A Pilot Randomized Controlled Trial of Augmented Reality Just-in-Time Guidance for the Performance of Rugged Field Procedures

INTRODUCTION

Medical resuscitations in rugged prehospital settings require emergency personnel to perform high-risk procedures in low-resource conditions. Just-in-Time Guidance (JITG) utilizing augmented reality (AR) guidance may be a solution. There is little literature on the utility of AR-mediated JITG tools for facilitating the performance of emergent field care.

STUDY OBJECTIVE

The objective of this study was to investigate the feasibility and efficacy of a novel AR-mediated JITG tool for emergency field procedures.

METHODS

Emergency medical technician-basic (EMT-B) and paramedic cohorts were randomized to either video training (control) or JITG-AR guidance (intervention) groups for performing bag-valve-mask (BVM) ventilation, intraosseous (IO) line placement, and needle-decompression (Needle-d) in a medium-fidelity simulation environment. For the interventional condition, subjects used an AR technology platform to perform the tasks. The primary outcome was participant task performance; the secondary outcomes were participant-reported acceptability. Participant task score, task time, and acceptability ratings were reported descriptively and compared between the control and intervention groups using chi-square analysis for binary variables and unpaired t-testing for continuous variables.

RESULTS

Sixty participants were enrolled (mean age 34.8 years; 72% male). In the EMT-B cohort, there was no difference in average task performance score between the control and JITG groups for the BVM and IO tasks; however, the control group had higher performance scores for the Needle-d task (mean score difference 22%; P = .01). In the paramedic cohort, there was no difference in performance scores between the control and JITG group for the BVM and Needle-d tasks, but the control group had higher task scores for the IO task (mean score difference 23%; P = .01). For all task and participant types, the control group performed tasks more quickly than in the JITG group. There was no difference in participant usability or usefulness ratings between the JITG or control conditions for any of the tasks, although paramedics reported they were less likely to use the JITG equipment again (mean difference 1.96 rating points; P = .02).

CONCLUSIONS

This study demonstrated preliminary evidence that AR-mediated guidance for emergency medical procedures is feasible and acceptable. These observations, coupled with AR's promise for real-time interaction and on-going technological advancements, suggest the potential for this modality in training and practice that justifies future investigation.

Rationale and Design of Healthy at Home for COPD: an Integrated Remote Patient Monitoring and Virtual Pulmonary Rehabilitation Pilot Study

Chronic Obstructive Pulmonary Disease (COPD) is a common, costly, and morbid condition. Pulmonary rehabilitation, close monitoring, and early intervention during acute exacerbations of symptoms represent a comprehensive approach to improve outcomes, but the optimal means of delivering these services is uncertain. Logistical, financial, and social barriers to providing healthcare through face-to-face encounters, paired with recent developments in technology, have stimulated interest in exploring alternative models of care. The Healthy at Home study seeks to determine the feasibility of a multimodal, digitally enhanced intervention provided to participants with COPD longitudinally over six months. This paper details the recruitment, methods, and analysis plan for the study, which is recruiting 100 participants in its pilot phase. Participants were provided with several integrated services including a smartwatch to track physiological data, a study app to track symptoms and study instruments, access to a mobile integrated health program for acute clinical needs, and a virtual comprehensive pulmonary support service. Participants shared physiologic, demographic, and symptom reports, electronic health records, and claims data with the study team, facilitating a better understanding of their symptoms and potential care needs longitudinally. The Healthy at Home study seeks to develop a comprehensive digital phenotype of COPD by tracking and responding to multiple indices of disease behavior and facilitating early and nuanced responses to changes in participants' health status. This study is registered at Clinicaltrials.gov (NCT06000696).

Factors Impacting the Implementation of Mobile Integrated Health Programs for the Acute Care of Older Adults

Objective: Emergency services utilization is increasing in older adult populations. Many such encounters may be preventable with better access to acute care in the community. Mobile integrated health (MIH) programs leverage mobile resources to deliver care and services to patients in the out-of-hospital environment and have the potential to improve clinical outcomes and decrease health care costs; however, they have not been widely implemented. We assessed barriers, potential facilitators, and other factors critical to the implementation of MIH programs with key vested partners.Methods: Professional and community-member partners were purposefully recruited to participate in recorded structured interviews. The study team used the Practical Robust Implementation and Sustainability Model (PRISM) framework to develop an interview guide and codebook. Coders employed a combination of deductive and inductive coding strategies to identify common themes across partner groups.Results: The study team interviewed 22 participants (mean age 56, 68% female). A cohort of professional subject matter experts included physicians, paramedics, public health personnel, and hospital administrators. A cohort of lay community partners included patients and caregivers. Coders identified three prominent themes that impact MIH implementation. First, MIH is disruptive to existing clinical workflows. Second, using MIH to improve patients' experience during acute care encounters is key to intervention adoption. Finally, legislative action is needed to augment central financial and regulatory policies to ensure the adoption of MIH programs.Conclusions: Common themes impacting the implementation of MIH programs were identified across vested partner groups. Multilevel strategies are needed to address patient adoption, clinical partners' workflow, and legislative policies to ensure the success of MIH programs.

A Pilot Trial of Continuous Glucose Monitoring Upon Emergency Department Discharge Among People With Diabetes Mellitus

OBJECTIVE

People with diabetes mellitus, particularly those with limited access to longitudinal care, frequently present to the emergency department (ED). Continuous glucose monitoring (CGM) has been shown to improve outcomes in ambulatory settings, so we hypothesized that it would be beneficial if initiated upon ED discharge.

METHODS

We randomized adults with diabetes who were seen in the ED for hypo- or hyperglycemia to either 14 days of flash CGM or care coordination alone. All participants were scheduled to follow up in our diabetes specialty clinic. Outcomes included clinic attendance, the 3-month change in hemoglobin A1c, and repeat ED utilization.

RESULTS

We recruited 30 participants, including 13 with newly diagnosed diabetes. All but one (97%) had type 2 diabetes. We found no significant difference between the CGM (n = 16) and control (n = 14) groups in terms of clinic attendance (75 vs 64%, P = .61) or repeat ED utilization (31 vs 50%, P = .35), although our power was low. The absolute reduction in A1c was greater in the CGM group (5.2 vs 2.4%, P = .08). Among newly diagnosed participants for whom we had data, 7 out of 7 in the CGM group had a follow-up A1c under 7% compared to 1 out of 3 in the control group (P = .03). Over 90% of patients and providers found the CGM useful.

CONCLUSIONS

Our data demonstrate the feasibility of starting CGM in the ED, a valuable setting for engaging difficult-to-reach patients. Our pilot study was limited by its small sample size, however, as recruitment in the ED can be challenging.

A mobile integrated health program for the management of undifferentiated acute complaints in older adults is safe and feasible

BACKGROUND

Poor care access and lack of proper triage of medical complaints leads to inappropriate use of acute care resources. Mobile integrated health (MIH) programs may offer a solution by providing adaptable on-demand care. There is little information describing programs that manage undifferentiated complaints in the community. The objective of this study was to assess the safety and feasibility of an MIH program that responds to the community to manage medical complaints in older adults.

METHODS

This was a prospective observational study examining a pilot MIH program. Seven ambulatory clinics and their affiliated patients aged 65 and older were oriented to the program and invited to use its services. Visit and follow-up data for all patients who underwent an MIH visit were abstracted, along with 30-day follow-up information. All demographic data and outcomes were reported descriptively.

RESULTS

In 21 months, 153 MIH visits were completed, involving 91 patients (mean age 81 years, 60.4% female). The most common chief complaints were generalized weakness (28.8%) and shortness of breath (18.9%). Electrocardiogram (57.5%) and point-of-care bloodwork (34.6%) were the most common diagnostic tests performed. Sixteen visits (10.4%) were followed by an emergency department (ED) visit within 72 h. In 11 encounters, the patient was referred to the ED; in five cases, the ED visit was unforeseen. Fifteen patients (9.8%) were admitted to the hospital after an MIH visit. There were two deaths within 30 days following an index visit.

CONCLUSIONS

An MIH program designed to address the acute complaints of community-dwelling older adults was feasible and safe, with low rates of unforeseen emergency services utilizations. MIH programs have valuable diagnostic and therapeutic capabilities and may serve to help triage the acute medical needs of patients. Further study is required to validate the efficacy and cost-effectiveness of MIH programs.

Performance of Rapid Antigen Tests to Detect Symptomatic and Asymptomatic SARS-CoV-2 Infection : A Prospective Cohort Study

BACKGROUND

The performance of rapid antigen tests (Ag-RDTs) for screening asymptomatic and symptomatic persons for SARS-CoV-2 is not well established.

