A protocol for stakeholder engagement in deliver-EE: A pragmatic randomized comparative effectiveness trial evaluating effects of meal delivery on the ability of homebound older adults to remain in the community

BACKGROUND

Few clinical trials include a detailed protocol for stakeholder engagement in the design and execution of the clinical trial. Deliver-EE is a pragmatic clinical trial to assess how different types of home-delivered meals can affect older adults' health and well-being. We present the protocol for stakeholder engagement in this national, multi-site trial and initial findings from our efforts.

METHODS

Twenty-nine participants were recruited to two stakeholder advisory panels. The "Lived Experience Perspectives" panel is defined as the clients, caregivers, and meal delivery drivers with first-hand knowledge and lived experiences with meal delivery. The "System Perspectives" panel is defined as representatives from the larger financial, clinical, regulatory, and operational environments in which meal delivery to homebound older adults operate. Together, these two groups holistically represent interested parties that coordinate the interdependent elements of meal delivery to homebound older adults in order to: 1) inform our understanding of what matters most to older adults, their families, and the larger health and social care systems; 2) provide strategies to overcome challenges conducting the study; 3) enhance dissemination and uptake of study findings; and 4) identify opportunities for future research.

RESULTS

Although stakeholder partners share a common goal of using home-delivered meals as a method to improve outcomes for homebound older adults, individuals have different goals for participating as advisors in this research.

CONCLUSIONS

Understanding what individual stakeholders hope to gain from their participation is critical in designing an effective engagement protocol and critical for meaningful and rigorous stakeholder engagement in clinical trials.

Fifty years of environmental progress for United States dairy farms

Dairy farms in the United States have changed in many ways over the past 50 yr. Milk production efficiency has increased greatly, with ∼30% fewer cows producing about twice the amount of milk today. Other improvements include increases in crop yields, fuel efficiency of farm equipment, and efficiency in producing most resources used on farms (e.g. electricity, fuel, fertilizer). These improvements have led to changes in the environmental impact of farms. Through simulation of representative dairy farms in 1971 and 2020, changes in nutrient losses and farmgate life cycle assessments of greenhouse gas (GHG) emissions, fossil energy use, and blue (ground and surface) water use were determined for 6 regions and the United States. For all environmental metrics studied, intensities expressed per unit of fat- and protein-corrected milk produced were reduced, but the total effects over all farms or milk produced increased for 5 of the 13 environmental metrics. Reductions in the impacts of dairy farms in the eastern United States were offset by large increases in western regions because of a major increase in cow numbers in the West. The national average intensity of GHG emissions decreased by 42%, which gave just a 14% increase in the total GHG emissions of all dairy farms over the 50-yr period. The intensity of fossil energy use decreased by 54%, with the total for all farms decreasing by 9%. Water use related to milk production decreased in intensity by 28%, but due to the large increase in dairy production in the dry western regions that have a greater dependence on irrigated feed crops, total blue water use increased by 42%. Major pathways of nitrogen loss included ammonia volatilization, leaching, and denitrification, where total ammonia emissions related to US dairy farms increased by 29%, while leaching losses decreased by 39%, with little change in nitrous oxide emissions. Simulated nitrogen and phosphorus runoff losses totaled for all dairy farms decreased by 27% to 51% through more efficient fertilizer use, reduced tillage, and greater use of cover crops. Emissions of methane and reactive non-methane volatile organic compounds increased by 32% and 53%, respectively, due to greater use of long-term manure storage and silage stored in bunkers and piles. Although much progress has been made in improving production efficiency, continued improvements with new strategies and technologies are needed to meet the demand for dairy products and mitigate total environmental impacts, particularly in view of projected climate variability.

Study of High-Transverse-Momentum Higgs Boson Production in Association with a Vector Boson in the qqbb Final State with the ATLAS Detector

This Letter presents the first study of Higgs boson production in association with a vector boson (V=W or Z) in the fully hadronic qqbb final state using data recorded by the ATLAS detector at the LHC in proton-proton collisions at sqrt[s]=13  TeV and corresponding to an integrated luminosity of 137  fb^{-1}. The vector bosons and Higgs bosons are each reconstructed as large-radius jets and tagged using jet substructure techniques. Dedicated tagging algorithms exploiting b-tagging properties are used to identify jets consistent with Higgs bosons decaying into bb[over ¯]. Dominant backgrounds from multijet production are determined directly from the data, and a likelihood fit to the jet mass distribution of Higgs boson candidates is used to extract the number of signal events. The VH production cross section is measured inclusively and differentially in several ranges of Higgs boson transverse momentum: 250-450, 450-650, and greater than 650 GeV. The inclusive signal yield relative to the standard model expectation is observed to be μ=1.4_{-0.9}^{+1.0} and the corresponding cross section is 3.1±1.3(stat)_{-1.4}^{+1.8}(syst)  pb.

Measurement of the Centrality Dependence of the Dijet Yield in p+Pb Collisions at sqrt[s_{NN}]=8.16 TeV with the ATLAS Detector

ATLAS measured the centrality dependence of the dijet yield using 165  nb^{-1} of p+Pb data collected at sqrt[s_{NN}]=8.16  TeV in 2016. The event centrality, which reflects the p+Pb impact parameter, is characterized by the total transverse energy registered in the Pb-going side of the forward calorimeter. The central-to-peripheral ratio of the scaled dijet yields, R_{CP}, is evaluated, and the results are presented as a function of variables that reflect the kinematics of the initial hard parton scattering process. The R_{CP} shows a scaling with the Bjorken x of the parton originating from the proton, x_{p}, while no such trend is observed as a function of x_{Pb}. This analysis provides unique input to understanding the role of small proton spatial configurations in p+Pb collisions by covering parton momentum fractions from the valence region down to x_{p}∼10^{-3} and x_{Pb}∼4×10^{-4}.

