Using research feedback loops to implement a disability case study with Aboriginal and Torres Strait Islander communities and service providers in regional and remote Australia

While there is a well-developed body of literature in the health field that describes processes to implement research, there is a dearth of similar literature in the disability field of research involving complex conditions. Moreover, the development of meaningful and sustainable knowledge translation is now a standard component of the research process. Knowledge users, including community members, service providers, and policy makers now call for evidence-led meaningful activities to occur rapidly. In response, this article presents a case study that explores the needs and priorities of Aboriginal and Torres Strait Islander women in Australia who have experienced a traumatic brain injury due to family violence. Drawing on the work of Indigenous disability scholars such as Gilroy, Avery and others, this article describes the practical and conceptual methods used to transform research to respond to the realities of community concerns and priorities, cultural considerations and complex safety factors. This article offers a unique perspective on how to increase research relevance to knowledge users and enhance the quality of data collection while also overcoming prolonged delays of knowledge translation that can result from the research-production process.

1301 Early MRI in the Diagnosis of Suspected Scaphoid Fractures – An Audit of a Redesigned Diagnostic Pathway

Introduction

MRI is the gold standard for investigation of suspected scaphoid fractures, which can be missed on initial x-rays. This full cycle audit reports the impact of our new patient pathway, which changes repeat x-rays at 2 weeks to urgent limited sequence scaphoid MRI for those with normal initial x-rays, but clinical suspicion of fracture at initial clinic visit.

Method

A second cycle audited MRI requests for suspected scaphoid fractures at Southmead hospital following implementation of the new pathway in October 2020. We collected wait times from request to scan, and radiologist reports. Results were compared to our first cycle, 6-month time period.

Results

he results for 24 limited sequence MRIs via our new pathway were compared to 134 full wrist MRIs of the first cycle. Two scans (9.1%) were positive for scaphoid fracture versus 12% in the first cycle. 19 scans (86%) identified alternate pathology including sprain (6), bone bruise (5), non-scaphoid fractures (4) and degenerative change (3). 1 scan (4.5%) was reported as normal. 73% of MRIs were performed within 14 days, compared to 63% in previous cohort.

Conclusions

Our new pathway using limited sequence MRI identified similar rates of scaphoid fractures. Reduced time to MRI was observed compared to the previous cohort due to shorter scan durations and resulted in earlier diagnosis and fewer outpatient follow-up appointments. Our new pathway has benefits to patient experience and also reduces footfall in hospital, during a time of global Covid-19 pandemic, with no increase in costs.

1277 A Closed-Loop Audit of the use of qFIT in Symptomatic “Two Week Wait” referrals in Somerset Foundation Trust

Introduction

Quantitative faecal immunochemical test (qFIT) is recommended as the replacement test for faecal occult blood testing by NICE. We audited qFIT use in two week-wait (2WW) referrals in Somerset Foundation Trust (SFT) following its introduction in 2019.

Method

Following qFIT being made available to general practitioners, all 2WW referrals received before (July 2019) and after (December 2019) the introduction of the new 2WW referral form were reviewed. Electronic patient records were analysed to determine investigations performed and if a diagnosis of cancer was made.

Results

July 2019: 288 2WW referrals with 74 patients eligible for qFIT – only 7 of these underwent qFIT; total of 93 qFIT performed by GPs with 11 positive tests. December 2019: 222 2WW referrals with 18 patients eligible for qFIT – all of whom underwent qFIT; total of 155 qFIT performed by GPs with 18 positive (and 137 negative) tests. 1 patient with a positive qFIT was found to have colorectal malignancy (qFIT = 267 g/dL, investigation showed benign TVA). An increase in qFIT was observed over time, coinciding with a reduction in 2WW referrals, including reduction in patients who were qFIT eligible. The 2WW service identified 11 (3.8%) cases of colorectal cancer in July 2019 compared to 12 (5.4%) cases in December 2019, showing an increased pickup rate.

Conclusions

High proportions of 2WW referrals undergo investigation. The results of this audit highlight the utility of qFIT in screening 2WW referrals and reducing burden on the service, particularly where access to investigations is severely restricted due to coronavirus.

Exploring the barriers and facilitators for the use of digital health technologies for the management of COPD: a qualitative study of clinician perceptions

BACKGROUND

Digital health technology (DHT) promises to support patients and healthcare professionals (HCPs) to optimize the management of chronic obstructive pulmonary disease (COPD). However, there is a lack of evidence demonstrating the effectiveness of DHT for the management of COPD. One reason for this is the lack of user-involvement in the development of DHT interventions in COPD meaning their needs and preferences are rarely accounted for in the design phase. Although HCP adoption issues have been identified in relation to DHT, little is known about the challenges perceived by HCPs providing care to COPD patients. Therefore, this study aims to qualitatively explore the barriers and facilitators HCPs perceive for the use of DHT in the management of COPD.