OBJECTIVE

To evaluate the performance of Ag-RDTs for detection of SARS-CoV-2 among symptomatic and asymptomatic participants.

DESIGN

This prospective cohort study enrolled participants between October 2021 and January 2022. Participants completed Ag-RDTs and reverse transcriptase polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 every 48 hours for 15 days.

SETTING

Participants were enrolled digitally throughout the mainland United States. They self-collected anterior nasal swabs for Ag-RDTs and RT-PCR testing. Nasal swabs for RT-PCR were shipped to a central laboratory, whereas Ag-RDTs were done at home.

PARTICIPANTS

Of 7361 participants in the study, 5353 who were asymptomatic and negative for SARS-CoV-2 on study day 1 were eligible. In total, 154 participants had at least 1 positive RT-PCR result.

MEASUREMENTS

The sensitivity of Ag-RDTs was measured on the basis of testing once (same-day), twice (after 48 hours), and thrice (after a total of 96 hours). The analysis was repeated for different days past index PCR positivity (DPIPPs) to approximate real-world scenarios where testing initiation may not always coincide with DPIPP 0. Results were stratified by symptom status.

RESULTS

Among 154 participants who tested positive for SARS-CoV-2, 97 were asymptomatic and 57 had symptoms at infection onset. Serial testing with Ag-RDTs twice 48 hours apart resulted in an aggregated sensitivity of 93.4% (95% CI, 90.4% to 95.9%) among symptomatic participants on DPIPPs 0 to 6. When singleton positive results were excluded, the aggregated sensitivity on DPIPPs 0 to 6 for 2-time serial testing among asymptomatic participants was lower at 62.7% (CI, 57.0% to 70.5%), but it improved to 79.0% (CI, 70.1% to 87.4%) with testing 3 times at 48-hour intervals.

LIMITATION

Participants tested every 48 hours; therefore, these data cannot support conclusions about serial testing intervals shorter than 48 hours.

CONCLUSION

The performance of Ag-RDTs was optimized when asymptomatic participants tested 3 times at 48-hour intervals and when symptomatic participants tested 2 times separated by 48 hours.

PRIMARY FUNDING SOURCE

National Institutes of Health RADx Tech program.

Performance of Rapid Antigen Tests Based on Symptom Onset and Close Contact Exposure: A secondary analysis from the Test Us At Home prospective cohort study

Background

The performance of rapid antigen tests for SARS-CoV-2 (Ag-RDT) in temporal relation to symptom onset or exposure is unknown, as is the impact of vaccination on this relationship.

Objective

To evaluate the performance of Ag-RDT compared with RT-PCR based on day after symptom onset or exposure in order to decide on 'when to test'.

Design Setting and Participants

The Test Us at Home study was a longitudinal cohort study that enrolled participants over 2 years old across the United States between October 18, 2021 and February 4, 2022. All participants were asked to conduct Ag-RDT and RT-PCR testing every 48 hours over a 15-day period. Participants with one or more symptoms during the study period were included in the Day Post Symptom Onset (DPSO) analyses, while those who reported a COVID-19 exposure were included in the Day Post Exposure (DPE) analysis.

Exposure

Participants were asked to self-report any symptoms or known exposures to SARS-CoV-2 every 48-hours, immediately prior to conducting Ag-RDT and RT-PCR testing. The first day a participant reported one or more symptoms was termed DPSO 0, and the day of exposure was DPE 0. Vaccination status was self-reported.

Main Outcome and Measures

Results of Ag-RDT were self-reported (positive, negative, or invalid) and RT-PCR results were analyzed by a central laboratory. Percent positivity of SARS-CoV-2 and sensitivity of Ag-RDT and RT-PCR by DPSO and DPE were stratified by vaccination status and calculated with 95% confidence intervals.

Results

A total of 7,361 participants enrolled in the study. Among them, 2,086 (28.3%) and 546 (7.4%) participants were eligible for the DPSO and DPE analyses, respectively. Unvaccinated participants were nearly twice as likely to test positive for SARS-CoV-2 than vaccinated participants in event of symptoms (PCR+: 27.6% vs 10.1%) or exposure (PCR+: 43.8% vs. 22.2%). The highest proportion of vaccinated and unvaccinated individuals tested positive on DPSO 2 and DPE 5-8. Performance of RT-PCR and Ag-RDT did not differ by vaccination status. Ag-RDT detected 78.0% (95% Confidence Interval: 72.56-82.61) of PCR-confirmed infections by DPSO 4. For exposed participants, Ag-RDT detected 84.9% (95% CI: 75.0-91.4) of PCR-confirmed infections by day five post-exposure (DPE 5).

Conclusions and Relevance

Performance of Ag-RDT and RT-PCR was highest on DPSO 0-2 and DPE 5 and did not differ by vaccination status. These data suggests that serial testing remains integral to enhancing the performance of Ag-RDT.

Finding a Needle in a Haystack: Design and Implementation of a Digital Site-less Clinical Study of Serial Rapid Antigen Testing to Identify Asymptomatic SARS-CoV-2 Infection

Background

Rapid antigen tests (Ag-RDT) for SARS-CoV-2 with Emergency Use Authorization generally include a condition of authorization to evaluate the test's performance in asymptomatic individuals when used serially.

Objective

To describe a novel study design to generate regulatory-quality data to evaluate serial use of Ag-RDT in detecting SARS-CoV-2 virus among asymptomatic individuals.

Design

Prospective cohort study using a decentralized approach. Participants were asked to test using Ag-RDT and molecular comparators every 48 hours for 15 days.

Setting

Participants throughout the mainland United States were enrolled through a digital platform between October 18, 2021 and February 15, 2022. Ag-RDTs were completed at home, and molecular comparators were shipped to a central laboratory.

Participants

Individuals over 2 years old from across the U.S. with no reported COVID-19 symptoms in the 14 days prior to study enrollment were eligible to enroll in this study.

Measurements

Enrollment demographics, geographic distribution, and SARS-CoV-2 infection rates are reported.

Key Results

A total of 7,361 participants enrolled in the study, and 492 participants tested positive for SARS-CoV-2, including 154 who were asymptomatic and tested negative to start the study. This exceeded the initial enrollment goals of 60 positive participants. We enrolled participants from 44 U.S. states, and geographic distribution of participants shifted in accordance with the changing COVID-19 prevalence nationwide.

Limitations

New, complex workflows required significant operational and data team support. Conclusions: The digital site-less approach employed in the 'Test Us At Home' study enabled rapid, efficient, and rigorous evaluation of rapid diagnostics for COVID-19, and can be adapted across research disciplines to optimize study enrollment and accessibility.

Comparison of Rapid Antigen Tests' Performance Between Delta and Omicron Variants of SARS-CoV-2 : A Secondary Analysis From a Serial Home Self-testing Study

BACKGROUND

It is important to document the performance of rapid antigen tests (Ag-RDTs) in detecting SARS-CoV-2 variants.

OBJECTIVE

To compare the performance of Ag-RDTs in detecting the Delta (B.1.617.2) and Omicron (B.1.1.529) variants of SARS-CoV-2.

DESIGN

Secondary analysis of a prospective cohort study that enrolled participants between 18 October 2021 and 24 January 2022. Participants did Ag-RDTs and collected samples for reverse transcriptase polymerase chain reaction (RT-PCR) testing every 48 hours for 15 days.

SETTING

The parent study enrolled participants throughout the mainland United States through a digital platform. All participants self-collected anterior nasal swabs for rapid antigen testing and RT-PCR testing. All Ag-RDTs were completed at home, whereas nasal swabs for RT-PCR were shipped to a central laboratory.

PARTICIPANTS

Of 7349 participants enrolled in the parent study, 5779 asymptomatic persons who tested negative for SARS-CoV-2 on day 1 of the study were eligible for this substudy.

MEASUREMENTS

Sensitivity of Ag-RDTs on the same day as the first positive (index) RT-PCR result and 48 hours after the first positive RT-PCR result.

