Parous women perform less moderate to vigorous physical activity than their nulliparous peers: a population-based study in Denmark

OBJECTIVES

The World Health Organization (WHO) highlights parous women as a key population for monitoring trends of physical activity (PA). We aimed to estimate the proportion of Danish women non-adhering to WHO PA guidelines in parous women compared with nulliparous women and to describe leisure-time PA intensity in each of these groups.

STUDY DESIGN

Cross-sectional study.

METHODS

This population-based study builds on a sample of 27,668 women aged 16-40 years from the Danish National Health Survey 2021. These data were linked with childbirth data from the Danish National Birth Registry. The primary outcome was self-reported weekly hours of moderate to vigorous leisure-time PA (MVPA) dichotomized into: (i) adhering to WHO guidelines for MVPA or (ii) not adhering to WHO guidelines for MVPA. Binomial regression analysis was used to calculate prevalence proportions (PP) and prevalence proportion ratios (PPR).

RESULTS

Of the 27,668 women, a total of 20,022 were included; 9338 (46.6%) parous women and 10,684 (53.4%) nulliparous women. The PP of women non-adhering to WHO PA guidelines was 63.8% (95% CI 62.9-64.8) for parous and 51.3% (95% CI 50.4-52.3) for nulliparous women, corresponding to a PPR of 1.24 (95% CI 1.21; 1.27).

CONCLUSIONS

The proportion of parous women who did not adhere to WHO PA guidelines for MVPA was 24% higher than that of nulliparous women. This highlights parous women as a subgroup of the adult population at increased risk of non-adherence to WHO PA guidelines. These findings call for future research to inform new strategies aiming to promote PA in parous women.

Evaluation of a virtual practice placement: A model to increase student capacity

AIM

To describe the development and evaluation of a novel virtual practice placement.

BACKGROUND

Health systems around the world face the challenge of recruiting and retaining sufficient nursing staff to provide high quality care. The need to train more nurses makes it hard to provide sufficient and varied high quality student placements to all students. This paper reports the result of one approach to the provision of a novel virtual placement for pre-registration student nurses.

DESIGN

Online virtual placement evaluated by a questionnaire conducted after the placement.

METHODS

A total of 195 students attended the virtual practice placement between 10th October 2022 and the 10th March 2023. The survey consisted of eight questions, of which one invited a qualitative response.

RESULTS

A total of 188 students completed the questionnaire and provided feedback. Of these 84 were adult nursing students, 67 child, 36 mental health and one learning disability student. The virtual placement required considerable resources to run, however was deemed as valuable by most students. When asked to rate the overall experience out of 5, the median scores were consistently high: adult (Mdn=5), child (Mdn=4), learning disability (Mdn=5) and mental health (Mdn=5) and mean values consistently high across fields: adult (M=4.73), child (M=5), learning disability (M=5) and mental health (M=4.67). Qualitatively, there were four main themes that emerged from the questionnaire responses: increased understanding of community healthcare and holistic approaches to care; developing interpersonal skills; a positive impact on their future career opportunities and the value of realistic case studies.

CONCLUSIONS

Virtual placements are a viable addition to traditional placements. However, they require careful planning and considerable resources including experienced and dedicated facilitators. Principles for the delivery of virtual placements were produced to replicate and share best practice.

Low-dose diazoxide is safe and effective in infants with transient hyperinsulinism

OBJECTIVE

Transient hyperinsulinism (THI) is the most common form of recurrent hypoglycaemia in neonates beyond the first week of life. Although self-resolving, treatment can be required. Consensus guidelines recommend the lower end of the diazoxide 5-15 mg/kg/day range in THI to reduce the risk of adverse events. We sought to determine if doses <5 mg/kg/day of diazoxide can be effective in THI.

DESIGN, PATIENTS, MEASURMENTS

Infants with THI (duration <6 months) were treated with low-dose diazoxide from October 2015 to February 2021. Dosing was based on weight at diazoxide start: 2 mg/kg/day in infants 1000-2000 g (cohort 1), 3 mg/kg/day in those 2000-3500 g (cohort 2) and 5 mg/kg/day in those >3500 g.

RESULTS

A total of 73 infants with THI (77% male, 33% preterm, 52% small-for-gestational age) were commenced on diazoxide at a median age of 11 days (range 3-43) for a median duration of 4 months (0.3-6.8), with no difference between cohorts. The mean effective diazoxide dose was 3 mg/kg/day (range 1.5-10); 35% (26/73) required an increase from their starting dose, including 60% (9/15) of cohort 1. There was no association between perinatal stress risk factors or treatment-related characteristics and dose increase. Adverse events occurred in 13 patients (18%); oedema (12%) and hyponatraemia (5%) were the most common. Two infants developed suspected necrotising enterocolitis (NEC); none had pulmonary hypertension.

CONCLUSION

Diazoxide doses <5 mg/kg/day are effective in THI. While the nature of the association between diazoxide and NEC was unclear, other adverse events were mild. We suggest considering starting doses as low as 2-3 mg/kg/day in THI to balance the side effect risk while maintaining euglycaemia.

Re-Thinking Hyperkalaemia Management in Chronic Kidney Disease-Beyond Food Tables and Nutrition Myths: An Evidence-Based Practice Review

Potassium dysregulation can be life-threatening. Dietary potassium modification is a management strategy for hyperkalaemia. However, a 2017 review for clinical guidelines found no trials evaluating dietary restriction for managing hyperkalaemia in chronic kidney disease (CKD). Evidence regarding dietary hyperkalaemia management was reviewed and practice recommendations disseminated. A literature search using terms for potassium, hyperkalaemia, and CKD was undertaken from 2018 to October 2022. Researchers extracted data, discussed findings, and formulated practice recommendations. A consumer resource, a clinician education webinar, and workplace education sessions were developed. Eighteen studies were included. Observational studies found no association between dietary and serum potassium in CKD populations. In two studies, 40-60 mmol increases in dietary/supplemental potassium increased serum potassium by 0.2-0.4 mmol/L. No studies examined lowering dietary potassium as a therapeutic treatment for hyperkalaemia. Healthy dietary patterns were associated with improved outcomes and may predict lower serum potassium, as dietary co-factors may support potassium shifts intracellularly, and increase excretion through the bowel. The resource recommended limiting potassium additives, large servings of meat and milk, and including high-fibre foods: wholegrains, fruits, and vegetables. In seven months, the resource received > 3300 views and the webinar > 290 views. This review highlights the need for prompt review of consumer resources, hospital diets, and health professionals' knowledge.

Standardised practices in the networked management of congenital hyperinsulinism: a UK national collaborative consensus

Congenital hyperinsulinism (CHI) is a condition characterised by severe and recurrent hypoglycaemia in infants and young children caused by inappropriate insulin over-secretion. CHI is of heterogeneous aetiology with a significant genetic component and is often unresponsive to standard medical therapy options. The treatment of CHI can be multifaceted and complex, requiring multidisciplinary input. It is important to manage hypoglycaemia in CHI promptly as the risk of long-term neurodisability arising from neuroglycopaenia is high. The UK CHI consensus on the practice and management of CHI was developed to optimise and harmonise clinical management of patients in centres specialising in CHI as well as in non-specialist centres engaged in collaborative, networked models of care. Using current best practice and a consensus approach, it provides guidance and practical advice in the domains of diagnosis, clinical assessment and treatment to mitigate hypoglycaemia risk and improve long term outcomes for health and well-being.

