An alternative model of maternity care for low-risk birth: Maternal and neonatal outcomes utilizing the midwifery-based birth center model

OBJECTIVE

To assess key birth outcomes in an alternative maternity care model, midwifery-based birth center care.

DATA SOURCES

The American Association of Birth Centers Perinatal Data Registry and birth certificate files, using national data collected from 2009 to 2019.

STUDY DESIGN

This observational cohort study compared key clinical birth outcomes of women at low risk for perinatal complications, comparing those who received care in the midwifery-based birth center model versus hospital-based usual care. Linear regression analysis was used to assess key clinical outcomes in the midwifery-based group as compared with hospital-based usual care. The hospital-based group was selected using nearest neighbor matching, and the primary linear regressions were weighted using propensity score weights (PSWs). The key clinical outcomes considered were cesarean delivery, low birth weight, neonatal intensive care unit admission, breastfeeding, and neonatal death. We performed sensitivity analyses using inverse probability weights and entropy balancing weights. We also assessed the remaining role of omitted variable bias using a bounding methodology.

DATA COLLECTION

Women aged 16-45 with low-risk pregnancies, defined as a singleton fetus and no record of hypertension or cesarean section, were included. The sample was selected for records that overlapped in each year and state. Counties were included if there were at least 50 midwifery-based birth center births and 300 total births. After matching, the sample size of the birth center cohort was 85,842 and the hospital-based cohort was 261,439.

PRINCIPAL FINDINGS

Women receiving midwifery-based birth center care experienced lower rates of cesarean section (-12.2 percentage points, p < 0.001), low birth weight (-3.2 percentage points, p < 0.001), NICU admission (-5.5 percentage points, p < 0.001), neonatal death (-0.1 percentage points, p < 0.001), and higher rates of breastfeeding (9.3 percentage points, p < 0.001).

CONCLUSIONS

This analysis supports midwifery-based birth center care as a high-quality model that delivers optimal outcomes for low-risk maternal/newborn dyads.

The birth center model of care: Staffing, business characteristics, and core clinical outcomes

OBJECTIVES

Interest in expanding access to the birth center model is growing. The purpose of this research is to describe birth center staffing models and business characteristics and explore relationships to perinatal outcomes.

METHODS

This descriptive analysis includes a convenience sample of all 84 birth center sites that participated in the AABC Site Survey and AABC Perinatal Data Registry between 2012 and 2020. Selected independent variables include staffing model (CNM/CM or CPM/LM), legal entity status, birth volume/year, and hours of midwifery call/week. Perinatal outcomes include rates of induction of labor, cesarean birth, exclusive breastfeeding, birthweight in pounds, low APGAR scores, and neonatal intensive care admission.

RESULTS

The birth center model of care is demonstrated to be safe and effective, across a variety of staffing and business models. Outcomes for both CNM/CM and CPM/LM models of care exceed national benchmarks for perinatal quality with low induction, cesarean, NICU admission, and high rates of breastfeeding. Within the sample of medically low-risk multiparas, variations in clinical outcomes were correlated with business characteristics of the birth center, specifically annual birth volume. Increased induction of labor and cesarean birth, with decreased success breastfeeding, were present within practices characterized as high volume (>200 births/year). The research demonstrates decreased access to the birth center model of care for Black and Hispanic populations.

CONCLUSIONS FOR PRACTICE

Between 2012 and 2020, 84 birth centers across the United States engaged in 90,580 episodes of perinatal care. Continued policy development is necessary to provide risk-appropriate care for populations of healthy, medically low-risk consumers.

Oral health messages for Australia: A national consensus statement

BACKGROUND

Oral health promotion initiatives must be evidence-based and consistent with broader health messaging. The Oral Health Messages for the Australian Public were first produced in 2009 and sought to enable a focused, and strategic approach to oral health promotion in Australia. As the evidence base and needs of the Australian population have since changed, this consensus statement was updated in 2022-2023.

METHODS

The process of updating the messages consisted of 3 phases (preparatory phase, the Delphi technique, final revision phase). The preparatory phase included public and expert consultation, an umbrella review of published scientific literature and review of available recommendations, policies and guidelines. The Delphi technique used in this study was guided by Guidance on Conducting and REporting DElphi Studies (CREDES) and included 2 voting rounds. There were 70 experts in round 1 and 60 experts in round 2. Delphi participants comprised of experts from a variety of fields to ensure diversity and inclusion, balance expertise and maximize stakeholder representation. Consensus was defined as 75% agreement.

RESULTS

A total of 11 messages were included in the 2022 update of Oral Health Messages for Australia.

CONCLUSION

The updated oral health messages will support oral health promotion policy and activity at both individual and population level to improve the oral health of Australians.

Examining the Effect of Income-Based Inequalities and Dental Service Provision on Dental Service Utilization among Older Australians: A Multiple Mediation Analysis

INTRODUCTION

Public service provision is one of the keys to reducing inequalities in the utilization of dental services. Given the increase in the aging population, there should be a focus on older adults' oral health. However, this is often overlooked.

OBJECTIVES

This study investigates the effectiveness of public services in reducing income-related inequalities in dental service utilization among older South Australians.

METHODS

A multiple counterfactual mediation analysis using the ratio of mediator probability weighting approach was used to explore the proposed mediation mechanism using a South Australian population of older adults (≥65 y). The exposure variable in the analysis was income, and the mediators were concession cards and the last dental sector (public or private). The outcome variable was the time of last dental visit.

RESULTS

Half of the older adults with high income (≥$40,000) owned a concession card, and 10% of those who attended public dental services belonged to this group. Interestingly, only 16.3% of the study participants had visited the public dental sector at their last dental appointment. Results showed a negligible indirect effect (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.85-1.05) and a significant direct effect (OR, 3.09; 95% CI, 2.24-4.87). By changing the potential outcome distributions to the counterfactual exposure distributions and taking the mediators' distribution as a counterfactual exposure distribution, the odds of dental visits occurring before the past 12 mo approximately tripled for low-income compared to high-income individuals.