RESULTS

A total of 207 participants were positive on RT-PCR (58 Delta, 149 Omicron). Differences in sensitivity between variants were not statistically significant (same day: Delta, 15.5% [95% CI, 6.2% to 24.8%] vs. Omicron, 22.1% [CI, 15.5% to 28.8%]; at 48 hours: Delta, 44.8% [CI, 32.0% to 57.6%] vs. Omicron, 49.7% [CI, 41.6% to 57.6%]). Among 109 participants who had RT-PCR-positive results for 48 hours, rapid antigen sensitivity did not differ significantly between Delta- and Omicron-infected participants (48-hour sensitivity: Delta, 81.5% [CI, 66.8% to 96.1%] vs. Omicron, 78.0% [CI, 69.1% to 87.0%]). Only 7.2% of the 69 participants with RT-PCR-positive results for shorter than 48 hours tested positive by Ag-RDT within 1 week; those with Delta infections remained consistently negative on Ag-RDTs.

LIMITATION

A testing frequency of 48 hours does not allow a finer temporal resolution of the analysis of test performance, and the results of Ag-RDTs are based on self-report.

CONCLUSION

The performance of Ag-RDTs in persons infected with the SARS-CoV-2 Omicron variant is not inferior to that in persons with Delta infections. Serial testing improved the sensitivity of Ag-RDTs for both variants. The performance of rapid antigen testing varies on the basis of duration of RT-PCR positivity.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute of the National Institutes of Health.

Determinants of regulatory compliance in health and social care services: a systematic review

Background

The delivery of high quality health and social care services is a fundamental goal for health systems worldwide. Quality is variable in services and settings. One response to variation in quality is a regulatory framework that looks to set minimum standards that are enforced by an independent public authority. This systematic review seeks to identify and describe determinants of regulatory compliance in health and social care services.

Methods

Systematic searches were carried out on five electronic databases and grey literature sources. Titles and abstracts were screened by two reviewers independently. Determinants evaluated in studies were identified, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The included studies were quality appraised by two reviewers independently. The results were synthesised narratively under each CFIR domain.

Results

The search yielded 6,515 articles for screening, of which 148 were included. Most studies were quantitative designs focused on specific exposures (e.g. staffing levels, size, for-profit status). Qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance. Most of the determinants identified fit within the inner and outer setting domains of the CFIR, many with mixed findings in terms of an association with compliance. There were fewer determinants identified in the intervention characteristics, characteristics of individuals, and process domains of the CFIR.

Conclusions

The literature in this field focuses on the broader concept of quality and appears to neglect the more nuanced issues surrounding the successful implementation of regulatory standards i.e. compliance. A number of gaps, particularly in terms of qualitative work focussed on the mechanism involved in implementing regulations, remain in the literature and further research in this area is needed to provide a clearer picture.

Key messages

• No clear determinants of regulatory compliance were identified, suggesting it is complex and context specific.

• There are gaps in the literature around the underlying processes which contribute to the achievement of compliance that warrant research attention.

If you build it, will they use it? Use of a Digital Assistant for Self-Reporting of COVID-19 Rapid Antigen Test Results during Large Nationwide Community Testing Initiative

Importance

Wide-spread distribution of rapid-antigen tests is integral to the United States' strategy to address COVID-19; however, it is estimated that few rapid-antigen test results are reported to local departments of health.

Objective

To characterize how often individuals in six communities throughout the United States used a digital assistant to log rapid-antigen test results and report them to their local Department of Health.

Design

This prospective cohort study is based on anonymously collected data from the beneficiaries of The Say Yes! Covid Test program, which distributed 3,000,000 rapid antigen tests at no cost to residents of six communities between April and October 2021. We provide a descriptive evaluation of beneficiaries' use of digital assistant for logging and reporting their rapid antigen test results.

Main Outcome and Measures

Number and proportion of tests logged and reported to the Department of Health through the digital assistant.

Results

A total of 178,785 test kits were ordered by the digital assistant, and 14,398 households used the digital assistant to log 41,465 test results. Overall, a small proportion of beneficiaries used the digital assistant (8%), but over 75% of those who used it reported their rapid antigen test results to their state public health department. The reporting behavior varied between communities and was significantly different for communities that were incentivized for reporting test results (p < 0.001). In all communities, positive tests were less reported than negative tests (60.4% vs 75.5%; p<0.001).

Conclusions and Relevance

These results indicate that app-based reporting with incentives may be an effective way to increase reporting of rapid tests for COVID-19; however, increasing the adoption of the digital assistant is a critical first step.

Comparison of Rapid Antigen Tests' Performance between Delta (B.1.61.7; AY.X) and Omicron (B.1.1.529; BA1) Variants of SARS-CoV-2: Secondary Analysis from a Serial Home Self-Testing Study

Background

There is a need to understand the performance of rapid antigen tests (Ag-RDT) for detection of the Delta (B.1.61.7; AY.X) and Omicron (B.1.1.529; BA1) SARS-CoV-2 variants.

Methods

Participants without any symptoms were enrolled from October 18, 2021 to January 24, 2022 and performed Ag-RDT and RT-PCR tests every 48 hours for 15 days. This study represents a non-pre-specified analysis in which we sought to determine if sensitivity of Ag-RDT differed in participants with Delta compared to Omicron variant. Participants who were positive on RT-PCR on the first day of the testing period were excluded. Delta and Omicron variants were defined based on sequencing and date of first RT-PCR positive result (RT-PCR+). Comparison of Ag-RDT performance between the variants was based on sensitivity, defined as proportion of participants with Ag-RDT+ results in relation to their first RT-PCR+ result, for different duration of testing with rapid Ag-RDT. Subsample analysis was performed based on the result of participants' second RT-PCR test within 48 hours of the first RT-PCR+ test.

Results

From the 7,349 participants enrolled in the parent study, 5,506 met the eligibility criteria for this analysis. A total of 153 participants were RT-PCR+ (61 Delta, 92 Omicron); among this group, 36 (23.5%) tested Ag-RDT+ on the same day, and 84 (54.9%) tested Ag-RDT+ within 48 hours as first RT-PCR+. The differences in sensitivity between variants were not statistically significant (same-day: Delta 16.4% [95% CI: 8.2-28.1] vs Omicron 28.2% [95% CI: 19.4-38.6]; and 48-hours: Delta 45.9% [33.1-59.2] vs. Omicron 60.9% [50.1-70.9]). This trend continued among the 86 participants who had consecutive RT-PCR+ result (48-hour sensitivity: Delta 79.3% [60.3-92.1] vs. Omicron: 89.5% [78.5-96.0]). Conversely, the 38 participants who had an isolated RT-PCR+ remained consistently negative on Ag-RDT, regardless of the variant.

Conclusions

The performance of Ag-RDT is not inferior among individuals infected with the SARS-CoV-2 Omicron variant as compared to the Delta variant. The improvement in sensitivity of Ag-RDT noted with serial testing is consistent between Delta and Omicron variant. Performance of Ag-RDT varies based on duration of RT-PCR+ results and more studies are needed to understand the clinical and public health significance of individuals who are RT-PCR+ for less than 48 hours.

A Dispatch Screening Tool to Identify Patients at High Risk for COVID-19 in the Prehospital Setting

INTRODUCTION

Emergency medical services (EMS) dispatchers have made efforts to determine whether patients are high risk for coronavirus disease 2019 (COVID-19) so that appropriate personal protective equipment (PPE) can be donned. A screening tool is valuable as the healthcare community balances protection of medical personnel and conservation of PPE. There is little existing literature on the efficacy of prehospital COVID-19 screening tools. The objective of this study was to determine the positive and negative predictive value of an emergency infectious disease surveillance tool for detecting COVID-19 patients and the impact of positive screening on PPE usage.

METHODS

This study was a retrospective chart review of prehospital care reports and hospital electronic health records. We abstracted records for all 911 calls to an urban EMS from March 1-July 31, 2020 that had a documented positive screen for COVID-19 and/or had a positive COVID-19 test. The dispatch screen solicited information regarding travel, sick contacts, and high-risk symptoms. We reviewed charts to determine dispatch-screening results, the outcome of patients' COVID-19 testing, and documentation of crew fidelity to PPE guidelines.

RESULTS

The sample size was 263. The rate of positive COVID-19 tests for all-comers in the state of Massachusetts was 2.0%. The dispatch screen had a sensitivity of 74.9% (confidence interval [CI], 69.21-80.03) and a specificity of 67.7% (CI, 66.91-68.50). The positive predictive value was 4.5% (CI, 4.17-4.80), and the negative predictive value was 99.3% (CI, 99.09-99.40). The most common symptom that triggered a positive screen was shortness of breath (51.5% of calls). The most common high-risk population identified was skilled nursing facility patients (19.5%), but most positive tests did not belong to a high-risk population (58.1%). The EMS personnel were documented as wearing full PPE for the patient in 55.7% of encounters, not wearing PPE in 8.0% of encounters, and not documented in 27.9% of encounters.

