Child abuse and pubertal timing: what is the role of child sex and identity of the perpetrator?

BACKGROUND

This study investigated the association between child abuse [child neglect (CN), emotional (CEA) and physical abuse (CPA)] and early puberty with special regard to sex-specific effects concerning child and parental perpetrator.

METHODS

Data assessment took place within the framework of the LIFE Child Depression study, a longitudinal study on the development of depressive symptoms and disorders between child- and adulthood in Leipzig, Germany. A sample of 709 children (8-14 years) was recruited from the general population and via psychiatric hospitals. Data on pubertal status were assessed using an instrument for self-assessment of tanner stages (scales of physical pubertal development). Information on menarche was provided by parents. The Parent-Child Conflict Tactics Scales (CTS-PC) served for data on child abuse.

RESULTS

Regarding physical puberty markers, significant correlations were found, especially with child neglect (CN) and child emotional abuse (CEA). Regression analyses, controlling for Body-Mass-Index (BMI) and Socioeconomic Status (SES), revealed that children affected by child neglect perpetrated by mother (CNm) and child emotional abuse (CEA) parent-non-specifically enter puberty significantly earlier. Sex-specific analyses identified child neglect perpetrated by mother (CNm) to be associated with early puberty in girls and child emotional abuse perpetrated by father (CEAf) with early puberty in boys. Concerning the onset of menstruation, there was a significant positive correlation between early menarche and parent-specific and non-specific child neglect (CN), as well as between early menarche and child emotional abuse perpetrated by the mother (CEAm). In regression models that controlled for Body-Mass-Index (BMI) and Socioeconomic Status (SES) no significant associations were maintained. Child physical abuse (CPA) was not associated with early puberty.

CONCLUSION

Results outlined child neglect (CN) and child emotional abuse (CEA) to be sex- and perpetrator-specific risk factors for early pubertal development. Knowledge of sex- and perpetrator-specific effects could help clinicians to specify their diagnostic process and to define differential prevention and treatment goals for children with experiences of CN and CEA. Further research on the sex-specific impact of parental CN and CEA on girls' and boys' puberty is needed.

Asymptomatic or symptomatic SARS-CoV-2 infection plus vaccination confers increased adaptive immunity to Variants of Concern

The ongoing evolution of SARS-CoV-2 requires monitoring the capability of immune responses to cross-recognize Variants of Concern (VOC). In this cross-sectional study, we examined serological and cell-mediated immune memory to SARS-CoV-2 variants, including Omicron, among a cohort of 18-21-year-old Marines with a history of either asymptomatic or mild SARS-CoV-2 infection 6 to 14 months earlier. Among the 210 participants in the study, 169 were unvaccinated while 41 received 2 doses of mRNA-based COVID-19 vaccines. Vaccination of previously infected participants strongly boosted neutralizing and binding activity and memory B and T cell responses including recognition of Omicron, compared to infected but unvaccinated participants. Additionally, no measurable differences were observed in immune memory in healthy young adults with previous symptomatic or asymptomatic infections, for ancestral or variant strains. These results provide mechanistic immunological insights into population-based differences observed in immunity against Omicron and other variants among individuals with different clinical histories.

Reconstruction of a Portion of the Articular Surface of the Distal Radius With a Vascularized Osteochondral Graft From the Proximal Phalanx of the Great Toe

Distal radius fractures are among the most common injuries to the upper extremity and have a bimodal distribution in younger male patients and older women. Young men suffer from high-energy injuries and older women from fragility fractures. Approximately 50% of these are intra-articular. Timely and appropriate treatment usually will lead to an acceptable outcome, but loss of congruity of the articular surface remains a difficult problem to manage. We report here on the case of a 16-year-old boy with malunion of the radial articular surface with lack of motion and pain. He was managed by replacing the displaced and damaged segment of the radial articular surface with a vascularized osteochondral graft from the proximal phalanx of the great toe. This matched the shape of this portion of the radius quite well, and he has had improvements in motion and pain in the 10 months since that time. The donor site has not caused him any difficulty to date.

