"One size does not fit all" - Barriers to and facilitators of physical activity in adolescents with epilepsy

OBJECTIVE

To explore the barriers to physical activity and to identify the support needed to facilitate physical activity in adolescents with epilepsy (AWE).

METHODS

AWE (aged 11-16 years) and their caregivers completed survey-based open questions regarding perceived barriers to, and facilitators of physical activity in young people with epilepsy. The responses were analysed using Thematic Analysis.

RESULTS

Themes concerning barriers to physical activity included concerns about seizure safety, general anxiety and anxiety related to seizures, stigma/negative attitudes associated with having epilepsy, tiredness, and perceived lack of physical competence. Themes regarding the support needed to facilitate physical activity included better education amongst staff/coaches about epilepsy (e.g., seizure management/prevention, associated fatigue/tiredness), improvements in societal attitudes towards epilepsy, flexibility/tailoring of activities to the child's needs (e.g., need for breaks), and peer support for young people with epilepsy to encourage engagement in physical activity.

CONCLUSIONS

There is a perception among AWE and caregivers, that significant barriers exist with regard to engaging in physical activity for young people with epilepsy. Barriers are related to concerns about seizure management but also wider safety and social issues. A number of facilitators were identified to promote physical activity engagement in AWE, including education for staff and caregivers, peer support, and tailoring activities to the adolescent's needs. There is a need to develop interventions to reduce barriers to physical activity in young people with epilepsy.

Safety of mapping the motor networks in the spinal cord using penetrating microelectrodes in Yucatan minipigs

OBJECTIVE

The goal of this study was to assess the safety of mapping spinal cord locomotor networks using penetrating stimulation microelectrodes in Yucatan minipigs (YMPs) as a clinically translational animal model.

METHODS

Eleven YMPs were trained to walk up and down a straight line. Motion capture was performed, and electromyographic (EMG) activity of hindlimb muscles was recorded during overground walking. The YMPs underwent a laminectomy and durotomy to expose the lumbar spinal cord. Using an ultrasound-guided stereotaxic frame, microelectrodes were inserted into the spinal cord in 8 animals. Pial cuts were made to prevent tissue dimpling before microelectrode insertion. Different locations within the lumbar enlargement were electrically stimulated to map the locomotor networks. The remaining 3 YMPs served as sham controls, receiving the laminectomy, durotomy, and pial cuts but not microelectrode insertion. The Porcine Thoracic Injury Behavioral Scale (PTIBS) and hindlimb reflex assessment results were recorded for 4 weeks postoperatively. Overground gait kinematics and hindlimb EMG activity were recorded again at weeks 3 and 4 postoperatively and compared with preoperative measures. The animals were euthanized at the end of week 4, and the lumbar spinal cords were extracted and preserved for immunohistochemical analysis.

RESULTS

All YMPs showed transient deficits in hindlimb function postoperatively. Except for 1 YMP in the experimental group, all animals regained normal ambulation and balance (PTIBS score 10) at the end of weeks 3 and 4. One animal in the experimental group showed gait and balance deficits by week 4 (PTIBS score 4). This animal was excluded from the kinematics and EMG analyses. Overground gait kinematic measures and EMG activity showed no significant (p > 0.05) differences between preoperative and postoperative values, and between the experimental and sham groups. Less than 5% of electrode tracks were visible in the tissue analysis of the animals in the experimental group. There was no statistically significant difference in damage caused by pial cuts between the experimental and sham groups. Tissue damage due to the pial cuts was more frequently observed in immunohistochemical analyses than microelectrode tracks.

CONCLUSIONS

These findings suggest that mapping spinal locomotor networks in porcine models can be performed safely, without lasting damage to the spinal cord.

Assessing the Impact of Nutrition Training Among Medical Students

Introduction

Nutrition education remains inadequate in American medical schools, and physicians often cite lack of nutrition knowledge as a barrier to counseling patients. The goal of this study was to evaluate the impact of additional nutrition curriculum on first-year medical students.

Methods

We created a 1-hour nutrition lecture, delivered to first-year medical students. Using pre-, post-, and 3-month follow-up surveys, we assessed the following: (1) change in student knowledge; (2) confidence in counseling patients; (3) motivation to change their personal dietary behaviors; and (4) satisfaction with the curriculum. We assessed objectives using multiple choice questions and 10-point Likert scale questions.

Results

Of the 142 students who attended the live lecture, 105 (73.9%) completed both pre- and postsurveys, and 65 (45.8%) completed the 3-month follow-up survey. Students' knowledge of the material increased from 37% to 82%, but retention dropped to 65% at the 3-month mark (P<.001). Comfort in assessing and counseling patients improved across the three survey iterations, from 3.53 to 5.90 to 8.00 (P<.001). Motivation to change personal behaviors was high overall at 8.04, 8.36 and 8.25 [P<.05]). Moreover, students were satisfied with the lecture, with a rating of 8.58/10.

Conclusions

This study supports the value of additional medical student nutrition education. This curriculum significantly increases student knowledge, comfort with the material, and confidence in counseling their future patients. A longitudinal curriculum that reinforces concepts over time will help improve long-term retention.

AAV9:PKP2 improves heart function and survival in a Pkp2-deficient mouse model of arrhythmogenic right ventricular cardiomyopathy

BACKGROUND

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a familial cardiac disease associated with ventricular arrhythmias and an increased risk of sudden cardiac death. Currently, there are no approved treatments that address the underlying genetic cause of this disease, representing a significant unmet need. Mutations in Plakophilin-2 (PKP2), encoding a desmosomal protein, account for approximately 40% of ARVC cases and result in reduced gene expression.

METHODS

Our goal is to examine the feasibility and the efficacy of adeno-associated virus 9 (AAV9)-mediated restoration of PKP2 expression in a cardiac specific knock-out mouse model of Pkp2.

