intensive treatment (comprising risk interventions, brief counselling, collaborative formulation and pharmacological treatment). The team utilised the Conversational Model (CM), a psychotherapeutic approach for complex trauma. Key features of the CM are described in this paper using a clinical case study. The addition of the Conversational Model approach to practice has enabled better understandings of consumers' capacities and ways to then engage, converse, and intervene. The implementation of this intervention has led to a greater sense of self-efficacy amongst clinicians, who can now articulate a clear counselling model of care.

Quality assessment of systematic reviews of vitamin D, cognition and dementia

BACKGROUND

There is conflicting evidence regarding the association of vitamin D with cognition performance and dementia.AimsWe aimed to summarise the evidence on the association of vitamin D with cognitive performance, dementia and Alzheimer disease through a qualitative assessment of available systematic reviews and meta-analyses.

METHOD

We conducted an overview of the systematic reviews of all study types with or without meta-analyses on vitamin D and either Alzheimer disease, dementia or cognitive performance up to June 2017.

RESULTS

Eleven systematic reviews were identified, nine of which were meta-analyses with substantial heterogeneity, differing statistical methods, variable methodological quality and quality of data abstraction. A Measurement Tool to Assess Systematic Reviews checklist scores ranged from 4 to 10 out of 11, with seven reviews of 'moderate' and four of 'high' methodological quality. Out of six meta-analyses on the association between low serum concentration of 25-hydroxyvitamin D and risk of dementia, five showed a positive association. Results of meta-analyses on the association between low serum concentration of 25-hydroxyvitamin D and memory function tests showed conflicting results.

CONCLUSIONS

This systematic evaluation of available systematic reviews provided a clearer understanding of the potential link between low serum vitamin D concentrations and dementia. This evaluation also showed that the quality of the available evidence is not optimal because of both the low methodological quality of the reviews and low quality of the original studies. Interpretation of these systematic reviews should therefore be made with care.Declaration of interestNone.

Social determinants of male health: a case study of Leeds, UK

BACKGROUND

The social determinants of health have a disproportionate impact on mortality in men. A study into the state of health of the male population in Leeds was undertaken to guide public health commissioning decisions. This paper reports on the data relating to the social lives of men.

METHODS

A cross-sectional study was undertaken, comprising descriptive analysis of data relating to educational attainment, housing, employment (including benefit claimants), marital status and relationships. Data was considered for the whole city and localised at the Middle Super Output Area (MSOA) level and mapped against the Index of Deprivation.

RESULTS

Boys' educational attainment was found to be lagging behind girls' from their earliest assessments (Early Years Foundation Stage Profile, 46% vs. 60%, P = 0.00) to GCSEs (53% vs. 63%, P = 0.00), leaving many men with no qualifications. There were 68% more men than women identified as being unemployed, with more men claiming benefits. Men living in social housing are more likely to be housed in high-rise flats. Almost 50% of men aged 16-64 are single, with 2254 lone fathers.

CONCLUSIONS

There appears to be a lack of sex/gender analysis of current cross city data. In areas of deprivation a complex picture of multiple social problems emerges, with marked gender differences in the social determinants of health, with males seeming to be more negatively affected. There is a need for more focused planning for reaching out and targeting boys and men in the most deprived inner city areas, so that greater efficiency in service delivery can be obtained.

A systematic review: efficacy of botulinum toxin in walking and quality of life in post-stroke lower limb spasticity

BACKGROUND

Improved walking is one of the highest priorities in people living with stroke. Post-stroke lower limb spasticity (PSLLS) impedes walking and quality of life (QOL). The understanding of the evidence of improved walking and QOL following botulinum toxin (BoNTA) injection is not clear. We performed a systematic review of the randomized control trials (RCT) to evaluate the effectiveness of BoNTA injection on walking and QOL in PSLLS.

METHODS

We searched PubMed, Web of Science, Embase, CINAHL, ProQuest Thesis and Dissertation checks, Google Scholar, WHO International Clinical Trial Registry Platform, ClinicalTrials.gov , Cochrane, and ANZ and EU Clinical Trials Register for RCTs looking at improvement in walking and QOL following injection of BoNTA in PSLLS. The original search was carried out prior to 16 September 2015. We conducted an additional verifying search on CINHAL, EMBASE, and MEDLINE (via PubMed) from 16 September 2015 to 6 June 2017 using the same clauses as the previous search. Methodological quality of the individual studies was critically appraised using Joanna Briggs Institute's instrument. Only placebo-controlled RCTs looking at improvement in walking and QOL were included in the review.

RESULTS

Of 2026 records, we found 107 full-text records. Amongst them, we found five RCTs qualifying our criteria. No new trials were found from the verifying search. Two independent reviewers assessed methodological validity prior to inclusion in the review using Joanna Briggs Institute's appraisal instrument. Two studies reported significant improvement in gait velocity (p = 0.020) and < 0.05, respectively. One study showed significant improvement in 2-min-walking distance (p < 0.05). QOL was recorded in one study without any significant improvement. Meta-analysis of reviewed studies could not be performed because of different methods of assessing walking ability, small sample size with large confidence interval and issues such as lack of power calculations in some studies. Findings from our systematic and detailed study identify the need for a well-designed RCT to adequately investigate the issues highlighted.