METHODS

Participants (n = 32) were recruited using snowball sampling from two university hospitals and several general practitioner clinics. A semi-structured interview was conducted with each participant. NVivo 12 software was used to complete thematic analysis on the data.

RESULTS

Themes identified include: data quality; evidence-based care; resource constraints; and digital literacy presented as barriers; and facilitators include the following themes: digital health training and education; improving HCP digital literacy; and Personalized prescribing. Patient-centered approaches, such as pulmonary rehabilitation and shared decision-making were suggested as implementation strategies to ease the adoption of digital health for the management of COPD.

CONCLUSION

These findings contribute new insights about the needs and preferences of HCPs working in COPD regarding DHT. The findings can be used to help mitigate user-experience issues by informing the design of person-centered implementation and adoption strategies for future digital health interventions in COPD.

Association of Gallbladder Mucocele Histologic Diagnosis with Selected Drug Use in Dogs: A Matched Case-Control Study

Background

The cause of gallbladder mucocele (GBM) formation in dogs currently is unknown. Many available drugs represent a newer generation of xenobiotics that may predispose dogs to GBM formation.

Objective

To determine if there is an association between the histologic diagnosis of GBM in dogs and administration of selected drugs.

Animals

Eighty‐one dogs with a histologic diagnosis of GBM and 162 breed, age, and admission date‐matched control dogs from a single referral institution.

Methods

Medical records of dogs with GBM and control dogs from 2001 to 2011 were reviewed. Owner verification of drug history was sought by a standard questionnaire. Reported use of heartworm, flea, and tick preventatives as well as nonsteroidal anti‐inflammatory drugs, analgesics, corticosteroids, or medications for treatment of osteoarthritis was recorded.

Results

Dogs with GBM were 2.2 times as likely to have had reported use of thyroxine (as a proxy for the diagnosis of hypothyroidism) as control dogs (95% confidence interval [CI], 0.949–5.051), 3.6 times as likely to have had reported treatment for Cushing's disease (95% CI, 1.228–10.612), and 2.3 times as likely to have had reported use of products containing imidacloprid (95% CI, 1.094–4.723). Analysis of a data subset containing only Shetland sheepdogs (23 GBM and 46 control) indicated that Shetland sheepdogs with GBM formation were 9.3 times as likely to have had reported use of imidacloprid as were control Shetland sheepdogs (95% CI, 1.103–78.239).

Conclusions and Clinical Importance

This study provides evidence for an association between selected drug use and GBM formation in dogs. A larger epidemiologic study of Shetland sheepdogs with GBM formation and exposure to imidacloprid is warranted.

Increasing productivity, reducing cost and improving quality in elective surgery in New Zealand: the Waitemata District Health Board joint arthroplasty pilot

BACKGROUND

In 2010, Waitemata District Health Board piloted a new model of care for total hip and knee arthroplasties. The pilot was incentive based and clinically led. The participating surgeons and anaesthetists were responsible for increasing surgical throughput. The pilot aimed to increase productivity, reduce cost and increase quality for patients.

AIM

To compare costs and outcomes for elective hip and knee arthroplasties carried out at the pilot site (Waitakere Hospital) compared with the main District Health Board hospital site (North Shore Hospital (NSH)).

METHODS

A retrospective matched cohort study of hip and knee replacements discharged between 1 July 2010 and 31 March 2011, comparing costs and outcomes at the pilot site compared with the NSH site. Only non-complex procedures were included, and routinely collected data were used.

RESULTS

One hundred and seventy-seven hip replacements (77 NSH, 100 pilot) and 158 knee replacements (88 NSH, 70 pilot) were analysed. Total inpatient event costs were 12% and 17% lower for hip and knee replacements, respectively, at the pilot site compared with NSH. Significant reduction in operation length (39% hip, 36% knee) and length of stay (38% hip, 39% knee) were found in the pilot groups compared with NSH.

CONCLUSION

Implementation of an innovative new model in a public hospital setting has produced significant increases in productivity and reduced overall costs. This model could potentially be used in other public healthcare settings for non-complex elective surgery.