CONCLUSION

This dispatch-screening questionnaire has a high negative predictive value but moderate sensitivity and therefore should be used with some caution to guide EMS crews in their PPE usage. Clinical judgment is still essential and may supersede screening status.

Practice surrounding adverse events in residential care facilities in Ireland

Background

Part of regulation of residential care facilities (RCFs) is the statutory responsibility of RCFs to notify the regulator about adverse events (AEs). Notifications typically include a description of practice in the aftermath of AEs and are an information source that can inform quality and safety improvements. The herein aim therefore was to analyse narratives in notifications received by the Health Information and Quality Authority (HIQA) in Ireland, to identify practice surrounding AE management and reporting.

Methods

A sample (n = 447) of notifications received by HIQA in 2018 was drawn from the Database of Statutory Notifications from Social Care in Ireland, 2013-2019. Inductive thematic analysis was conducted. Analysis was structured using the a priori agreed themes of: practice in the aftermath of an AE, system vulnerabilities and reporting practices.

Results

Two overarching themes were identified. The first, a chronological theme contained three sub-themes: pre event, including existing measures and situations, response to the event and continued response. Measures that are resident focused and follow policies and protocols in RCFs to prevent or mitigate the seriousness of AEs, were evident in the response and continued response. From this chronological order emerged the cyclical theory where short and longer term actions become part of the pre-event of future similar or repeated AEs. The second overarching theme, regulatory input, encapsulated procedural notes, requests for further information and notes on repetitive patterns.

Conclusions

RCFs respond to AEs with short and longer term actions with resident health and wellbeing as the focus. These actions in turn become part of the pre-event of future AEs. This cycle can be leveraged for quality improvement initiatives. Input from inspectors was positive and constructive but highlighted some regulatory burden. Dissemination of these results as good practice guides may improve management and reporting of AEs.

Key messages

Residential care facilities respond to adverse events with short and long term measures which feed into the management of future AEs. This cycle can be leveraged for quality improvement initiatives. Improvement opportunities in reporting practices were found. The development of good practice guides for residential care facilities and inspectors could reduce regulatory burden.

How will disaster victims react to first responder commands-A survey of simulated disaster victims

OBJECTIVE

To determine whether victim behavior and interaction with triage personnel would conform to expected actions as dictated by the Simple Triage and Rapid Treatment (START) triage methodology, which emphasizes that victims will accept their assigned -triage category.

METHODS

In total, 105 volunteers were recruited to complete a 32-question survey after portraying victims in a triage-focused mass casualty incident (MCI) simulation. Questions included sociodemographic characteristics, willingness to follow commands of first responders, and willingness to help first responders. The authors examined whether the outcomes differed by demographics, healthcare experience, or disaster exposure of participants.

RESULTS

The survey response rate was 90 percent (95/105). The mean age of participants was 31 years (58 percent women). Half of respondents indicated that they would ask responders to change their triage color if they disagreed with it and 75 percent would ask first responders to change their friend or family members' triage colors. Twenty-one percent of victims reported that they would alter their own triage tag to receive treatment faster and 38 percent would alter a friend or family member's triage color. The youngest (<20 years) and oldest (>40 years) respondents were most likely to act maladaptively.

CONCLUSION

Triage algorithms rely upon -victims following the instructions of rescuers. This study suggests that maladaptive behavior by some victims should be anticipated.

An in vitro investigation of the survival and/or growth of Campylobacter jejuni in broiler digestate from different feed types

Campylobacter spp. is the leading cause of bacterial gastroenteritis worldwide and poultry are the primary reservoir. The aim of this study was to investigate the survival and/or growth of Campylobacter jejuni NCTC 11168 in broiler digestate prepared from commercial starter, grower and finisher feed formulations. Bolton broth and digestates were prepared, inoculated with C. jejuni NCTC 11168 (approximately 3 log₁₀ CFU per ml) and incubated under microaerobic conditions at 42°C for 24 h. Samples were taken at t = 0 (immediately after inoculation) and every 3 h thereafter, serially diluted and plated onto mCCDA. Campylobacter jejuni grew as expected in Bolton broth (control) reaching the early stationary phase after approximately 15 h. In contrast, although bacterial concentrations were maintained for at least 9 h, none of the feed digestates supported the growth of C. jejuni, which were not detected after 15 h. It is suggested that the nutrients available in the feed digestates are not enough to support C. jejuni growth and that additional factors may be at play in the avian gastrointestinal tract.

Paramedic Pain Management Practice with Introduction of a Non-opiate Treatment Protocol

Introduction

There is concern about the initiation of opiates in healthcare settings due to the risk of future misuse. Although opiate medications have historically been at the core of prehospital pain management, several states are introducing non-opiate alternatives to prehospital care. Prior studies suggest that non-opiate analgesics are non-inferior to opiates for many acute complaints, yet there is little literature describing practice patterns of pain management in prehospital care. Our goal was to describe the practice patterns and attitudes of paramedics toward pain management after the introduction of non-opiates to a statewide protocol.

Methods

This study was two-armed. The first arm employed a pre/post retrospective chart review model examining medication administrations reported to the Massachusetts Ambulance Trip Information System between January 1, 2017–December 31, 2018. We abstracted instances of opiate and non-opiate utilizations along with patients’ clinical course. The second arm consisted of a survey administered to paramedics one year after implementation of non-opiates in the state protocol, which used binary questions and Likert scales to describe beliefs pertaining to prehospital analgesia.

Results

Pain medications were administered in 1.6% of emergency medical services incidents in 2017 and 1.7% of incidents in 2018. The rate of opiate analgesic use was reduced by 9.4% in 2018 compared to 2017 (90.6% vs 100.0%). The absolute reduction in opiate use in 2018 was 3.6%. Women were less likely (odds ratio [OR] = 0.78, 95% confidence interval [CI], 0.69–0.89) and trauma patients were more likely to receive opiates (OR = 2.36, CI, 1.96–2.84). Mean transport times were longer in opiate administration incidents (36.97 vs 29.35 minutes, t = 17.34, p<0.0001). We surveyed 100 paramedics (mean age 41.98, 84% male). Compositely, 85% of paramedics planned to use non-opiates and 35% reported having done so. Participants planning to use non-opiates were younger and less experienced. Participants indicated that concern about adverse effects, efficacy, and time to effect impacted their practice patterns.

Conclusion

The introduction of non-opiate pain medication to state protocols led to reduced opiate administration. Men and trauma patients were more likely to receive opiates. Paramedics reported enthusiasm for non-opiate medications. Beliefs about non-opioid analgesics pertaining to adverse effects, onset time, and efficacy may influence their utilization.

Measuring Agreement Among Prehospital Providers and Physicians in Patient Capacity Determination

OBJECTIVES

If a patient wishes to refuse treatment in the prehospital setting, prehospital providers and consulting emergency physicians must establish that the patient possesses the capacity to do so. The objective of this study is to assess agreement among prehospital providers and emergency physicians in performing patient capacity assessments.

METHODS

This study involved 139 prehospital providers and 28 emergency medicine physicians. Study participants listened to 30 medical control calls pertaining to patient capacity and were asked to interpret whether the patients in the scenarios had the capacity to refuse treatment. Participants also reported their comfort level using modified Likert scales. Inter-rater reliability was calculated utilizing Fleiss' and Model B kappa statistics. Fisher's exact tests were used to calculate p-values comparing the proportion in each cohort that responded "no capacity." Primary outcomes included inter-rater reliability in the physician and prehospital provider cohorts.

RESULTS

The inter-rater agreement between the physicians was low (Fleiss' kappa = 0.31, standard error [SE] =0.06; model-based kappa = 0.18, SE = 0.04). Agreement was similarly low for the 135 prehospital providers (Fleiss' kappa = 0.30, SE = 0.06; model-based kappa = 0.28, SE = 0.04). The difference between the proportion of physicians and prehospital providers who responded "no capacity" was statistically significant in five of 30 scenarios. Median prehospital provider and physician confidence, on a 1 to 4 scale, was 2.00 (Q1-Q3 = 1.00-3.00 for prehospital providers and Q1-Q3 =1.0-2.0 for physicians).

CONCLUSIONS

There was poor inter-rater reliability in capacity determination between and among the prehospital provider and physician cohorts. This suggests that there is need for additional study and standardization of this task.

Development and pilot study of simple suicide risk rulers for use in the emergency department

BACKGROUND

Many patients treated in the emergency department (ED) for non-psychiatric complaints have elevated suicide risk. Universal screening can detect occult suicide risk, but gold standard risk measurement tools, such as the Beck Scale for Suicidal Ideation (BSS), are too long and cumbersome for ED use.