Development and internal validation of clinical prediction models for outcomes of complicated intra-abdominal infection

BACKGROUND

Complicated intra-abdominal infections (cIAIs) are associated with significant morbidity and mortality. The aim of this study was to describe the clinical characteristics of patients with cIAI in a multicentre study and to develop clinical prediction models (CPMs) to help identify patients at risk of mortality or relapse.

METHODS

A multicentre observational study was conducted from August 2016 to February 2017 in the UK. Adult patients diagnosed with cIAI were included. Multivariable logistic regression was performed to develop CPMs for mortality and cIAI relapse. The c-statistic was used to test model discrimination. Model calibration was tested using calibration slopes and calibration in the large (CITL). The CPMs were then presented as point scoring systems and validated further.

RESULTS

Overall, 417 patients from 31 surgical centres were included in the analysis. At 90 days after diagnosis, 17.3 per cent had a cIAI relapse and the mortality rate was 11.3 per cent. Predictors in the mortality model were age, cIAI aetiology, presence of a perforated viscus and source control procedure. Predictors of cIAI relapse included the presence of collections, outcome of initial management, and duration of antibiotic treatment. The c-statistic adjusted for model optimism was 0.79 (95 per cent c.i. 0.75 to 0.87) and 0.74 (0.73 to 0.85) for mortality and cIAI relapse CPMs. Adjusted calibration slopes were 0.88 (95 per cent c.i. 0.76 to 0.90) for the mortality model and 0.91 (0.88 to 0.94) for the relapse model; CITL was -0.19 (95 per cent c.i. -0.39 to -0.12) and - 0.01 (- 0.17 to -0.03) respectively.

CONCLUSION

Relapse of infection and death after complicated intra-abdominal infections are common. Clinical prediction models were developed to identify patients at increased risk of relapse or death after treatment, these now require external validation.

92 Clinical Frailty Scoring Is Crucial For the COVID-19 Era and Beyond

Introduction

The COVID-19 pandemic placed a new focus on provision of clinical resources. With high mortality and limited capacity; appropriate decisions to escalate to critical care were vital for just resource allocation but also to prevent harm where interventions would not change outcomes. NICE guidance highlighted Clinical frailty scoring (CFS) as central to the decision-making process. 1, Despite initial criticism, recent evidence has confirmed increasing CFS as an independent risk factor to inpatient mortality in COVID-19.2 We conducted a quality improvement project with the aim of improving CFS documentation at the Royal Free Hospital.

Methods

We reviewed the notes of 71 inpatients over the age of 65 years from 6 wards on 08/05/20–12/05/20 for both a CFS score documentation and clear treatment escalation plan at time points of initial clerking, post-take and following ward admission with an audit standard of 100%. We developed teaching sessions, promoted the CFS mobile application, developed a post-take sticker and an elderly medicine ward admission proforma. We re-audited 66 inpatient notes from the same 6 wards from 25/06/20–07/07/20.

Results

Documentation.of CFS improved from 7% to 17% for clerking and post-take and from 13% to 24% on the ward admission. The number of patients with treatment escalation plans was 50%.

Conclusion

CFS is crucial for the COVID-19 era and beyond. We have demonstrated that increased awareness improves use of CFS, though it is not yet being widely used in escalation decisions. 1. Covid-19 Rapid guideline: Critical Care in adults. NICE guideline [NG159]: https://www.nice.org.uk/guidance/ng159 Accessed July 2020 2. Hewitt J et al (2020): The effect of frailty on survival in patients with COVID -19 (COPE): a multicentre, European, observational cohort study; The Lancet: https://doi.org/10.1016/S2468-2667(20)30146-8.

Suicide among immigrants in Germany

AIMS

The identification of high-risk groups is crucial in public health suicide prevention approaches. This study aims to compare suicide risks of Germans with nine of the largest immigrant populations living in Germany.