Search for New Phenomena in Two-Body Invariant Mass Distributions Using Unsupervised Machine Learning for Anomaly Detection at sqrt[s]=13 TeV with the ATLAS Detector

Searches for new resonances are performed using an unsupervised anomaly-detection technique. Events with at least one electron or muon are selected from 140  fb^{-1} of pp collisions at sqrt[s]=13  TeV recorded by ATLAS at the Large Hadron Collider. The approach involves training an autoencoder on data, and subsequently defining anomalous regions based on the reconstruction loss of the decoder. Studies focus on nine invariant mass spectra that contain pairs of objects consisting of one light jet or b jet and either one lepton (e,μ), photon, or second light jet or b jet in the anomalous regions. No significant deviations from the background hypotheses are observed. Limits on contributions from generic Gaussian signals with various widths of the resonance mass are obtained for nine invariant masses in the anomalous regions.

Rapid systematic review of interventions to improve antenatal screening rates for syphilis, hepatitis B, and HIV in low- and middle-income countries

BACKGROUND

Infectious diseases including syphilis, HIV, and hepatitis B are major contributors to maternal and neonatal morbidity and mortality worldwide, especially in low- and middle-income countries (LMICs). The World Health Organization has prioritized elimination of vertical transmission of these three diseases.

OBJECTIVES

To rapidly assess the impact of interventions designed to improve antenatal screening rates for syphilis, HIV, and hepatitis B in LMICs and to identify areas for future implementation research.

SEARCH STRATEGY

A comprehensive search was conducted across PubMed, Embase, and EconLit, targeting articles published between January 1, 2013, and June 27, 2023.

SELECTION CRITERIA

We included quantitative interventional studies in English, involving pregnant adults (15 years or older) from LMICs. Exclusions were studies based in high-income countries, qualitative studies, or those investigating accuracy of diagnostic methods.

DATA COLLECTION AND ANALYSIS

From an initial 5549 potential studies, 27 were finalized for review after various screening stages. Data extraction covered aspects such as study design, intervention details, and outcomes. Findings were qualitatively synthesized within a systems thinking framework.

MAIN RESULTS

The interventions assessed varied in terms of geographic locations, health care system levels, and modalities. The review highlighted the effectiveness of interventions such as community health interventions, service quality improvements, and financial incentives.

CONCLUSIONS

The study underscores the potential of specific interventions in enhancing antenatal screening rates in LMICs. However, there is a discernible research gap concerning hepatitis B. The findings emphasize the importance of capacity building and health systems strengthening in public health interventions.

Observation of WZγ Production in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

This Letter reports the observation of WZγ production and a measurement of its cross section using 140.1±1.2  fb^{-1} of proton-proton collision data recorded at a center-of-mass energy of 13 TeV by the ATLAS detector at the Large Hadron Collider. The WZγ production cross section, with both the W and Z bosons decaying leptonically, pp→WZγ→ℓ^{'}^{±}νℓ^{+}ℓ^{-}γ (ℓ^{(^{'})}=e, μ), is measured in a fiducial phase-space region defined such that the leptons and the photon have high transverse momentum and the photon is isolated. The cross section is found to be 2.01±0.30(stat)±0.16(syst)  fb. The corresponding standard model predicted cross section calculated at next-to-leading order in perturbative quantum chromodynamics and at leading order in the electroweak coupling constant is 1.50±0.06  fb. The observed significance of the WZγ signal is 6.3σ, compared with an expected significance of 5.0σ.

"Time Saved" Calculations to Improve Decision-Making in Progressive Disease Studies

BACKGROUND

Disease modifying therapies (DMTs) may be most beneficial in early disease, when progression is slow and changes small, with clinical relevance difficult to interpret.

OBJECTIVES

Time component tests (TCTs) translate differences between treatments from mean change, vertical distance between longitudinal trajectories, into intuitively understood time saved, horizontal distance between trajectories, which can be readily combined across endpoints in a global TCT (gTCT).

DESIGN

The value of composites, time savings estimates, and combination scores to optimize measurement and interpretation of DMTs are demonstrated, along with construction details and simulation studies.

SETTING

TCT methods were applied to a randomized phase II clinical trial.

PARTICIPANTS

Patients with early Alzheimer's disease (N=332).

INTERVENTION

Three treatment groups with AFFITOPE® AD02 and two control groups with aluminum oxyhydroxide, AD04.

MEASUREMENTS

The co-primary efficacy outcomes were an adapted ADAS-Cog (aADAS) and adapted ADCS-ADL (aADL), which were optimized composite scales specific to cognitive and functional domains. A composite based on these two scores was the study's prespecified primary outcome. The CDR-sb and standard non-adapted ADCS-ADL and ADAS-Cog scales were prespecified secondary outcomes.

RESULTS

The AD04 2 mg group showed some statistically significant effects compared with other study arms. It is unclear whether the observed 3.8-point difference on the composite is clinically meaningful. TCT results show a time savings of 11 months in an 18-month study with AD04 2 mg.

CONCLUSION

The relevance of 11 months saved is more universally understood than a mean difference of 3.8 points in the composite outcome. These results suggest that a combination of a composite approach and a time savings interpretation offers a powerful approach for detecting and interpreting disease modifying effects.

Combined Measurement of the Higgs Boson Mass from the H→γγ and H→ZZ^{*}→4ℓ Decay Channels with the ATLAS Detector Using sqrt[s]=7, 8, and 13 TeV pp Collision Data

A measurement of the mass of the Higgs boson combining the H→ZZ^{*}→4ℓ and H→γγ decay channels is presented. The result is based on 140  fb^{-1} of proton-proton collision data collected by the ATLAS detector during LHC run 2 at a center-of-mass energy of 13 TeV combined with the run 1 ATLAS mass measurement, performed at center-of-mass energies of 7 and 8 TeV, yielding a Higgs boson mass of 125.11±0.09(stat)±0.06(syst)=125.11±0.11  GeV. This corresponds to a 0.09% precision achieved on this fundamental parameter of the Standard Model of particle physics.

Search for Dark Photons in Rare Z Boson Decays with the ATLAS Detector

A search for events with a dark photon produced in association with a dark Higgs boson via rare decays of the standard model Z boson is presented, using 139  fb^{-1} of sqrt[s]=13  TeV proton-proton collision data recorded by the ATLAS detector at the Large Hadron Collider. The dark boson decays into a pair of dark photons, and at least two of the three dark photons must each decay into a pair of electrons or muons, resulting in at least two same-flavor opposite-charge lepton pairs in the final state. The data are found to be consistent with the background prediction, and upper limits are set on the dark photon's coupling to the dark Higgs boson times the kinetic mixing between the standard model photon and the dark photon, α_{D}ϵ^{2}, in the dark photon mass range of [5, 40] GeV except for the ϒ mass window [8.8, 11.1] GeV. This search explores new parameter space not previously excluded by other experiments.