CONCLUSION

Income inequalities were associated with relatively delayed dental visits in older South Australians, and provision of public services could not improve this pattern. This might happen due to inequitable access to concession cards and public services. A review of policies is required, including addressing income inequalities and implementing short-term approaches to improve service utilization patterns in older South Australians.

KNOWLEDGE TRANSFER STATEMENT

The findings of this study can enable policymakers for informed decision-making about the provision of public dental services for older Australians. This study emphasizes the importance of reviewing the current public dental services and subsidies and implementing short-term approaches to reduce income inequalities for older Australians.

Racial identity and concussion diagnosis and recovery trajectories in collegiate athletes: a LIMBIC MATARS investigation

OBJECTIVE

To determine if there were concussion diagnosis and recovery disparities between collegiate athletes with Black and White racial identities.

DESIGN

Retrospective cohort study.

METHODS

Concussion information was extracted from NCAA athlete medical files at LIMBIC MATARS member institutions from the 2015-16' to 2019-20' academic years. A total of 410 concussions from 9 institutions were included that provided all independent (i.e. racial identity of Black or White) and dependent variable information (i.e. dates of injury, diagnosis, symptom resolution, and return to sport) that were analyzed using Mann-Whitney U tests. The sample consisted of 114 (27.8%) concussions sustained by Black athletes and 296 (72.1%) sustained by White athletes.

RESULTS

The overall sample had a median of 0 days between injury occurrence to diagnosis, 7 days to symptom resolution, and 12 days to return to sport. No significant timing differences were observed for concussion diagnosis (p = .14), symptom resolution (p = .39), or return to sport (p = 0.58) between collegiate athletes with Black versus White racial identities.

CONCLUSIONS

These findings may reflect equitable access to onsite sports medicine healthcare resources that facilitate concussion management in the collegiate sport setting. Future work should explore these associations with a larger and more diverse sample of collegiate athletes.

Design and testing the validity of an inexpensive and accessible sham dry needling protocol

OBJECTIVE

To use a simple method of needle blunting to produce a placebo dry needling protocol which is indistinguishable from the sensations felt during therapeutic dry needling.

METHODS

A randomised cross-over design was used to compare the perception of needle skin penetration, pain experienced and types of sensations experienced following a single placebo dry needling and a single therapeutic dry needling application.

RESULTS

There were no significant differences in the proportions of patients reported ability to perceive needle penetration (p = 0.646), description of needling sensations (p = 0.3) or pain rating (p = 0.405) when comparing placebo needling to therapeutic dry needling.

CONCLUSION

Needle tip bending creates a simple, cost-effective and effective placebo needle for use in comparisons with therapeutic dry needling. This offers researchers a viable alternative to expensive and inappropriate acupuncture sham devices when conducting dry needling trials.

Examining maternal morbidity across a spectrum of delivery locations: An analysis of the Global Network's Maternal and Neonatal Health Registry

OBJECTIVE

To better understand maternal morbidity, using quality data from low- and middle-income countries (LMICs), including out-of-hospital deliveries. Additionally, to compare to the WHO estimate that maternal morbidity occurs in 15% of pregnancies, which is based largely on hospital-level data.

METHODS

The Global Network for Women's and Children's Health Research Maternal Newborn Health Registry collected data on all pregnancies from seven sites in six LMICs between 2015 and 2020. Rates of maternal mortality and morbidity and the differences in morbidity across delivery location and birth attendant type were evaluated.

RESULTS

Among the 280 584 deliveries included in the present analysis, the overall maternal mortality ratio was 138 per 100 000, while 11.7% of women experienced at least one morbidity. Rates of morbidity were generally higher for deliveries occurring within hospitals (19.8%) and by physicians (23.6%). The lowest rates of morbidity were noted among women delivering in non-hospital healthcare facilities (5.6%) or with non-physician clinicians (e.g. nurses, midwives [5.4%]).

CONCLUSION

The present study shows important differences in reported maternal morbidity across delivery sites, with a trend towards lower morbidity in non-hospital healthcare facilities and among non-physician clinicians.

Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 6. Management of pregnancy complications at Community Birthing Centers (Casas Maternas Rurales)

BACKGROUND

In Guatemala, Indigenous women have a maternal mortality ratio over twice that of non-Indigenous women. Long-standing marginalization of Indigenous groups and three decades of civil war have resulted in persistent linguistic, economic, cultural, and physical barriers to maternity care. Curamericas/Guatemala facilitated the development of three community-built, -owned, and -operated birthing centers, Casas Maternas Rurales (referred to here as Community Birthing Centers), where auxiliary nurses provided physically accessible and culturally acceptable clinical care. The objective of this paper is to assess the management of complications and the decision-making pathways of Birthing Center staff for complication management and referral. This is the sixth paper in the series of 10 articles. Birthing centers are part of the Expanded Census-based, Impact-oriented Approach, referred to as CBIO+.

METHODS

We undertook an explanatory, mixed-methods study on the handling of pregnancy complications at the Birthing Centers, including a chart review of pregnancy complications encountered among 1,378 women coming to a Birthing Center between 2009 and 2016 and inductively coded interviews with Birthing Center staff.

RESULTS

During the study period, 1378 women presented to a Birthing Center for delivery-related care. Of the 211 peripartum complications encountered, 42.2% were successfully resolved at a Birthing Center and 57.8% were referred to higher-level care. Only one maternal death occurred, yielding a maternal mortality ratio of 72.6 maternal deaths per 100,000 live births. The qualitative study found that staff attribute their successful management of complications to frequent, high-quality trainings, task-shifting, a network of consultative support, and a collaborative atmosphere.

CONCLUSION

The Birthing Centers were able to resolve almost one-half of the peripartum complications and to promptly refer almost all of the others to a higher level of care, resulting in a maternal mortality ratio less than half that for all Indigenous Guatemalan women. This is the first study we are aware of that analyzes the management of obstetrical complications in such a setting. Barriers to providing high-quality maternity care, including obtaining care for complications, need to be addressed to ensure that all pregnant women in such settings have access to a level of care that is their fundamental human right.

Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ approach of Curamericas: 2. Study site, design, and methods

BACKGROUND

The Curamericas/Guatemala Maternal and Child Health Project, 2011-2015, included implementation research designed to assess the effectiveness of an approach referred to as CBIO+ , composed of: (1) the Census-Based, Impact-Oriented (CBIO) Approach, (2) the Care Group Approach, and (3) the Community Birthing Center Approach. This is the second paper in a supplement of 10 articles describing the implementation research and its findings. Paper 1 describes CBIO+ , the Project Area, and how the Project was implemented.

OBJECTIVE

This paper describes the implementation research design and details of how it was carried out.

METHODS

We reviewed the original implementation research protocol and the methods used for all data collection related to this Project. The protocol and methods used for the implementation research related to this Project were all standard approaches to the monitoring and evaluation of child survival projects as developed by the United States Agency for International Development Child Survival and Health Grants Program (CSHGP) and the CORE Group. They underwent independent peer review supervised by the CSHGP before the implementation research began.

RESULTS

The study area was divided into two sets of communities with a total population of 98,000 people. Project interventions were implemented in Area A from 2011 until the end of the project in 2015 (44 months) and in Area B from late 2013 until 2015 (20 months). Thus, Area B served as a quasi-comparison area during the first two years of Project implementation. The overarching study question was whether the CBIO+ Approach improved the health and well-being of children and mothers. The outcome indicators included (1) changes in population coverage of evidence-based interventions, (2) changes in childhood nutritional status, (3) changes in the mortality of children and mothers, (4) quality of care provided at Community Birthing Centers, (5) the impact of the Project on women's empowerment and social capital, (6) stakeholder assessment of the effectiveness of the CBIO+ Approach, and (7) the potential of wider adoption of the CBIO+ Approach.

CONCLUSION

The implementation research protocol guided the assessment of the effectiveness of the CBIO+ Approach in improving the health and well-being of children, mothers, and their communities.

923 How Did the Initial Wave Of COVID-19 Affect CEPOD Waiting Times for Vascular Surgery? A Comparative Audit

Aim

Many vascular patients present acutely, relying on emergency theatre availability when surgical intervention is required. The prioritisation of the CEPOD operating list is a challenge, and the additional pressures of the COVID-19 pandemic have necessitated changes to established practice. The purpose of this audit was to review the effects of the pandemic on the CEPOD waiting times for vascular patients at the main centre for the South West Wales Vascular Network.

Method

The CEPOD waiting times for vascular patients during the initial wave of the COVID-19 pandemic were compared with the same period the previous year. Data was analysed according to booking category and procedure type.

Results

98 emergency vascular procedures were performed during the initial wave of the COVID pandemic, compared to 133 in 2019. In 2019, amputations (major and minor) accounted for 47% of cases, which rose to 53% during the pandemic. Median waiting times for category 1 and 2a operations were significantly shorter in 2020, whilst category 3 waiting times rose. There was no significant difference overall in the proportion of patients operated on within the target timescale, regardless of CEPOD booking category.

Conclusions

Managing the impact of COVID-19 required change to established practice. Although fewer procedures were performed, significant logistical challenges were faced. By adjusting the organisation of CEPOD, the most urgent vascular cases were performed quicker during this time. It is important to identify and promote the positive organisational changes that have arisen as a result of COVID-19, and to continue to review procedures as the pandemic progresses.

917 Metaplastic Thymic Sarcoma of The Thyroid: A Case Report and A Review of The Literature

In this paper, the authors present a case diagnosed as ‘metaplastic thymic sarcoma’. Tumours of the thymus are extremely rare: there is a disparity in terminology and histology observed, although there have been efforts to make classification clearer. The reported case concerns a seventy-eight-year-old woman, who presented with a rapidly enlarging neck mass. Histological diagnosis was made challenging by the unusual characteristics of the tumour; the diagnosis of ‘metaplastic thymic sarcoma’ was eventually established, following consultation with an internationally renowned soft tissue pathologist. Review of the relevant literature demonstrated no comparable cases; the presentation of a thymic tumour within the thyroid is also considered unusual. The tumour observed did not conform to any previously sub type of thymic tumour and is therefore believed to be a distinct entity. The patient suffered aggressive recurrence of the disease shortly after her surgery. Genetic testing indicated the tumour was BRAF positive, and there was a dramatic clinical response to Dabrafenib/ Trametinib treatment. The successful use of immunotherapy is encouraging finding, however the diagnosis of another distinct sub type of thymic tumour, further demonstrates the diagnostic and therapeutic challenges presented by this rare and heterogenous group.

1087 Establishing Guidelines for VTE Prophylaxis for Acute ENT Admissions

Aim

VTE prophylaxis is a vital aspect of patient safety. The decision whether to offer pharmacological thromboprophylaxis is a balance of risk versus benefit. There is a low incidence of VTE in ENT patients, admissions are often short and active bleeding on admission is not uncommon (epistaxis patients, already on anticoagulation are particularly difficult to manage}. There are no clear, specialty specific guidelines to assist in these frequently encountered endeavours.

Method

The number of emergency ENT admissions who had a documented VTE during admission or in the 28 days following was used to calculate the incidence of VTE in acute admissions. An audit of VTE prophylaxis and documentation was also conducted using 20 admissions over 24 hours.

Results

Incidence was 0.12%. 75% had a documented VTE risk assessment. Only 50% patients were prescribed chemical and mechanical thromboprophylaxis. 0% had appropriately documented that the patient did not require thromboprophylaxis on the drug chart (as per trust guidelines).

Conclusions

The results showed that both documentation and prescribing related to VTE prevention were poor. By highlighting the low incidence amongst this patient group, we were able to establish clearer guidance for VTE prophylaxis in acute ENT admissions and a protocol to standardise the management of anticoagulation in actively bleeding epistaxis patients.