RESULTS

We show that a single dose of AAV9:PKP2 gene delivery prevents disease development before the onset of cardiomyopathy and attenuates disease progression after overt cardiomyopathy. Restoration of PKP2 expression leads to a significant extension of lifespan by restoring cellular structures of desmosomes and gap junctions, preventing or halting decline in left ventricular ejection fraction, preventing or reversing dilation of the right ventricle, ameliorating ventricular arrhythmia event frequency and severity, and preventing adverse fibrotic remodeling. RNA sequencing analyses show that restoration of PKP2 expression leads to highly coordinated and durable correction of PKP2-associated transcriptional networks beyond desmosomes, revealing a broad spectrum of biological perturbances behind ARVC disease etiology.

CONCLUSIONS

We identify fundamental mechanisms of PKP2-associated ARVC beyond disruption of desmosome function. The observed PKP2 dose-function relationship indicates that cardiac-selective AAV9:PKP2 gene therapy may be a promising therapeutic approach to treat ARVC patients with PKP2 mutations.

Do comparative judgements affect the perceived relevance of mobile phone road safety campaigns?

OBJECTIVE

Given the prevalence of illegal mobile phone use while driving and reliance upon messaging campaigns in deterring the behavior, there is a need to explore to what extent comparative judgements may influence desired outcomes of such campaigns. This exploratory study investigated (a) the perceived relevance and influence of different mobile phone road safety campaigns within a sample of Queensland motorists who reported using their mobile phone while driving and (b) if these varied depending on whether participants believed that their crash risk whilst using a phone was higher (comparative pessimism), lower (comparative optimism) or similar to the same-age and sex driver.

METHODS

A total of 350 licensed drivers residing within Queensland (Australia) were included in this study, of which 200 reported using their hand-held phone on some occasion. Participation involved completing a 20-25 min online anonymous survey, which included viewing three mobile phone road safety campaigns (injury-based, sanction-based and humor) and responding to questions about the perceived relevance and impact of each campaign.

RESULTS

A total of 64 (32%) participants displayed comparative optimism, 50 displayed similar judgements (25%) and 86 (43%) exhibited comparative pessimism. First, it was found that the injury-based campaign was perceived to be significantly more relevant than the humor campaign. Second, whilst the relevance of each campaign did not vary as a function of group membership, the campaigns were significantly less relevant to those displaying comparative optimism relative to those with similar judgements and comparative pessimism. Finally, the injury-based campaign was perceived to be significantly more influential than the other campaigns. However, overall, participants displaying comparative optimism believed that they would be less influenced by the campaigns compared to those with comparative pessimism.

CONCLUSIONS

Although preliminary, these findings suggest that low perceptions of risk may dilute or extinguish the desired behavioral outcomes of mobile phone road safety campaigns. Nonetheless, experimental research is needed to examine these effects directly.

A survey of patient informational preferences when choosing between medical and surgical therapy for ulcerative colitis: a sub-study from the DISCUSS project

AIM

People living with ulcerative colitis (UC) have two broad treatment avenues, namely medical or surgical therapy. The choice between these can depend on patient preference as well as the receipt of relevant information. The aim of this study was to define the informational needs of patients with UC.

METHOD

A postal survey was designed to capture respondent demographics, treatment experienced within the previous 12 months and informational preferences by rating a long list of items. It was delivered through two hospitals that provide tertiary inflammatory bowel disease services. Descriptive analyses were performed to describe demographics and experiences. Principal component analysis was carried out using a varimax rotation to investigate informational needs.

RESULTS

A total of 101 responses were returned (20.1% response rate). The median age of respondents was 45 years and the median time since diagnosis was 10 years. Control preferences skewed towards shared (42.6%) or patient-led but clinician-informed (35.6%). Decision regret was low for the population (median 12.5/100, range 0-100). Key informational needs related to medical therapy were benefits and risks of long-term therapy, burden of hospital attendance, reproductive health, need for steroid treatment and impact on personal life. For surgery, these were stoma information, effect on daily life, effect on sexual and reproductive health, risks and benefits and disruption of life due to surgery.

CONCLUSION

This study has identified key areas for discussion when counselling patients about treatment decisions around medical therapy and surgery for UC.

1298 THE IMPACT OF ACUTE HEALTHCARE UTILISATION ON FUNCTIONAL DECLINE IN OLDER ADULTS OVER TIME: A POPULATION-BASED COHORT STUDY

Introduction

Acute healthcare use varies by age, with older adults the highest users of most acute healthcare services. International reports have highlighted increased use of Emergency Department (ED) services by older adults. Older adults who visit the ED may be admitted to hospital or discharged home and are vulnerable to adverse outcomes including cognitive decline, falls, readmission, mortality and hospital acquired limitations in activities of daily living. Using data from The Irish Longitudinal Study on Ageing (TILDA), the aim of this study was to investigate the impact of acute healthcare utilisation at baseline on subjective and objective measures of function at four-year follow-up in older adults.

Methods

This study represents a secondary analysis of a prospective cohort study where data from Wave 1 (baseline) and Wave 3 (four-year follow up) of TILDA were analysed in conjunction with a public and patient involvement group of older adults. Acute healthcare utilisation was defined as an ED visit with or without hospitalisation in the previous 12 months. Function was assessed objectively using Timed-Up-and Go (TUG) and grip strength and subjectively using self-report limitations in activities of daily living and instrumental activities of daily living.

Results

A total of 1516 participants met the study inclusion criteria. Mean age was 70.9 years (SD=4.6) and 48% were male. At baseline, 1280 participants reported no acute healthcare use. 118 indicated an ED visit but no hospitalisation in the previous twelve months and 118 reported both an ED visit and hospitalisation. Adjusting for all covariates, compared to those with no acute healthcare utilisation, those with an ED visit with no hospital admission had poorer TUG performance at follow up (β= 0.67, 95% CI: 0.34, 1.29, p=0.039).

Conclusion

The results of this study support a relationship between acute healthcare utilisation and functional decline assessed by TUG at follow-up.