Measurement of the Sensitivity of Two-Particle Correlations in pp Collisions to the Presence of Hard Scatterings

A key open question in the study of multiparticle production in high-energy pp collisions is the relationship between the "ridge"-i.e., the observed azimuthal correlations between particles in the underlying event that extend over all rapidities-and hard or semihard scattering processes. In particular, it is not known whether jets or their soft fragments are correlated with particles in the underlying event. To address this question, two-particle correlations are measured in pp collisions at sqrt[s]=13  TeV using data collected by the ATLAS experiment at the LHC, with an integrated luminosity of 15.8  pb^{-1}, in two different configurations. In the first case, charged particles associated with jets are excluded from the correlation analysis, while in the second case, correlations are measured between particles within jets and charged particles from the underlying event. Second-order flow coefficients, v_{2}, are presented as a function of event multiplicity and transverse momentum. These measurements show that excluding particles associated with jets does not affect the measured correlations. Moreover, particles associated with jets do not exhibit any significant azimuthal correlations with the underlying event, ruling out hard processes contributing to the ridge.

Observation of an Excess of Dicharmonium Events in the Four-Muon Final State with the ATLAS Detector

A search is made for potential ccc[over ¯]c[over ¯] tetraquarks decaying into a pair of charmonium states in the four muon final state using proton-proton collision data at sqrt[s]=13  TeV, corresponding to an integrated luminosity of 140  fb^{-1} recorded by the ATLAS experiment at LHC. Two decay channels, J/ψ+J/ψ→4μ and J/ψ+ψ(2S)→4μ, are studied. Backgrounds are estimated based on a hybrid approach involving Monte Carlo simulations and data-driven methods. Statistically significant excesses with respect to backgrounds dominated by the single parton scattering are seen in the di-J/ψ channel consistent with a narrow resonance at 6.9 GeV and a broader structure at lower mass. A statistically significant excess is also seen in the J/ψ+ψ(2S) channel. The fitted masses and decay widths of the structures are reported.

Dementia and the prison population: identifying need

Older adults are the fastest growing group within the UK prison population yet there continues to be a lack of national strategy to ensure consistent care is provided to this group, in line with the general population. The number of older adults with dementia is also rising globally however the prevalence of dementia in prisons remains largely unknown. The impact of dementia on older adults in prison is also largely unexplored. Subsequently a review by Brooke et al. 2020 was undertaken to identify prevalence of dementia in the UK prison population and to explore how such prisoners are assessed, diagnosed, treated and supported. This article critically appraises and evaluates the systematic review by Brooke et al. 2020, and expands upon the findings in context to practice.

Ca-HELP: Adaptation of a Communication Tool to Help Geriatric Cancer Patients in Rural Settings Talk to Their Doctors About Pain

Background and Objectives

Among the older adult population living in the rural United States, undertreated cancer pain is very common. The need for interventions targeting pain management communication between older adults with cancer in rural communities and their doctors outpaces the current evidence base. Adaptation of existing pain interventions may improve the speed at which clinicians can respond to pain in this vulnerable population.

Research Design and Methods

The Cancer Health Empowerment for Living without Pain (Ca-HELP) is an evidence-based communication tool that coaches patients to communicate about pain by asking questions, making requests, and signaling distress to their physicians in order to achieve improved pain control. Guided by the Method for Program Adaptation through Community Engagement (M-PACE) model, which utilizes detailed stakeholder feedback to guide the adaptation of an intervention for an appropriate target audience, we proactively adapted the Ca-HELP and its delivery for use among geriatric cancer patients living in rural settings using qualitative feedback from patients, informal caregivers, and providers as a planned step in a multiphase pilot study.

Results

All stakeholders agreed that the Ca-HELP was a promising candidate intervention to improve pain among older adults with cancer. They suggested modifications to the delivery, context, and content of the intervention. A multidisciplinary team of nurse leaders and researchers evaluated stakeholder feedback and recommendations before determining which adaptations were made. Adaptations were cataloged and reported using the Framework for Reporting Adaptations and Modifications-Enhanced model.

Discussion and Implications

Our multistakeholder team proactively modified the Ca-HELP intervention tool using end-user feedback with a goal to optimize fit for use by older adults with cancer in rural settings without compromising the active ingredients. Documenting and reporting modifications to interventions are critical to their implementation and will lay the groundwork for further testing of the efficacy of the adapted Ca-HELP intervention.

Home-delivered meals for people with dementia: Which model delays nursing home placement? - Protocol for a feasibility pilot

BACKGROUND

Home-delivered meals promote food security, socialization, and independence among homebound older adults. However, it is unclear which of the two predominant modes of meal delivery, daily-delivered vs. drop-shipped, frozen meals, promotes community living for homebound older adults with dementia. Our objective is to present the protocol for a pilot multisite, two-arm, pragmatic feasibility trial comparing the effect of two modes of meal delivery on nursing home placement among people with dementia. We include justifications for individual randomization with different consent processes and waivers for specific elements of the trial.

METHODS

236 individuals with dementia on waiting lists at three Meals on Wheels programs' in Florida and Texas will be randomized to receive either: 1) meals delivered multiple times per week by a Meals on Wheels volunteer or paid driver who may socialize with and provide an informal wellness check or 2) frozen meals that are mailed to participants' homes every two weeks. We will evaluate and refine processes for recruitment and randomization; assess adherence to the intervention; identify common themes in participant experience; and test processes for linking participant data with Medicare records and nursing home assessment data. We will conduct exploratory analyses examining time to nursing home placement, the primary outcome for the larger trial.

CONCLUSION

This pilot will inform the follow-on large-scale, definitive pragmatic trial. In addition, the justifications for individual randomization with differing consent procedures for elements of a pragmatic trial provide a model for future trialists looking to develop ethical and feasible pragmatic studies enrolling people with dementia.

102 Postoperative Haemoglobin Monitoring in Neck of Femur Fracture Patients. Can a Simple Teaching Session Improve Patient Safety on the Orthopaedic Ward?