919 Surgical Voice Restoration – Improving Out of Hours Management: A Multidisciplinary Quality Improvement Project

Aim

Swansea Bay University Health Board have a caseload of 37 surgical voice restoration (SVR) laryngectomies. These patients are excellently managed during working hours, by a SALT-led service. Concerns were raised regarding the quality of out of hours management: the aim of this project was to identify and address the factors contributing to the difference in care received.

Method

A questionnaire was sent to current junior doctors to assess knowledge and confidence when managing SVR patients. Phone interviews were conducted with SVR patients to discuss the issues from a patient’s perspective. The junior doctor team and SALT team liaised to identify contributing logistical issues.

Results

The junior doctor survey indicated both experience and confidence were low, including amongst senior trainees. 58.3% were unfamiliar with equipment used to change a speech valve. Patient interviews revealed several issues, such as delays to treatment and unnecessary admissions. Logistical concerns included inability to access equipment out of hours and an absence of departmental guidelines.

Conclusions

This project demonstrates a collaborative approach between junior doctors and SALT, to improve the quality of care for a sub-set of patients with highly specialised needs. We identified the contributing factors for the disparity in services and tailored interventions to provide the junior doctors responsible for out of hours care, with the knowledge and skills to provide a better standard of care.

1121 Single Use Nasal Endoscopes – A Review of The Cost and Organisational Implications Based on Department Size

Aim

Single use nasal endoscopes have become increasingly popular since the COVID-19 pandemic. By avoiding the risk of cross contamination and reducing exposure by eliminating the need for re-processing, the disposable scopes have clear safety benefits. Despite ENT UK guidelines recommending that disposable nasal endoscopes be available in every department for use in emergencies, they have often been considered prohibitively expensive. The aim of this study was to analyse the costs associated with traditional nasal endoscopes and compare them to the single use scopes.

Method

A micro costing exercise was undertaken in three ENT departments: 2 university hospitals, and 1 district general hospital. The outcomes were compared and discussed with relation to the logistics of the departments, as well as organizational considerations.

Results

Cost per procedure varied according to the reprocessing methods used in the different departments. The cost of the disposable nasal endoscopes appears high, however there are many hidden costs associated with the traditional scopes, which can be difficult to quantify accurately.

Conclusions

Although disposable endoscopes appear costly, reprocessing and frequent repairs required for re-usable scopes account for the comparable cost per procedure. The high risk of COVID-19 transmission from examining the upper aerodigestive tract means that the safety benefits bear more weight in the current climate. However, concerns regarding environmental impact, image quality and storage of examinations also need to be considered.

1098 Prophylactic Doxycycline Prior To The Excision of Ulcerated Skin Lesions. An Audit of Dose Timings and Adverse Effects

Aim

Antibiotic prophylaxis to reduce the incidence of surgical site infections following excision of ulcerated skin lesions is frequently recommended, although the evidence base is limited. Current Swansea Bay guidelines recommend pre-operative administration of antibiotics: for procedures performed under local anaesthetic in the Plastic Surgery Treatment Centre (PSTC), oral route is preferable. It was noted that a number of patients were experiencing nausea and vomiting following administration of the recommended oral agent (doxycycline). The aim of this audit was to quantify the proportion of patients experiencing adverse effects, and to assess whether the prophylactic dose was being administered within the recommended time frame.

Method

Data was collected over a three-week period (28/10/20- 18/11/20). All patients that received doxycycline pre-operatively during this period were included: the time the doxycycline was given, the time of operation and whether there were any adverse effects was recorded for each patient.

Results

14 patients received doxycycline during the monitored period. On average the doxycycline was given 52 minutes prior to the procedure. 2 patients received their doxycycline dose after their procedures. 4 patients experienced side effects from the doxycycline (3 vomited, 1 nausea), the average time this subset of patients received their dose was 50 minutes prior to their procedure.

Conclusions

A significant proportion of patients experience adverse after receiving doxycycline, whilst there is limited evidence to prove its benefits. Trust guidelines are under review to consider alternative antibiotics, but better evidence is required to clarify the need for antibiotic prophylaxis for ulcerated lesions.

Multi-energy reconstructions, central electron temperature measurements, and early detection of the birth and growth of runaway electrons using a versatile soft x-ray pinhole camera at MST

A multi-energy soft x-ray pinhole camera has been designed, built, and deployed at the Madison Symmetric Torus to aid the study of particle and thermal transport, as well as MHD stability physics. This novel imaging diagnostic technique employs a pixelated x-ray detector in which the lower energy threshold for photon detection can be adjusted independently on each pixel. The detector of choice is a PILATUS3 100 K with a 450 μm thick silicon sensor and nearly 100 000 pixels sensitive to photon energies between 1.6 and 30 keV. An ensemble of cubic spline smoothing functions has been applied to the line-integrated data for each time-frame and energy-range, obtaining a reduced standard-deviation when compared to that dominated by photon-noise. The multi-energy local emissivity profiles are obtained from a 1D matrix-based Abel-inversion procedure. Central values of T_e can be obtained by modeling the slope of the continuum radiation from ratios of the inverted radial emissivity profiles over multiple energy ranges with no a priori assumptions of plasma profiles, magnetic field reconstruction constraints, high-density limitations, or need of shot-to-shot reproducibility. In tokamak plasmas, a novel application has recently been tested for early detection, 1D imaging, and study of the birth, exponential growth, and saturation of runaway electrons at energies comparable to 100 × T_e,0; thus, early results are also presented.

Laboratory Resolved Structure of Supercritical Perpendicular Shocks

Supermagnetosonic perpendicular flows are magnetically driven by a large radius theta-pinch experiment. Fine spatial resolution and macroscopic coverage allow the full structure of the plasma-piston coupling to be resolved in laboratory experiment for the first time. A moving ambipolar potential is observed to reflect unmagnetized ions to twice the piston speed. Magnetized electrons balance the radial potential via Hall currents and generate signature quadrupolar magnetic fields. Electron heating in the reflected ion foot is adiabatic.