Accuracy and impact on quality of life of real-time continuous glucose monitoring in children with hyperinsulinaemic hypoglycaemia

Objective

Continuous glucose monitoring (CGM) is the standard of care for glucose monitoring in children with diabetes, however there are limited data reporting their use in hyperinsulinaemic hypoglycaemia (HH). Here, we evaluate CGM accuracy and its impact on quality of life in children with HH.

Methods

Real-time CGM (Dexcom G5 and G6) was used in children with HH aged 0-16years. Data from self-monitoring capillary blood glucose (CBG) and CGM were collected over a period of up to 28days and analysed. Quality of life was assessed by the PedsQL4.0 general module and PedsQL2.0 family impact module, completed by children and their parents/carers before and after CGM insertion. Analysis of accuracy metrics included mean absolute relative difference (MARD) and proportion of CGM values within 15, 20, and 30% or 15, 20, and 30 mg/dL of reference glucose values >100 mg/dL or ≤100 mg/dL, respectively (% 15/15, % 20/20, % 30/30). Clinical reliability was assessed with Clarke error grid (CEG) analyses.

Results

Prospective longitudinal study with data analysed from 40 children. The overall MARD between reference glucose and paired CGM values (n=4,928) was 13.0% (Dexcom G5 12.8%, Dexcom G6 13.1%). The proportion of readings meeting %15/15 and %20/20 were 77.3% and 86.4%, respectively, with CEG analysis demonstrating 97.4% of all values in zones A and B. Within the hypoglycaemia range (<70 mg/dL), the median ARD was 11.4% with a sensitivity and specificity of 64.2% and 91.3%, respectively. Overall PedsQL child report at baseline and endpoint were 57.6 (50.5 - 75.8) and 87.0 (82.9 - 91.2), and for parents were 60.3 (44.8 - 66.0) and 85.3 (83.7 - 91.3), respectively (both p<0.001).

Conclusion

Use of CGM for children with HH is feasible, with clinically acceptable accuracy, particularly in the hypoglycaemic range. Quality of life measures demonstrate significant improvement after CGM use. These data are important to explore use of CGM in disease indications, including neonatal and paediatric diabetes, cystic fibrosis and glycogen storage disorders.

Adding mini meals to a nasogastric refeeding protocol for patients with eating disorders can be achieved on general hospital wards

BACKGROUND

Treatment of medically compromised patients with eating disorders is difficult in general hospital wards. There is currently no consensus on the best feeding method; however, previous research has demonstrated the safety of using enteral feeding. Because an oral diet has benefits on psychological and behavioural pathways, concurrent feeding requires further investigation. The present study aimed to examine acceptability and safety of implementing mini meals to a previously nil-by-mouth 7-day enteral feeding protocol.

METHODS

This was mixed methods research including a retrospective observational study and participant survey. Patients admitted to a tertiary hospital in Brisbane, Australia, between July 2020 and March 2021 were eligible. Eligible participants were provided mini meals from day 5. Type and quantity of meals consumed alongside clinical incident data were collected. The survey examined acceptability of mini meals. Descriptive statistics were used to interpret findings. Content analyses were conducted on survey responses.

RESULTS

Sixty-four participants (95%, n = 57/60 female, 25.2 ± 8.9 years; 75%, n = 45/60 diagnosed with anorexia nervosa) were included. At least half of the participants consumed some or all of the mini meals at each meal period. No clinical incidents were reported. Twenty-six (50%, n = 26/52) surveys were returned. Half (54%, n = 14/26) agreed-strongly agreed that mini meals improved their experience. Eleven participants desired more choice in menu items.

CONCLUSIONS

The present study found that introducing mini meals into an enteral feeding protocol is acceptable and safe for patients with eating disorders. Participants reported benefits in returning to eating; however, some items on the menu require reconsideration to enable increased consumption.

Patient Confidence and Information Preferences during the Treatment Decision-making Process: Results from a Large Multiple Myeloma Patient Survey Across 12 Countries in Europe and Israel

BACKGROUND

The relapsing nature of multiple myeloma (MM) means that patients typically receive different and multiple lines of therapy, requiring many treatment decisions over the disease course. The aim of this study was to explore patient confidence and information preferences during the treatment decision-making process.

PATIENTS AND METHODS

A multinational, cross-sectional survey enrolled patients with MM. It was co-developed and distributed by Myeloma Patients Europe across 12 countries in Europe and Israel from May 2019 to March 2020. Eligibility criteria included a self-reported diagnosis of MM and being able to recall the decision-making process at the start of their latest treatment line.

RESULTS

A total of 1559 patients were included, with complete responses received from 1081 (69%) patients. The median age range was 54 to 64 years; there was an equal gender split and 57% had their latest treatment decision made within the past year. Overall, 54% of patients felt "very confident" in the latest treatment decision. Patients deemed the most important information to be safety/tolerability and treatment effectiveness, but the latter was among the least frequently received. Most patients reported that their primary physician treating MM was their main source for all types of information (range, 62%-94%), with 87% of patients reporting a "very good" or "good" relationship with them.

CONCLUSION

Over half of patients felt very confident in their latest treatment decision; however, patients reported not routinely receiving important treatment effectiveness information. Addressing the discrepancies between information that patients receive and consider important may enhance confidence in decision-making.

Patient Perceptions Regarding Ciltacabtagene Autoleucel Treatment: Qualitative Evidence From Interviews With Patients With Relapsed/Refractory Multiple Myeloma in the CARTITUDE-1 Study

INTRODUCTION

Ciltacabtagene autoleucel (cilta-cel), a novel chimeric antigen receptor T (CAR-T) cell therapy, has demonstrated early, deep, and durable clinical responses in heavily pretreated patients with relapsed/refractory multiple myeloma (RRMM), and improvements in health-related quality of life (HRQoL) in CARTITUDE-1 (NCT03548207). Patient perspectives on treatment provide context to efficacy outcomes and are an important aspect of therapeutic evaluation.

METHODS

Qualitative interviews were conducted in a subset of CARTITUDE-1 patients (n = 36) at screening, Day 100, and Day 184 post cilta-cel on living with MM, therapy expectations, and treatment experiences during the study.

RESULTS

Patients most wanted to see change in symptoms with the greatest impact on HRQoL: pain (85.2%) and fatigue (74.1%). The primary treatment expectation was achieving remission (40.7%), followed by extended life expectancy (14.8%). Patients most often defined meaningful change as improvement in symptoms (70.4%) and return to normalcy (40.7%). The percentage of patients reporting symptoms (pain, fatigue, bone fracture, gastrointestinal, neuropathy, and weakness) decreased from 85.2% to 22.2% across symptom types at baseline to 29.2% to 0% on Day 184 after cilta-cel. Improved symptoms and positive sentiments corresponded with improved perception of overall health status and reduced pain level, respectively. Most patients reported that their expectations of cilta-cel treatment had been met (70.8%) or exceeded (20.8%) at Day 184, and 70.8% of patients considered cilta-cel therapy better than their previous treatments.

CONCLUSION

Overall HRQoL improvements and qualitative interviews showed cilta-cel met patient expectations of treatment and suggest the long treatment-free period also contributed to positive sentiments.