Aim

Patients who suffer neck of femur fractures (NOF#) are typically frail and at risk of postoperative anaemia which can contribute to a high mortality in this demographic.

This QiP reviewed how well postoperative haemoglobin (Hb) was being monitored on a Orthopaedic unit and assessed the effectiveness of a teaching session to improve this.

A secondary measure was to compare day 1 and day 3 Hb to establish an evidence base for the timing of postoperative Hb monitoring.

Method

Two cycles (1st loop: 8/3/21–21/3/21, n = 21. 2nd loop:3/7/21–16/7/21, n=15) were performed either side of a teaching session.

Day 1 and day 3 post-op Hb were recorded.

Inclusion criteria were patients who fitted NOF# best practice tariffs.

Results

Pre-intervention saw 90% of patients have day 1 Hb and 52% have day 3 Hb taken, this increased to 93% and 67% post intervention.

81% of patients showed a Hb drop between day 1 and day 3 (mean = 11 g/dL), with 90% of day 1 bloods already below reference range.

Conclusions

We demonstrated that a teaching session highlighting the importance of Hb monitoring in this patient demographic can improve the monitoring of postoperative haemoglobin and thus improve patient safety.

Secondly, a Hb drop is possible from day 1 to day 3 and therefore a day 1 Hb should not be relied on.

Future work will aim to investigate the longer-term trend of postoperative Hb to establish when an outpatient Hb should be performed.

Prediction of thrombosis in atrial fibrillation with compact atrial shape representation

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): IHU LIRYC ANR-10-IAHU-04

ERACoSysMed PARIS Project

Background

The impact of LA shape on clot formation in AF is yet to be understood

Purpose

To analyze the impact of LA, PVs and LAA orientations on clot formation

Methods

Pts with history of AF and an indication for LAA closure underwent pre-operative cardiac CT. Those with either a prior history of embolism or a clot detected on arterial and venous-enhanced CT images were categorized as clot positive. On CT images, the LA was segmented and meshed. Automated labelling of PVs and LAA was employed to build a compact skeleton representation of the LA (by registering labels from a template to all cases, and by connecting the center of mass of each labels). LA skeletons were used to train a novel Neural Network model for joint classification of heterogeneous data, such as images taken at different phases of the cardiac cycle. Such model consists of one encoder per dataset followed by a common classifier, enforcing a joint representation of all datasets in the same latent space. This is made possible by writing the task as a variational problem to optimise, we call this model a multi-channel variational classifier. The model was trained to predict clot positive patients and its generalizability was assessed on a test population.

Results

237 pts were included (age 74±8, 70% males, CHADS-VASc 4.3±1.2). CTs were acquired during systole in 117 and diastole in 120. 100 (42%) patients were considered clot positive. Segmentation, labeling and skeletization was successfully achieved in all pts. The model was trained using a 10-Fold cross validation. We compared the results after training on diastole and systole cases independently and by jointly training on both datasets. At testing, our model reached a 0.72 overall accuracy for the prediction of LAA clots (0.83 for systole and 0.61 for diastole), while training separately on systole and diastole was prone to strong overfitting and mode collapse with 0.52 and 0.48 accuracy, respectively.

Conclusion

While LA shape, LA size, PV and LAA orientations alone may not be sufficient for robust clot prediction, we introduce a compressed representation of the global anatomy that closely relates to LAA thrombosis, possibly identifying global features related to adverse hemodynamics. The method is reproducible and introduces a novel approach to accommodate heterogeneous diastole and systole datasets.

Addressing hesitancy to COVID-19 vaccines in healthcare assistants

COVID-19 vaccination rates have been suboptimal in frontline healthcare assistants (HCAs). We sought to characterize contributors to COVID-19 vaccine hesitancy among HCAs. We conducted an analysis of online survey responses from members of the National Association of Health Care Assistants from December 2020-January 2021. Respondents were asked what it would take for them to be vaccinated against COVID-19. Responses from 309 HCAs were coded to characterize respondents' willingness to be vaccinated and identify contributors to vaccine hesitancy. Approximately 60% (n = 185) of HCAs expressed hesitancy but would consider getting vaccinated under certain circumstances. We identified 8 overarching themes for contributors to COVID-19 vaccine hesitancy, the most common being safety concerns (70% of respondents). Others included efficacy (11.4%), workplace requirements (9.7%), societal influence (9.2%), and compensation (8.1%). Interventions to increase vaccine uptake among HCAs may be most effective by addressing concerns regarding the short-term and long-term safety implications of COVID-19 vaccines.

Evaluating the Findings of the IMPACT-C Randomized Clinical Trial to Improve COVID-19 Vaccine Coverage in Skilled Nursing Facilities

IMPORTANCE

Identifying successful strategies to increase COVID-19 vaccination among skilled nursing facility (SNF) residents and staff is integral to preventing future outbreaks in a continually overwhelmed system.

OBJECTIVE

To determine whether a multicomponent vaccine campaign would increase vaccine rates among SNF residents and staff.

DESIGN, SETTING, AND PARTICIPANTS

This was a cluster randomized trial with a rapid timeline (December 2020-March 2021) coinciding with the Pharmacy Partnership Program (PPP). It included 133 SNFs in 4 health care systems across 16 states: 63 and 70 facilities in the intervention and control arms, respectively, and participants included 7496 long-stay residents (>100 days) and 17 963 staff.

INTERVENTIONS

Multicomponent interventions were introduced at the facility level that included: (1) educational material and electronic messaging for staff; (2) town hall meetings with frontline staff (nurses, nurse aides, dietary, housekeeping); (3) messaging from community leaders; (4) gifts (eg, T-shirts) with socially concerned messaging; (5) use of a specialist to facilitate consent with residents' proxies; and (6) funds for additional COVID-19 testing of staff/residents.

MAIN OUTCOMES AND MEASURES

The primary outcomes of this study were the proportion of residents (from electronic medical records) and staff (from facility logs) who received a COVID-19 vaccine (any), examined as 2 separate outcomes. Mixed-effects generalized linear models with a binomial distribution were used to compare outcomes between arms, using intent-to-treat approach. Race was examined as an effect modifier in the resident outcome model.