Calibration of a versatile multi-energy soft x-ray diagnostic for WEST long pulse plasmas

A compact multi-energy soft x-ray diagnostic is being installed on the W Environment in Steady-state Tokamak (WEST), which was designed and built to test ITER-like tungsten plasma facing components in a long pulse (∼1000 s) scenario. The diagnostic consists of a pinhole camera fielded with the PILATUS3 photon-counting Si-based detector (≲100 kpixel). The detector has sensitivity in the range 1.6-30 keV and enables energy discrimination, providing a higher energy resolution than conventional systems with metal foils and diodes with adequate space and time resolution (≲1 cm and 2 ms). The lower-absorption cut-off energy is set independently on each one of the ∼100 kpixels, providing a unique opportunity to measure simultaneously the plasma emissivity in multiple energy ranges and deduce a variety of plasma parameters (e.g., T_e, n_Z, and ΔZ_eff). The energy dependence of each pixel is calibrated here over the range 3-22 keV. The detector is exposed to a variety of monochromatic sources-fluorescence emission from metallic targets-and for each pixel, the lower energy threshold is scanned to calibrate the energy dependence. The data are fit to a responsivity curve ("S-curve") that determines the mapping between the possible detector settings and the energy response for each pixel. Here, the calibration is performed for three energy ranges: low (2.3-6 keV), medium (4.5-13.5 keV), and high (5.4-21 keV). We determine the achievable energy resolutions for the low, medium, and high energy ranges as 330 eV, 640 eV, and 950 eV, respectively. The main limitation for the energy resolution is found to be the finite width of the S-curve.

Transcriptomic and epigenomic effects of insoluble particles on J774 macrophages

Here we report epigenomic and transcriptomic changes in a prototypical J774 macrophage after engulfing talc or titanium dioxide particles in presence of estrogen. Macrophages are the first immune cells to engage and clear particles of various nature. A novel paradigm is emerging, that exposure to so-called 'inert' particulates that are considered innocuous is not really free of consequences. We hypothesized that especially the insoluble, non-digestible particles that do not release a known hazardous chemical can be underappreciated agents acting to affect the regulation inside macrophages upon phagocytosis. We performed gene chip microarray profiling and found that talc alone, and especially with oestrogen, has induced a substantially more prominent gene expression change than titanium dioxide; the affected genes were involved in pathways of cell proliferation, immune response and regulation, and, unexpectedly, enzymes and proteins of epigenetic regulation. We therefore tested the DNA methylation profiles of these cells via epigenome-wide bisulphite sequencing and found vast epigenetic changes in hundreds of loci, remarkably after a very short exposure to particles; ELISA assay for methylcytosine levels determined the particles induced an overall decrease in DNA methylation. We found a few loci where both the transcriptional changes and epigenetic changes occurred in the pathways involving immune and inflammatory signalling. Some transcriptomic and epigenomic changes were shared between talc and titanium dioxide, however, it is especially interesting that each of the two particles of similar size and insoluble nature has also induced a specific pattern of gene expression and DNA methylation changes which we report here.

A-09 Time to Unrestricted Participation Following Sport-Related Concussion in High School Athletes

Objective

To measure time-to-unrestricted participation in high school athletes following a sport-related concussion (SRC) diagnosis.

Method

This was a descriptive epidemiological study using the Michigan High School Athletic Association (MHSAA) online Head Injury Reporting System (HIRS). This study included 10,411 (65.9%) male and 5,412 (34.1%) female SRC cases that occurred in 20 sports with greater than 30 SRC cases during the 2015–2016 to 2018–2019 academic years. The HIRS includes dates for SRC injury events and medical clearance for unrestricted return-to-participation for each case; dates were used to calculate recovery time. Kaplan-Meier time-to-event analysis identified crude proportions of athletes that had not obtained medical clearance in weekly increments (e.g., 7 days, 14 days, 21 days, 28 days, 35 days) across sports.

Results

The median time-to-unrestricted participation was 11 days. Overall, 71.8% of SRC cases took longer than 7 days to return, 29.6% of SRC cases took longer than 14 days, 13.1% of cases took longer than 21 days to return, and 6.5% took longer than 28 days to return to their respective sports. Results by sport show that over 25% of gymnasts took longer than 28 days to return-to-unrestricted participation, followed by competitive cheerleaders (15.5%), wrestlers (12.1%), and male divers (12.0%).

Conclusions

Almost one in three high school athletes with SRC took longer than 14 days to return-to-unrestricted participation. These results serve as proportional time estimates for return-to-unrestricted participation across a sample of 20 high school sports; and provide rationale to further evaluate recovery patterns in individual sport groups.

0715 Long-term CPAP Adherence In A Public Sleep Clinic

Introduction

CPAP adherence may drop substantially over a long time frame. Since minorities including Hispanics and low socioeconomic groups have lower short-term acceptance and adherence, long-term adherence may also be reduced. We adapted a brief motivational enhancement education program (BMEEP) (Lai, CHEST 2014) in a Los Angeles County safety-net sleep clinic and found improved CPAP adherence at 3 months. We now report longitudinal long-term adherence over &gt;=2 years. Our hypothesis: Many patients would meet CMS adherence criteria over &gt;= 2 years.

Methods

During 3/1/2016 - 4/1/17, 118 patients completed BMEEP during CPAP initiation and were scheduled for a reinforcement session and routine clinic visits at 1 and 3 months and every 6 months thereafter. Electronic adherence and efficacy data were accessed each visit. Multivariate regression analyses explored association of adherence variables with demographic, clinical and workflow features.