POTS and Pregnancy: A Review of Literature and Recommendations for Evaluation and Treatment

Postural Orthostatic Tachycardia Syndrome (POTS) is a disorder of the autonomic nervous system most commonly affecting women of reproductive age. Studies on POTS and pregnancy are limited, and there is a lack of clinical guidelines regarding assessment and management of pregnant women with POTS. The purpose of this review is to summarize data from the available studies on the topic of pregnancy in POTS and common comorbid conditions and to provide the clinical recommendations regarding evaluation and treatment of POTS in pregnant women, based on the available studies and clinical experience. We conclude that pregnancy appears to be safe for women with POTS and is best managed by a multi-disciplinary team with knowledge of POTS and its various comorbidities. Importantly, large, prospective studies are needed to better delineate the course and outcomes of pregnancy, as well as possible pregnancy-related complications in women with POTS. Clinicians should be aware of the clinical presentation, diagnostic criteria, and treatment options in pregnant women with POTS to optimize outcomes and improve medical care during pregnancy and post-partum period.

The Burden of a Multiple Myeloma Diagnosis on Patients and Caregivers in the First Year: Western European Findings

Background

This research aimed to quantify the burden of illness (BoI) in transplant eligible (TE) and transplant non-eligible (TNE) newly diagnosed multiple myeloma (NDMM) patients and their caregivers, in the first year after diagnosis: at months 0, 3, and 12.

Methods

Prospective, cross-sectional, observational NDMM study of TE and TNE patients and their caregivers from France, Germany, Italy, and Spain was conducted between May 2019 and January 2021. A structured, online questionnaire measuring disease burden, direct and costs, out-of-pocket expenses, and health-related quality of life (HRQoL) was used. Descriptive statistics were performed.

Results

A total of 164, 160, and 190 NDMM patients [>65 years; self-described healthy; not working; living with caregiver] answered at months 0, 3, and 12. Patients lost independence to perform daily activities; mean pain intensity rose and opioid utilization increased, more significantly among TNE patients. Overall health status and HRQoL remained stable. Median 3-month direct medical costs peaked at month 3. Specialist consultations and hospital admissions were the greatest cost amongst TE and TNE patients. Home adaptations increased out-of-pocket expenditures amongst TNE patients. Patients describing themselves as working spent a median 0 hours in the office at all time points. A total of 131, 122, and 124 caregivers answered at months 0, 3, and 12. Mean self-rated burden score rose. By month 12, half of caregivers developed stress, anxiety or depression. Most employed caregivers continued working. Productivity was low at month 0 with a trend of recovering at month 12. Caregivers of TNE compared to TE patients reported greater time burden. Caregivers' HRQoL was stable over time.

Conclusion

NDMM is burdensome for patients and caregivers in the first year after diagnosis. TNE patients are more dependent on caregivers and incur higher care costs than TE patients. Despite the financial, physical, and emotional burden, HRQoL remains stable possibly indicating resilience and illness adjustment amongst patients and caregivers.

What matters most to patients with multiple myeloma? A Pan-European patient preference study

INTRODUCTION

Given the rapid increase in novel treatments for patients with multiple myeloma (MM), this patient preference study aimed to establish which treatment attributes matter most to MM patients and evaluate discrete choice experiment (DCE) and swing weighting (SW) as two elicitation methods for quantifying patients' preferences.

METHODS

A survey incorporating DCE and SW was disseminated among European MM patients. The survey included attributes and levels informed by a previous qualitative study with 24 MM patients. Latent class and mixed logit models were used to estimate the DCE attribute weights and descriptive analyses were performed to derive SW weights. MM patients and patient organisations provided extensive feedback during survey development.

RESULTS

393 MM patients across 21 countries completed the survey (M years since diagnosis=6; M previous therapies=3). Significant differences (p<.01) between participants' attribute weights were revealed depending on participants' prior therapy experience, and their experience with side-effects and symptoms. Multivariate analyses showed that participants across the three MM patient classes identified via the latent class model differed regarding their past number of therapies (F=4.772, p=.009). Patients with the most treatments (class 1) and those with the least treatments (class 3) attached more value to life expectancy versus quality of life-related attributes such as pain, mobility and thinking problems. Conversely, patients with intermediary treatment experience (class 2) attached more value to quality of life-related attributes versus life expectancy. Participants highlighted the difficulty of trading-off between life expectancy and quality of life and between physical and mental health. Participants expressed a need for greater psychological support to cope with their symptoms, treatment side-effects, and uncertainties. With respect to patients' preferences for the DCE or SW questions, 42% had no preference, 32% preferred DCE, and 25% preferred SW.

CONCLUSIONS

Quality of life-related attributes affecting MM patients' physical, mental and psychological health such as pain, mobility and thinking problems were considered very important to MM patients, next to life expectancy. This underscores a need to include such attributes in decision-making by healthcare stakeholders involved in MM drug development, evidence generation, evaluation, and clinical practice. This study highlights DCE as the preferred methodology for understanding relative attribute weights from a patient's perspective.

Access to and affordability of CAR T-cell therapy in multiple myeloma: an EBMT position paper

Chimeric antigen receptor (CAR) T-cell therapy is a promising immunotherapeutic approach in the treatment of multiple myeloma, and the recent approval of the first two CAR T-cell products could result in improved outcomes. However, it remains a complex and expensive technology, which poses challenges to health-care systems and society in general, especially in times of crises. This potentially accelerates pre-existing inequalities as access to CAR T-cell therapy varies, both between countries, depending on the level of economic development, and within countries, due to structural disparities in access to quality health care-a parameter strongly correlated with socioeconomic status, ethnicity, and lifestyle. Here, we identify two important issues: affordability and access to CAR T-cell treatment. This consensus statement from clinical investigators, clinicians, nurses, and patients from the European Society for Blood and Marrow Transplantation (EBMT) proposes solutions as part of an innovative collaborative strategy to make CAR T-cell therapy accessible to all patients with multiple myeloma.

Validation of the virtual measurement of the Essential Frailty Toolset

Funding Acknowledgements

Type of funding sources: None.

Background

The Essential Frailty Toolset (EFT) is a valid measurement of frailty in people with heart valve disease. COVID-19 has prompted the transition to virtual health consultations and necessitates the validation of the virtual assessment of frailty.

Methods

We conducted a prospective observational cohort study to compare the measurement of EFT in person and virtual format within a maximum 2-week window of repeated measurement. The weighted Kappa tests was used to measure the agreement of EFT scores between assessments; we explored the effect of the sequence of measurement using the Cochran-Mantel-Haenszel statistic to test the general association between the timing of measurement and differences of EFT score.

Results

We recruited a sample of 49 patients, with a mean age of 81 ± 7 years, including 29 men (59.2%); the primary valvular heart diseases were aortic stenosis (n=40, 81.6%), mitral regurgitation (n=2, 4.1%) and tricuspid regurgitation (n=7, 14.3%). The virtual measurement of frailty was conducted using a standardised protocol. The platform for virtual connection selected by patients was FaceTime (n=20, 40.8%) and Zoom (n=29, 59.2%); the median (IQR) number of days between the in-person and the virtual assessment was 5 (3,10). The weighted Kappa estimate was 0.69 (95% CI 0.55, 0.82), illustrating a strong agreement between the separate scores obtained. The test for the general association was non-significant (p=0.82), indicating a lack of evidence for detecting an association between EFT scores and chronological order of assessment.

Conclusion

The EFT can be reliably measured virtual in older patients with valvular heart disease to inform clinical care.

Urolithiasis in pregnancy: Advances in imaging modalities and evaluation of current trends in endourological approaches

OBJECTIVE

Given the challenges involved in diagnosis and treatment of pregnant women with urolithiasis, we aim to review the imaging modalities and current endourological management of these patients.