RESULTS

Most facilities were for-profit (95; 71.4%), and 1973 (26.3%) of residents were Black. Among residents, 82.5% (95% CI, 81.2%-83.7%) were vaccinated in the intervention arm, compared with 79.8% (95% CI, 78.5%-81.0%) in the usual care arm (marginal difference 0.8%; 95% CI, -1.9% to 3.7%). Among staff, 49.5% (95% CI, 48.4%-50.6%) were vaccinated in the intervention arm, compared with 47.9% (95% CI, 46.9%-48.9%) in usual care arm (marginal difference: -0.4%; 95% CI, -4.2% to 3.1%). There was no association of race with the outcome among residents.

CONCLUSIONS AND RELEVANCE

A multicomponent vaccine campaign did not have a significant effect on vaccination rates among SNF residents or staff. Among residents, vaccination rates were high. However, half the staff remained unvaccinated despite these efforts. Vaccination campaigns to target SNF staff will likely need to use additional approaches.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04732819.

Clinical Trial Endpoints and Their Clinical Meaningfulness in Early Stages of Alzheimer's Disease

As the focus of Alzheimer's disease (AD) therapeutic development shifts to the early stages of the disease, the clinical endpoints used in drug trials, and how these might translate into clinical practice, are of increasing importance. The clinical meaningfulness of trial outcome measures is often unclear, with a lack of conclusive evidence as to how these measures correlate to changes in disease progression and treatment response. Clarifying this would benefit all, including patients, care partners, primary care providers, regulators, and payers, and would enhance our understanding of the relationship between clinical trial endpoints and assessments used in everyday practice. At present, there is a wide range of assessment tools used in clinical trials for AD and substantial variability in measures selected as endpoints across these trials. The aim of this review is to summarize the most commonly used assessment tools for early stages of AD, describe their use in clinical trials and clinical practice, and discuss what might constitute clinically meaningful change in these measures in relation to disease progression and treatment response.

Engaging Stakeholders in a Pragmatic Trial of Home-Delivered Meals for Persons with Dementia

Gathering stakeholder feedback is essential to designing and implementing relevant and actionable research. Additionally, stakeholders, particularly those directly impacted by an intervention, bring unique insights and experiences. This paper presents the process and findings of a research endeavor to co-design a pragmatic clinical trial with a Stakeholder Advisory Panel (SAP) in an effort to understand facilitators and barriers to conducting the research and implementing study findings. The proposed trial compares the impact of frozen, drop-shipped meals versus daily home-delivered meals provided by Meals on Wheels (MOW) programs on the ability of individuals living with dementia to age in place. We recruited nine SAP members, who were compensated for their time. The SAP is composed of a) MOW clients with dementia, b) family members of MOW clients with dementia, c) paid or volunteer MOW drivers, and d) MOW staff. A research team member facilitated two 90-minute meetings with the SAP members via Zoom. The topics of the meetings included potential benefits and challenges with each mode of meal delivery, the importance of the primary outcome (time to nursing home placement), topics of interest to include in interviews with clients and caregivers, and how participants would explain the study to a friend. Audio of the Zoom meetings was transcribed, and meeting summaries were shared with the SAP. Benefits of forming and engaging a SAP, as well as key lessons learned from SAP members and how recommendations were reflected in changes to the study protocol will be discussed.

Keeping the ICRP recommendations fit for purpose

The International Commission on Radiological Protection (ICRP) has embarked on a review and revision of the system of Radiological Protection that will update the 2007 general recommendations in ICRPPublication 103. This is the beginning of a process that will take several years, involving open and transparent engagement with organisations and individuals around the world. While the system is robust and has performed well, it must adapt to address changes in science and society to remain fit for purpose. The aim of this paper is to encourage discussions on which areas of the system might gain the greatest benefit from review, and to initiate collaborative efforts. Increased clarity and consistency are high priorities. The better the system is understood, the more effectively it can be applied, resulting in improved protection and increased harmonisation. Many areas are identified for potential review including: classification of effects, with particular focus on tissue reactions; reformulation of detriment, potentially including non-cancer diseases; re-evaluation of the relationship between detriment and effective dose, and the possibility of defining detriments for males and females of different ages; individual variation in the response to radiation exposure; heritable effects; and effects and risks in non-human biota and ecosystems. Some of the basic concepts are also being considered, including the framework for bringing together protection of people and the environment, incremental improvements to the fundamental principles of justification and optimisation, a broader approach to protection of individuals, and clarification of the exposure situations introduced in 2007. In addition, ICRP is considering identifying where explicit incorporation of the ethical basis of the system would be beneficial, how to better reflect the importance of communications and stakeholder involvement, and further advice on education and training. ICRP invites responses on these and other areas relating to the review of the System of Radiological Protection.

Perceptions of COVID-19 vaccines among healthcare assistants: A national survey

Background

Limited COVID‐19 vaccination acceptance among healthcare assistants (HCAs) may adversely impact older adults, who are at increased risk for severe COVID‐19 infections. Our study objective was to evaluate the perceptions of COVID‐19 vaccine safety and efficacy in a sample of frontline HCAs, overall and by race and ethnicity.

Methods

An online survey was conducted from December 2020 to January 2021 through national e‐mail listserv and private Facebook page for the National Association of Health Care Assistants. Responses from 155 HCAs, including certified nursing assistants, home health aides, certified medical assistants, and certified medication technicians, were included. A 27‐item survey asked questions about experiences and perceptions of COVID‐19 vaccines, including how confident they were that COVID‐19 vaccines are safe, effective, and adequately tested in people of color. Multivariable regression was used to identify associations with confidence in COVID‐19 vaccines.

Results

We analyzed data from 155 completed responses. Among respondents, 23.9% were black and 8.4% Latino/a. Most respondents worked in the nursing home setting (53.5%), followed by hospitals (12.9%), assisted living (11.6%), and home care (10.3%). Respondents expressed low levels of confidence in COVID‐19 vaccines, with fewer than 40% expressing at least moderate confidence in safety (38.1%), effectiveness (31.0%), or adequate testing in people of color (27.1%). Non‐white respondents reported lower levels of confidence in adequate testing of vaccines compared to white respondents. In bivariate and adjusted models, respondents who gave more favorable scores of organizational leadership at their workplace expressed greater confidence in COVID‐19 vaccines.

