Chagas disease deaths detected among garbage codes registered in mortality statistics in Brazil: a study from the buRden of ChAgas dISEase in the contemporary world (RAISE) project

OBJECTIVES

The objective of this study was to identify Brazil's most critical garbage codes (GCs) reclassified to Chagas disease (ChD) in mortality data and their proportions. We also estimated the potential impact of misclassification on the number of deaths attributed to ChD.

STUDY DESIGN

Population-based descriptive study.

METHODS

We used the Mortality Information System (SIM; in Portuguese) data before and after routine GC investigation in 2015-2019 to evaluate ChD deaths detected among them. We identified priority GCs, which contributed more than 0.1 % to the percentage of total ChD deaths registered. Spearman's correlation was used to evaluate the association between the reclassification of priority GCs and ChD prevalence. Then, we applied the GC correction factors to estimate the number of deaths attributed to ChD.

RESULTS

22,154 deaths were reported as ChD in the study period. Among them, 1004 deaths originally listed as priority GCs were deaths reclassified to ChD after an investigation in the SIM final database. Unspecific cardiomyopathy (10.2 %), unspecific heart diseases (4.7 %), and heart failure (2.8 %) were GCs with the highest proportions of reclassification to ChD in Brazil. Higher ChD prevalence at the state level was associated with a higher proportion of GC deaths reclassified as ChD. When applying correction factors identified after investigation, we estimated an increase of 26.4 % in registered ChD deaths, mostly in states with higher endemicity.

CONCLUSIONS

GCs might conceal deaths due to ChD, particularly in Brazil's states with higher endemicity. The approach suggested in this study may offer an alternative method for estimating ChD-related deaths in endemic countries.

1234 IMPROVING HEART FAILURE MANAGEMENT WITHIN HOSPITAL AT HOME

Introduction

Heart failure (HF) is a common problem managed in our West Lothian multi-disciplinary hospital at home (HaH) service, however significant variation in practice was noted with considerable resource implications. We aimed to standardise and improve this by developing a dedicated protocol.

Methods

We developed a protocol to guide the assessment and management of HF within HaH. We collected baseline (n=25) and follow-up data (n=10) after protocol introduction from patients referred to HaH with heart failure. Outcomes reviewed included anticipatory care planning (ACP) decisions, length of stay (LOS) and treatment strategy. We held staff education sessions and surveyed staff confidence regarding HF management.

Results

ACP discussion rates improved after protocol introduction, with decision rates improving for both escalation of care (28% to 80%) and resuscitation (44% to 60%). LOS reduced after protocol introduction (mean 6.3 days to 5.9 days). Titration of oral diuretics alone (71%) was associated with a shorter LOS (mean 5.4 days) compared to IV (29%, mean 8.1 days), with no difference in 28 day outcome. In those with HF with reduced ejection fraction, the rates of beta-blocker prescription increased (57% to 80%) however ACE-inhibitor prescription decreased (29% to 20%). Use of add-on therapy (e.g. thiazide diuretics) increased (12% to 30%) with a decrease in complication rates (12% to 0%). All staff found the protocol helpful with an improvement in confidence levels.

Conclusions

Through introducing a standardised protocol, we observed an improvement in anticipatory care discussion rates and a trend towards shorter LOS. Oral diuretic titration was less resource intensive without an adverse impact on outcome. Future plans include ongoing education and data collection, trialling a joint multi-disciplinary meeting with cardiology for discussion of complex patients and embedding a treatment strategy of oral diuretic titration with a ‘discharge with planned review' approach in appropriate patients.

164 Standardised Anticipatory Care Planning in Care Homes Reduces Unscheduled Hospital Admissions

Background

Anticipatory care planning (ACP) is a proactive person-centred approach for “thinking ahead”, exploring and recording a person’s goals and preferred actions when their health deteriorates. As a key part of Comprehensive Geriatric Assessment of frail patients, care home (CH) residents would benefit from ACP.