METHODS

Based on a German national database of mortality statistics, the number of suicides in Germans and immigrants was available for the study period (2000 - 2017), stratified for gender and age groups. Standard mortality ratios (SMR) for suicide were computed since age distributions differed between populations. Moreover, SMR of immigrant populations were correlated with potential risk and resilience factors.

RESULTS

The analysed dataset covers a period of 18 years, which translates to over 1.47 billion life years (LY) and 206,056 recorded suicides. 134,971,779 LY (10.1%) and 8,936 (4.3%) suicides were assigned to non-German citizens. SMR, calculated for nine of the largest immigrant populations, were lower compared with the German reference population ranging from 0.24 (Greek nationality) to 0.86 (Russian nationality). SMR in immigrants was highest in adolescents and declined with age. SMR was associated with country of origin (CO) suicide rates as well as with socio-economic factors of immigrant groups in Germany. With the global financial crisis, suicide risk of immigrants from the most affected countries decreased more strongly compared to immigrants from other CO.

CONCLUSIONS

The suicide risk strongly differs between the individual immigrant groups and is associated with risk factors of the respective CO. Therefore, future suicide prevention approaches in immigrants should take CO-specific vulnerabilities into account as well as age-related risk factors.

Supporting individuals with intellectual and developmental disability during the first 100 days of the COVID-19 outbreak in the USA

BACKGROUND

It is unknown how the novel Coronavirus SARS-CoV-2, the cause of the current acute respiratory illness COVID-19 pandemic that has infected millions of people, affects people with intellectual and developmental disability (IDD). The aim of this study is to describe how individuals with IDD have been affected in the first 100 days of the COVID-19 pandemic.

METHODS

Shortly after the first COVID-19 case was reported in the USA, our organisation, which provides continuous support for over 11 000 individuals with IDD, assembled an outbreak committee composed of senior leaders from across the health care organisation. The committee led the development and deployment of a comprehensive COVID-19 prevention and suppression strategy, utilising current evidence-based practice, while surveilling the global and local situation daily. We implemented enhanced infection control procedures across 2400 homes, which were communicated to our employees using multi-faceted channels including an electronic resource library, mobile and web applications, paper postings in locations, live webinars and direct mail. Using custom-built software applications enabling us to track patient, client and employee cases and exposures, we leveraged current public health recommendations to identify cases and to suppress transmission, which included the use of personal protective equipment. A COVID-19 case was defined as a positive nucleic acid test for SARS-CoV-2 RNA.

RESULTS

In the 100-day period between 20 January 2020 and 30 April 2020, we provided continuous support for 11 540 individuals with IDD. Sixty-four per cent of the individuals were in residential, community settings, and 36% were in intermediate care facilities. The average age of the cohort was 46 ± 12 years, and 60% were male. One hundred twenty-two individuals with IDD were placed in quarantine for exhibiting symptoms and signs of acute infection such as fever or cough. Sixty-six individuals tested positive for SARS-CoV-2, and their average age was 50. The positive individuals were located in 30 different homes (1.3% of total) across 14 states. Fifteen homes have had single cases, and 15 have had more than one case. Fifteen COVID-19-positive individuals were hospitalised. As of 30 April, seven of the individuals hospitalised have been discharged back to home and are recovering. Five remain hospitalised, with three improving and two remaining in intensive care and on mechanical ventilation. There have been three deaths. We found that among COVID-19-positive individuals with IDD, a higher number of chronic medical conditions and male sex were characteristics associated with a greater likelihood of hospitalisation.

CONCLUSIONS

In the first 100 days of the COVID-19 outbreak in the USA, we observed that people with IDD living in congregate care settings can benefit from a coordinated approach to infection control, case identification and cohorting, as evidenced by the low relative case rate reported. Male individuals with higher numbers of chronic medical conditions were more likely to be hospitalised, while most younger, less chronically ill individuals recovered spontaneously at home.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Analysing the impacts of air quality policies on ecosystem services; a case study for Telemark, Norway