Sol-Gel Deposition of Electronic Ceramic Films

We describe a dip-coating method of depositing thin electronic ceramic coatings on various substrates from sol-gel solutions. The solutions we use are alkoxide-based, although the specific formulations depend on the system being deposited. We are working with two electronic ceramic systems: barium titanate on glass, and alumina, and yttrium barium copper oxide on alumina. We discuss methods used to reduce and remove processing defects such as crazing, cracking and pin-holing. We are also studying the effects of varying the processing conditions (dipping, hydrolysis and firing) on the electronic properties of the films. Initial results on BaTiO3 indicate that it is better to deposit thin films (∼0.1 – 0.2μm) and build up the coating thickness by repeated dipping.

Initial experience with transvaginal incisional hernia repair

INTRODUCTION

Natural orifice surgery has evolved from a preclinical setting into a common occurrence at the University of California San Diego (UCSD). With close to 40 transvaginal cases, we have become comfortable with this technique and are exploring other indications. One of the perceived advantages in natural orifice surgery is the potential reduction in the incidence of hernia formation. Patients with abdominal wall hernias may be at increased risk of forming additional hernias at incision sites. In addition, patients with recurrent incisional hernias may, likewise, be at increased risk. We believe that reducing or eliminating abdominal wall incisions may be of benefit in the repair of abdominal wall hernias. Here, we describe what we believe to be the first natural orifice transluminal endoscopic surgical (NOTES) approach to the repair of an abdominal wall hernia.

METHODS

The patient is a 38-year-old female with a painful recurrent umbilical hernia, previously repaired 8 years prior with a polypropylene-based mesh. The patient underwent a transvaginal recurrent umbilical hernia repair with one other 5-mm port in the abdomen for safety.

RESULTS

The patient had no intraoperative or postoperative complications. At 5 months follow up, the patient had no complaints, no evidence of hernia recurrence, and was very pleased with her result.

CONCLUSIONS

The repair of primary and incisional hernias of the ventral abdominal wall via a transvaginal approach is technically feasible, and the result of our initial case was exceptional. However, there are still significant obstacles which must be addressed before this approach can be widely utilized. These obstacles include safe entrance into the abdominal cavity via a transvaginal approach, the proper mesh to be placed during the repair, and the risk of infection.

Dual-lumen natural orifice translumenal endoscopic surgery (NOTES): a new method for performing a safe anastomosis

BACKGROUND

Bowel anastomosis is one of the most challenging and difficult tasks to perform during natural orifice translumenal endoscopic surgery (NOTES). The difficulty is mainly due to the technical limitations of the endoscopic instruments available. Currently, endoscopic clips, T-bar sutures, or cumbersome suturing devices are used. A dual-lumen NOTES approach can facilitate bowel resection in a pig model by allowing the use of laparoscopic staplers through the rectum.

METHODS

Acute studies were performed on four 40-kg pig models. The dual-lumen NOTES approach was used to perform small bowel resection and anastomosis. An endoscope was passed into the stomach and pushed through the stomach wall into the peritoneal cavity (first lumen), and a 12-mm trocar was placed through the anterior rectal wall, allowing access to the peritoneum (second lumen). Handling of the bowel, resection, and anastomosis were performed using endoscopic instruments through the gastric lumen and laparoscopic instruments through the rectal lumen. The resected small bowel then was removed through the rectum.

RESULTS

Small bowel resection and anastomosis was successfully completed in all four animals using the dual-lumen NOTES approach. The laparoscopic stapler was used one more time to close the gastrotomy through the rectal port. At autopsy, intact suture lines were noted at the bowel anastomosis and at the stomach, with no evidence of leak from either site.

CONCLUSIONS

Performing a sutured anastomosis in NOTES is complex and time consuming. The use of stapling devices designed for laparoscopic procedures greatly facilitates gastrointestinal tract operations in NOTES. Using both the upper and lower gastrointestinal tract as entry sites for NOTES eliminates some of the current technical limitations of these procedures.