Introduction

West Lothian has 16 care homes with 853 residents. Between Oct—Dec 2017, 5.21% of CH residents were admitted to hospital each month. Some of these admissions could have been avoided had there been robust ACP in place.

Methods

In 2017 West Lothian Health and Social Care Partnership appointed a GP lead for Care Homes. Through standardising ACP for CH residents, the goal was to improve the pathway for managing medical emergencies and reduce unnecessary unscheduled care calls and admissions. In 2019 this role was taken over by a team of 2WTE Advanced Nurse Practitioners and 1WTE Staff Nurse. Outcome measures include hospital admission rates, number of ACPs in place and uptake of ACP training amongst CH staff.

Interventions

In collaboration with the Medicine of the Elderly Department at St John’s Hospital, a standardised ACP Summary document was developed for use in all CHs. A medical advice and emergency flowchart was created to reduce unnecessary hospital admissions. An continuous education programme was delivered across all CH staff to facilitate and implement this.

Results

Medical admission rates from CHs have decreased by 60% from 6 to 2.2 admissions per week. The largest reduction is in CHs with full ACP use.

Conclusions

Standardised ACP significantly reduces the number of medical admissions. Continuous education and training is crucial in maintaining its implementation, and ensuring its routine use throughout CHs in West Lothian.

109 Improving Escalation and Treatment Plans in the Borders General Hospital (BGH) During COVID-19

Topic

Clear escalation and treatment plans created in discussion with patients are crucial to managing patients safely and appropriately. Our goal was to introduce a standardised, easily identifiable document for this purpose, with an aim of 90% of medical inpatients having a clear escalation plan discussed and documented.

Intervention

We developed a Treatment Escalation Plan (TEP), raised awareness via different platforms and delivered teaching for staff. For baseline and subsequent data collections following interventions, we reviewed the notes of twenty random medical inpatients for decisions regarding escalation, patient involvement in decision making including capacity and specific interventions considered. We also included time taken to find information; documented patient/family discussions and whether a TEP was present. We collected qualitative feedback from staff.

Improvement

After introduction, TEP was present in 35/60 patients (58%). Improvement was demonstrated across all measured domains when a TEP form was present: escalation decision (no TEP 80%, TEP 100%), discussion with patient/relative (no TEP 4%, TEP 85%), capacity decision regarding escalation (no TEP 52%, TEP 91%), decision on specific interventions (no TEP 12%, TEP 94%), mean time taken to find information (no TEP 84 seconds, TEP 34 seconds). Qualitative feedback from staff was positive, particularly the inclusion of specific care decisions beyond “DNACPR”.

Discussion

We felt it was critical to develop a TEP to ensure appropriate decisions are made and clearly documented for medical inpatients, especially in light of COVID-19. In patients with a TEP completed, we observed improvements in all domains, particularly in the involvement of patients/relatives in escalation decisions, which is key to delivering patient-centered care. Implementing a new system in a pandemic had challenges, such as continuity of staffing, however feedback was uniformly positive. This is an ongoing project that will continue to promote TEPs to improve patient care.

0038 The Effects of Morning Blue Light Therapy on Insomnia Severity and PTSD Symptoms in a Clinical Sample

Introduction

Individuals with Post Traumatic Stress Disorder (PTSD) often present with insomnia, which may exacerbate other symptoms of the disorder. Morning Blue Light Therapy (BLT) can regulate circadian rhythms and may even improve sleep and mood in individuals with major depressive disorder. However, it is unclear whether morning BLT could also be an effective treatment for the insomnia associated with PTSD. We investigated whether 6 weeks of daily morning BLT would improve insomnia severity and symptom presentation in individuals with PTSD in comparison to a placebo condition of amber light (ALT). We hypothesized that changes in insomnia severity would correlate with improvement in PSTD symptom severity.