There is an increasing interest in considering the effects of air pollution on ecosystem services supply in order to enhance cost-benefit analyses of air pollution policies. This paper presents a generic, conceptual approach that can be used to link atmospheric deposition of air pollutants to ecosystem services supply and societal benefits. The approach is applied in a case study in the Telemark county of Norway. First, we examine the potential effects of four European air quality policy scenarios on N deposition in the ecosystems of this county. Second, we analyse the subsequent impacts on the supply of three ecosystem services: carbon sequestration, timber production and biodiversity. Changes in the supply of the first two services are analysed in both physical and monetary units, biodiversity effects are only analysed in physical terms. The scenarios derive from work conducted in the context of the European National Emissions Ceilings Directive. In the 2010 base case the benefits of carbon sequestration are estimated at 13 million euro per year and the value of timber harvesting at 2.9 million euro per year. Under the examined policy scenarios aiming to reduce nitrogen emissions the societal benefits resulting from these two ecosystem services in Telemark are found to be reduced; the scenarios have little effect on terrestrial biodiversity. Such results cannot be scaled up, individual ecosystem services respond differently to changes in air pollution depending upon type of pollutant, type of ecosystem, type of service, and the magnitude of change. The paper further presents an analysis of the uncertainties that need to be considered in linking air pollution and ecosystem services including those in deposition rates, ecosystem responses, human responses and in the values of ecosystem services. Our conceptual approach is also useful for larger scale analysis of air pollution effects on ecosystem services, for example at national or potentially European scale.

Dietary practices in propionic acidemia: A European survey

Background

The definitive dietary management of propionic acidaemia (PA) is unknown although natural protein restriction with adequate energy provision is of key importance.

Aim

To describe European dietary practices in the management of patients with PA prior to the publication of the European PA guidelines.

Methods

This was a cross-sectional survey consisting of 27 questions about the dietary practices in PA patients circulated to European IMD dietitians and health professionals in 2014.

Results

Information on protein restricted diets of 186 PA patients from 47 centres, representing 14 European countries was collected. Total protein intake [PA precursor-free L-amino acid supplements (PFAA) and natural protein] met WHO/FAO/UNU (2007) safe protein requirements for age in 36 centres (77%). PFAA were used to supplement natural protein intake in 81% (n = 38) of centres, providing a median of 44% (14–83%) of total protein requirement. Seventy-four per cent of patients were prescribed natural protein intakes below WHO/FAO/UNU (2007) safe levels in one or more of the following age groups: 0–6 m, 7–12 m, 1–10 y, 11–16 y and > 16 y. Sixty-three per cent (n = 117) of patients were tube fed (74% gastrostomy), but only 22% received nocturnal feeds.

Conclusions

There was high use of PFAA with intakes of natural protein commonly below WHO/FAO/UNU (2007) safe levels. Optimal dietary management can only be determined by longitudinal, multi-centre, prospective case controlled studies. The metabolic instability of PA and small patient cohorts in each centre ensure that this is a challenging undertaking.

Global and targeted serum metabolic profiling of colorectal cancer progression

BACKGROUND

Patients with colorectal adenoma polyps (PLPs) are at higher risk for developing colorectal cancer (CRC). However, the development of improved and robust biomarkers to enable the screening, surveillance, and early detection of PLPs and CRC continues to be a challenge. The aim of this study was to identify biomarkers of progression to CRC through metabolomic profiling of human serum samples with a multistage approach.

METHODS

Metabolomic profiling was conducted with the Metabolon platform for 30 CRC patients, 30 PLP patients, and 30 control subjects, and this was followed by the targeted validation of the top metabolites in an additional set of 50 CRC patients, 50 PLP patients, and 50 controls with liquid chromatography-tandem mass spectrometry. Unconditional multivariate logistic regression models, adjusted for covariates, were used to evaluate associations with PLP and CRC risk.