MATERIALS AND METHODS

We performed a review of the available literature on urolithiasis in pregnancy. This included evaluation, diagnostic imaging, and therapeutic options. The databases we searched from included Google Scholar and PubMed. A total of 346 abstracts were screened. After our inclusion/exclusion criteria were met, we were left with 42 sources: 18 retrospective studies, 10 reviews/meta-analyses, 8 sets of guidelines, 5 randomized control trials, and 1 prospective cohort.

RESULTS

We begin our review with the literature available on the safety and efficacy of imaging modalities in the surgical planning for urolithiasis in pregnant patients. This includes renal ultrasound, abdominal x-ray, computed tomography scan, and magnetic resonance imaging. While computed tomography may result in an added radiation exposure, with possible safety concerns, magnetic resonance imaging seems to be safer, however a less sensitive test. We next describe safety, efficacy, and outcomes of various surgical interventions for urolithiasis in pregnant patients. This encompasses ureteral stenting, percutaneous nephrostomy, ureteroscopy, extracorporeal shock wave lithotripsy, and percutaneous nephrolithotomy. Ureteroscopy is a safer approach, but percutaneous nephrolithotomy offers higher stone-free rates. Using an evidence-based approach, we propose an algorithm for management of the pregnant women with renal colic.

CONCLUSION

Management of the pregnant women with suspected urolithiasis is a unique challenge for healthcare providers. A multi-disciplinary approach should be taken to optimize outcomes through an evidence-based approach.

017 Year 1 performance of adveva® programme for patients taking cladribine tablets for relapsing-remitting multiple sclerosis

Background

The nurse-led, telephone-based adveva® programme - including dosing advice, appoint- ment reminders and a home-based phlebotomy service - supports patients with relapsing-remitting multiple sclerosis (RRMS) in taking cladribine tablets (CT) as prescribed (the full first year cumulative dose of 1.75 mg/kg). We report year 1 results of the adveva® progamme for patients with highly active RRMS taking CT.

Methods

Aggregated and anonymised telephone conversation records were reviewed between December 2017 and August 2018. Patient-reported adherence, plus basic and additional support data, were analysed.

Results

262 patients were registered with adveva® and 133 were included in this assessment as they self- reported to have completed treatment in year 1 at the time of assessment. 130 (98%) patients completed their first-year course as prescribed (the remaining 3 patients received the required dose at a different time interval to that recommended). 22 (17%) patients required additional support during their treatment days, included advice on treatment/dosing/adverse events.

Conclusions

All 133 patients self-reported that they achieved the required CT dose in year 1; the adveva® programme was of particular value to patients requiring additional support. This is the first report in a post- approval and real-world setting suggesting the majority of patients find CT simple-to-take.

kate.morgan@merckgroup.com

Observed High Adherence to Recombinant Human Growth Hormone Treatment Using a Multi-Component Approach to Improve Adherence in Individuals with Growth Disorders

We explored whether a multi-component approach - using a digital health device, the easypod™ auto-injector, the 'MySupport' patient support programme (PSP) and a Patient Activation Measure® (PAM®) - could improve adherence in patients receiving recombinant human growth hormone (r-hGH). A 13-item PAM was used to assess caregiver self-reported knowledge, resulting in two PAM scores for 88 patients at four UK hospitals after an average of 5.6 months. Most patients improved their PAM score by ≥1 level (43%) or maintained it (>-1 and <1; 21%). In parallel, 74% of patients maintained (-5 to +5%) or improved (≥5%) their adherence. Further studies are required to evaluate a multi-component approach to adherence in a larger population and for a longer duration.

Variation in Glycaemic Outcomes in Focal Forms of Congenital Hyperinsulinism - The UK Perspective

Context

In focal congenital hyperinsulinism (CHI), localized clonal expansion of pancreatic β-cells causes excess insulin secretion and severe hypoglycemia. Surgery is curative, but not all lesions are amenable to surgery.

Objective

We describe surgical and nonsurgical outcomes of focal CHI in a national cohort.

Methods

Patients with focal CHI were retrospectively reviewed at 2 specialist centers, 2003-2018.

Results

Of 59 patients with focal CHI, 57 had heterozygous mutations in ABCC8/KCNJ11 (51 paternally inherited, 6 de novo). Fluorine-18 L-3,4 dihydroxyphenylalanine positron emission tomography computed tomography scan identified focal lesions in 51 patients. In 5 patients, imaging was inconclusive; the diagnosis was established by frozen section histopathology in 3 patients, a lesion was not identified in 1 patient, and 1 declined surgery. Most patients (n = 56) were unresponsive to diazoxide, of whom 33 were unresponsive or partially responsive to somatostatin receptor analog (SSRA) therapy. Fifty-five patients underwent surgery: 40 had immediate resolution of CHI, 10 had persistent hypoglycemia and a focus was not identified on biopsy in 5. In the 10 patients with persistent hypoglycemia, 7 underwent further surgery with resolution in 4 and ongoing hypoglycemia requiring SSRA in 3. Nine (15% of cohort) patients (1 complex surgical access; 4 biopsy negative; 4 declined surgery) were managed conservatively; medication was discontinued in 8 children at a median (range) age 2.4 (1.5-7.7) years and 1 remains on SSRA at 16 years with improved fasting tolerance and reduction in SSRA dose.

Conclusion

Despite a unifying genetic basis of disease, we report inherent heterogeneity in focal CHI patients impacting outcomes of both surgical and medical management.

Evaluation of environmental conditions as a decontamination approach for SARS‐CoV ‐2 when applied to common library, archive, and museum related materials

Aims

The purpose of this study was to evaluate the effects of ambient or altered environmental conditions on the inactivation of SARS‐CoV‐2 applied to materials common in libraries, archives and museums.

Methods and Results

Porous and non‐porous materials (e.g. paper, plastic protective book cover) were inoculated with approximately 1 × 10⁵ TCID₅₀ SARS CoV‐2 (USA‐WA1/2020), dried, placed within test chamber in either a stacked or unstacked configuration, and exposed to environmental conditions ranging from 4 to 29°C at 40 ± 10% relative humidity. The amount of infectious SARS‐CoV‐2 was then assessed at various timepoints from 0 to 10 days. Ambient conditions resulted in varying inactivation rates per material type. Virus inactivation rate decreased when materials were stacked or at colder temperatures. Virus inactivation rate increased when materials were unstacked or at warmer temperatures.

Conclusions

SARS‐CoV‐2 at ambient conditions resulted in the inactivation of virus below limit of quantitation (LOQ) for all materials by Day 8. Warmer temperatures, for a subset of materials, increased SARS‐CoV‐2 inactivation, and all were <LOQ by Day 3.

Significance and Impact of the Study

These results provide information for the library, archives and museum community regarding the inactivation of SARS‐CoV‐2, showing that inactivation is possible using prescribed environmental conditions and is a potential method of decontamination for items not compatible with common liquid disinfectants.

Online Virtual Nursing Placements: A Case Study on Placement Expansion

Introduction

A need to increase student placements, in a culture that is under unprecedented demand, means that practice providers and partner higher education institutions need to find new and innovative ways to ensure quality learning experiences for students. Virtual placements are just one way of providing student placements, and this study presents a case for this.

Objective

This research aims to explore the student’s experience of virtual blended placements and to consider future sustainability.