299 OLDER PERSONS’ EXPERIENCES AND PERSPECTIVES OF COMPREHENSIVE GERIATRIC ASSESSMENT

Background

There is an abundance of evidence to demonstrate the positive impacts of Comprehensive Geriatric Assessment (CGA) on clinical and process outcomes for older adults across settings of care. However, it is unclear how older adults themselves view CGA and their experiences of the care process. The aim of this qualitative evidence synthesis is to explore the experiences and perspectives of older adults of CGA.

Methods

A comprehensive literature search was completed across MEDLINE, CINAHL, PsycINFO, PsycARTICLES and Social Sciences Full Text. Qualitative or mixed methods studies that included qualitative data on the perspectives and experiences of older adults of CGA were included. The methodological quality of the included studies was appraised using the Critical Appraisal Skills Programme checklist for qualitative research. Findings were synthesised using thematic analysis

Results

Nine studies were included in the synthesis, including studies where CGA was completed in hospital, outpatient assessment unit and home settings. Divergent experiences of CGA were reported. Older adults reported experiences of being respected and listened to during CGA and attention paid to all their issues and priorities. Good communication by healthcare providers was central to these positive experiences (theme 1). In contrast, experiences of being unclear about the aim of CGA or perceived benefits of CGA, feeling that the outcome of CGA did not align with their priorities (theme 2) and not feeling involved in decision making during CGA (theme 3) were also commonly reported.

Conclusion

Findings indicate that CGA is a process by which older adults can felt respected and paid attention to. However, scope exists to further improve older adults’ experiences of CGA. Enhanced healthcare provider communication and facilitation of older adult involvement in decision-making are priority areas for improvement. Further research should focus on exploring other stakeholder groups experiences of CGA including caregivers and healthcare professionals.

267 WHAT IS THE IMPACT OF ACUTE HEALTHCARE UTILISATION ON FUNCTIONAL DECLINE IN OLDER ADULTS OVER TIME? A POPULATION-BASED COHORT STUDY

Background

Acute healthcare use varies by age, with older adults the highest users of most acute healthcare services. Using data from The Irish Longitudinal Study on Ageing (TILDA), the aim of this study was to investigate the impact of acute healthcare utilisation at baseline on subjective and objective measures of function at four-year follow-up in older adults.

Methods

This study represents a secondary analysis of a prospective cohort study where data from Wave 1 (baseline) and Wave 3 (four-year follow up) of TILDA were analysed in conjunction with a public and patient involvement group of older adults. Acute healthcare utilisation was defined as an Emergency Department (ED) visit with or without hospitalisation in the previous 12 months. Function was assessed objectively using Timed-Up-and Go (TUG) and grip strength and subjectively using self-report limitations in activities of daily living and instrumental activities of daily living. Linear regression was used to investigate the relationship between ED use at baseline and grip strength and TUG performance at Wave 3. Logistic regression was used to investigate the relationship between ED use at baseline and whether a participant had a disability in ADL and IADL, or not, at Wave 3.

Results

A total of 1516 participants met the study inclusion criteria. Mean age was 70.9 years (SD=4.6) and 48% were male. At baseline, 1280 participants reported no acute healthcare use. 118 indicated an ED visit but no hospitalisation in the previous twelve months and 118 reported both an ED visit and hospitalisation. Adjusting for all covariates, compared to those with no acute healthcare utilisation, those with an ED visit with no hospital admission had poorer TUG performance at follow up (β= 0.67, 95% CI: 0.34, 1.29, p=0.039).

Conclusion

The results of this study support a relationship between acute healthcare utilisation and functional decline assessed by TUG at follow-up.

265 A PHYSIOTHERAPY-LED TRANSITION TO HOME INTERVENTION FOR OLDER ADULTS FOLLOWING EMERGENCY DEPARTMENT DISCHARGE: A PILOT FEASIBILITY RANDOMISED-CONTROLLED TRIAL

Background

Older adults frequently attend the Emergency Department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. A presentation to an ED can be viewed as an opportunity to assess those at risk of adverse outcomes and initiate a care plan in those deemed as ‘high risk'. Our aim was to evaluate the feasibility of a physiotherapy led integrated care intervention for older adults discharged from the ED (ED-PLUS).

Methods

Older adults presenting to the ED with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED-PLUS (Trial registration: NCT04983602). ED-PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient’s own home. Feasibility (recruitment and retention rates) and acceptability of the programme were assessed quantitatively and qualitatively. Functional decline was examined post-intervention using the Barthel Index. All outcomes were assessed by a research nurse blinded to group allocation.

Results

29 participants were recruited, indicating 97% of our recruitment target. 90% of participants completed the ED-PLUS intervention. All participants expressed positive feedback about the intervention. The incidence of functional decline at 6 weeks was 10% in the ED-PLUS group versus 70-89% in the usual care and CGA-only groups.

Conclusion

High adherence and retention rates were observed among participants and preliminary findings indicate a lower incidence of functional decline in the ED-PLUS group. Recruitment challenges existed in the context of COVID-19. Data collection is ongoing for six-month outcomes.

Establishing Covid-19 Research in UK Care Homes – Infrastructure Challenges for Trial Design

Background

The Covid-19 pandemic brought into sharp relief the role that long-term care facilities play in health and social care of an aging population. It also cast a spotlight upon the need for high-quality research to assess the effectiveness of any care home interventions. The Prophylactic Therapies in Care Homes (PROTECT-CH) trial was one such study (funded by the UK National Institute for Health and Care Research). PROTECT-CH was designed to collect data in 200 care homes (approximately 6,400 residents), and whilst the changing epidemiology of Covid-19 in the UK (due to vaccination take-up) made this unfeasible other insights were gained about establishing large-scale research in care homes.

Methods

An iterative process evaluation of the set-up phase of a large, platform trial testing prophylactic measures in long-term care facilities. Including a documentary review of the PROTECT-CH working groups and an online survey of working group members.