RESULTS

For the discovery phase, 404 serum metabolites were detected, with 50 metabolites showing differential levels between CRC patients, PLP patients, and controls (P for trend < .05). After validation, the 3 top metabolites (xanthine, hypoxanthine, and d-mannose) were validated: lower levels of xanthine and hypoxanthine and higher levels of d-mannose were found in PLP and CRC cases versus controls. A further exploratory analysis of metabolic pathways revealed key roles for the urea cycle and caffeine metabolism associated with PLP and CRC risk. In addition, a joint effect of the top metabolites with smoking and a significant interaction with the body mass index were observed. An analysis of the ratio of hypoxanthine levels to xanthine levels indicated an association with CRC progression.

CONCLUSIONS

These results suggest the potential utility of circulating metabolites as novel biomarkers for the early detection of CRC. Cancer 2017;123:4066-74. © 2017 American Cancer Society.

Integrative review of older adult loneliness and social isolation in Aotearoa/New Zealand

OBJECTIVE

To conduct an integrative review of empirical studies of loneliness for older people in Aotearoa/New Zealand. Loneliness is a risk factor for older people's poor physical and cognitive health, serious illness and mortality. A national survey showed loneliness rates vary by gender and ethnicity.

METHODS

A systematic search of health and social science databases was conducted. Of 21 scrutinised articles, nine were eligible for inclusion and subjected to independent quality appraisal. One qualitative and eight quantitative research articles were selected.

RESULTS

Reported levels and rates of loneliness vary across age cohorts. Loneliness was significantly related to social isolation, living alone, depression, suicidal ideation, being female, being Māori and having a visual impairment. Qualitatively, older Korean immigrants experienced loneliness and social isolation, along with language and cultural differences.

CONCLUSION

Amongst older New Zealanders loneliness is commonly experienced by particular ethnic groups, highlighting a priority for targetted health and social services.

Dietary practices in isovaleric acidemia: A European survey

Background

In Europe, dietary management of isovaleric acidemia (IVA) may vary widely. There is limited collective information about dietetic management.

Aim

To describe European practice regarding the dietary management of IVA, prior to the availability of the E-IMD IVA guidelines (E-IMD 2014).

Methods

A cross-sectional questionnaire was sent to all European dietitians who were either members of the Society for the Study of Inborn Errors of Metabolism Dietitians Group (SSIEM-DG) or whom had responded to previous questionnaires on dietetic practice (n = 53). The questionnaire comprised 27 questions about the dietary management of IVA.

Results

Information on 140 patients with IVA from 39 centres was reported. 133 patients (38 centres) were given a protein restricted diet. Leucine-free amino acid supplements (LFAA) were routinely used to supplement protein intake in 58% of centres. The median total protein intake prescribed achieved the WHO/FAO/UNU [2007] safe levels of protein intake in all age groups. Centres that prescribed LFAA had lower natural protein intakes in most age groups except 1 to 10 y. In contrast, when centres were not using LFAA, the median natural protein intake met WHO/FAO/UNU [2007] safe levels of protein intake in all age groups. Enteral tube feeding was rarely prescribed.

Conclusions

This survey demonstrates wide differences in dietary practice in the management of IVA across European centres. It provides unique dietary data collectively representing European practices in IVA which can be used as a foundation to compare dietary management changes as a consequence of the first E-IMD IVA guidelines availability.

Descriptive analysis of a 1:1 physiotherapy outpatient intervention post primary lumbar discectomy: one arm of a small-scale parallel randomised controlled trial across two UK sites

OBJECTIVE

There is a lack of high-quality evidence for physiotherapy post lumbar discectomy. Substantial heterogeneity in treatment effects may be explained by variation in quality, administration and components of interventions. An optimised physiotherapy intervention may reduce heterogeneity and improve patient benefit. The objective was to describe, analyse and evaluate an optimised 1:1 physiotherapy outpatient intervention for patients following primary lumbar discectomy, to provide preliminary insights.

DESIGN

A descriptive analysis of the intervention embedded within an external pilot and feasibility trial.

SETTING

Two UK spinal centres.

PARTICIPANTS

Participants aged ≥18; post primary, single level, lumbar discectomy were recruited.

INTERVENTION

The intervention encompassed education, advice, mobility and core stability exercises, progressive exercise, and encouragement of early return to work/activity. Patients received ≤8 sessions for ≤8 weeks, starting 4 weeks post surgery (baseline).