Conclusion

Frontline HCAs reported low confidence in COVID‐19 vaccines. Stronger organizational leadership in the workplace appears to be an important factor in influencing HCA's willingness to be vaccinated. Action is needed to enhance COVID‐19 vaccine uptake in this important population with employers playing an important role to build vaccine confidence and trust among employees.

Engaging Stakeholders in the Design and Conduct of Embedded Pragmatic Clinical Trials for Alzheimer's Disease and Alzheimer's Disease-Related Dementias

Embedded pragmatic clinical trials (ePCTs) of nondrug interventions for Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) are conducted in real-world clinical settings and designed to generate an evidence base to inform clinical and policy decisions about care for this vulnerable population. The ePCTs exist within a complex ecosystem of relationships between researchers, payors, policymakers, healthcare systems, direct care staff, advocacy groups, families, caregivers, and people living with dementia (PLWD). Because the rapid increase of the number of Americans with AD/ADRD outpaces curative treatments, there is an urgent need to mobilize the power of these relationships to improve dementia care and address a mounting public health crisis. Stakeholder engagement in ePCTs is essential to generate research questions, establish the relevancy of trials to the intended end users, and understand the factors that influence dissemination and implementation in real-world clinical settings. The process of including stakeholders in ePCTs for dementia is similar to stakeholder engagement in ePCTs for other diseases and conditions; however, the unique nature of embedded research, prevalence of caregiver and provider burden, and the progressive worsening of cognitive impairment in PLWD must be approached with additional strategies. This article presents key considerations of stakeholder engagement for ePCTs in AD/ADRD and main activities of the stakeholder engagement team in the National Institute on Aging IMPACT Collaboratory to move the field forward. J Am Geriatr Soc 68:S62-S67, 2020.

Embedded Pragmatic Trials in Dementia Care: Realizing the Vision of the NIA IMPACT Collaboratory

Close to 6 million Americans have Alzheimer's disease (AD) or Alzheimer's disease and related dementia (AD/ADRD). These high-need, high-cost patients are vulnerable to receiving poor quality uncoordinated care, ultimately leading to adverse health outcomes, poor quality of life, and misuse of resources. Improving the care of persons living with dementia (PLWD) and their caregivers is an urgent public health challenge that must be informed by high-quality evidence. Although prior research has elucidated opportunities to improve AD/ADRD care, the adoption of promising interventions has been stymied by the lack of research evaluating their effectiveness when implemented under real-world conditions. Embedded pragmatic clinical trials (ePCTs) in healthcare systems have the potential to accelerate the translation of evidence-based interventions into clinical practice. Building from the foundation of the National Institutes of Healthcare Systems Collaboratory, in September 2019 the National Institute on Aging Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratory was launched. Its mission is to build the nation's capacity to conduct ePCTs within healthcare systems for PLWD and their caregivers by (1) developing and disseminating best practice research methods, (2) supporting the design and conduct of ePCTs including pilot studies, (3) building investigator capacity through training and knowledge generation, (4) catalyzing collaboration among stakeholders, and (5) ensuring the research includes culturally tailored interventions for people from diverse backgrounds. This report presents the rationale, structure, key activities, and markers of success for the overall NIA IMPACT Collaboratory. The articles that follow in this special Issue describe the specific work of its 10 core working groups and teams. J Am Geriatr Soc 68:S1-S7, 2020.

Introduction to project ECHO (extension for community heathcare outcomes)

Introduction:

Nationally and internationally, there is a gap between the need and availability of child mental health services. This gap stems from a lack of trained specialists, workforce misdistribution, variations in insurance and financing, and family concerns about the benefits of existing services. Of the possible solutions to these problems, expansion of the child mental health capacity of primary care providers (PCPs) has been proposed as a feasible and scalable approach. The Extension for Community Healthcare Outcomes (ECHO) model was originally conceived and executed by Dr. Sanjeev Arora at the University of New Mexico for Hepatitis C. It serves to de-monopolize medical expertise by extending knowledge from specialists to PCPs

Dementia patients have greater anti-cholinergic drug burden on discharge from hospital: A multicentre cross-sectional study

Introduction

Anticholinergic medications block cholinergic transmission. The central effects of anticholinergic drugs can be particularly marked in patients with dementia. Furthermore, anticholinergics antagonise the effects of cholinesterase inhibitors, the main dementia treatment.

Objectives

This study aimed to assess anticholinergic drug prescribing among dementia patients before and after admission to UK acute hospitals.

Methods

352 patients with dementia were included from 17 hospitals in the UK. All were admitted to surgical, medical or Care of the Elderly wards in 2019. Information about patients’ prescriptions were recorded on a standardised form. An evidence-based online calculator was used to calculate the anticholinergic drug burden of each patient. The correlation between two subgroups upon admission and discharge was tested with Spearman’s Rank Correlation.

Results

Table 1 shows patient demographics. On admission, 37.8% of patients had an anticholinergic burden score ≥1 and 5.68% ≥3. At discharge, 43.2% of patients had an anticholinergic burden score ≥1 and 9.1% ≥3. The increase was statistically significant (rho 0.688; p=2.2x10-16). The most common group of anticholinergic medications prescribed at discharge were psychotropics (see Figure 1). Among patients prescribed cholinesterase inhibitors, 44.9% were also taking anticholinergic medications.

Conclusions

This multicentre cross-sectional study found that people with dementia are frequently prescribed anticholinergic drugs, even if also taking cholinesterase inhibitors, and are significantly more likely to be discharged with a higher anticholinergic drug burden than on admission to hospital.

Conflict of interest

This project was planned and executed by the authors on behalf of SPARC (Student Psychiatry Audit and Research Collaborative). We thank the National Student Association of Medical Research for allowing us use of the Enketo platform. Judith Harrison was su

KKI-NECT: Kennedy krieger institute’s network for early childhood tele-education (US)

Introduction

The Kennedy Krieger Institute Network for Early Childhood Tele-Education (KKI-NECT) is a federally funded ECHO project. Its hub consists of a child psychiatrist, developmental pediatricians and a behavioral psychologist. Its community partners are primary care providers(PCPs) in underserved areas. Its goal is to create local experts in early childhood behavioral, emotional and developmental disorders.