Results

Documents were reviewed from 24 working groups, which in a hub and spoke model represented the PROTECT-CH trial infrastructure; representative of 20 of these groups completed an online survey about their organisation and working. Data demonstrated the number and organisation of individuals required to set up a large-scale care-home trial - 91 individuals representing a mix of academic, clinical, and methodological contributions from 25 organisations. Data demonstrated working groups specific to care home research, and activities designed to address the specific challenges of researching in care homes. PROTECT-CH produced dedicated training materials and reporting templates for care home research. PROTECT-CH established novel mechanisms for prescribing and clinical oversight in care home research.

Conclusions

PROTECT-CH has highlighted the complexity of establishing large, scale RCT research in long-term care facilities. It has produced resources which might be of use in subsequent care home research.

Key messages

• Infrastructure is required to support high quality research in long-term care facilities.

• RCTs in long-term care facilities pose specific challenged to researchers.

Predicting falls in older adults: an umbrella review of instruments assessing gait, balance, and functional mobility

Background

To review the validated instruments that assess gait, balance, and functional mobility to predict falls in older adults across different settings.

Methods

Umbrella review of narrative- and systematic reviews with or without meta-analyses of all study types. Reviews that focused on older adults in any settings and included validated instruments assessing gait, balance, and functional mobility were included. Medical and allied health professional databases (MEDLINE, PsychINFO, Embase, and Cochrane) were searched from inception to April 2022. Two reviewers undertook title, abstract, and full text screening independently. Review quality was assessed through the Risk of Bias Assessment Tool for Systematic Reviews (ROBIS). Data extraction was completed in duplicate using a standardised spreadsheet and a narrative synthesis presented for each assessment tool.

Results

Among 2736 articles initially identified, 31 reviews were included; 11 were meta-analyses. Reviews were primarily of low quality, thus at high risk of potential bias. The most frequently reported assessments were: Timed Up and Go, Berg Balance Scale, gait speed, dual task assessments, single leg stance, functional Reach Test, tandem gait and stance and the chair stand test. Findings on the predictive ability of these tests were inconsistent across the reviews.

Conclusions

In conclusion, we found that no single gait, balance or functional mobility assessment in isolation can be used to predict fall risk in older adults with high certainty. Moderate evidence suggests gait speed can be useful in predicting falls and might be included as part of a comprehensive evaluation for older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03271-5.

941 EFFECTIVENESS OF ACUTE GERIATRIC UNIT CARE AMONG HOSPITALISED OLDER ADULTS WITH ACUTE MEDICAL COMPLAINTS: A META-ANALYSIS

Introduction

Older adults are clinically heterogeneous and are at increased risk of adverse outcomes during hospitalisation due to the presence of multiple comorbid and complex conditions. This systematic review and meta-analysis aims to update and synthesise the totality of research evidence on the effectiveness of acute geriatric unit (AGU) care for older adults admitted to hospital with acute medical complaints.

Method

MEDLINE, CINAHL, CENTRAL, and Embase databases were systematically searched from 2008 to February 2021. Screening, data extraction, and quality grading were undertaken by two reviewers. Only trials with a randomised design comparing AGU care and conventional care units were included. Meta-analyses were performed in Review Manager 5.4 and the Grading of Recommendations, Assessment, Development and Evaluations framework was used to assess the certainty of evidence for outcomes reported. The primary outcome measure was incidence of functional decline between baseline two-week prehospital admission status and discharge and at follow-up.

Results

11 trials recruiting 7,496 participants across three countries were included. AGU care was associated with a 23% reduction in functional decline at six-month follow-up (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.64–0.92; moderate certainty evidence), and significant cost savings (mean difference (MD) -538.01USD, 95% CI -571.05USD—-504.96USD; low certainty evidence). No differences were found in functional decline at hospital discharge or at three-month follow-up, length of hospital stay, the likelihood of living at home, mortality, hospital readmission, cognitive function, or patient satisfaction with the index admission.

Conclusion

AGU care improves clinical and process outcomes for older adults admitted to hospital with acute medical complaints. Future research should focus on greater inclusion of clinical and patient reported outcome measures including quality of life. Use of such measures may lead to a greater focus on patient-centered care and service provision priorities.

1075 THE EFFECTIVENESS OF INTERVENTIONS TO REDUCE ADVERSE OUTCOMES AMONG OLDER ADULTS FOLLOWING EMERGENCY DEPARTMENT DISCHARGE

Background

Population ageing is increasing rapidly worldwide. Older adults are frequent users of health care services including the Emergency Department (ED) and experience a number of adverse outcomes following an ED visit. Adverse outcomes include functional decline, unplanned hospital admission and an ED revisit. Given these adverse outcomes a number of interventions have been examined to improve the outcomes of older adults. The aim of this umbrella review was to evaluate the effectiveness of ED interventions in reducing adverse outcomes in older adults discharged from the ED.

Method

Systematic reviews of randomised controlled trials investigating ED interventions for older adults presenting to the ED exploring clinical, patient experience and healthcare utilisation outcomes were included. A comprehensive search strategy was employed in eleven databases and grey literature was searched. Quality was assessed using the A MeaSurement Tool to Assess Systematic Reviews 2 tool. Overlap between systematic reviews was assessed and an algorithm to assign the Grading of Recommendations Assessment, Development and Evaluation to assess the strength of evidence was applied to outcomes.

Results

Nine systematic reviews including 29 randomised controlled trials were included. Interventions comprised of solely ED-based or transitional interventions. The specific interventions delivered were highly variable. There was high overlap and low methodological quality of the trials informing the systematic reviews. There is low quality evidence to support ED interventions in reducing functional decline, improving patient experience and improving quality of life. The quality of evidence of the effectiveness of ED interventions to reduce mortality and ED revisits varied from very low to moderate.

Conclusion

Older adults are the most important emerging group in healthcare for several economic, social and political reasons. The evidence for the effectiveness of ED interventions for older adults is limited. Higher quality intervention studies in line with current geriatric medicine research guidelines are recommended.