OUTCOMES

Blinded outcome assessment at baseline and 12 weeks (post intervention) included the Roland Morris Disability Questionnaire. STarT Back data were collected at baseline. Statistical analyses summarised participant characteristics and preplanned descriptive analyses. Thematic analysis grouped related data.

FINDINGS

Twenty-two of 29 allocated participants received the intervention. STarT Back categorised n=16 (55%) participants 'not at low risk'. Physiotherapists identified reasons for caution for 8 (36%) participants, commonly risk of overdoing activity (n=4, 18%). There was no relationship between STarT Back and physiotherapists' evaluation of caution. Physiotherapists identified 154 problems (mean (SD) 5.36 (2.63)). Those 'not at low risk', and/or requiring caution presented with more problems, and required more sessions (mean (SD) 3.14 (1.16)).

CONCLUSIONS

Patients present differently and therefore require tailored interventions. These differences may be identified using clinical reasoning and outcome data.

TRIAL REGISTRATION NUMBER

ISRCTN33808269; post results.

Stepped-wedge cluster randomised controlled trial to assess the effectiveness of an electronic medication management system to reduce medication errors, adverse drug events and average length of stay at two paediatric hospitals: a study protocol

INTRODUCTION

Medication errors are the most frequent cause of preventable harm in hospitals. Medication management in paediatric patients is particularly complex and consequently potential for harms are greater than in adults. Electronic medication management (eMM) systems are heralded as a highly effective intervention to reduce adverse drug events (ADEs), yet internationally evidence of their effectiveness in paediatric populations is limited. This study will assess the effectiveness of an eMM system to reduce medication errors, ADEs and length of stay (LOS). The study will also investigate system impact on clinical work processes.

METHODS AND ANALYSIS

A stepped-wedge cluster randomised controlled trial (SWCRCT) will measure changes pre-eMM and post-eMM system implementation in prescribing and medication administration error (MAE) rates, potential and actual ADEs, and average LOS. In stage 1, 8 wards within the first paediatric hospital will be randomised to receive the eMM system 1 week apart. In stage 2, the second paediatric hospital will randomise implementation of a modified eMM and outcomes will be assessed. Prescribing errors will be identified through record reviews, and MAEs through direct observation of nurses and record reviews. Actual and potential severity will be assigned. Outcomes will be assessed at the patient-level using mixed models, taking into account correlation of admissions within wards and multiple admissions for the same patient, with adjustment for potential confounders. Interviews and direct observation of clinicians will investigate the effects of the system on workflow. Data from site 1 will be used to develop improvements in the eMM and implemented at site 2, where the SWCRCT design will be repeated (stage 2).

ETHICS AND DISSEMINATION

The research has been approved by the Human Research Ethics Committee of the Sydney Children's Hospitals Network and Macquarie University. Results will be reported through academic journals and seminar and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ANZCTR) 370325.

Abstract 8: Global and targeted metabolomic profiling of colorectal cancer progression

Background: Colorectal cancer (CRC) is one of the most prevalent and deadly cancers in the world. The development of improved and robust biomarkers to enable screening, surveillance, and early detection of CRC continues to be a challenge. Patients with colorectal adenoma are at higher risk of developing colon cancer; however, noninvasive methods to identify these patients are still on demand. The aim of this study was to identify biomarkers of CRC disease progression by using metabolomic profiling of human serum samples in a multistep approach.

Methods: We performed global metabolomic profiling on 30 human serum samples from patients with colorectal adenoma, 30 CRC patients and 30 healthy controls who were matched by age, gender and ethnicity. For validation, we measured the three top differentially expressed metabolites in an additional set of 50 adenoma, 50 CRC and 50 healthy controls.