Objectives

After attendance at this session, the learner will be able to: 1. report the rates of co-occurring developmental, behavioral and emotional disorders presented by primary care participants 2. explain the efficacy of case based learning and a structured curriculum as a mechanism for expanding the workforce. The goal of this presentation is to build awareness of and interest in ECHOs specifically targeted to child behavioral, emotional and developmental issues.

Methods

Dr. Leppert will discuss KKI-NECT, particularly the process of procuring funding, setting up an ECHO, and getting institutional “buy-in". She will describe the use of case based learning and a structured curriculum in a longitudinal CME program, report the comorbidities in cases that participants present for discussion, and demonstrate the impact on participants’ practice.

Results

Data from four cohorts demonstrate that PCPs showed increased comfort levels, improved knowledge of behavioral, emotional and developmental disorders. PCPs expanded the scope issues they could address in their practice as a result of participation in KKI-NECT.

Conclusion

KKI-NECT is a viable response to the workforce shortage of child psychiatrists by confidently increasing the role of the PCP in treating childhood developmental and mental health disorders.

Disclosure

No significant relationships.

"Somebody Like Me": Understanding COVID-19 Vaccine Hesitancy among Staff in Skilled Nursing Facilities

Objective

The vaccination of skilled nursing facility (SNF) staff is a critical component in the battle against COVID-19. Together, residents and staff constitute the single most vulnerable population in the pandemic. The health of these workers is completely entangled with the health of those they care for. Vaccination of SNF staff is key to increasing uptake of the vaccine, reducing health disparities, and reopening SNFs to visitors. Yet, as the vaccine rollout begins, some SNF staff are declining to be vaccinated. The purpose of this article is to describe reasons for COVID-19 vaccine hesitancy reported by staff of skilled nursing facilities and understand factors that could potentially reduce hesitancy.

Design

Five virtual focus groups were conducted with staff of SNFs as part of a larger project to improve vaccine uptake.

Setting and Participants

Focus groups with 58 staff members were conducted virtually using Zoom.

Measures

Focus groups sought to elicit concerns, perspectives, and experiences related to COVID-19 testing and vaccination.

Results

Our findings indicate that some SNF staff are hesitant to receive the COVID-19 vaccine. Reasons for this hesitancy include beliefs that the vaccine has been developed too fast and without sufficient testing; personal fears about pre-existing medical conditions, and more general distrust of the government.

Conclusions and Implications

SNF staff indicate that seeing people like themselves receive the vaccination is more important than seeing public figures. We discuss the vaccination effort as a social enterprise and the need to develop long-term care provider-academic-community partnerships in response to COVID-19 and in expectation of future pandemics.

Snaps of a tiny amphipod push the boundary of ultrafast, repeatable movement

Surprisingly, the fastest motions are not produced by large animals or robots. Rather, small organisms or structures, including cnidarian stinging cells, fungal shooting spores, and mandible strikes of ants, termites, and spiders, hold the world acceleration records.^1-5 These diverse systems share common features: they rapidly convert potential energy - stored in deformed material or fluid - into kinetic energy when a latch is released.^4-6 However, the fastest of these are not repeatable, because mechanical components are broken or ejected.^5,6 Furthermore, some of these systems must overcome the added challenge of moving in water, where high density and viscosity constrain acceleration at small sizes. Here we report the kinematics of repeatable, ultrafast snaps by tiny marine amphipods (Dulichiella cf. appendiculata). Males use their enlarged major claw, which can exceed 30% of body mass, to snap a 1 mm-long dactyl with a diameter equivalent to a human hair (184 μm). The claw snaps closed extremely rapidly, averaging 93 μs, 17 m s^-1, and 2.4 x 10⁵ m s^-2. These snaps are among the smallest and fastest of any documented repeatable movement, and are sufficiently fast to operate in the inertial hydrodynamic regime (Reynolds number (Re) >10,000). They generate audible pops and rapid water jets, which occasionally yield cavitation, and may be used for defense. These amphipod snaps push the boundaries of acceleration and size for repeatable movements, particularly in water, and exemplify how new biomechanical insights can arise from unassuming animals. VIDEO ABSTRACT.

Verification and Validation of Digital Pathology (Whole Slide Imaging) for Primary Histopathological Diagnosis: All Wales Experience

Aims:

The study is aimed to verify Aperio AT2 scanner for reporting on the digital pathology platform (DP) and to validate the cohort of pathologists in the interpretation of DP for routine diagnostic histopathological services in Wales, United Kingdom.

Materials, Methods and Results:

This was a large multicenter study involving seven hospitals across Wales and unique with 22 (largest number) pathologists participating. 7491 slides from 3001 cases were scanned on Leica Aperio AT2 scanner and reported on digital workstations with Leica software of e-slide manager. A senior pathology fellow compared DP reports with authorized reports on glass slide (GS). A panel of expert pathologists reviewed the discrepant cases under multiheader microscope to establish ground truth. 2745 out of 3001 (91%) cases showed complete concordance between DP and GS reports. Two hundred and fifty-six cases showed discrepancies in diagnosis, of which 170 (5.6%) were deemed of no clinical significance by the review panel. There were 86 (2.9%) clinically significant discrepancies in the diagnosis between DP and GS. The concordance was raised to 97.1% after discounting clinically insignificant discrepancies. Ground truth lay with DP in 28 out of 86 clinically significant discrepancies and with GS in 58 cases. Sensitivity of DP was 98.07% (confidence interval [CI] 97.57–98.56%); for GS was 99.07% (CI 98.72–99.41%).

Conclusions:

We concluded that Leica Aperio AT2 scanner produces adequate quality of images for routine histopathologic diagnosis. Pathologists were able to diagnose in DP with good concordance as with GS.

Strengths and Limitations of this Study:

Strengths of this study – This was a prospective blind study. Different pathologists reported digital and glass arms at different times giving an ambience of real-time reporting. There was standardized use of software and hardware across Wales. A strong managerial support from efficiency through the technology group was a key factor for the implementation of the study.

Limitations:

This study did not include Cytopathology and in situ hybridization slides. Difficulty in achieving surgical pathology practise standardization across the whole country contributed to intra-observer variations.