Methods

Forty-one participants with a clinical diagnosis of PTSD were randomized to receive 6 weeks of either daily morning BLT (n=22) or ALT (n=19). Insomnia and PTSD symptom severity were evaluated at pre- and post-treatment using the Insomnia Severity Index (ISI) and the Clinician-Administered PTSD Scale (CAPS) for DSM-5, respectively.

Results

Both groups showed a significant decrease in their PTSD symptom severity (p<0.001) and insomnia severity (p<0.001) over the 6-week treatment period. However, improvement in insomnia severity significantly predicted improvements in PTSD symptom severity for the BLT group only (BLT: r =0.542, p=0.009; ALT: r=-0.095, p=0.699). The difference between the two correlation coefficients was significant (Z=-2.07, p=0.039).

Conclusion

The results suggest that morning BLT may be effective in improving PTSD symptoms by regulating the circadian rhythm and improving sleep. While ALT also led to improved PTSD symptom severity, it appears that those changes cannot be explained by improved sleep and may have other underlying mechanisms (e.g., placebo effect). Morning BLT may be a promising adjunctive method to bolster current treatment approaches for PTSD. Because of its ease of administration, it could be easily added to ongoing treatment as usual. This approach warrants further research.

Support

US Army Medical Research and Materiel Command: W81XWH-14-1-0570

0081 Habitual Sleep Duration is Negatively Correlated with Emotional Reactivity within the Rostral Anterior Cingulate Cortex in Individuals with PTSD

Introduction

Sleep difficulties, such as insomnia, are highly prevalent in individuals with Post-Traumatic Stress Disorder (PTSD). However, sleep deprivation can also increase emotional reactivity to positive (as well as negative) stimuli. While the effects of sleep loss on emotional perception healthy individuals has been documented, it remains unclear how lack of sleep in individuals with PTSD may affect their emotional reactivity to positive stimuli. We hypothesized that lower habitual sleep duration would be associated with greater functional brain activation changes in response to subliminally presented happy faces in brain areas of the reward network, such as the rostral anterior cingulate cortex (rACC).

Methods

Thirty-nine individuals with DSM-5 confirmed PTSD were administered the Pittsburgh Sleep Quality Index (PSQI) as a measure of their average nightly sleep duration over the past month. Participants then underwent fMRI imagining while viewing subliminal presentations of faces displaying happiness, using a backward masked facial affect paradigm to minimize conscious awareness of the expressed emotion. Brain activation to masked happy expressions was regressed against sleep duration in SPM12.

Results

There was a negative correlation between habitual sleep duration and activation within the rACC in response to the masked happy faces (x=14,y=40,z=0; k=102, pFWE-corr= 0.008).

Conclusion

Individuals with PTSD who average less sleep at night showed greater emotional reactivity, as indexed by greater functional brain activation changes within an area of the reward network, than individuals who obtained more sleep per night. Future research involving actual sleep duration manipulation will be necessary to determine whether this finding reflects the well-known antidepressant effect of sleep deprivation or a form of greater emotional expression error monitoring among traumatized patients when lacking sleep. Regardless, these findings suggest that insufficient sleep could affect unconsciously perceived emotion in faces and potentially affect social and emotional responses among individuals with PTSD.

Support

US Army Medical Research and Materiel Command: W81XWH-14-1-0570

Mortality differences and inequalities within and between 'protected characteristics' groups, in a Scottish Cohort 1991-2009

BACKGROUND

Little is known about the interaction between socio-economic status and 'protected characteristics' in Scotland. This study aimed to examine whether differences in mortality were moderated by interactions with social class or deprivation. The practical value was to pinpoint population groups for priority action on health inequality reduction and health improvement rather than a sole focus on the most deprived socioeconomic groups.

METHODS

We used data from the Scottish Longitudinal Study which captures a 5.3 % sample of Scotland and links the censuses of 1991, 2001 and 2011. Hazard ratios for mortality were estimated for those protected characteristics with sufficient deaths using Cox proportional hazards models and through the calculation of European age-standardised mortality rates. Inequality was measured by calculating the Relative Index of Inequality (RII).