Method

This is a qualitative, exploratory study observing the attitudes, thoughts, and feelings of student nurse experiences of online virtual nursing placements. Key cases were identified, and two participants were asked to reflect upon their experiences of the blended virtual learning placement. Student evaluations, and virtual placement day plans, form part of the data collection, and results are presented in a theory building and comparative approach, adopting pattern matching.

Results

Three themes emerged from the narratives, supported by student evaluations and day plans. Students reviewed the placement positively in that they were able to achieve their required practice proficiencies. Second, they discussed the way in which the virtual days were facilitated and that building relationships with professionals and peers while on placement was of high importance.

Conclusion

This case study presents a novel and unique student experience within a 0–19 community nursing service, which through 3 days of practice placement supported by two virtually taught days, students were able to reach their practice proficiencies. This virtual placement model offers a unique way to reduce the pressures on frontline staff and enriches the students’ experiences.

Patient Preferences for Multiple Myeloma Treatments: A Multinational Qualitative Study

Background: Investigational and marketed drugs for the treatment of multiple myeloma (MM) are associated with a range of characteristics and uncertainties regarding long term side-effects and efficacy. This raises questions about what matters most to patients living with this disease. This study aimed to understand which characteristics MM patients find most important, and hence should be included as attributes and levels in a subsequent quantitative preference survey among MM patients. Methods: This qualitative study involved: (i) a scoping literature review, (ii) discussions with MM patients (n = 24) in Belgium, Finland, Romania, and Spain using Nominal Group Technique, (iii) a qualitative thematic analysis including multi-stakeholder discussions. Results: MM patients voiced significant expectations and hopes that treatments would extend their lives and reduce their cancer signs and symptoms. Participants however raised concerns about life-threatening side-effects that could cause permanent organ damage. Bone fractures and debilitating neuropathic effects (such as chronic tingling sensations) were highlighted as major issues reducing patients' independence and mobility. Patients discussed the negative impact of the following symptoms and side-effects on their daily activities: thinking problems, increased susceptibility to infections, reduced energy, pain, emotional problems, and vision problems. MM patients were concerned with uncertainties regarding the durability of positive treatment outcomes, and the cause, severity, and duration of their symptoms and side-effects. Patients feared short-term positive treatment responses complicated by permanent, severe side-effects and symptoms. Conclusions: This study gained an in-depth understanding of the treatment and disease-related characteristics and types of attribute levels (severity, duration) that are most important to MM patients. Results from this study argue in favor of MM drug development and individual treatment decision-making that focuses not only on extending patients' lives but also on addressing those symptoms and side-effects that significantly impact MM patients' quality of life. This study underscores a need for transparent communication toward MM patients about MM treatment outcomes and uncertainties regarding their long-term efficacy and safety. Finally, this study may help drug developers and decision-makers understand which treatment outcomes and uncertainties are most important to MM patients and therefore should be incorporated in MM drug development, evaluation, and clinical practice.

Decreasing the Use of Restraints on Children Admitted for Behavioral Health Conditions

OBJECTIVES

Pediatric behavioral health admissions to children's hospitals for disposition planning are steadily increasing. These children may exhibit violent behaviors, which can escalate to application of physical limb restraints for safety. Using quality improvement methodology, we sought to decrease physical restraint use on children admitted to our children's hospital for behavioral health conditions from a baseline mean of 2.6% of behavioral health patient days to <1%.

METHODS

We included all children ≥3 years of age admitted to our hospital medicine service with a primary behavioral health diagnosis from July 1, 2016, to February 1, 2020. A multidisciplinary team, formed in July 2018, tested interventions based on key drivers targeted toward our aim. The primary outcome measure was the percent of behavioral health patient days on which physical restraints were ordered. The balancing measure was the percent of patient days with a staff injury event. Statistical process control charts were used to view and analyze data.

RESULTS

Our cohort included 3962 consecutive behavioral health patient encounters, encompassing a total of 9758 patient days. A 2-year baseline revealed physical restraint orders placed on 2.6% of behavioral health patient days, which was decreased to 0.9% after interventions and has been sustained over 19 months without any change in staff injuries.

CONCLUSIONS

Team-based quality improvement methodology was associated with a sustained reduction in physical restraint use on children admitted for behavioral health conditions to our children's hospital. These results indicate that physical restraint use can be safely reduced in children's hospitals.

Unusual Glycemic Presentations in a Child with a Novel Heterozygous Intragenic INSR Deletion

BACKGROUND

Mutations of the insulin receptor (INSR) gene lead to a wide spectrum of inherited insulin resistance (IR) syndromes. Among these, type A-IR, usually caused by dominant negative INSR mutations, generally presents peri-pubertally in girls.

CASE

A 2.8-year-old girl was referred due to recurrent postprandial and fasting hypoglycemia. She had been born at full-term with birth weight 1.89 kg, and had developed transient neonatal diabetes. Examination showed satisfactory growth, reduced adipose tissue, acanthosis nigricans, and isolated thelarche. After 12 h of fasting, she developed hypoglycemia (glucose 2.8 mmol/L), with inappropriately raised plasma insulin concentration of 5.4 mU/L and suppressed fatty acids and ketone bodies. Oral glucose tolerance testing showed severely increased plasma insulin concentration (>300 mU/L) with hypoglycemia (glucose 1.6 mmol/L) at 2.5 h. She was initially managed on dietary modifications, cornstarch, and then trialed on acarbose for postprandial hyperinsulinemic hypoglycemia (PPHH) with some response. However, she was noted to have increased frequency of hyperglycemia after a couple of years of treatment. She was then switched to metformin and continued to have dietary carbohydrate modification including cornstarch that improved fasting tolerance, hyperglycemia, and postprandial hypoglycemia. Genetic testing identified heterozygous deletion of the last exon of the INSR gene, exon 22.

CONCLUSION

We present a case of type A-IR, caused by a novel INSR deletion, presenting unusually early with transient neonatal diabetes, followed by episodes of hypoglycemia and hyperglycemia during later childhood. Early life presentations, including neonatal diabetes and PPHH, should lead to consideration of type A-IR.

Introduction to automatic forage stations and measurement of forage intake rate in an active open barn for horses

Interest in the use of open barns on Swedish horse farms is increasing as an alternative to keeping horses in box stalls and as a 2007 law requires phasing out of tie stalls. To provide adequate forage to satisfy welfare requirements for nutrition, gut health and behavioural needs, the use of automated feeding is also increasing. Studies on forage intake rate report wide variation but provide little information on how to introduce horses to an automatic forage station and on how forage intake rate varies in individual horses fed using an automatic forage station. This study documented the process of training 22 horses to use a transponder-controlled automatic forage feeding station and measured forage intake rates. Observations on the learning period of horses for transponder-controlled automatic forage stations showed that after 4 days, 48% of the horses had reached the goal of 90% intake. After 8 days, learning was completed in 71% of horses and at 16 days in 95% of horses. Measurements of forage intake rate revealed significant differences between individual horses. Overall mean intake rate ± SD, based on 314 observations, was 22.4 ± 6.7 min/kg forage DM. Evaluation of the number of intake measurements required to set a representative average ration in the automatic station for an individual horse showed that the variation levelled off at four samples. In conclusion, horses quickly learned how to use an automatic forage station, with two-thirds of horses achieving this within 7 days. To ensure the correct ration in a timed transponder-controlled automatic forage station, each horse's forage intake rate must be measured at least four times to obtain a representative average.