Results

Baseline characteristics (mean (SD) or percent): Age 57.2 (17.8); Women 44.9%; Hispanic 69.5%, Non-Hispanic-White 22.9%, Other 5%, Black 3%; BMI 37; Epworth score 10.4 (6.05). Home sleep testing (69 patients) respiratory event indices were &gt;=15/hr in 67% and &gt;=30/hr in 57%. Polysomnography (81 patients) apnea hypopnea indices were (AHI) &gt;= 15 in 78% and &gt;=30/hr in 43%. By 7/1/2019, 23 (19%) patients were lost with unknown CPAP use status, while 76 (70.5%) of remaining patients continued to use CPAP. At 2 years, CPAP adherence parameters included: Average nightly use, 75% (27.7); Average hours/night, 4.74 (2.5); Average nightly use &gt;=4 hours, 65.2% (31.6); &gt;=70% nightly use &gt;= 4 hours, 35 (51.5%). Average residual AHI was 2.05 (1.69). Adherence parameters in individual patients remained similar throughout 2 years. Long-term adherence was not associated with the demographic, clinical or workflow variables tested.

Conclusion

Programs that educate, motivate and provide regular follow-up for predominantly Hispanic low income populations can achieve acceptable long-term CPAP adherence rates.

Support

None

The role of smartphone applications in clinical practice: a review

OBJECTIVE

The number of medical mobile phone applications continues to grow. Although otorhinolaryngology-specific applications represent a small proportion, there are exciting innovations emerging for the specialty. This article will assess the number of applications available and review how they may be used in clinical practice.

METHOD

The application stores of the two most popular mobile phone platforms, Apple and android, were searched using multiple search terms.

RESULTS

A total of 107 ENT applications were identified and categorised according to intended use. Eight applications were reviewed in more detail and assessed on whether a doctor or allied health professional was involved in their design and if they were evidence-based.

CONCLUSION

There are a number of ENT-specific smartphone applications currently available. As the technology progresses, their scope has extended beyond being purely for reference. Nevertheless, it remains difficult to assess the validity and security of these applications.

An Evaluation of the Hybrid Model for Predicting Surgery Duration

The degree of accuracy in surgery duration estimation directly impacts on the quality of planned surgical lists. Model selection for the prediction of surgery duration requires technical expertise and significant time and effort. The result is often a collection of viable models, the performance of which varies across different strata of the surgical population. This paper proposes a prediction framework to be used after a comprehensive model selection process has been completed for surgery duration prediction. The framework produces a partition of the surgical cases and a "hybrid model" that allocates different predictors from the collection of viable models to different parts of the surgical population. The intention is a flexible prediction process that can reassign models and adapt as surgical processes change. The framework is tested via a simulation study, and its utility is demonstrated by predicting surgery durations for Ear, Nose and Throat surgeries in a New Zealand hospital. The results indicate that the hybrid model is effective, performing better than standard model selection in two of the three simulation studies, and marginally worse when the selected model was the true underlying process.

Addition of docetaxel to hormonal therapy in low- and high-burden metastatic hormone sensitive prostate cancer: long-term survival results from the STAMPEDE trial

BACKGROUND

STAMPEDE has previously reported that the use of upfront docetaxel improved overall survival (OS) for metastatic hormone naïve prostate cancer patients starting long-term androgen deprivation therapy. We report on long-term outcomes stratified by metastatic burden for M1 patients.

METHODS

We randomly allocated patients in 2 : 1 ratio to standard-of-care (SOC; control group) or SOC + docetaxel. Metastatic disease burden was categorised using retrospectively-collected baseline staging scans where available. Analysis used Cox regression models, adjusted for stratification factors, with emphasis on restricted mean survival time where hazards were non-proportional.

RESULTS

Between 05 October 2005 and 31 March 2013, 1086 M1 patients were randomised to receive SOC (n = 724) or SOC + docetaxel (n = 362). Metastatic burden was assessable for 830/1086 (76%) patients; 362 (44%) had low and 468 (56%) high metastatic burden. Median follow-up was 78.2 months. There were 494 deaths on SOC (41% more than the previous report). There was good evidence of benefit of docetaxel over SOC on OS (HR = 0.81, 95% CI 0.69-0.95, P = 0.009) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P = 0.827). Analysis of other outcomes found evidence of benefit for docetaxel over SOC in failure-free survival (HR = 0.66, 95% CI 0.57-0.76, P < 0.001) and progression-free survival (HR = 0.69, 95% CI 0.59-0.81, P < 0.001) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P > 0.5 in each case). There was no evidence that docetaxel resulted in late toxicity compared with SOC: after 1 year, G3-5 toxicity was reported for 28% SOC and 27% docetaxel (in patients still on follow-up at 1 year without prior progression).

CONCLUSIONS

The clinically significant benefit in survival for upfront docetaxel persists at longer follow-up, with no evidence that benefit differed by metastatic burden. We advocate that upfront docetaxel is considered for metastatic hormone naïve prostate cancer patients regardless of metastatic burden.

The meaningfulness of open data in Public Health and Healthcare

Background

The growing challenges and opportunities of Big Data for Public Health have revealed the potential to improve the efficiency and cost-effectiveness of public policy, for example through better targeting of resources with regard to General Practice (GP) prescribing. Open data has an important role due to its easy access and potential to complement proprietary data sources from, e.g., regional hospitals, and also itself be complemented with social data acquired by specialized approaches.

Methods

MIDAS pipeline of open source tools aiming integrating, analysing and visualising Open Data enabling health professionals and decision-makers to: (i) improve the usability of open data in combination with proprietary data through combining multiple visualisation tools in an integrated dashboard (ii) to explore the meaning of data in a global/local context based on new information using tone analysis and natural language techniques; and (iii) to have better informed decision-making based on evidence from trusted knowledge-bases. Specific data sources used have included information extracted from the biomedical database MEDLINE, worldwide news and government open data. Social media sources have also been used to gather information from the general public.

Results

Results include a strong correlation between antidepressant prescribing and economic deprivation, and a wide variation in how individual GP practices respond to demographic conditions. Automated anomaly detection based on the Local Outlier Probability has also been shown to be an easily understood and controllable approach to identifying prescribing outliers.