Site of metastases does not influence the clinical outcome of children with metastatic Germ Cell Tumors (GCT). A report from the Childrens Oncology Group (COG)

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Background: To describe the clinical outcome of children with metastatic GCT (stage IV) at diagnosis according to the primary metastatic site(s). Methods: From March 1990 to February 1996, 299 children and adolescents with stage III/IV gonadal and stage I-IV extragonadal GCT were eligible for a Pediatric Intergroup high-risk (HR) GCT trial. Patients were randomized to receive 4–6 courses of cisplatin (P) standard dose [ 20 mg/m2/day (d) × 5] or high-dose (HDP) [40 mg/m2/d × 5] with etoposide (E) 100 mg/m2/d × 5 and bleomycin (B) 15 mg/m2 on d1. We retrospectively investigated the outcome of patients with stage IV and compared their outcome according to metastatic site(s). Results: There were 133 patients with stage IV disease. The median age was 2.6 years (y) [range, 3 d-19.3 y], 70 were female. Primary sites included: 43 testicular, 14 ovarian, 76 extragonadal (45 sacroccocygeal, 28 mediastinal, 3 other). Histologies included: 66 pure yolk sac tumors, 21 immature teratomas and yolk sac tumors, 26 mixed germ cell tumors, 7 pure germinoma/seminoma/dysgerminomas, 1 immature teratoma with a non-classic germ cell tumor, 2 mixed germ cell tumor admixed with a nonclassic germ cell tumor, 5 pure choriocarcinomas, and 5 patients with unknown histology. There were no statistically significant differences in the 5-year EFS or OS rates by site of metastases. Of the 19 patients with either bone or brain involvement, 17 patients had bone and 3 had brain metastases. Conclusion: The outcome for patients with metastatic GCT is excellent with contemporary cisplatin-based regimes and is independent of the site of metastatic disease.

[Table: see text]

No significant financial relationships to disclose.

Prostate-specific antigen velocity and the odds of detecting gleason 8 to 10 prostate cancer at biopsy

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Background: Increased detection of high-grade prostate cancer was observed in the Prostate Cancer Prevention Trial (PCPT) in men receiving finasteride that halves prostate-specific antigen (PSA) and eliminates subsequent PSA rise from benign prostatic hyperplasia. Therefore despite doubling PSA, men receiving finasteride needed a larger PSA rise to exceed 4 ng/ml and have prostate biopsy recommended compared to placebo. We evaluated whether the PSA rise during the year before biopsy (PSA velocity) was associated with prostate cancer detection. Methods: Between 1/90 and 12/03, of 2125 prostate biopsies performed for a PSA exceeding 4 ng/ml or a nodule on digital rectal examination (DRE), prostate cancer was identified in 1418. Multivariable logistic regression analyses were performed evaluating the detection of Gleason 6 or less, 7, or 8 to 10 cancer. Covariates included the continuous variables of PSA velocity and level, number of prior negative biopsies and age and the categorical variables of ethnicity, DRE findings and family history. Results: As shown in the table , PSA velocity was only associated with Gleason 8 to 10 cancers (Adjusted Odds Ratio: 1.05 [95% Confidence Interval: 1.02 to 1.08]; p = 0.001). Age, PSA level and DRE status were associated across Gleason scores (p-values 0.005 or less), whereas family history (p-values 0.02 or less) and number of prior negative biopsies (p-values 0.01 or less) were associated with Gleason 7 or less cancers. Conclusion: PSA velocity is associated with Gleason 8 to 10 cancers at biopsy providing rationale for the PCPT results and a tool to enhance detection of clinically significant prostate cancer.

[Table: see text]

No significant financial relationships to disclose.

Effect of oral iron supplementation on oxidative stress and colonic inflammation in rats with induced colitis

BACKGROUND

Iron supplementation may increase disease activity in ulcerative colitis, possibly through the production of reactive oxygen species from the Fenton reaction.

AIM

To assess the effects of two doses of oral iron on intestinal inflammation and oxidative stress in experimental colitis.

METHODS

Colitis was induced in rats by giving 5% dextran sulphate sodium in drinking water for 7 days. First, using a 2 x 2 factorial design, rats with or without dextran sulphate sodium received the regular diet or a diet containing iron 3%/kg diet. Second, rats with dextran sulphate sodium-induced colitis were supplemented with iron 0.3%/kg diet and compared with rats on dextran sulphate sodium and regular diet. The body weight change, histological scores, colon length, rectal bleeding, plasma and colonic lipid peroxides, colonic glutathione peroxidase and plasma vitamin E and C were measured. Faecal analysis for haem and total, free and ethylenediaminetetra-acetic acid-chelatable iron was also performed.

RESULTS

Iron 3% and iron 0.3% increased the activity of dextran sulphate sodium-induced colitis, as demonstrated by higher histological scores, heavier rectal bleeding and further shortening of the colon. This was associated with increased lipid peroxidation and decreased antioxidant vitamins. Faecal iron available to the Fenton reaction was increased in a dose-dependent manner.

CONCLUSIONS

Iron supplementation taken orally enhanced the activity of dextran sulphate sodium-induced colitis and is associated with an increase in oxidative stress.