OBJECTIVE

To test the performance of seven novel 0- to 10-point suicide risk "rulers" against the BSS.

METHOD

399 patients from three EDs completed seven novel risk rulers, traditional binary screening items, and the BSS. Using BSS criterion references, we tested the diagnostic performance of each risk ruler and examined correlations between the rulers and BSS scores.

RESULTS

By varying thresholds on the risk rulers, high levels of sensitivity and specificity were obtained. A threshold of 3 on the "sadness" ruler gave 89% sensitivity for the BSS criterion reference, and a threshold of 1 on the "wish to be dead" ruler provided 94-97% specificity.

CONCLUSION

Our novel risk rulers may be an efficient way to detect risk and triage potentially suicidal patients, showing good concurrent validity with the BSS. Clinicians can obtain high sensitivity and high specificity using just two rulers. Further research should examine the rulers' ability to predict independent clinician risk ratings and prospective suicidal behavior.

Characteristics of Patients with Recurrent Emergency Medical Services Utilization for Symptomatic Hypoglycemia in an Urban Setting

Background: Symptomatic hypoglycemia frequently results in utilization of emergency medical services (EMS). Understanding the characteristics of hypoglycemic patients with high EMS utilization may help providers optimize resource allocation. Objective: To describe characteristics of patients utilizing EMS for hypoglycemia and to determine if any factors identifiable in the prehospital setting are associated with recurrent EMS utilization. Methods: A retrospective chart review of prehospital care records from an urban EMS system was performed. Patients who received oral glucose, parenteral glucose, or intramuscular glucagon for hypoglycemia over a one-year period were identified. Extracted information included demographics, prehospital treatment, disposition, zip code median income, and the number of subsequent EMS utilizations within 365 days. Results: We identified 549 subjects, mean age 55 years (range 5 to 104, 65% male). The mean glucose level for all patients was 44 mg/dl with standard deviation (SD) of 15. In total, 69% of patients received oral glucose, 26% received parenteral glucose, 3% received glucagon, and 2% received more than one medication. At the index visit, 81% of patients accepted hospital transportation. The rate of recurrent EMS utilization for hypoglycemia was 10%, and 3% of patients had 3 or more repeat utilizations within 365 days. The mean finger-stick glucose at index visit was 39 mg/dL (SD 15) for patients with multiple EMS utilizations and 44 mg/dL (SD 14) for those with one EMS visit (P = 0.006). Repeat utilizers were more likely to have received medications other than oral glucose at index visit, 51% vs. 28% (P < 0.001). Age, gender, median zip code income, and disposition were not associated with recurrent EMS utilization. The overall annual rate of hypoglycemia requiring EMS treatment per estimated diabetic population was 0.84%. Conclusion: A low proportion of patients utilizing EMS for hypoglycemia had subsequent EMS visits within 365 days. Those who did had lower initial blood glucose at the index visit and were more likely to have received prehospital treatment with medications other than oral glucose. Demographic characteristics did not yield any patterns predictive of repeat utilization. Refusing transport to the hospital after EMS treatment for hypoglycemia did not increase the risk of recurrent utilization.

An international survey of current physiotherapy practice in diagnosis and knowledge translation of greater trochanteric pain syndrome (GTPS)

PURPOSE

To evaluate how physiotherapists across three countries (Australia, New Zealand (NZ) and Ireland) diagnose greater trochanteric pain syndrome (GTPS) using clinical tests and imaging findings, and how physiotherapists update their knowledge regarding GTPS.

DESIGN

Cross-sectional observational study of physiotherapists.

METHODS

An online survey was distributed to registered physiotherapists in Australia, NZ and Ireland. Ordinal and nominal data were analysed using frequency counts or mean ranks; medians and interquartile ranges were calculated for numerical data. Comparisons between the three countries were made using Chi-squared analyses for nominal/ordinal data and Kruskal Wallis tests for numerical data. Statistical significance was set at p < 0.05.

RESULTS/FINDINGS

Valid responses were received from 361 physiotherapists; 61% were female and 79.8% worked in private practice. Most respondents were very confident in diagnosing GTPS (67.9%) and incorporated a range of symptoms and tests, including validated tests, in their diagnosis. However, many physiotherapists were not commonly using some available validated diagnostic tests (e.g. FABER and FADER-R). Approximately 30% of physiotherapists used imaging to inform assessment, with ultrasound being most preferred. Physiotherapists rated hands-on experience as most valuable for updating their knowledge of GTPS, followed by courses.

CONCLUSION

While most clinicians appear to be using current evidence in their assessment of patients with GTPS, a proportion use suboptimal methods and/or a limited range of diagnostic tests, suggesting that despite their confidence in diagnosis, further knowledge translation may be required. Future research should determine the best methods of facilitating knowledge acquisition and translation of research into practice.

Physiotherapy management of greater trochanteric pain syndrome (GTPS): an international survey of current physiotherapy practice

OBJECTIVES

This study aimed to establish and compare current physiotherapy management of GTPS in Australia, New Zealand (NZ) and Ireland.

DESIGN

Cross-sectional observational survey of physiotherapists.

METHODS

An online survey was distributed to registered musculoskeletal physiotherapists in Australia, NZ and Ireland. Ordinal and nominal data were analysed using frequency counts or mean ranks; median and interquartile ranges were calculated for numerical data. Inter-country comparisons were made using Chi-squared analyses for nominal/ordinal data and Kruskal-Wallis tests for numerical data. Statistical significance was set at P<0.05.

RESULTS/FINDINGS

Valid responses were received from 361 physiotherapists, 61% were female and 80% worked in private practice. Overall, consistency in treatment of GTPS was observed across the three countries. All physiotherapists used education and exercise (most commonly strengthening and neuromuscular control) primarily targeting the gluteal muscles. Other interventions included massage (90%), stretching (53%), range of motion (40%), thermal modalities (50%), taping (38%) and electrotherapy (25%), whilst 40% commonly recommended up to 2 to 3 corticosteroid injections per patient/per annum. Physiotherapists used pain severity scales as their primary outcome measure (79%). Single leg stance was the most common physical measure used (68%), and global rating scores or standardised physical measures were less commonly used.

CONCLUSION

This international survey established the physiotherapy management of GTPS. Education used in conjunction with exercise is in line with current evidence, but a proportion of clinicians use adjunct treatments without clear rationale or supporting evidence. Results indicate the need to further define optimal management of GTPS using robust methodologies such as randomised controlled trials.

MON-169 Characteristics of Patients with Recurrent EMS Utilization for Hypoglycemia in a Large Urban System

Background: Hypoglycemia is a life-threatening condition that frequently results in utilization of Emergency Medical Services (EMS). After prehospital treatment, many patients refuse to be transported to the hospital. Understanding the characteristics of hypoglycemic patients with high EMS utilization may help providers optimize resource allocation. Objective: To describe the demographics and clinical characteristics of patients who utilize EMS for hypoglycemia and to determine which factors are associated with recurrent EMS utilization. Methods: We performed a retrospective chart review of prehospital care records from the municipal EMS provider in a large city. All patients who received prehospital treatment for hypoglycemia (oral glucose, parenteral dextrose, or intramuscular glucagon) over a one-year period were identified. Patients with no recorded finger-stick glucose or an initial glucose level greater than 70 mg/dl were excluded, as were those in cardiac arrest and under 5 years of age. Extracted information included demographics, prehospital treatment, disposition, and the number of subsequent EMS utilizations within 365 days. We obtained median income data from the U.S. Census Bureau and the overall prevalence of diabetes in the city from the public health commission. Results: We identified 549 subjects, mean age 55 years (range 9 to 104, 65% male). The mean minimum glucose level was 44 mg/dl with standard deviation (SD) of 15. For treatment, 69% of patients received oral glucose, 26% received parenteral dextrose, 3% received glucagon, and 2% received more than one medication. At the index visit, 81% of patients accepted hospital transport and 19% refused. The rate of recurrent EMS utilization for hypoglycemia was 10%, and 3% of patients had three or more utilizations within the year. The mean blood glucose at the index visit was 38 mg/dl (SD 15) for patients with multiple EMS utilizations and 44 mg/dl (SD 14) in those with only one EMS visit (P=0.006). Repeat utilizers were more likely to have received medications other than oral glucose at the index visit, 51% versus 28% (P<0.001). Age, gender, median zip code income, and disposition were not associated with recurrent EMS utilization. The overall incidence of hypoglycemia requiring EMS treatment relative to the estimated diabetic population was 0.84% per year. Conclusion: A low proportion of patients utilizing EMS for hypoglycemia had subsequent EMS visits within 365 days. Those who did had lower blood glucose levels at the index visit and were more likely to receive prehospital treatment with medications other than oral glucose. Demographic characteristics were less useful at predicting repeat utilization. Refusing transport to the hospital after EMS treatment for hypoglycemia did not raise a patient's risk of recurrent utilization, suggesting that EMS treat-and-release protocols may be appropriate for some patients.