Conclusions

MIDAS demonstrates the significant value of open data from heterogeneous sources as basis decision-making in public health and healthcare, particularly when it is combined with proprietary or closed datasets. A key challenge in this regard is the ability to integrate and utilize data from diverse sources in a variety of formats and standards.

Key messages

MIDAS is exemplar on tackling the need for improved standards of open data, and new software architectures, tools and platforms addressing a complex ecosystem of heterogenous data sources and formats. MIDAS demonstrates the significant value of open data from heterogeneous sources as basis decision-making in public health and healthcare, particularly when combined with proprietary datasets.

Evaluating the Prevalence of Low Factor Scores on the ImPACT™ Quick Test in Adolescents and Adults using Multivariate Base Rates

Purpose

The ImPACT™ Quick Test (QT) is a brief iPad-based battery of neurocognitive tests that has been standardized on a sample of children, adolescents, and adults (ages 12-70). We sought to provide information regarding the prevalence of low ImPACT™ QT scores in the normative sample to improve clinical interpretation and reduce the risk of over-interpreting, or misinterpreting, a single low score.

Methods

Participants included 616 individuals ranging in age from 12 to 70, who were assessed individually. The ImPACT QT includes five subtests, contributing to three factor scores: Motor Speed, Memory, and Attention Tracker. The prevalence of low factor scores, stratified by age and gender, were calculated using multivariate base rates.

Results

In the total sample, obtaining 1 score below the 25th percentile was common (base rate, BR=31.8%), but obtaining 2 or more scores in this range was uncommon (BR=13.3%). Similarly, obtaining 1 score below the 16th percentile was common (BR=22.3%), but obtaining two or more scores in this range was very uncommon (BR=5.4%). There were small differences in base rate between genders and the number of low scores were fairly similar across the age groups.

Conclusion

Results from this study parallel previous work illustrating that a substantial percentage of healthy individuals will obtain one or more low test score when administered a battery of multiple cognitive test measures. Given that some healthy, non-concussed individuals will obtain a single score below expected cut-offs, clinicians should caution against overinterpreting a single low test score.

Influence of Pre-Morbid Migraine History on Baseline Vestibular/Ocular Motor Screening and King-Devick Test Performance

Purpose

To examine the effects of premorbid migraine history on baseline Vestibular/Ocular Motor Screening (VOMS) and King-Devick (KD) test performance in youth athletes.

Methods

This study implemented a cross-sectional design and was conducted at a series of youth sport venues in a designated research area. Youth athletes between the ages of 8 and 14 years with a diagnosed history of migraine headaches (n=28) and match controls (n=28) were administered a baseline VOMS and KD test. Between-group comparisons for provocation scores on the VOMS (smooth pursuit, saccades, convergence, vestibular-ocular reflex [VOR], and visual motion sensitivity [VMS]), Near-point of convergence [NPC] average distance (cm), and KD time (seconds) were conducted.

Results

Individuals diagnosed with migraine headaches reported greater VOMS scores compared to match controls on smooth pursuit (0.43±1.1 vs. 0.00±0.0; p=.02), convergence (0.46±1.2 vs. 0.04±0.1; p=.04), horizontal VOR (0.89±1.4 vs. 0.07±0.2; p<.001), vertical VOR (0.61±1.1 vs. 0.11±0.3; p=.04), and VMS (0.86±1.5 vs. 0.04±0.1; p=.01). Differences were also observed on the KD test with worse times in the diagnosed migraine group (54.33±11.8s) compared to match controls (47.17±8.9s; p=.02). No differences were reported on NPC distance between the migraine (2.22±3.1cm) and control group (0.83±1.2; p=.06).

Conclusion

Youth athletes with diagnosed migraine history reported higher baseline VOMS scores and worse KD time compared to match controls, further illustrating the influence of premorbid migraine headaches as a risk factor for elevated baseline concussion assessment. Special consideration may be warranted for post-concussion assessment in athletes with diagnosed migraine headaches.

Immunodeficiency and EBV-induced lymphoproliferation caused by 4-1BB deficiency

BACKGROUND

The tumor TNF receptor family member 4-1BB (CD137) is encoded by TNFRSF9 and expressed on activated T cells. 4-1BB provides a costimulatory signal that enhances CD8⁺ T-cell survival, cytotoxicity, and mitochondrial activity, thereby promoting immunity against viruses and tumors. The ligand for 4-1BB is expressed on antigen-presenting cells and EBV-transformed B cells.

OBJECTIVE

We investigated the genetic basis of recurrent sinopulmonary infections, persistent EBV viremia, and EBV-induced lymphoproliferation in 2 unrelated patients.

METHODS

Whole-exome sequencing, immunoblotting, immunophenotyping, and in vitro assays of lymphocyte and mitochondrial function were performed.

RESULTS

The 2 patients shared a homozygous G109S missense mutation in 4-1BB that abolished protein expression and ligand binding. The patients' CD8⁺ T cells had reduced proliferation, impaired expression of IFN-γ and perforin, and diminished cytotoxicity against allogeneic and HLA-matched EBV-B cells. Mitochondrial biogenesis, membrane potential, and function were significantly reduced in the patients' activated T cells. An inhibitory antibody against 4-1BB recapitulated the patients' defective CD8⁺ T-cell activation and cytotoxicity against EBV-infected B cells in vitro.

CONCLUSION

This novel immunodeficiency demonstrates the critical role of 4-1BB costimulation in host immunity against EBV infection.

Simulation, design, and first test of a multi-energy soft x-ray (SXR) pinhole camera in the Madison Symmetric Torus (MST)

A multi-energy soft x-ray pinhole camera has been designed and built for the Madison Symmetric Torus reversed field pinch to aid the study of particle and thermal-transport, as well as MHD stability physics. This novel imaging diagnostic technique combines the best features from both pulse-height-analysis and multi-foil methods employing a PILATUS3 x-ray detector in which the lower energy threshold for photon detection can be adjusted independently on each pixel. Further improvements implemented on the new cooled systems allow a maximum count rate of 10 MHz per pixel and sensitivity to the strong Al and Ar emission between 1.5 and 4 keV. The local x-ray emissivity will be measured in multiple energy ranges simultaneously, from which it is possible to infer 1D and 2D simultaneous profile measurements of core electron temperature and impurity density profiles with no a priori assumptions of plasma profiles, magnetic field reconstruction constraints, high-density limitations, or need of shot-to-shot reproducibility. The expected time and space resolutions will be 2 ms and <1 cm, respectively.