Results: Global biochemical profiles of 404 metabolites were detected, with 301 metabolites remaining after quality control procedures. In discovery phase, 50 metabolites had differential levels between colorectal adenoma, CRC and controls (P for trend &lt;0.05), with 19 metabolites showing increased levels in CRC and adenoma in comparison to controls and 31 metabolites with decreased levels. Further exploratory analyses of these metabolites showed a key role for metabolic pathways involving urea cycle, caffeine and galactose metabolism as associated with CRC progression. The top 3 differentially expressed metabolites (Xanthine, Hypoxanthine and D-mannose) were selected for validation. Consistent with the discovery phase, CRC cases and adenoma had lower levels of Xanthine than controls (mean ± SD; 9.95 ±0.92 mg/ml vs 10.63±0.97 mg/ml; P&lt;0.001 and 9.87±0.75 vs 10.63±0.97 mg/ml; P&lt;0.001). The same trend was observed for Hypoxanthine (mean ± SD; 10.72 ±0.62 mg/ml vs 12.29±1.60; P&lt;0.001 and 10.71±0.61 vs 12.29±1.60 mg/ml; P &lt;0.001) whereas higher levels of D-mannose where observed in both CRC cases and adenoma when compared to controls (3.32±0.58 mg/ml vs 2.32 ±0.90mg/ml; P&lt;0.001 and 3.32±0.58 mg/ml vs 2.32 ±0.90mg/ml; P&lt;0.001). Using the median value of controls as a cut-off point, 94% of the adenoma and CRC cases showed low levels of Xanthine (Odds Ratio (OR) = 10.47, 95% confidence interval (CI) = 2.63-41.63 for adenoma; OR = 38.76 and 95% CI = 6.58-228.51 for CRC). For Hypoxanthine, 90% of the adenoma and CRC cases showed low levels (OR = 6.50 and 95% CI = 1.98–21.24 for adenoma; OR = 11.19 and 95% CI = 3.28-38.21 for CRC). For D-Mannose, all adenoma cases had high levels (OR is not available due to 0 count) and 92% of CRC cases (OR = 15.99, 95% Ci = 4.07-62.88, P&lt; 0.001) had high levels of D-Mannose, compared to 50% of controls having high levels of D-Mannose.

Conclusions: Our results suggest the potential utility of the identified metabolites as new valuable biomarkers for early detection of CRC.

Citation Format: Beatriz Sanchez-Espiridion, Lindsey White, Lopa Mishra, Gottumukkala S. Raju, Scott Kopetz, Jian Gu, Yuanquing Ye, Xifeng Wu, Dong Liang. Global and targeted metabolomic profiling of colorectal cancer progression. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 8.

Development of an optimised 1:1 physiotherapy intervention post first-time lumbar discectomy: a mixed-methods study

OBJECTIVES

To develop an optimised 1:1 physiotherapy intervention that reflects best practice, with flexibility to tailor management to individual patients, thereby ensuring patient-centred practice.

DESIGN

Mixed-methods combining evidence synthesis, expert review and focus groups.

SETTING

Secondary care involving 5 UK specialist spinal centres.

PARTICIPANTS

A purposive panel of clinical experts from the 5 spinal centres, comprising spinal surgeons, inpatient and outpatient physiotherapists, provided expert review of the draft intervention. Purposive samples of patients (n=10) and physiotherapists (n=10) (inpatient/outpatient physiotherapists managing patients with lumbar discectomy) were invited to participate in the focus groups at 1 spinal centre.

METHODS

A draft intervention developed from 2 systematic reviews; a survey of current practice and research related to stratified care was circulated to the panel of clinical experts. Lead physiotherapists collaborated with physiotherapy and surgeon colleagues to provide feedback that informed the intervention presented at 2 focus groups investigating acceptability to patients and physiotherapists. The focus groups were facilitated by an experienced facilitator, recorded in written and tape-recorded forms by an observer. Tape recordings were transcribed verbatim. Data analysis, conducted by 2 independent researchers, employed an iterative and constant comparative process of (1) initial descriptive coding to identify categories and subsequent themes, and (2) deeper, interpretive coding and thematic analysis enabling concepts to emerge and overarching pattern codes to be identified.