Drug use among men who have sex with men in Ireland: Prevalence and associated factors from a national online survey

BACKGROUND

Little is known about the prevalence and determinants of drug use among men who have sex with men (MSM) in Ireland. The aims of this study were to measure the prevalence of recreational drug use among MSM in a national sample, and to identify sub-groups of MSM who may benefit from targeted preventive interventions.

METHODS

The MSM Internet Survey Ireland (MISI) 2015 was a community-recruited, nationally-promoted, self-completed online survey for MSM. MISI 2015 included standardised questions on recreational drugs, poppers, and drugs associated with chemsex (i.e. crystal methamphetamine, GBL/GHB, mephedrone, ketamine). Multivariable-adjusted logistic regression was used to identify factors associated with use of these substances.

RESULTS

In the previous year, 36% of MSM used recreational drugs, 33% used poppers, and 7% used drugs associated with chemsex. Five percent were diagnosed HIV-positive. Recreational drug users were significantly younger than non-users (median = 27 vs. 32 years; p < 0.001); popper users were significantly older than non-users (median = 34 vs. 28 years; p < 0.001). The odds of recreational drug use were higher among MSM diagnosed HIV-positive (vs. never tested; AOR 2.27, 95%CI 1.39-3.70). Use of poppers, and use of drugs associated with chemsex, were also higher among MSM diagnosed HIV-positive (vs. never tested; AOR 3.77, 95%CI 2.41-5.90, and AOR 5.87, 95%CI 3.08-11.18 respectively).

CONCLUSIONS

The prevalence of recreational drug use is higher among MSM than in the general population in Ireland, and it is particularly high among MSM diagnosed HIV-positive. Targeted harm reduction messages and preventive interventions are warranted to complement population-based approaches to reducing drug use in this population.

Outcomes of Prehospital Chemical Sedation With Ketamine Versus Haloperidol and Benzodiazepine or Physical Restraint Only

OBJECTIVE

The goal of this study is to describe complications and outcomes of prehospital ketamine use for agitation as compared to other methods of physical or chemical restraint such as haloperidol plus benzodiazepine or physical restraint only.

METHODS

We conducted a single-center retrospective review of patient encounters in which restraint was administered in the prehospital setting. At the beginning of our study window, only physical restraint was available to paramedics managing agitated patients but subsequently, haloperidol and benzodiazepines were introduced, followed by ketamine 2 years later. By comparing patients before and after each transition, we divided subjects into 3 cohorts based on restraint type: physical restraint, haloperidol plus benzodiazepine, and ketamine. Demographic data were collected, and outcome measures included intubation rate, need for additional physical or chemical restraint, emergency department (ED) length of stay, need for hospital admission, and employee injury.

RESULTS

Of 214 subjects included in the study, 95 patients were administered ketamine, 68 received haloperidol and benzodiazepine, and 51 were physically restrained. Eleven of the patients (11.6%) who received ketamine were intubated. Compared to patients who received haloperidol plus benzodiazepine, patients who received ketamine were more likely to be intubated (odds ratio [OR] = 8.77, 95% confidence interval [CI], 1.10-69.68) and were more likely to require additional chemical restraint when compared to haloperidol/benzodiazepine or physical restraint only (OR =2.94, 95% CI, 1.49-5.80, and OR =2.15, 95% CI, 1.07-4.31, respectively). There were no differences between the 2 chemical sedation groups in terms of ED length of stay or hospital admission rate.

CONCLUSIONS

This study demonstrates a lower intubation rate in patients administered ketamine than prior literature in association with a lower weight-based dosing regimen. Ketamine use was correlated with a higher frequency of intubation and a greater need for additional chemical restraint when compared with other restraint modalities, though exogenous factors such as provider preference may have impacted this result. There was no difference in ED length of stay or admission rate between the ketamine and haloperidol plus benzodiazepine groups. Further prospective study is needed to determine whether there is a subset of patients for whom ketamine would be beneficial compared to other therapies.

Quantifying postoperative mobilisation following oesophagectomy

OBJECTIVE

Early mobilisation is in integral component of postoperative recovery following complex surgical procedures such as oesophageal cancer resections, however evidence to guide early mobilisation protocols in critical care settings is limited. Furthermore, little is known about actual mobilisation levels postoperatively. This study quantified postoperative mobilisation post- oesophagectomy and investigated barriers to mobility.

DESIGN

Prospective observational study.

SETTING

Postoperative critical care setting in a tertiary care referral centre for oesophagectomy.

PARTICIPANTS

Thirty participants (mean age 65 (SD 7) years, n=19 males) scheduled for oesophagectomy.

MAIN OUTCOME MEASURES

The primary outcome, postoperative physical activity, was measured objectively using the Actigraph GT3X+. Medical records were examined for a range of outcomes including medical status, pain scores and physiotherapy comments to identify factors which may have influenced mobility.

RESULTS

During postoperative day (POD) 1-5, participants spent the majority of time (>96%) sedentary. Participation in light intensity activity was low but did increase daily from a median of 12 (IQR 19) minutes/day on POD1 to a median of 53 (IQR 73.25) minutes/day on POD5 p<0.001), with a corresponding increase in daily step count. Haemodynamic instability was the most common reason reported by physiotherapists for either not attempting mobility or limiting postoperative mobilisation levels.

CONCLUSIONS

These data demonstrate that despite daily physiotherapy, there are multiple challenges to postoperative mobilisation. Haemodynamic instability, likely related to thoracic epidurals, was the key limitation to early mobilisation. Goal-directed mobilisation in collaboration with the multidisciplinary team may play a considerable role in overcoming modifiable barriers to postoperative mobilisation.

'Careful goodbye at the door': is there role for antimicrobial stewardship interventions for antimicrobial therapy prescribed on hospital discharge?

BACKGROUND

Antimicrobial stewardship (AMS) interventions largely target inpatient antimicrobial prescribing. Literature on appropriateness of antimicrobials prescribed at the interface between hospital and the community is minimal. This study was designed to assess the appropriateness of antimicrobials prescribed on hospital discharge and evaluate the impact of AMS interventions.

METHODS

Patients with discharge medications processed by the pharmacy were identified using a computerized pharmacy medication tracker over a four week period. The antimicrobials prescribed on discharge were assessed independently for appropriateness of antimicrobial choice, dose, frequency and duration. Data on various AMS interventions was collected. Univariate followed by multivariate logistic regression (MVLR) analysis was performed using SPSS V 23 (IBM, California).

RESULTS

A total of 892 discharge prescriptions were processed by the pharmacy department, 236 of which contained antibiotic prescriptions. Of these, 74% were appropriate for antimicrobial choice, 64% for dose, 64% for frequency and 21% for duration. In particular, 71% of patients received a course in excess of Therapeutic Guidelines-Australia(TG-A) recommended length of treatment. On univariate analysis, discharge antimicrobial prescriptions were more likely to be appropriate for antimicrobial choice, frequency and duration; appropriate microbiological specimens were more likely to be taken and targeted therapy more likely to be given when the AMS team was involved. On MVLR, appropriateness with antimicrobial dosing frequency [OR 5.6(1.9-19.2)], microbiological specimens [OR 4.3(1.6-11.6)] and receipt of targeted therapy [OR 2.8(1.8-6.2)] with AMS involvement remained significant.

CONCLUSIONS

A large discrepancy exists between antimicrobial regimens prescribed on hospital discharge and those recommended in consensus guidelines, particularly concerning duration of treatment. While AMS interventions are well established for improving antimicrobial prescribing in hospital inpatients, the hospital-community interface remains a challenge in terms of antimicrobial prescribing and exposes patients to potential harm. There is a clear need for AMS interventions to extend to antimicrobial therapy prescribed on discharge.