1030 EXPERIENCES OF EARLY SUPPORTED DISCHARGE SERVICES FOLLOWING A STROKE: A QUALITATIVE EVIDENCE SYNTHESIS

Background

Early supported discharge (ESD) facilitates people with a stroke to be discharged from the hospital environment earlier than conventional care to continue their rehabilitation within the home with a multi-disciplinary team. Known benefits of ESD from Randomised Controlled Trials conducted include reducing the length of a hospital stay, long term dependency, and cost savings. There is limited qualitative evidence available on ESD. This systematic review and qualitative synthesis explored the experiences of those involved in ESD including people with stroke, family members, caregivers as well as healthcare professionals.

Method

A literature search was completed in 11 databases which generated 3,425 articles. Qualitative or mixed

Method

studies that included qualitative data on the experiences of people with stroke, family members, caregivers and healthcare professionals of an ESD service were included. The Critical Appraisal Skills Programme checklist was used to appraise the methodological quality of the papers. The findings were synthesised using the three step process for thematic synthesis.

Results

A total of fourteen studies were included with the methodological quality of the studies deemed good overall. Four key themes emerged: 1) ESD is experienced by people with stroke as a goal-focused and supportive process leading to positive outcomes, 2) ESD eases the transition from the hospital to the home environment but the transition from ESD to social and community services is often problematic, 3) Organisational, logistical and inter-professional factors are critical to the success of ESD and 4) The home environment enhances rehabilitation.

Conclusion

The findings of this qualitative evidence synthesis highlight the importance of the home environment in the rehabilitation process post stroke. Key practice implications point to the need for increased attention to periods where care transitions occur from ESD to community services.

Burden of stroke incidence among atrial fibrillation, valvular heart disease and coronary heart disease patients

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Health and Medical Research Council of Australia

Background

The public health burden of stroke has continued to increase in recent decades. In patients with cardiac disease, the risk of stroke is 2-4 times higher than in the general population, and therefore investigating stroke incidence in these patients is important for identifying opportunities for stroke prevention.

Purpose

We aimed to measure the incidence of stroke in people with atrial fibrillation (AF), valvular heart disease (VHD) or coronary heart disease (CHD) to assess the risk of stroke by age, sex, pre-existing vs new cardiac disease, and nonfatal/fatal status.

Methods

We used a person-linked hospitalisation/mortality dataset to identify all people hospitalized with AF, VHD or CHD from 1985 to 2017 in a whole-population setting. These cardiac cases were stratified as pre-existing (hospitalised between 1985 and 2012, who were alive at 31st October 2012 with no history of stroke) or new (first-ever cardiac hospitalisation from November 1st, 2012 to October 31st, 2017, with no prior hospitalisation for AF, VHD or CHD, and no history of stroke). Patients aged 20-94 years were included in the study. Pre-existing and new cardiac cases were followed over the 5-year study period (1st November 2012 to 31st December 2017) to identify first-ever stroke events. Age-specific and age-standardised rates (ASR) for stroke incidence were calculated for all cardiac cases combined, and separately for pre-existing and new cases.

Results

The cohort comprised 175,560 patients. The majority of the cohort had a single cardiac condition (55.7% CHD; 23.0% AF; 5.0% VHD), while 16.3% of patients had multiple cardiac conditions. There were 5,871 (3.3%) first-ever strokes (5.2% in AF patients, 4.0% in VHD, 2.8% in CHD). Stroke incidence ASRs were greater in women than men across each cardiac group and irrespective of the presence of single or multiple cardiac conditions (Figure). This was largely driven by women aged ≥75 years, with stroke incidence being greater in women than men in each cardiac group. In women aged 20-54 years, there was a 4.9-fold higher incidence of stroke in those with multiple versus single cardiac conditions, and this differential appeared to decline with increasing age (Figure). Incidence of non-fatal strokes was greater than fatal stroke in all age groups except among 85-94 year olds. Incidence rates in each cardiac group were between 1.2 and 2.4 times higher in those with new versus pre-existing cardiac disease.

Conclusions

Stroke incidence is substantial in patients with cardiac disease. Older women with AF and VHD had the highest stroke rates overall, although younger patients with multiple cardiac conditions were also at high risk. These cardiac patients should be targeted for evidence-based management to minimise their stroke risk, especially in the period immediately following diagnosis when risk is highest.

Figure Legend. Age-specific and age-standardised stroke incidence rates in all cardiac cases.

Overground gait kinematics and muscle activation patterns in the Yucatan mini pig

Objective The objectives of this study were to assess gait biomechanics and the effect of overground walking speed on gait parameters, kinematics, and electromyographic (EMG) activity in the hindlimb muscles of Yucatan Minipigs (YMPs). Approach Nine neurologically-intact, adult YMPs were trained to walk overground in a straight line. Whole-body kinematics and EMG activity of hindlimb muscles were recorded and analyzed at 6 different speed ranges (0.4-0.59, 0.6-0.79, 0.8-0.99, 1.0-1.19, 1.2-1.39, and 1.4-1.6 m/s). A MATLAB program was developed to detect strides and gait events automatically from motion-captured data. The kinematics and EMG activity were analyzed for each stride based on the detected events. Main results Significant decreases in stride duration, stance and swing times and an increase in stride length were observed with increasing speed. A transition in gait pattern occurred at the 1.0m/s walking speed. Significant increases in the range of motion of the knee and ankle joints were observed at higher speeds. Also, the points of minimum and maximum joint angles occurred earlier in the gait cycle as the walking speed increased. The onset of EMG activity in the biceps femoris muscle occurred significantly earlier in the gait cycle with increasing speed. Significance YMPs are becoming frequently used as large animal models for preclinical testing and translation of novel interventions to humans. A comprehensive characterization of overground walking in neurologically-intact YMPs is provided in this study. These normative measures set the basis against which the effects of future interventions on locomotor capacity in YMPs can be compared.