RESULTS

The intervention reflected best available evidence and provided flexibility to ensure patient-centred care. The intervention comprised up to 8 sessions of 1:1 physiotherapy over 8 weeks, starting 4 weeks postsurgery. The intervention was acceptable to patients and physiotherapists.

CONCLUSIONS

A rigorous process informed an optimised 1:1 physiotherapy intervention post-lumbar discectomy that reflects best practice. The developed intervention was agreed on by the 5 spinal centres for implementation in a randomised controlled trial to evaluate its effectiveness.

Prioritizing vulnerable children: strategies to address inequity

BACKGROUND

While current strategies to address the needs of vulnerable child populations in Australia aim to reduce inequities, they are isolated, group specific and disparate.

AIM

The aim of this study was to address health inequities by generating tools that are useful in clinical service settings to assist with the identification, prioritization and monitoring of all vulnerable populations.

METHODOLOGY

Current local and national initiatives to address inequities were reviewed. Shared strategies in delivering health services to vulnerable populations were highlighted, and existing tools used for identification and prioritization were adapted.

FINDINGS

Analysis of at-risk populations resulted in the formulation of four key questions to identify vulnerable children at presentation to services and strategies for prioritizing children within services. An existing refugee child health service delivery framework was adapted as a proposal for use in the development and evaluation of services for all vulnerable child populations.

CONCLUSION

A systemic approach across all vulnerable populations, supplemented by group-specific measures, is likely to add value to health service delivery as well as be more efficient and sustainable than multiple group-specific interventions. Given the limited outcome evidence available, there is also a need to collect data on vulnerable children and to track the effectiveness of interventions designed to address their health needs.

Prioritizing vulnerable children: why should we address inequity?

BACKGROUND

Children and young people from vulnerable population groups, including Indigenous Australians, those in out of home care, those with disabilities and those from refugee families, have difficulties in accessing health services and are at high risk of adverse outcomes, driving population health inequity. Although heterogeneous, these groups face common disadvantage and shared challenges in health service utilization.

AIM

This study aims to analyse the demographics of vulnerable child populations in NSW, the rationale for focussing on their health needs and strategies for addressing population health inequity.

METHODOLOGY

A literature review was undertaken on vulnerable child populations and successful strategies for improving their health outcomes. NSW data on vulnerable children were collated.

FINDINGS

Vulnerable children in NSW are estimated to comprise 10-20% of the childhood population. Efforts to improve their health and well-being can be justified based on child rights, a focus on equity and effectiveness of care, public opinion and the evidence base supporting such interventions. Targeted (subpopulation specific) interventions and delivery of universally applied (population wide) strategies that disproportionately benefit vulnerable populations have been shown to be effective in reducing healthcare disparities. Most available information relates to specific vulnerable population groups. However, some effective strategies and key principles are broadly applicable to the vulnerable child population as a whole.

CONCLUSION

Vulnerable children should be a key focus of healthcare interventions if inequities are to be addressed.

Evidence-based development of a post-surgical lumbar discectomy leaflet intervention: a Delphi consensus study

OBJECTIVE

To produce free, expert-informed postoperative information for lumbar discectomy patients, satisfying UK National Health Service Information Standards.

DESIGN

A mixed methods approach utilising the Delphi technique and focus groups.

SETTING

Five spinal centres across the UK.

PARTICIPANTS

Panel members included 23 physiotherapists, 11 patients and 17 spinal surgeons.

INTERVENTION

Three rounds of questionnaires including open and closed questions and attendance at a clinician/patient focus group.

RESULTS

Response rates of 85%, 26% and 35% were achieved for the Delphi rounds. Ten clinicians and six patients participated in the focus groups. Consensus for leaflet sections was achieved in round 1 and content in round 3. The focus groups informed further revisions.

CONCLUSIONS

A consensually agreed, Information Standard compliant, patient lumbar discectomy leaflet was produced containing: (1) normal spine anatomy; (2) anatomy disc herniation and surgery; (3) back protection strategies and (4) frequently asked questions. Illustrations of exercises enable tailoring to the individual patient.