CONCLUSIONS

This review could not conclude there was sufficient evidence to support or refute improvement on walking or QOL following BoNTA injection. Reasons for this are discussed, and methods for future RCTs are developed.

A Cost-Effectiveness Model for Frail Older Persons: Development and Application to a Physiotherapy-Based Intervention

INTRODUCTION

The clinical importance of frailty is increasing. Existing economic evaluations of interventions to manage frailty have limited time horizons, but even in older populations there may be important longer-term differences in costs and outcomes. This paper reports on the development of a cost-effectiveness model to predict publicly funded health and aged care costs and quality-adjusted life years (QALYs) over the remaining lifetime of frail Australians and a model-based cost-utility analysis of a physiotherapy-based intervention for frail individuals.

METHODS

A cohort-based state transition (Markov) model was developed to predict costs and QALYs over the remaining lifetime of a frail population. Frailty is defined using the phenotypic definition of frailty, and the model comprises health states that describe frailty status, residential status, the experience of bone fractures and depression, and death. Model input parameters were estimated and calibrated using the Dynamic Analyses to Optimise Ageing dataset, supplemented with data from the published literature.

RESULTS

The cost-effectiveness model was subject to a range of validation approaches, which did not negate the validity of the model. The evaluated physiotherapy-based frailty intervention has an expected incremental cost per QALY gained of Australian $8129 compared to usual care, but there is a probability of 0.3 that usual care is more effective and less costly than the intervention.

DISCUSSION

Frailty reduces quality of life, is costly to manage and it's prevalence is increasing, but new approaches to managing frailty need to demonstrate value for money. The value of the reported cost-effectiveness model is illustrated through the estimation of all important costs and effects of a physiotherapy-based frailty intervention, which facilitates comparisons with funding decisions for other new technologies in Australia.

Post-exposure treatment of non-human primates lethally infected with Ebola virus with EBOTAb, a purified ovine IgG product

Despite sporadic outbreaks of Ebola virus (EBOV) over the last 4 decades and the recent public health emergency in West Africa, there are still no approved vaccines or therapeutics for the treatment of acute EBOV disease (EVD). In response to the 2014 outbreak, an ovine immunoglobulin therapy was developed, termed EBOTAb. After promising results in the guinea pig model of EBOV infection, EBOTAb was tested in the cynomolgus macaque non-human primate model of lethal EBOV infection. To ensure stringent therapeutic testing conditions to replicate likely clinical usage, EBOTAb was first delivered 1, 2 or 3 days post-challenge with a lethal dose of EBOV. Results showed a protective effect of EBOTAb given post-exposurally, with survival rates decreasing with increasing time after challenge. Viremia results demonstrated that EBOTAb resulted in a decreased circulation of EBOV in the bloodstream. Additionally, assay of liver enzymes and histology analysis of local tissues identified differences between EBOTAb-treated and untreated groups. The results presented demonstrate that EBOTAb conferred protection against EBOV when given post-exposure and should be explored and developed further as a potential intervention strategy for future outbreaks, which are likely to occur.

An Empirical Comparison of the EQ-5D-5L, DEMQOL-U and DEMQOL-Proxy-U in a Post-Hospitalisation Population of Frail Older People Living in Residential Aged Care

OBJECTIVE

To empirically compare the measurement properties of the DEMQOL-U and DEMQOL-Proxy-U instruments to the EQ-5D-5L and its proxy version (CEQ-5D-5L) in a population of frail older people living in residential aged care in the post-hospitalisation period following a hip fracture.

METHODS

A battery of instruments to measure health-related quality of life (HRQoL), cognition, and clinical indicators of depression, pain and functioning were administered at baseline and repeated at 4 weeks' follow-up. Descriptive summary statistics were produced and psychometric analyses were conducted to assess the levels of agreement, convergent validity and known group validity between clinical indicators and HRQoL measures.

RESULTS

There was a large divergence in mean (SD) utility scores at baseline for the EQ-5D-5L and DEMQOL-U [EQ-5D-5L mean 0.21 (0.19); DEMQOL-U mean 0.79 (0.14)]. At 4 weeks' follow-up, there was a marked improvement in EQ-5D-5L scores whereas DEMQOL-U scores had deteriorated. [EQ-5D-5L mean 0.45 (0.38); DEMQOL-U mean 0.58 (0.38)]. The EQ-5D and CEQ-5D-5L were more responsive to the physical recovery trajectory experienced by frail older people following surgery to repair a fractured hip, whereas the DEMQOL-U and DEMQOL-Proxy-U appeared more responsive to the changes in delirium and dementia symptoms often experienced by frail older people in this period.

CONCLUSIONS

This study presents important insights into the HRQoL of a relatively under-researched population of post-hospitalisation frail older people in residential care. Further research should investigate the implications for economic evaluation of self-complete versus proxy assessment of HRQoL and the choice of preference-based instrument for the measurement and valuation of HRQoL in older people exhibiting cognitive decline, dementia and other co-morbidities.