Nursing practicum equity for a changing nurse student demographic: a qualitative study

Background

The nursing practicum (clinical practice) is an essential but often highly stressful aspect of the nursing degree. A review of the published literature reveals a strong focus on the stressors that originate within the practicum environment, rather than the student’s life outside the university and practice setting. This article reports on an Australian study, completed before the COVID-19 pandemic, of the university experiences of undergraduate women nurse students with family responsibilities. The findings reveal the importance of factors outside the university on the women students’ practicum experience and their ability to engage and achieve.

Methods

The study was qualitative, guided by Gadamer’s hermeneutic philosophy. Twenty-nine women students with family responsibilities (partners and children) were interviewed at two stages of their degree journey. Over 50 h of data were thematically analysed.

Findings

The themes ‘family pressure’ and ‘practicum poverty’ describe the impact of domestic work, family finances and practicum organisation on student stress, wellbeing, achievement, thoughts of attrition, and family tension. These findings are particularly pertinent to Australia and other developed nations where the nurse student demographic continues to age. An interpretation of these findings against the recent impact of COVID-19 on nurse education and women’s life choices reveals the likelihood that these difficulties have intensified for women students with family responsibilities since the pandemic began.

Conclusions and Recommendations

Many developed nations, including Australia, are increasingly reliant on older women nurse students to maintain the future graduate nursing workforce. This change in nurse student demographic to the mature-age student requires a revision of the organisation of the nursing practicum. Recommendations to nurse education to improve practicum accessibility for women students who have family responsibilities include the application of a flexible and collaborative approach to practicum organisation and communication. Wider recommendations to Government include a revision of the way the nursing student is financially supported during the practicum. Further research that explores the practicum experience for women nurse students during and following the COVID-19 pandemic is also recommended.

24 EXPERIENCES OF EARLY SUPPORTED DISCHARGE SERVICES FOLLOWING A STROKE: A QUALITATIVE EVIDENCE SYNTHESIS

Background

Early supported discharge (ESD) facilitates people with a stroke to be discharged from the hospital environment earlier than conventional care to continue their rehabilitation within the home with a multi-disciplinary team. From Randomised Controlled Trials, benefits of ESD include reducing long term dependency, the length of hospital stay and cost savings. This systematic review and qualitative synthesis explores the experiences of those involved in ESD including people with stroke, family members, caregivers as well as the healthcare professionals.

Methods

A literature search was completed in 11 databases which generated 3,425 articles. Qualitative or mixed methods studies that included qualitative data on the experiences of people with stroke, family members, caregivers and healthcare professionals of an ESD service were included. Methodological quality was appraised using the Critical Appraisal Skills Programme checklist. Findings were synthesised using thematic synthesis.

Results

A total of fourteen studies were identified. The methodological quality of the studies was good overall. Four key themes emerged: 1) ESD is experienced by people with stroke as a goal-focused and supportive process leading to positive outcomes, 2) ESD eases the transition from the hospital to the home environment but the transition from ESD to social and community services is often problematic, 3) Organisational, logistical and inter-professional factors are critical to the success of ESD and 4) The home environment enhances rehabilitation.

Conclusion

Our findings highlight the importance of home in the rehabilitation process post stroke. Key practice implications point to the need for increased attention to periods where care transitions occur.

Tumor detection with transoral use of flexible endoscopy for unknown primary head and neck cancer

OBJECTIVES

With the advent of new optical technologies, early pharyngolaryngeal cancerous lesions can be better visualized. Although the conventional transnasal approach offers great views of the hypopharynx and larynx, the visualization of the oropharynx and palatine tonsils is limited. Through the transoral insertion of a flexible video-laryngoscope, direct views of the oropharynx and oral cavity can be obtained. Thus, transoral examination may contribute to primary detection of cancers of unknown primary (CUP).

METHODS

Eighty-five CUP patients from Tokai University were included retrospectively in this study, from 2006 to 2017. Starting in 2010, we employed the transoral examination in addition to our conventional method. The primary detection rates were compared before and after 2010. Oropharyngeal primaries were further analyzed for tumor subsite and p16 status.

RESULTS

The overall primary detection rate did not improve with the addition of transoral examination. However, greater numbers of oropharyngeal primaries were detected. The oropharyngeal lesions detected by transoral examination were mainly p16 positive, located on the palatine tonsil.

CONCLUSION

Transoral examination is a noninvasive, easy method to adopt in an outpatient setting, and a promising technique to improve tumor detection in this era of human papillomavirus-associated head and neck cancers.

LEVEL OF EVIDENCE

3.

Optimal care for the management of older people non-weight bearing after lower limb fracture: a consensus study

Background

Older people who are non-weight-bearing after a lower limb fracture are at risk of poor outcomes but there are no clinical guidelines for this group of patients. Given the paucity of the research evidence base, we conducted a consensus exercise to ascertain expert opinion about the management of this group.

Methods

A three-round e-Delphi technique was planned to use the online JISC survey tool with a multidisciplinary panel of health professionals. Panellists were invited by email via professional organisations and UK NHS Trusts. The initial statements for this study were prepared by the authors based upon the findings of their scoping review. Consensus required >/= 70% agreement with statements.

Results

Only 2 survey rounds were required. Ninety panellists, representing seven clinical disciplines, reached consensus for 24 statements about general issues (osteoporosis detection and management, falls risk reduction and nutrition) and specific non-weight bearing issues (such as the need for activity to be promoted during this period).

Conclusions

These findings can be used in the generation of a clinical guideline for this group of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02265-z.

Seroprevalence of SARS-CoV-2 antibodies, associated epidemiological factors and antibody kinetics among healthcare workers in Connecticut

BACKGROUND

Healthcare workers (HCWs) are at the front line of the ongoing coronavirus 2019 (COVID-19) pandemic. Comprehensive evaluation of the seroprevalence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) among HCWs in a large healthcare system could help to identify the impact of epidemiological factors and the presence of symptoms on the immune response to the infection over time.

AIM

To determine the seroprevalence of SARS-CoV-2-specific antibodies among HCWs, identify associated epidemiological factors and study antibody kinetics.