Costs and Reimbursements for Mental Health Hospitalizations at Children's Hospitals

The financial impact of the rising number of pediatric mental health hospitalizations is unknown. Therefore, this study assessed costs, reimbursements, and net profits or losses for 111,705 mental health and non-mental health medical hospitalizations in children's hospitals with use of the Pediatric Health Information System and Revenue Management Program. Average financial margins were calculated as (reimbursement per day) - (cost per day), and they were lowest for mental health hospitalizations ($136/day), next lowest for suicide attempt ($518/day), and highest for other medical hospitalizations ($611/day). For 10 of 17 hospitals, margin per day for mental health hospitalizations was lower than margin per day for other medical hospitalizations. For these 10 hospitals, the total net loss for inpatient and observation status mental health hospitalizations, compared with other medical hospitalizations, was $27 million (median, $2.2 million per hospital). Financial margins were usually lower for mental health vs non-mental health medical hospitalizations.

0539 Are Short Sleepers Uncoupled Sleepers?

Introduction

While short sleep durations (&lt;7h/night) are associated with increased diabetes risk, there is limited evidence that increasing the habitual sleep duration of short sleepers is either feasible, or will reliably improve metabolic health outcomes. Furthermore, in the absence of insomnia disorder, it remains unclear whether habitual short sleep mainly reflects a genetic predisposition or a lifestyle choice. In a randomized controlled study we delivered a sleep extension protocol based on CBTi principles to overweight ‘short sleepers’ at increased risk of Type II diabetes.

Methods

18 male short sleepers (Mage=41.4; MBMI=29.57; baseline mean TST=5.8 h/ night) with no complaints of insomnia were randomized to the sleep extension intervention or control condition (printed sleep hygiene advice). The 6-week intervention commenced with personalized sleep re-scheduling negotiated in a 60-minute 1-to-1 session, and supported by elements of sleep hygiene, stimulus control, relaxation and cognitive strategies. Outcomes included sleep duration (actigraphy), fasting insulin, Mean Amplitude of Glycemic Excursions (MAGE) from continuous glucose monitoring, and blood pressure. Data were analyzed in linear fixed effects models including time, group and baselines values.

Results

Adherence to the 6-week protocol was high. Relative to controls (n=8), intervention participants (n = 10) showed a significant increase in TST (95%CI 46.91min, 101.64min, p&lt;0.001; MDiff = 79.4min, p&lt;0.001) and significant reductions in fasting insulin (95%CI -32.08 pmol/L, -.97.0 pmol/L; p=0.04; MDiff = -10.2 pmol/L, p=0.06); MAGE (95%CI -0.77, -0.08, p=0.02; MDiff -0.35, p=0.05) and diastolic (95%CI -22, -5, p=0.004; MDiff=-12, p=0.004); and systolic blood pressure (95%CI -20, -2, p=0.03; MDiff=-10, p=0.006).

Conclusion

CBTi-based sleep extension protocols offer feasible and effective lifestyle interventions in the management of metabolic health in overweight short sleepers who fit published categorization of non-complaining poor sleepers with an undeveloped insomnia identity whose subjective sleep experience and objective sleep characteristics are ‘uncoupled’.

Support

School of Sport, Exercise and Health Sciences, Loughborough University

The effect on consent rates for deceased organ donation in Wales after the introduction of an opt-out system

Organ transplantation saves and transforms lives. Failure to secure consent for organ retrieval is widely regarded as the single most important obstacle to transplantation. A soft opt‐out system of consent for deceased organ donation was introduced into Wales in December 2015, whilst England maintained the existing opt‐in system. Cumulative data on consent rates in Wales were compared with those in England, using a two‐sided sequential procedure that was powered to detect an absolute difference in consent rates between England and Wales of 10%. Supplementary risk‐adjusted logistic regression analysis examined whether any difference in consent rates between the two nations could be attributed to variations in factors known to influence UK consent rates. Between 1 January 2016 and 31 December 2018, 8192 families of eligible donors in England and 474 in Wales were approached regarding organ donation, with overall consent rates of 65% and 68%, respectively. There was a steady upward trend in the proportion of families consenting to donation after brain death in Wales as compared with England and after 33 months, this reached statistical significance. No evidence of any change in the donation after circulatory death consent rate was observed. Risk‐adjusted logistic regression analysis revealed that by the end of the study period the probability of consent to organ donation in Wales was higher than in England (OR [95%CI] 2.1 [1.26–3.41]). The introduction of a soft opt‐out system of consent in Wales significantly increased organ donation consent though the impact was not immediate.

Preparedness for advancing future health: a national qualitative exploration of dietetics graduates' experiences

Effective health workforce preparation is critical to the health of those who stand to benefit from its services. Emerging dietitians can provide important insights on an evolving workforce that is well-placed to advance future global health. This study aimed to explore a national sample of dietetics graduates' experiences of, and challenges faced in, dietetics workforce preparation and preparedness in Australia. An interpretive description methodology guided this study whereby researchers interpreted the meanings that participants attributed to their experiences. Twenty dietitians (graduated within the last 2 years) were purposively sampled from across Australia and detailed insights were obtained through semi-structured interviews. A multi-analyst approach employing thematic and template analysis, enabled five themes to be identified across the data set. These included: (1) being held back; (2) chasing the prize; (3) valuing real learning; (4) easing the transition; and (5) encountering influencers. While graduates appreciated their preparation, they were not empowered or equipped to embrace opportunities in diverse and emerging areas of dietetics practice. Graduates were challenged by the competitive landscape of securing obvious job opportunities and by a lack of support in transitioning into the workforce. Practice exposures and encounters with influential dietitians were highly valued. Research on role-emerging dietetics placements along with enhanced support mechanisms for novice dietitians is urgently required to ensure appropriate alignment between future dietetics preparation and practice. Obtaining insights into health professional graduates' experiences of their education can be used to ensure that emerging health workforces are relevant and responsive to future market needs.

Post-Prandial Hyperinsulinaemic Hypoglycaemia after Oesophageal Surgery in Children

INTRODUCTION

Post-prandial hyperinsulinaemic hypoglycaemia (PPHH) is a recognized complication of various gastric surgeries in children, but rarely reported after oesophageal atresia repair. We report 2 children diagnosed with PPHH after oesophageal surgery and the challenges of their management. Case 1: A 2-year-old boy diagnosed with oesophageal atresia at birth was surgically repaired requiring 6 oesophageal dilatations in the first year of life. At 11 months of age, he manifested hypoglycaemic seizures and investigations confirmed PPHH. Acarbose and diazoxide trials failed. He was managed with 17-h continuous gastrostomy feeds. Currently, he is 28 months old with euglycaemia on daytime bolus gastrostomy feeds and overnight 12-h continuous gastrostomy feeds. Case 2: A 6-month-old girl diagnosed with Wolf-Hirschhorn syndrome and tracheo-oesophageal fistula was surgically repaired, requiring monthly oesophageal dilatations. At 5 months of age, she was reported to have hypoglycaemia and PPHH was confirmed. She responded to diazoxide and continuous nasogastric tube feeds, but developed pulmonary hypertension pos-sibly diazoxide-induced. Subsequently, diazoxide was stopped and normoglycaemia was secured via 20-h continuous gastrostomy feeds.

CONCLUSION

PPHH may be an underdiagnosed complication in children undergoing surgery for oesophageal atresia. These children must be monitored closely for symptoms of hypoglycaemia and if there are concerns must be screened for possible PPHH. Our cases demonstrate that continuous feeding regimens might be the only therapeutic option, until PPHH gradually lessens in intensity over time.