A model for locating fodder shrub plantations sites in the Jordanian badiyah

We developed a GIS desktop model to accurately locate and map prospective areas for sustainable establishment and production of Atriplex plantations and other fodder shrubs in the desert in the north-eastern Jordanian Badiyah. The aim is to provide a tool to assist managers, local communities and development projects in Mediterranean arid and semi-arid rangelands. The model uses freely available data and GIS layers of current land use, land cover, settlement location, soil information, and derivatives from a digital elevation model to provide critical locations of drainage lines and to calculate Areas of Accumulated Water from concentrated runoff. The model identified, accurately located and mapped ~4500 ha (1.44% of the test zone) as technically appropriate for potential shrub plantations sites. The final site map must be field-checked and validated with the local communities and authorities. Our model has potential for wide application over arid and semi-arid Mediterranean rangelands from Morocco to Pakistan, with local adjustment of our parameters and rules. The model considerably reduces the risk and costs of fodder plantation establishment operations, thus increasing the feasibility of efforts to maximise fodder shrub establishment, survival and production.

Description of a multi-university education and collaborative care child psychiatry access program: New York State's CAP PC

OBJECTIVE

Although, child mental health problems are widespread, few get adequate treatment, and there is a severe shortage of child psychiatrists. To address this public health need many states have adopted collaborative care programs to assist primary care to better assess and manage pediatric mental health concerns. This report adds to the small literature on collaborative care programs and describes one large program that covers most of New York state.

PROGRAM DESCRIPTION

CAP PC, a component program of New York State's Office of Mental Health (OMH) Project TEACH, has provided education and consultation support to primary care providers covering most of New York state since 2010. The program is uniquely a five medical school collaboration with hubs at each that share one toll free number and work together to provide education and consultation support services to PCPs.

METHODS

The program developed a clinical communications record to track information about all consultations which forms the basis of much of this report. 2-week surveys following consultations, annual surveys, and pre- and post-educational program evaluations have also been used to measure the success of the program.

RESULTS

CAP PC has grown over the 6years of the program and has provided 8013 phone consultations to over 1500 PCPs. The program synergistically provided 17,523 CME credits of educational programming to 1200 PCPs. PCP users of the program report very high levels of satisfaction and self reported growth in confidence.

CONCLUSIONS

CAP PC demonstrates that large-scale collaborative consultation models for primary care are feasible to implement, popular with PCPs, and can be sustained. The program supports increased access to child mental health services in primary care and provides child psychiatric expertise for patients who would otherwise have none.

More than a virus: a qualitative study of the social implications of hepatitis B infection in China

Background

China has the largest absolute number of people living with hepatitis B with up to 300,000 people estimated to die each year from hepatitis B related diseases. Despite advances in immunisation, clinical management, and health policy, there is still a lack of accessible and affordable health care for people with hepatitis B. Through in-depth interviews, this study identifies the personal, social and economic impact of living with hepatitis B and considers the role of stigma and discrimination as barriers to effective clinical management of the disease.

Methods

Semi-structured qualitative interviews were held with 41 people living with hepatitis B in five Chinese cities. Participants were recruited through clinical and non-government organisations providing services to people with hepatitis B, with most (n = 32) being under the age of 35 years.

Results

People living with hepatitis B experience the disease as a transformative intergenerational chronic infection with multiple personal and social impacts. These include education and employment choices, economic opportunities, and the development of intimate relationships. While regulations reducing access to employment and education for people with hepatitis B have been repealed, stigma and discrimination continue to marginalise people with hepatitis B.

Conclusions

Effective public policy to reduce morbidity and mortality associated with hepatitis B needs to address the lived impact of hepatitis B on families, employment and educational choices, finances, and social marginalisation.

Influence of blanketing and season on vitamin D and parathyroid hormone, calcium, phosphorus, and magnesium concentrations in horses in New Zealand

The aims of the study were to determine the effect of season and blanketing on vitamin D synthesis in horses and examine the interaction between vitamin D and other analytes involved in calcium homeostasis. Twenty-one healthy horses at pasture were included; 5 were covered with standard horse blankets including neck rugs. Blood samples were collected for 13 mo and analyzed for 25-hydroxyvitamin D2 (25OHD2) and 25-hydroxyvitamin D3 (25OHD3), 1,25-dihydroxyvitamin D (1,25[OH]2D), ionized calcium (iCa), total calcium (tCa), phosphorus (P), total magnesium (tMg), and parathyroid hormone (PTH). Grass and hay samples were collected and analyzed for vitamin D, calcium, phosphorus, and magnesium. Climate data were also collected. The serum concentration of 25OHD3 in horses was either undetectable or below the detection limit of the assay, and the main form of 25OHD was 25OHD2. No differences in serum 25OHD2, 1,25(OH)2D, iCa, tCa, P, tMg, and PTH (P ≥ 0.05) concentrations were seen between the 2 groups. Associations were seen between iCa and PTH (P < 0.05), iCa and tMg (P < 0.05), and dietary vitamin D and 25OHD2 (P < 0.05). A strong seasonal trend was seen in serum 25OHD2 (P < 0.0001), which was higher during spring and summer when the amount of sunshine and UV radiation was higher. Parathyroid hormone and 1,25(OH)2D showed opposing trends with PTH higher in winter whereas 1,25(OH)2D was higher in summer. The results suggest that dietary vitamin D may be necessary for horses to fulfill their vitamin D requirements; however, further research is required to determine the contribution of vitamin D3 synthesis in the skin to the vitamin D status of the horse.