METHODS

A longitudinal evaluation of the seroprevalence and epidemiology of SARS-CoV-2-specific antibodies was undertaken in approximately 30,000 HCWs in the largest healthcare system in Connecticut, USA.

FINDINGS

At baseline, the prevalence of SARS-CoV-2 antibody among 6863 HCWs was 6.3% [95% confidence interval (CI) 5.7-6.9%], and was highest among patient care support (16.7%), medical assistants (9.1%) and nurses (8.2%), and lower for physicians (3.8%) and advanced practice providers (4.5%). Seroprevalence was significantly higher among African Americans [odds ratio (OR) 3.26 compared with Caucasians, 95% CI 1.77-5.99], in participants with at least one symptom of COVID-19 (OR 3.00, 95% CI 1.92-4.68), and in those reporting prior quarantine (OR 3.83, 95% CI 2.57-5.70). No symptoms were reported in 24% of seropositive participants. Among the 47% of participants who returned for a follow-up serological test, the seroreversion rate was 39.5% and the seroconversion rate was 2.2%. The incidence of re-infection in the seropositive group was zero.

CONCLUSION

Although there is a decline in the immunoglobulin G antibody signal over time, 60.5% of seropositive HCWs had maintained their seroconversion status after a median of 5.5 months.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Contamination in complex healthcare trials: the falls in care homes (FinCH) study experience

Background

Trials are at risk of contamination bias which can occur when participants in the control group are inadvertently exposed to the intervention. This is a particular risk in rehabilitation studies where it is easy for trial interventions to be either intentionally or inadvertently adopted in control settings. The Falls in Care Homes (FinCH) trial is used in this paper as an example of a large randomised controlled trial of a complex intervention to explore the potential risks of contamination bias. We outline the FinCH trial design, present the potential risks from contamination bias, and the strategies used in the design of the trial to minimise or mitigate against this. The FinCH trial was a multi-centre randomised controlled trial, with embedded process evaluation, which evaluated whether systematic training in the use of the Guide to Action Tool for Care Homes reduced falls in care home residents.

Data were collected from a number of sources to explore contamination in the FinCH trial. Where specific procedures were adopted to reduce risk of, or mitigate against, contamination, this was recorded. Data were collected from study e-mails, meetings with clinicians, research assistant and clinician network communications, and an embedded process evaluation in six intervention care homes.

During the FinCH trial, there were six new falls prevention initiatives implemented outside the study which could have contaminated our intervention and findings. Methods used to minimise contamination were: cluster randomisation at the level of care home; engagement with the clinical community to highlight the risks of early adoption; establishing local collaborators in each site familiar with the local context; signing agreements with NHS falls specialists that they would maintain confidentiality regarding details of the intervention; opening additional research sites; and by raising awareness about the importance of contamination in research among participants.

Conclusion

Complex rehabilitation trials are at risk of contamination bias. The potential for contamination bias in studies can be minimized by strengthening collaboration and dialogue with the clinical community. Researchers should recognise that clinicians may contaminate a study through lack of research expertise.

Effect of anesthesia on motor responses evoked by spinal neural prostheses during intraoperative procedures

OBJECTIVE

The overall goal of this study was to investigate the effects of various anesthetic protocols on the intraoperative responses to intraspinal microstimulation (ISMS). ISMS is a neuroprosthetic approach that targets the motor networks in the ventral horns of the spinal cord to restore function after spinal cord injury. In preclinical studies, ISMS in the lumbosacral enlargement produced standing and walking by activating networks controlling the hindlimb muscles. ISMS implants are placed surgically under anesthesia, and refinements in placement are made based on the evoked responses. Anesthesia can have a significant effect on the responses evoked by spinal neuroprostheses; therefore, in preparation for clinical testing of ISMS, we compared the evoked responses under a common clinical neurosurgical anesthetic protocol with those evoked under protocols commonly used in preclinical studies.

APPROACH

Experiments were conducted in seven pigs. An ISMS microelectrode array was implanted in the lumbar enlargement and responses to ISMS were measured under three anesthetic protocols: (1) isoflurane, an agent used pre-clinically and clinically, (2) total intravenous anesthesia (TIVA) with propofol as the main agent commonly used in clinical neurosurgical procedures, (3) TIVA with sodium pentobarbital, an anesthetic agent used mostly preclinically. Responses to ISMS were evaluated based on stimulation thresholds, movement kinematics, and joint torques. Motor evoked potentials (MEP) and plasma concentrations of propofol were also measured.

MAIN RESULTS

ISMS under propofol anesthesia produced large and functional responses that were not statistically different from those produced under pentobarbital anesthesia. Isoflurane, however, significantly suppressed the ISMS-evoked responses.

SIGNIFICANCE

This study demonstrated that the choice of anesthesia is critical for intraoperative assessments of motor responses evoked by spinal neuroprostheses. Propofol and pentobarbital anesthesia did not overly suppress the effects of ISMS; therefore, propofol is expected to be a suitable anesthetic agent for clinical intraoperative testing of an intraspinal neuroprosthetic system.

Abstract P6-18-18: Phase I trial of eribulin and everolimus in patients with metastatic triple negative breast cancer

Background: Alteration of PI3K/Akt/mTOR pathway is the most common genomic abnormality detected in triple negative breast cancer (TNBC). Everolimus acts synergistically with eribulin in inducing apoptosis in TNBC cell lines and xenografts in our preclinical study. This phase I trial was designed to test the safety and tolerability of combining eribulin and everolimus in patients (pts) with metastatic TNBC.