Design and Region-Specific Adaptation of the Dietary Intervention Used in the SODIUM-HF Trial: A Multicentre Study

Background

Restricting dietary sodium consumption has been considered a major component of self-care management in heart failure (HF); however, the evidence supporting this recommendation has not been conclusive. The Study of Dietary Intervention Under 100 MMOL in Heart Failure (SODIUM-HF) trial aims to assess the effects of dietary sodium reduction on clinical outcomes in a HF population using a pragmatic design to provide empirical evidence to guide dietary sodium intake recommendations in patients with chronic HF.

Methods

SODIUM-HF is a multicentre, open-label, blinded adjudicated endpoint, randomized controlled trial in ambulatory patients with chronic HF. This trial involves participants recruited from sites in Canada, Australia, New Zealand, Mexico, Colombia, and Chile, who are followed up to 24 months. Rationale and methods of the SODIUM-HF trial were published elsewhere. As an international pragmatic dietary trial, SODIUM-HF was designed to address several challenges, such as defining the most suitable intervention to account for country-specific variations in food intake and availability. In SODIUM-HF, we implemented the Nutrition-Care Model to provide a comprehensive intervention delivered directly to patients, focusing on modifying the nutrient composition of the diet (sodium restriction), using a personalized counselling and close follow-up.

Results

Available upon completion of the trial.

Conclusions

This long-term dietary trial is one of the first in its type in the HF field. This article describes in detail the rationale and methods for the dietary intervention employed and the region-specific adaptation of the SODIUM-HF intervention, so that the learning and processes taken in this trial can be applied to future multicountry dietary clinical trials.

The Use of a Long-Acting Somatostatin Analogue (Lanreotide) in Three Children with Focal Forms of Congenital Hyperinsulinaemic Hypoglycaemia

BACKGROUND

A long-acting somatostatin analogue (lanreotide) is used in the management of a diazoxide-unresponsive diffuse form of congenital hyperinsulinism (CHI). However, no reports of its use in patients with the focal form of CHI exist. Case 1: A 1-month-old boy diagnosed with diazoxide-unresponsive CHI due to a paternal heterozygous ABCC8 gene mutation showed partial response to octreotide. 18F-DOPA-PET/CT scan revealed a focal lesion in the pancreatic head. Surgical removal of the lesion was unsuccessful. He was switched to monthly lanreotide treatment at the age of 11 months, which stabilised his blood glucose over a 12-month period. Case 2: A 1-month-old boy with diazoxide-unresponsive CHI due to a paternal heterozygous KCNJ11 gene mutation was partially responsive to octreotide. 18F-DOPA-PET/CT scan confirmed a focal pancreatic head lesion. Over 6 months, he underwent 3 lesionectomies and afterwards responded to octreotide. At the age of 9 months, treatment was switched to monthly lanreotide. Currently, he is aged 3, with stable glycaemia, and improved fasting tolerance. Case 3: A 3-week-old girl with a paternal heterozygous ABCC8 gene mutation was unresponsive to diazoxide. 18F-DOPA-PET/CT scan confirmed a focal pancreatic head lesion. She responded to octreotide, and her parents preferred to avoid pancreatic surgery. At the age of 20 months, treatment was switched to monthly lanreotide, resulting in euglycaemia over the last 7 months.

CONCLUSION

CHI patients with focal pancreatic head lesions are challenging, especially if not surgically amenable. Conservative treatment is preferable, and lanreotide might be an option. The therapeutic impact of lanreotide treatment in patients with the focal forms of CHI should be confirmed in prospective studies with close monitoring of the side effects.

Mental Health Recovery Narratives and Their Impact on Recipients: Systematic Review and Narrative Synthesis

OBJECTIVE

Mental health recovery narratives are often shared in peer support work and antistigma campaigns. Internet technology provides access to an almost unlimited number of narratives, and yet little is known about how they affect recipients. The aim of this study was to develop a conceptual framework characterizing the impact of recovery narratives on recipients.

METHOD

A systematic review of evidence about the impact of mental health recovery narratives was conducted. Searches used electronic databases (n = 9), reference tracking, hand-searching of selected journals (n = 2), grey literature searching, and expert consultation (n = 7). A conceptual framework was generated through a thematic analysis of included articles, augmented by consultation with a Lived Experience Advisory Panel.

RESULTS

In total, 8137 articles were screened. Five articles were included. Forms of impact were connectedness, understanding of recovery, reduction in stigma, validation of personal experience, affective responses, and behavioural responses. Impact was moderated by characteristics of the recipient, context, and narrative. Increases in eating disorder behaviours were identified as a harmful response specific to recipients with eating disorders.

CONCLUSIONS

Mental health recovery narratives can promote recovery. Recovery narratives might be useful for clients with limited access to peers and in online interventions targeted at reducing social isolation in rural or remote locations, but support is needed for the processing of the strong emotions that can arise. Caution is needed for use with specific clinical populations. Protocol registration: Prospero-CRD42018090923.

The association between evidence of a predator threat and responsiveness to alarm calls in Western Australian magpies (Cracticus tibicen dorsalis)

Alarm calls are a widespread form of antipredator defence and being alerted to the presence of predators by the alarm calls of conspecifics is considered one of the benefits of group living. However, while social information can allow an individual to gain additional information, it can also at times be inaccurate or irrelevant. Such variation in the accuracy of social information is predicted to select for receivers to discriminate between sources of social information. In this study, we used playback experiments to determine whether Western Australian magpies (Cracticus tibicen dorsalis) respond to the predator information associated with alarm calls. Magpies were exposed to the alarm calls of two group members that differed in the threat associated with the alarm call: one call was played in the presence of a predator model while the other was not—in order to establish differences in the predator information provided by each caller. We then played back the alarm calls of the same group members in the absence of the predator model to determine whether magpies responded differently to signallers in response to the previous association between the alarm call and a predator threat. We found that receivers showed significantly greater levels of responsiveness to signallers that previously gave alarm calls in the appropriate context. Thus, the accuracy of threat-based information influenced subsequent receiver response.

CLOSING THE LEAK: KEEPING LATE-DECIDING STUDENTS IN THE PIPELINE TO BIOMEDICAL RESEARCH CAREERS

With the increased competitiveness of undergraduate, graduate, and professional programs, the continuously accelerating rate of technological innovation and development of new global means of communication, and the evolving face of the local, national, and global job markets, choosing a long-term career has become a challenge for many. More and more students opt to take a gap period in their education, pre- or post-college, for soul searching to determine their future path or for improving their skills and competitiveness for successfully applying to academic institutions. Even though such gap years can lead to more mature and determined students, they often derail the educational path of the individual by leading to loss of interest or to new commitments which hinder going back to school. Engaging students in academic and skills training programs that keep them within the academic environment and provide them with exposure to the benefits of higher education has been shown to increase their persistence, leading to an increased rate of attaining higher-level degrees. A number of United States (US) federal funding agencies, including the National Institutes of Health (NIH), have programs such as the Bridges to Baccalaureate Program (support for easing a student's transition from a 2-year junior or community college to a 4-year baccalaureate-granting institution) and Post-baccalaureate Research Education Program (PREP, support for recent college graduates from underrepresented groups or disadvantaged backgrounds to strengthen their research skills and academic competitiveness for pursuing a doctorate degree in the Biomedical Sciences). At Xavier University of Louisiana (Xavier), we have developed a post-baccalaureate technician program under Project Pathways (the NIH National Institute of General Medical Sciences (NIGMS) Division of Training, Workforce Development, and Diversity (TWD)-funded Building Infrastructure Leading to Diversity (BUILD) Program), that provides research experience and training in soft skills to recent Xavier graduates to increase their preparation and competitiveness for graduate programs. The BUILD Technicians also receive both mentee and mentor training and serve as near-peer mentors to undergraduate students in their labs, increasing their scientific identity and preparing them for their future role as graduate teaching assistants. Here, we report the lessons learned from this program and how its differences from other post-baccalaureate programs, including those under the NIH PREP umbrella, have led to improved outcomes for Xavier graduates gaining admission to graduate programs in the Biomedical Sciences.