Risk Factors for Relapsing Remitting Multiple Sclerosis

Relapsing remitting is the most common type of multiple sclerosis, affecting approximately 85% of all patients. Previous evidence has suggested that the risk factors for developing relapsing remitting multiple sclerosis is multifactorial. Similarly, it has been suggested that these factors also influence the risk of relapse. This article critically appraises and evaluates a systematic review that examined multiple factors associated with the risk of relapse for relapsing remitting multiple sclerosis.

Silicone adhesive multilayer foam dressings as adjuvant prophylactic therapy to prevent hospital-acquired pressure ulcers: a pragmatic noncommercial multicentre randomized open-label parallel-group medical device trial

Background

Silicone adhesive multilayer foam dressings are used as adjuvant therapy to prevent hospital‐acquired pressure ulcers (PUs).

Objectives

To determine whether silicone foam dressings in addition to standard prevention reduce the incidence of PUs of category 2 or worse compared with standard prevention alone.

Methods

This was a multicentre, randomized controlled medical device trial conducted in eight Belgian hospitals. At‐risk adult patients were centrally randomized (n = 1633) to study groups based on a 1 : 1 : 1 allocation: experimental groups 1 (n = 542) and 2 (n = 545) – pooled as the treatment group – and the control group (n = 546). The experimental groups received PU prevention according to hospital protocol, and a silicone foam dressing on the relevant body sites. The control group received standard of care. The primary endpoint was the incidence of a new PU of category 2 or worse at the studied body sites.

Results

In the intention‐to‐treat population (n = 1605), PUs of category 2 or worse occurred in 4·0% of patients in the treatment group and 6·3% in the control group [relative risk (RR) 0·64, 95% confidence interval (CI) 0·41–0·99, P = 0·04]. Sacral PUs were observed in 2·8% and 4·8% of the patients in the treatment group and the control group, respectively (RR 0·59, 95% CI 0·35–0·98, P = 0·04). Heel PUs occurred in 1·4% and 1·9% of patients in the treatment and control groups, respectively (RR 0·76, 95% CI 0·34–1·68, P = 0·49).

Conclusions

Silicone foam dressings reduce the incidence of PUs of category 2 or worse in hospitalized at‐risk patients when used in addition to standard of care. The results show a decrease for the sacrum, but no statistical difference for the heel and trochanter areas.

What is already known about this topic?

The incidence of hospital‐acquired pressure ulcers (PUs) remains high despite the implementation of best‐practice recommendations.

The concept of using silicone foam dressings as an additional prophylactic strategy in PU prevention has been investigated in previous studies but with some limitations.

Most RCTs were monocentric studies, restricted to either critically ill or acute care patients and did not observe more than two anatomical at‐risk skin sites, which limited the generalizability of the findings.

What does this study add?

This large pragmatic RCT suggests that it is beneficial to use silicone adhesive multilayer foam dressings on the sacrum, in addition to standard of care, to help prevent hospital‐acquired PUs.

Clinical decision making for heel dressings should be based on the clinical effectiveness of the intervention weighed against the potential risk of falling.

Linked Comment: F. Coyer. Br J Dermatol 2021; 185:4–5.

Reflections on the IJHPR's article collection on dementia

Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) constitute a worldwide public health crisis. In light of the AD/ADRD epidemic now existing within the global COVID-19 pandemic, the need for global action to improve dementia care is greater than ever. The article collection "Dementia- an Interdisciplinary Approach," in the Israeli Journal of Health Policy and Research (IJHPR) highlights the need for interprofessional approaches to improving outcomes for people living with dementia and their care partners, as well as the complexities of conducting dementia care research.

Adopting evidence-based guidelines for acute stroke care: barriers and enablers for health professionals

An evidence summary based on the systematic review: Baatiema L, Otim ME, Mnatzaganian G, de-Graft Aikins A, Coombes J, Somerset S. Health professionals' views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review. Implement Sci. 2017;12:74. 10.1186/s13012-017-0599-3

Evidence-based practice is the keystone of clinical practice, policy and management. Despite this, a knowledge-to-practice gap still exists, and it is estimated to take 17 years for evidence to be translated into clinical practice. The reasons for slow translation in acute stroke care are not completely understood.

Filament identification in wide-angle high speed imaging of the mega amp spherical tokamak

A new tomographic inversion technique is presented for the identification of plasma filaments in wide-angle visible camera data. The technique works on the assumption that background subtracted images of filaments can be represented as a superposition of uniformly emitting magnetic equilibrium field lines. A large collection of equilibrium magnetic field lines is traced and projected onto the camera field of view and combined to form a geometry matrix describing the coordinate transformation from magnetic field aligned coordinates to image pixel coordinates. Inverting this matrix enables the reprojection of the emission in the camera images onto a field aligned basis, from which filaments are readily identifiable. The inversion is a poorly conditioned problem which is overcome using a least-squares approach with Laplacian regularization. Blobs are identified using the "watershed" algorithm and 2D Gaussians are fitted to get the positions, widths, and amplitudes of the filaments. A synthetic camera diagnostic generating images containing experimentally representative filaments is utilized to rigorously benchmark the accuracy and reliability of the technique. 74% of synthetic filaments above the detection amplitude threshold are successfully detected, with 98.8% of detected filaments being true positives. The accuracy with which filament properties and their probability density functions are recovered is discussed, along with sources of error and methods to minimize them.

The Environmental Protection Agency in the Early Trump Administration: Prelude to Regulatory Capture

We explore and contextualize changes at the Environmental Protection Agency (EPA) over the first 6 months of the Trump administration, arguing that its pro-business direction is enabling a form of regulatory capture. We draw on news articles, public documents, and a rapid response, multisited interview study of current and retired EPA employees to (1) document changes associated with the new administration, (2) contextualize and compare the current pro-business makeover with previous ones, and (3) publicly convey findings in a timely manner. The lengthy, combined experience of interviewees with previous Republican and Democratic administrations made them valuable analysts for assessing recent shifts at the Scott Pruitt-led EPA and the extent to which these shifts steer the EPA away from its stated mission to "protect human and environmental health." Considering the extent of its pro-business leanings in the absence of mitigating power from the legislative branch, we conclude that its regulatory capture has become likely-more so than at similar moments in the agency's 47-year history. The public and environmental health consequences of regulatory capture of the EPA will probably be severe and far-reaching.