Extensive hepatitis A outbreak in an urban childcare facility in Ireland, associated with considerable adult morbidity

Hepatitis A infection results in a spectrum of illness from asymptomatic disease to severe fulminant hepatitis. Since 2000, <50 cases have been reported annually in Ireland. We report on an outbreak of hepatitis A associated with a childcare facility(CCF) in 2015 in Ireland. Between January and July 2015, 12 outbreak-associated symptomatic hepatitis A cases were identified, including one delayed, retrospective diagnosis. Seven (58%) cases were adults, eight (67%) were male, six of the adults required hospitalisation. All 12 cases were confirmed on serology and the four cases that were genotyped were identical on phylogenetic analysis. Potential environmental exposures and hygiene practices at the CCF were investigated. Outbreak control measures included the provision of: hepatitis A information, infection prevention advice, hepatitis A vaccination to 554 CCF contacts, and voluntary closure of the CCF for deep-cleaning and staff education. From a healthcare perspective1, outbreak control costs were in excess of €45 000. This outbreak illustrates the considerable adult morbidity that can occur in hepatitis A outbreaks, highlights the challenges in controlling a large CCF-associated outbreak and the importance of early recognition by clinicians of hepatitis A.

Elevated IL-33 expression is associated with pediatric eosinophilic esophagitis, and exogenous IL-33 promotes eosinophilic esophagitis development in mice

We tested whether the T helper (Th) type 2 (Th2) cell agonist and allergenic ligand IL-33 was associated with eosinophilic esophagitis (EoE) development in a pediatric cohort and whether IL-33 protein could induce disease symptoms in mice. Biopsies from EoE patients or controls were used to measure IL-33 mRNA and protein expression. Increased expression of IL-33 mRNA was found in the esophageal mucosa in EoE. IL-33 protein was detected in cells negative for CD45, mast cells, and epithelial cell markers near blood vessels. Circulating levels of IL-33 were not increased. The time course for IL-33 gene expression was quantified in an established Aspergillus fumigatus allergen mouse model of EoE. Because IL-33 induction was transient in this model and chronicity of IL-33 expression has been demonstrated in humans, naive mice were treated with recombinant IL-33 for 1 wk and esophageal pathology was evaluated. IL-33 application produced changes consistent with phenotypically early EoE, including transmural eosinophilia, mucosal hyperproliferation, and upregulation of eosinophilic genes and chemokines. Th2 cytokines, including IL-13, along with innate lymphoid cell group 2, Th1/17, and M2 macrophage marker genes, were increased after IL-33 application. IL-33-induced eosinophilia was ablated in IL-13 null mice. In addition, IL-33 induced a profound inhibition of the regulatory T cell gene signature. We conclude that IL-33 gene expression is associated with pediatric EoE development and that application of recombinant protein in mice phenocopies the early clinical phase of the human disease in an IL-13-dependent manner. IL-33 inhibition of esophageal regulatory T cell function may induce loss of antigenic tolerance, thereby providing a mechanistic rationale for EoE development.

A Survey of GPs Awareness and Use of Risk Assessment Tools and Cardiovascular Disease Prevention Guidelines

Cardiovascular disease (CVD) is the leading cause of death worldwide. This study aimed to benchmark awareness and use of CVD risk assessment (RA) tools and prevention guidelines in Irish general practice. 493 (18%) Irish general practitioners (GPs) were invited to participate in a cross-sectional study in 2011. 213 (43%) GPs responded with most being male (n = 128, 58.2%) and aged ≥ 45 years (n = 124, 56.8%). While 197 (92.5%) GPs were aware of at least one RA tool, only 69 (32.4%) GPs reported frequent use. 187 (87.8%) GPs were aware of one or more CVD prevention guidelines with 115 (54.0%) GPs reporting frequent use of at least one guideline. No age or gender difference observed. Barriers to implementation of CVD prevention guidelines were lack of remuneration, too many CVD guidelines and time constraints. Most Irish GPs were aware of RA tools and CVD prevention guidelines with half reporting frequent use of guidelines.

A prolonged outbreak of invasive meningococcal disease in an extended Irish Traveller family across three Health Service Executive (HSE) areas in Ireland, 2010 to 2013

Between March 2010 and November 2013 eight laboratory-confirmed cases of serogroup B, invasive meningococcal disease (IMD) were identified in an extended Irish Traveller family across three Health Service Executive (HSE) areas of Ireland. Cases were aged between 5 and 46 months, and were either a cousin or sibling of another case. All eight cases survived. Chemoprophylaxis was given to relevant nuclear family members and close contacts on each occasion, but failed to prevent further cases. Neisseria meningitidis isolates from six cases were highly related, belonging to the ST-41/44 clonal complex, and shared the porA designation 7–2,4. In November 2013, the outbreak control team recommended that directly observed ciprofloxacin chemoprophylaxis be administered simultaneously to the extended family, and that the four component meningococcal B (4CMenB) vaccine be administered to family members aged 2 months to 23 years inclusive and relevant close contacts of the eighth case. Subsequently these recommendations were implemented at three regional clinics. Additionally pharyngeal swabs (n=112) were collected to assess carriage rates of N. meningitidis in this extended family. Pharyngeal carriage of N. meningitidis was detected in 15 (13%) family members. From the epidemiological investigation and carriage study overcrowding was the most likely risk factor identified in this outbreak. To date, the combination of directly observed ciprofloxacin chemoprophylaxis and use of 4CMenB vaccine have controlled the outbreak with no further cases diagnosed.

Preparedness of elderly long-term care facilities in HSE East for influenza outbreaks

Abstract We assessed preparedness of HSE East elderly long-term care facilities for an influenza outbreak, and identified Public Health Department support needs. We surveyed 166 facilities based on the HSE checklist document for influenza outbreaks, with 58% response rate. Client flu vaccination rates were > 75%; leading barriers were client anxiety and consent issues. Target flu vaccine uptake of 40% in staff occurred in 43% of facilities and was associated with staff vaccine administration by afacility-attached GP (p = 0.035), having a facility outbreak plan (p = 0.013) and being anon-HSE run facility (p = 0.013). Leading barriers were staff personal anxiety (94%) and lack of awareness of the protective effect on clients (21%). Eighty-nine percent found Public Health helpful, and requested further educational support and advocacy. Staff vaccine uptake focus, organisational leadership, optimal vaccine provision models, outbreak plans and Public Health support are central to the influenza campaign in elderly long-term care facilities.

Outbreak of hepatitis A infection associated with the consumption of frozen berries, Ireland, 2013--linked to an international outbreak

In May 2013, a European alert was issued regarding a hepatitis A virus (HAV) outbreak in Italy. In June 2013, HAV subgenotype IA with an identical sequence was identified in Ireland in three cases who had not travelled to Italy. The investigation consisted of descriptive epidemiology, a case-control study, microbiological testing of human and food specimens, molecular typing of positive specimens and food traceback. We identified 21 outbreak cases (14 confirmed primary cases) with symptom onset between 31 January and 11 October 2013. For the case-control study, we recruited 11 confirmed primary cases and 42 matched controls. Cases were more likely than controls to have eaten berry cheesecake (matched odds ratio (mOR): 12; 95% confidence interval (CI): 1.3-114), whole frozen berries (mOR: 9.5; 95% CI: 1.0-89), yoghurt containing frozen berries (mOR: 6.6, 95% CI: 1.2-37) or raw celery (mOR: 4; 95% CI: 1.2-16). Among cases, 91% had consumed at least one of four products containing frozen berries (mOR: 12; 95% CI: 1.5-94). Sixteen food samples tested were all negative for HAV. As products containing frozen berries were implicated in the outbreak, the public were advised to heat-treat frozen berries before consumption.

Parents' experience of living with and caring for an adult son or daughter with schizophrenia at home in Ireland: a qualitative study

This study explored the experience of parents living with, and caring for, an adult son or daughter with schizophrenia. There is increasing emphasis on the involvement of carers and users in the care for people with schizophrenia. 'A Vision for Change' highlights the need for a partnership approach and emphasizes that carers are an integral part in the planning and delivery of mental health services. In order to meet such requests, it was necessary to explore the meaning of caregiving for Irish families. A descriptive qualitative design was used to enable parents to describe their experiences. Semi-structured, in-depth interviews with a convenience sample of six parents in Ireland were carried out in 2007. The study encompassed four major themes: psychological tsunami, caring activities, coping with enduring illness and an uncertain pathway. Parents reported severe psychological distress when their son or daughter was diagnosed with schizophrenia. Their deep sense of loss was followed by acceptance of the situation. Feelings of love and a sense of responsibility helped to give meaning to their caring role. This study gave a voice to some parents of a son or daughter with schizophrenia. A family-centred approach should be at the core of care planning for this vulnerable population.