Venous thromboembolism in IBD: Increased risk for women in CD?

Although coagulation disturbances have been described in inflammatory bowel disease (IBD), it remains unclear how common venous thromboembolism (VTE) is in IBD, and what factors influence VTE frequency. We evaluated VTE in Crohn's disease (CD) and ulcerative colitis (UC) at LSUHSC-S, a southern US medical center with an approximately equal White: African-American (AA) (1.12:1) patient base. This retrospective study evaluated VTE as a co-morbidity in IBD as a function of age, gender and race based on ICD-10 coding (2011-2015.) Results. Of 276 IBD diagnostic records, 213 were for CD (77.17%) and 63 for UC (22.8%). 52% of the CD patients were white, 42% were AA, and 6% were other. 42% of CD patients were male, with 58% were female. 6.1% (13 patients) of the 213 CD patients had a VTE. Of these 13 CD patients, 9 had active disease and 4 were in remission. 9 of 13 were female and 4 were male, with 5 white patients and 4 A A patients. 63 patients were diagnosed with UC, 3.38-fold fewer cases than CD. 25 UC patients were white, 25 were AA and 13 were in other ethnic groups. Of 63 UC cases, 2 UC patients had a VTE, both with active disease. At our institution, VTE appears to be 3x more frequently associated with CD than UC and was more common in white female patients. The recognition of VTE risk in CD, particularly in women, may be an important observation which may guide therapy and limit potentially life-threatening consequences.

Dietetics students' experiences of dietetics workforce preparation and preparedness: a systematic review and qualitative synthesis

BACKGROUND

Dietetics students are a widely researched group. As emerging dietitians, they can provide valuable insights to inform how dietetics education programmes may be enhanced to meet contemporary healthcare needs. This review aimed to systematically synthesise dietetics students' experiences of dietetics workforce preparation.

METHODS

MEDLINE, CINAHL, Embase, PsycINFO, ERIC, Informit and ProQuest Dissertations and Theses Global were searched to identify research published until June 2017. Studies investigating dietetics students' experiences of dietetics workforce preparation, and employing qualitative data collection and analysis methods were included. Data analysis was guided by thematic synthesis, where themes were constructed through an iterative and inductive process. Study quality was appraised using the RATS Qualitative Research Review Guidelines.

RESULTS

From the 3301 records identified, five studies met the inclusion criteria and the views of 120 dietetics students from two countries over a 9-year period were synthesised. The overarching theme of 'navigating through the ups and downs' was underpinned by four main themes: enduring hurdles; reconciling expectations; transforming self; and making and breaking connections. Quality appraisal results rated selection bias as being inadequate/inappropriate across all studies.

CONCLUSIONS

Dietetics students undertake a transformational journey through dietetics education. They are inspired by seeing what is possible through meaningful encounters with practitioners in diverse settings. However, they are challenged by competitive environments and perceived ideals that are embedded in the profession. Strategies that focus on exposing dietetics students to inspirational practitioners, increasing and celebrating diversity in academic/placement settings, and incentivising collaboration across dietetics education, could act as catalysts to enhance the experience of future dietetics students and the nutrition-related health of those they will serve.

BUILDING INFRASTRUCTURE LEADING TO DIVERSITY PROGRAM AT XAVIER UNIVERSITY OF LOUISIANA, PROJECT PATHWAYS

Xavier University of Louisiana (XULA) is the only historically Black and Catholic institution of higher education in the United States. XULA's mission focuses on "the promotion of a more just and humane society" by educating students in a diverse learning environment. Even though Xavier's reputation in the sciences attracts many of the best and brightest students in the nation, the University also continues to provide an excellent educational opportunity to many students who, due to socioeconomic disparities, lack the appropriate preparation for college. The ultimate goal of Project Pathways, the National Institutes of Health (NIH)-funded BUILD (Building Infrastructure Leading to Diversity) Program at Xavier, is to increase the number of students who enter graduate programs in biomedical disciplines, successfully earn terminal degrees, and enter the biomedical research workforce. Xavier's plan to meet this challenge is based on a holistic approach, providing an integrated and coordinated student support and research skills training network. This coordinated effort cuts across academic departments in biomedical disciplines, academic support offices that include the Student Academic Success Office (SASO), the Office of Career Services (OCS), and the Center for Undergraduate Research and Graduate Opportunity (CURGO), as well as the Center for the Advancement of Teaching and Faculty Development (CAT+FD) for faculty support and mentor training. This work seeks to counter the regular practice at higher education institutions that have yet to address the importance of integrated programming across academic programs, student support programs, and research programs. This lack of coordinated and integrated programming often leads to duplication of efforts and ineffective use of resources. Xavier's BUILD program intentionally provides mechanisms and safeguards to ensure that coordination and integration occur at all levels. The overall hypothesis of Project Pathways is that when in a systematic way underrepresented minorities are provided with: early awareness and deepening exposure to biomedical careers;supportive relationships for students as they move through the pathway;suitable infrastructure; andmeaningful student engagement in biomedical research experiences and adequate research resources, a higher number will succeed in first entering, and later successfully completing graduate programs, leading to increased diversity in the biomedical research workforce. Preliminary assessment results are very encouraging; these results show higher course pass rates and better student preparation overall. The Project Pathways' initiatives can be replicated at other institutions with similar goals.

Challenges in preparing the dietetics workforce of the future: An exploration of dietetics educators' experiences

AIM

Dietetics educators represent a small but influential workforce group that has experienced significant change in recent years. The workforce development challenges faced by this group have been largely unexplored. The present study aimed to explore the experiences of, and challenges faced by, academic dietetics educators in preparing dietitians for the workforce.

METHODS

The approach taken in the present study was informed by qualitative description. Fifteen dietetics educators employed by 13 universities across Australia were purposively sampled. In-depth, semi-structured interviews conducted via telephone (n = 12) or face-to-face (n = 3) were digitally recorded then transcribed verbatim. Data were managed with NVivo and inductively analysed using open coding. Codes were condensed into themes through an iterative process involving multiple researchers.

RESULTS

The overarching theme of 'aiming for a moving target' was underpinned by the themes of: (i) striving for betterment; (ii) bridging dissonance and (iii) distressing impossibilities. Interviewees described how they were driven to enhance the preparation of dietitians but acknowledged disparity between what graduates are being prepared for and what they need to be prepared for. Heightened expectations of others, professional constraints and a lack of collegiality among the profession were among the challenges that manifested in a sense of frustration, concern and isolation.

CONCLUSIONS

Dietetics educators are motivated to shape and enhance the future profession. However, they face numerous challenges in their efforts to prepare graduates who are well-equipped for increasingly diverse dietetics practice. Strong leadership, academic collaboration and greater engagement of the broader workforce are required for the benefit of the entire profession.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.