Methods: The overall objective of this study was to describe the safety and toxicities of the combination. The secondary objective was to assess activity based on response rate (RR) and progression free survival (PFS). Eligibility criteria included pts with metastatic TNBC, ECOG 0-2, 0-3 lines of prior chemotherapy in metastatic setting, and prior treatment with anthracycline and/or taxane therapy. The study utilized the toxicity equivalence range (TEQR) design with a target equivalence range for dose-limiting toxicities (DLTs) of 0.20-0.35. The recommended phase 2 dose (RP2D) will be the dose closest to the target of 0.25 below 0.51 based on isotonic regression.Three dosing levels of the combinations were tested: level A1 (everolimus 5mg daily; eribulin 1.4 mg/m2 days 1, 8 every 3 weeks), level A2 (everolimus 7.5mg daily; eribulin 1.4 mg/m2, days 1, 8 every 3 weeks), level B1(everolimus 5mg daily; eribulin 1.1 mg/m2 days 1, 8 every 3 weeks). Nanostring RNA analysis and genomic mutation analysis were conducted in 16 pts with available tumor tissue.

Results: A total of 27 pts were enrolled. Median age was 55 years (range 36-76). Two pts were ineligible due to HER2+ on repeat biopsy and were only included in the toxicity analysis. Dose level B1 (everolimus 5mg daily and eribulin 1.1 mg/m2 days 1, 8 every 3 weeks) was determined to be the RP2D doses. The DLTs were neutropenia, stomatitis and hyperglycemia. Across all cycles, 59% (16/27) had a ≥ Gr3 toxicity attributed to treatment at the possible or above level. 44% (12/27) had Gr3 heme-toxicities. The most common toxicities were ≥ Gr3 neutropenia (10 pts), Gr3 lymphopenia (6 pts) and ≥ Gr3 leukopenia (7 pts). 33% (9/27) had Gr3 non-heme toxicities. The most common were Gr3 stomatitis (3 pts), Gr3 hyperglycemia (3 pts) and Gr3 fatigue (5 pts). The median number of cycles completed was 4 (0-8). 68% (17/25) had a dose modification or hold, 14 of 25 (56%) were for eribulin and 15 of 25 (60%) were for everolimus. Of 25 eligible pts, 8 (32%) achieved a best response as partial response, 11 (44%) had stable disease and 6 (24%) had progression. 80% (20/25) experienced progression by RECIST or showed clinical progression, and the median time to progression was 2.7 mo (95% CI (2.2, 4.6)). At the time of this analysis, 16 participants had died, median OS was 6.3 mo (95% CI (5.3, undefined)). Two pts are still being followed on treatment. PI3K-Akt-mTOR pathway genes and mutations profiles were studied.

Conclusion: Eribulin 1.1 mg/m2 days 1, 8 and everolimus 5mg daily was defined as the RP2D. Genomic analysis is currently underway to understand the molecular mechanisms of resistance.

Citation Format: Yuan Y, Yost S, Blanchard S, Yin H, Li M, Robinson K, Tang A, Martinez N, Leong L, Somlo G, Tank Patel N, Waisman J, Portnow J, Hurria A, Luu T-H, Mortimer J. Phase I trial of eribulin and everolimus in patients with metastatic triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-18.

Ultrasound-guided spinal stereotactic system for intraspinal implants

OBJECTIVE

The overall goal of this study was to develop an image-guided spinal stereotactic setup for intraoperative intraspinal microstimulation (ISMS). System requirements were as follows: 1) ability to place implants in various segments of the spinal cord, targeting the gray matter with a < 0.5-mm error; 2) modularity; and 3) compatibility with standard surgical tools.

METHODS

A spine-mounted stereotactic system was developed, optimized, and tested in pigs. The system consists of a platform supporting a micromanipulator with 6 degrees of freedom. It is modular and flexible in design and can be applied to various regions of the spine. An intraoperative ultrasound imaging technique was also developed and assessed for guidance of electrode alignment prior to and after electrode insertion into the spinal cord. Performance of the ultrasound-guided stereotactic system was assessed both in pigs (1 live and 6 fresh cadaveric pigs) and on the bench using four gelatin-based surrogate spinal cords. Pig experiments were conducted to evaluate the performance of ultrasound imaging in aligning the electrode trajectory using three techniques and under two conditions. Benchtop experiments were performed to assess the performance of ultrasound-guided targeting more directly. These experiments were used to quantify the accuracy of electrode alignment as well as assess the accuracy of the implantation depth and the error in spatial targeting within the gray matter of the spinal cord. As proof of concept, an intraoperative ISMS experiment was also conducted in an additional live pig using the stereotactic system, and the resulting movements and electromyographic responses were recorded.

RESULTS

The stereotactic system was quick to set up (< 10 minutes) and provided sufficient stability and range of motion to reach the ISMS targets reliably in the pigs. Transverse ultrasound images with the probe angled at 25°–45° provided acceptable contrast between the gray and white matter of the spinal cord. In pigs, the largest electrode alignment error using ultrasound guidance, relative to the minor axis of the spinal cord, was ≤ 3.57° (upper bound of the 95% confidence interval). The targeting error with ultrasound guidance in bench testing for targets 4 mm deep into the surrogate spinal cords was 0.2 ± 0.02 mm (mean ± standard deviation).

CONCLUSIONS

The authors developed and evaluated an ultrasound-guided spinal stereotactic system for precise insertion of intraspinal implants. The system is compatible with existing spinal instrumentation. Intraoperative ultrasound imaging of the spinal cord aids in alignment of the implants before insertion and provides feedback during and after implantation. The ability of ultrasound imaging to distinguish between spinal cord gray and white matter also improves confidence in the localization of targets within the gray matter. This system would be suitable for accurate guidance of intraspinal electrodes and drug or cell injections.

Creation of Secondary AV Fistulas from Failed Hemodialysis Grafts: The Role of Routine Vein Mapping

Pre-existing forearm grafts lead to dilatation of upper arm veins of the ipsilateral arm that greatly facilitates the creation of secondary arteriovenous fistulas (AVF). In this retrospective review of 18 patients, the routine and periodical revision of failed grafts were discontinued. Vein mapping by physical examination or Duplex studies was performed prior to graft failure and a secondary AVF was created when the graft failed. Using this management strategy, an AVF creation success rate of 95% was achieved despite high incidence of co-morbidity factors within the patient population. This success rate demonstrates the value of vein selection by vascular mapping prior to graft failure and early vascular access planning in the successful creation of secondary AVF.