Water intakes and dietary sources of a nationally representative sample of Irish adults

BACKGROUND

Despite evidence that even mild dehydration is associated with various morbidities, water intake estimates in free-living populations are lacking. The present study aimed to estimate water intakes and dietary sources in a nationally representative sample of the Irish adult population.

METHODS

A 4-day semi-weighed food record was used to collect dietary intake data from 1500 free-living adults aged 18-90 years in the Irish National Adult Nutrition Survey (NANS) (2008-2010) from which water intake was estimated. To enable fluid intake estimation, additional questions on how water and milk were consumed were incorporated. Total water intake was calculated as drinking water plus water from other beverages and food moisture.

RESULTS

The mean (SD) daily total water intake for Irish adults was 2.31 (0.92) L day(-1) [males 2.52 (1.00) L day(-1) ; females 2.09 (0.79) L day(-1)]. Intakes were lowest in elderly adults, as well as in those with less education, a lower social class, less energy expenditure and a higher body mass index and body fat percentage. In total, 67% of water came from beverages and 33% came from food moisture. Alcoholic beverages and teas individually contributed to total water intake in amounts similar to the drinking water contribution.

CONCLUSIONS

These data may be used as a foundation for further research in the area of the effect of under consumption of water on health outcomes to guide public health messages regarding adequate water intakes.

Cre transgene results in global attenuation of the cAMP/PKA pathway

Use of the cre transgene in in vivo mouse models to delete a specific 'floxed' allele is a well-accepted method for studying the effects of spatially or temporarily regulated genes. During the course of our investigation into the effect of cyclic adenosine 3',5'-monophosphate-dependent protein kinase A (PKA) expression on cell death, we found that cre expression either in cultured cell lines or in transgenic mice results in global changes in PKA target phosphorylation. This consequently alters gene expression profile and changes in cytokine secretion such as IL-6. These effects are dependent on its recombinase activity and can be attributed to the upregulation of specific inhibitors of PKA (PKI). These results may explain the cytotoxicity often associated with cre expression in many transgenic animals and may also explain many of the phenotypes observed in the context of Cre-mediated gene deletion. Our results may therefore influence the interpretation of data generated using the conventional cre transgenic system.

Surveillance of verocytotoxigenic Escherichia coli in Irish bovine dairy herds

Verocytotoxigenic Escherichia coli (VTEC) are highly significant zoonotic threats to public health, and have been the causative agent implicated in numerous high-profile outbreaks affecting large numbers of people. Serovar O157 is most frequently linked with human illness; however, other serovars, such as O26, O103, O111 and O145, have also been implicated. This study aimed to characterize the prevalence and virulence determinants of these five serovars in Irish dairy farm herds, and their milk. Using real-time PCR (RTi-PCR), bovine rectal faecal swabs and raw milk samples, along with milk filters, were screened for the presence of vt genes. Positive samples were then screened for the five serovars using sero-specific PCR. Serovar-positive samples were subjected to immunomagnetic separation, to isolate viable VTEC strains. These isolates were subsequently screened for four virulence factors: vt1, vt2, eaeA and hlyA. Three hundred and eighty six of the 600 rectal faecal swabs, 85 of the 117 milk-filters and 43 of the 120 bulk-tank milk samples, were positive for vt genes. From these 514 total vt-positive samples, 58 O26, 162 O103, 1 O111, 324 O145 and 26 O157 positives were detected by sero-specific RTi-PCR. Immunomagnetic separation yielded 12 O26, 26 O103, 0 O111, 19 O145 and 10 O157 isolates. Ten of these isolates contained at least one of the four virulence determinants screened for (i.e. vt1, vt2, eaeA and hlyA). Of these 10 isolates, pulsed-field gel electrophoresis showed that two of the O26 isolates from different farms were indistinguishable. Two O157 isolates were also indistinguishable. This study found serovars O103 and O145 to be the most prevalent in samples tested. Apart from the occurrence of VTEC in dairy herds, this study shows a high occurrence of vt genes in the environment, creating the possibility of horizontal gene transfer and emergence of new VTEC strains.

Novel pyrrolo-1,5-benzoxazepine compounds display significant activity against resistant chronic myeloid leukaemia cells in vitro, in ex vivo patient samples and in vivo

BACKGROUND

Imatinib is a direct and potent inhibitor of the constitutively active tyrosine kinase, breakpoint cluster region-Abelson (Bcr-Abl), which is central to the pathogenesis of chronic myeloid leukaemia (CML) patients. As such, imatinib has become the front-line treatment for CML patients. However, the recent emergence of imatinib resistance, commonly associated with point mutations within the kinase domain, has led to the search for alternative drug treatments and combination therapies for CML.

METHODS

In this report, we analyse the effects of representative members of the novel pro-apoptotic microtubule depolymerising pyrrolo-1,5-benzoxazepines or PBOX compounds on chemotherapy-refractory CML cells using a series of Bcr-Abl mutant cell lines, clinical ex vivo patient samples and an in vivo mouse model.

RESULTS

The PBOX compounds potently reduce cell viability in cells expressing the E225K and H396P mutants as well as the highly resistant T315I mutant. The PBOX compounds also induce apoptosis in primary CML samples including those resistant to imatinib. We also show for the first time, the in vivo efficacy of the pro-apoptotic PBOX compound, PBOX-6, in a CML mouse model of the T315I Bcr-Abl mutant.

CONCLUSION

Results from this study highlight the potential of these novel series of PBOX compounds as an effective therapy against CML.

Synthetic oligosaccharide stimulates and stabilizes angiogenesis: structure-function relationships and potential mechanisms

To determine the proangiogenesis effect of series of saccharides and a synthetic oligosaccharide and potential mechanisms, an in vitro 3-dimensional endothelial cell sprouting (3D-ECS) assay and the chick chorioallantoic membrane (CAM) model were used. We demonstrated that a sulfated oligosaccharide significantly promotes the endothelial capillary network initiated by vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (b-FGF). Furthermore, although the capillary network initiated by VEGF and b-FGF lasts no more than 7 days, addition of a sulfated oligosaccharide significantly amplifies angiogenesis and stabilizes the capillary network of new blood vessels. In the CAM model, sulfated oligosaccharide also stimulated angiogenesis. In both the CAM and the 3D-ECS assay, structure-function studies reveal that increased saccharide chain length up to the hexa- to decasaccharide show optimal proangiogenesis efficacy. In addition, the sulfation and molecular shape (branched vs linear) of oligosaccharide are important for sustained proangiogenesis efficacy. Data indicate that chemically defined synthetic oligosaccharides can play an important role in regulation of capillary structure and stability, which may contribute to future advances in therapeutic angiogenesis. The proangiogenesis efficacy of an oligosaccharide is mediated via integrin alphavbeta3 and involves mitogen-activated protein kinase signaling mechanisms.

Mushroom host influence on Lycoriella mali (Diptera: Sciaridae) life cycle

Lycoriella mali Fitch (Diptera: Sciaridae) infests mushroom crops early in the crop cycle. Recent observations in mushroom houses indicated a difference in emergence time and size of adult L. mali developing on various strains of commercial mushrooms. Samples of adult flies from isolated mushroom houses growing Portabella mushrooms were significantly heavier then those from oyster mushroom houses, whereas flies from shiitake mushroom houses were lightest in weight. Flies collected from isolated Portabella mushroom houses were reared on four strains and species of Agaricus and Pleurotus mushrooms. After the adults emerged, females were weighed, mated, and allowed to oviposit. The number of eggs laid increased as the weight of the female increased. Flies collected from isolated Portabella mushroom houses were reared on eight strains and species of mushrooms. Flies were reared for four generations on each host mushroom mycelium then switched to different host mushrooms. Overall, the hybrid strain of Agaricus bisporus (Lange) Imbach (Agaricales: Agaricomycetideae) was the most favorable host for L. mali, whereas the wild strain of A. bisporus was the least favorable host. Mushroom hosts influence developmental time, survivorship, weight, and reproduction of L. mali.

Mother-baby psychiatric units in Australia - the Victorian experience

This article reviews the women admitted to Mother Baby Psychiatric Units in 2002, in the State of Victoria, Australia, looking at characteristics of postpartum disorders with respect to admission and outcome in a region with a high number of mother-baby unit beds relative to other Australian regions and other cities. Differences among units are noted, including the differential impact of whether the unit is associated with a psychiatric service or an obstetric service. This includes length of stay and referral patterns. Details of diagnosis, admission and outcome are compared to similar admissions in the United Kingdom, with similar factors predictive of poor outcome, defined as separation from the infant. Mother-Baby Units have an important potential role in improving these outcomes, with longer-term studies of these women needed.