RESULTS

The Asian population had a polarised distribution across deprivation deciles and was more likely to be in social class I and II. Those reporting disablement were more likely to live in deprived areas, as were those raised Roman Catholic, whilst those raised as Church of Scotland or as 'other Christian' were less likely to. Those aged 35-54 years were the least likely to live in deprived areas and were most likely to be in social class I and II. Males had higher mortality than females, and disabled people had higher mortality than non-disabled people, across all deprivation deciles and social classes. Asian males and females had generally lower mortality hazards than majority ethnic ('White') males and females although the estimates for Asian males and females were imprecise in some social classes and deprivation deciles. Males and females who reported their raised religion as Roman Catholic or reported 'No religion' had generally higher mortality than other groups, although the estimates for 'Other religion' and 'Other Christian' were less precise.Using both the area deprivation and social class distributions for the whole population, relative mortality inequalities were usually greater amongst those who did not report being disabled, Asians and females aged 35-44 years, males by age, and people aged <75 years. The RIIs for the raised religious groups were generally similar or too imprecise to comment on differences.

CONCLUSIONS

Mortality in Scotland is higher in the majority population, disabled people, males, those reporting being raised as Roman Catholics or with 'no religion' and lower in Asians, females and other religious groups. Relative inequalities in mortality were lower in disabled than nondisabled people, the majority population, females, and greatest in young adults. From the perspective of intersectionality theory, our results clearly demonstrate the importance of representing multiple identities in research on health inequalities.

Cloning and expression of the large zebrafish protocadherin gene, Fat

The cadherin superfamily members play an important role in mediating cell-cell contact and adhesion (Takeichi, M., 1991. Cadherin cell adhesion receptors as a morphogenetic regulator. Science 251, 1451-1455). A distinct subfamily, neither belonging to the classical or protocadherins includes Fat, the largest member of the cadherin super-family. Fat was originally identified in Drosophila. Subsequently, orthologues of Fat have been described in man (Dunne, J., Hanby, A. M., Poulsom, R., Jones, T. A., Sheer, D., Chin, W. G., Da, S. M., Zhao, Q., Beverley, P. C., Owen, M. J., 1995. Molecular cloning and tissue expression of FAT, the human homologue of the Drosophila fat gene that is located on chromosome 4q34-q35 and encodes a putative adhesion molecule. Genomics 30, 207-223), rat (Ponassi, M., Jacques, T. S., Ciani, L., ffrench, C. C., 1999. Expression of the rat homologue of the Drosophila fat tumour suppressor gene. Mech. Dev. 80, 207-212) and mouse (Cox, B., Hadjantonakis, A. K., Collins, J. E., Magee, A. I., 2000. Cloning and expression throughout mouse development of mfat1, a homologue of the Drosophila tumour suppressor gene fat [In Process Citation]. Dev. Dyn. 217, 233-240). In Drosophila, Fat has been shown to play an important role in both planar cell polarity and cell boundary formation during development. In this study we describe the characterization of zebrafish Fat, the first non-mammalian, vertebrate Fat homologue to be identified. The Fat protein has 64% amino acid identity and 80% similarity to human FAT and an identical domain structure to other vertebrate Fat proteins. During embryogenesis fat mRNA is expressed in the developing brain, specialised epithelial surfaces the notochord, ears, eyes and digestive tract, a pattern similar but distinct to that found in mammals.

The effects of deinstitutionalization on adults with learning disabilities

We compared a group of people with learning disabilities who have been deinstitutionalized with a control group remaining in an institution on measures of adaptive and maladaptive behaviour, community living skills, social skills, and quality of life. In general, there was no change over 30 months for the control group. Changes for the experimental group were either not seen or were generally modest in scale, and tended to occur within 6 months of moving, the measures staying relatively stable thereafter. Implications for detailed examination of the effects of deinstitutionalization were discussed.